Journal of Foot & Ankle Surgery最新文献

Background: Lesser metatarsophalangeal (MTPJ) joint instability, often presenting as second crossover toe deformity, commonly results from plantar plate attenuation. Indirect surgical approaches, such as metatarsal osteotomy or tendon transfer, can correct alignment but often lead to complications like floating toe, transfer metatarsalgia, and stiffness. The direct plantar approach allows for anatomic repair but is underutilized due to concerns about scar-related pain.

Purpose: To evaluate outcomes of second plantar plate repair via a direct plantar approach, focusing on pain, alignment, satisfaction, and scar morbidity.

Study design: Retrospective case series.

Methods: We reviewed 196 primary second plantar plate repairs performed from 2013-2023. All patients had at least 12 months of follow-up (mean 48 months). Adjunctive procedures included Hohmann osteotomy and proximal interphalangeal joint arthrodesis. Outcomes included Numeric Pain Rating Scale (NPRS) scores, scar symptoms, satisfaction, symptom improvement, and willingness to recommend the procedure. Radiographic alignment was assessed in sagittal and transverse planes on weightbearing views.

Results: Radiographic correction averaged 24.0° sagittal and 3.6° transverse (11.7° with osteotomy). Mean NPRS pain scores improved from 5.4 to 0.4. 88% of patients were "very satisfied," and 91% would recommend the procedure. Scar-related pain occurred in 2.0% of cases. Plantar callus improved in 52%, and 6.1% reported postoperative stiffness.

Conclusion: Direct plantar plate repair provides durable correction, considerable pain relief, and high satisfaction with minimal scar morbidity. This is the largest, longest follow-up study of its kind.

Background: Intramedullary hindfoot nailing remains a valuable technique for deformity correction, trauma, and limb salvage in high-risk patients. Despite widespread use, limited post-market data exist characterizing device-related complications in real-world practice.

Purpose: This study examines device-related complications associated with hindfoot intramedullary nailing as reported in the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

Study design: Descriptive epidemiologic database study.

Methods: MAUDE reports from 2020-2024 related to hindfoot intramedullary nailing were reviewed, screened, and de-duplicated. Events were categorized by primary complication type. Descriptive statistics summarized complication patterns. Chi-square analysis compared mechanical versus biological complications, and linear regression assessed temporal reporting trends.

Results: Of 426 identified reports, 144 unique events met inclusion criteria. Mechanical complications accounted for 68.1% (n = 98), while biological or patient-driven complications comprised 31.9% (n = 46) (p < 0.001). The most frequent mechanical events involved targeting guide or jig failure (25.0%), nail body failure (18.8%), and screw-related failure (16.0%). Biological complications most commonly included hardware pain (10.4%), infection or wound-related events (9.7%), and nonunion (9.0%). Reporting peaked in 2021, declined in 2022, and rebounded modestly in 2023-2024, with no significant linear trend (p = 0.81).

Conclusion: Most reported complications were mechanical and often reflect expected intraoperative challenges inherent to complex hindfoot reconstruction. Nonetheless, true device failures remain clinically meaningful, highlighting the need for meticulous technique, continued implant refinement, and robust post-market surveillance to optimize patient safety.

Background: Insertional Achilles tendinopathy is an extremely common pathology to all foot and ankle surgeons. The relationship between calcaneal morphology and the Achilles has been recognized since its original description by Swedish orthopedist Dr Haglund in 1928. Minimal invasive surgery (MIS) often allows for smaller incisions, optimal skin healing, and maintenance of the Achilles tendon insertion which may be more beneficial in specific patient populations.

Purpose: The primary goal of this study was to evaluate damage to the Achilles tendon following burr resection of the calcaneal tuber.

Study design/methods: Twenty, ten matched-pairs, thawed fresh-frozen cadaveric below-knee specimens were used to assess impact of MIS burr resection to posterior superior calcaneus and potential damage caused to the Achilles tendon.

Results: We found a 15% incidence of partial Achilles tendon damage. No full thickness tearing or ruptures occurred, as well as no neurovascular damage in any specimen.

Conclusion: These findings support the use of MIS burr resection for use of calcaneal tuber resection in setting of Haglund's deformity while also underscoring the need for meticulous surgical planning to optimize patient outcomes. Further clinical trials are warranted to confirm these results and guide future surgical practices.

Background: Total ankle replacement (TAR) is an established option for end-stage ankle arthritis, providing pain relief and functional recovery. Precise implant sizing and alignment are crucial for long-term prosthesis survival. In the transfibular approach, determining the appropriate talar component size intraoperatively can be challenging, especially in the presence of residual deformities.

Purpose: To assess the correlation between preoperative CT-based mediolateral (ML) talar width and the final implanted talar component size in transfibular TAR.

Study design: Retrospective analysis of consecutive primary TAR cases.

Patients and methods: Fifty primary TARs using non-cemented Zimmer Trabecular Metal implants via a transfibular approach were reviewed. Cases requiring additional procedures were excluded. Preoperative CT scans were used to measure ML talar dome width at its highest convex point on coronal images. Measurements were performed by a blinded radiologist and compared with intraoperatively implanted component sizes.

Results: CT-based ML width showed excellent correspondence with implanted sizes. The mean difference between CT measurements and implanted components was 0.0 mm (SD 1.12 mm; range -2.4 to +2.4 mm). Exact matching occurred in 38/50 cases (76%), and all cases were within ±1 size. The maximum deviation of 1.2 mm remained below half a size increment.

Conclusion: Preoperative CT-based ML talar measurement is a reliable, reproducible, and cost-effective tool for predicting talar component size in transfibular TAR, improving preoperative planning and intraoperative decision-making.

Level of evidence: III.

Background: Intravenous ketorolac is widely used for perioperative pain control in arthroplasty, but its impact on wound healing, infection, and implant outcomes after total ankle arthroplasty (TAA) remains unclear.

Purpose: This study aims to compare the outcomes of patients that were given intravenous ketorolac on the day of surgery with patients who are not.

Study design: Retrospective cohort study using a large national database.

Methods: A retrospective analysis was performed using the TriNetX Research Network, identifying patients who underwent primary TAA. Patients who received intravenous ketorolac on the day of surgery were compared with those who did not and were matched 1:1 using propensity score matching with a caliper of 0.1. Outcomes were assessed at 90 days and 1 year.

Results: Among all TAA patients, 10.4% received IV ketorolac. A total of 2,200 ketorolac patients were matched to 2,200 controls with balanced baseline characteristics (p > 0.05). At 90 days, ketorolac use was associated with higher rates of surgical site infection (5.10% vs 2.85%, RR 1.79, p = 0.0001), wound dehiscence (4.00% vs 1.98%, RR 2.02, p < 0.0001), and acute post-hemorrhagic anemia (5.00% vs 2.91%, RR 1.72, p = 0.0004). At 1 year, ketorolac recipients had higher rates of periprosthetic joint infection (4.89% vs 3.66%, RR 1.34, p = 0.0436) and revision surgery (2.74% vs 1.28%, RR 2.14, p = 0.0006).

Conclusions: Perioperative ketorolac exposure during TAA was associated with higher ninety-day and one-year complications. However, these findings should be interpreted cautiously given ketorolac's short half-life and limited exposure.

Level of evidence: III.

Background: Venous thromboembolism (VTE) is a potentially fatal complication following surgery. Incidence rates vary significantly depending on the procedure, ranging from 45-57% after pelvic surgery to 0.22-5.09% after foot surgery. Because of this variability, the use of prophylaxis in foot and ankle surgery has been debated.

Purpose: This study aimed to evaluate the incidence of VTE in forefoot and rearfoot procedures and assess whether a patient-specific prophylaxis protocol reduced risk.

Study design: Retrospective and prospective cohort study conducted over a four-year period.

Methods: Patients were divided into two cohorts. In Period 1 (retrospective), patients did not receive prophylaxis. In Period 2 (prospective), patients were managed with a standardized protocol incorporating chemoprophylaxis and mechanical pneumatic compression based on patient-specific risk factors. A total of 1305 patients were included: 342 in Period 1 (174 forefoot, 168 rearfoot) and 963 in Period 2 (719 forefoot, 244 rearfoot). VTE incidence rates were calculated for each group.

Conclusion: This study highlights the importance of distinguishing forefoot from rearfoot surgery when evaluating VTE risk. There were six occurrences of VTE following rearfoot surgery without prophylaxis. The use of a risk factor-based prophylaxis protocol was associated with a marked reduction in VTE events, supporting objective risk stratification to guide prophylaxis decisions and improve patient outcomes.

Level of clinical evidence: Level 3.

Purpose: To investigate the prognostic value of neutrophil-to-lymphocyte ratio (NLR) in predicting post-traumatic osteoarthritis (PTOA) following surgical fixation of intra-articular ankle fractures.

Methods: This retrospective cohort study included patients who underwent surgery for closed, intra-articular ankle fractures in a tertiary care center between January 2019 and December 2021, with a minimum follow-up of 3 years. NLR was calculated from routine blood tests within 24 hours post-injury. PTOA was diagnosed radiographically based on the Kellgren-Lawrence grading system. Multivariable logistic regression was employed to assess the independent predictive role of NLR after adjusting for covariates.

Results: A total of 764 patients were included, including 455 (59.6%) males and 309 (40.4%) females, with a mean age of 43.9±14.6 years. The restricted cubic spline (RCS) model demonstrated a nonlinear relationship between NLR and PTOA, with risk sharply rising above the 6.5 threshold. High-NLR patients (n = 159) also exhibited higher surgical complexity, increased bleeding, and more frequent emergency interventions, as compared with low-NLR group (n = 605). The risk of PTOA was 37.7% (60/159) and 19.5% (118/605) in both groups, respectively (P < 0.001). An NLR ≥ 6.5 was associated with a significantly increased risk of PTOA (adjusted OR = 2.299, 95% CI: 1.517-3.483, P < 0.001).

Conclusions: These findings suggest that elevated early post-injury NLR may be associated with the development of PTOA following ankle fracture surgery; however, given the single time-point assessment, further prospective studies with serial measurements are needed to clarify its role.

Level of evidence: 3:

Background: Plantar fibromatosis (PFI) is a rare condition that affects the plantar aponeurosis resulting in painful nodules on the foot/feet.

Purpose: There are no clinical guidelines for treatment in the United States, and real-world evidence regarding treatment patterns is limited.

Methods: This retrospective cohort study used linked data from adjudicated claims and electronic medical records to identify patients with incident PFI. PFI prevalence in 2021 was estimated, and treatment patterns for conservative (nonsurgical) and surgical interventions were assessed during the 24 months after diagnosis.

Results: Age- and sex-adjusted PFI prevalence was 57.03 cases per 100,000 in 2021. In the incident PFI cohort (N=620), 392 patients (63.23%) were female. During the 12-month baseline period before diagnosis, 19.03% of patients had evidence of foot/ankle pain or stiffness, and 53.55% received prescribed analgesics or steroids. Most patients (91.13%) received conservative treatment during follow-up, including injectable corticosteroids (59.19%), oral corticosteroids (44.68%), and physical/occupational therapy (PT/OT, 40.81%). On average, treated patients had 2.10 oral and 2.63 injectable steroid claims and 15.8 PT/OT visits during follow-up. Surgical interventions were rarely used (n=42; 6.77%); excision of foot tumor (n=15/42; 35.71%) was the most common surgical procedure. Following surgery, conservative treatments were commonly observed (n=39; 92.86%).

Conclusions: Our findings suggest patients newly diagnosed with PFI typically received conservative treatments. Although surgery is infrequent, conservative treatments often continue after surgery, which may suggest disease recurrence or persistent symptoms. Additional studies are warranted to develop an understanding of long-term clinical and patient-reported outcomes with/without treatment, among patients with refractory disease.

Background: There is a lack of recent, nationally representative reporting of Achilles tendon rupture (ATR) repair epidemiology.

Purpose: To evaluate the incidence and prevalence of ATR repairs in the US in the last decade and assess medical and orthopedic complications post-ATR repair.

Study design: Retrospective cohort study.

Methods: The TriNetX database was used to identify US patients who experienced an ATR repair from 2015-2024. The primary outcome was incidence proportion (IP), stratified by sex and age. Rates of medical complications (30, 60, 90 days) and orthopedic complications (1, 2 years) were assessed.

Results: 18,061 patients had an ATR repair from 2015-2024. In 2024, the IP of ATR repairs was 7.28 (95 % CI 6.99-7.59) per 100,00 patients, significantly increased from 2015. The annual percent change in IP was 12.8 % % per year. Males comprised 65 % of the cohort and consistently had higher IP than females. The mean age was 31 ± 7 years and the highest IP in 2024 was in those aged 30-39. Stratified by age and sex, males aged 25-29 experienced the most ATR repairs overall (60.94 (95 % CI 58.14-63.87) per 100,000 patients), while the peak in female ATR repairs was in females aged 45-49 (23.08 (95 % CI 21.45-24.84) per 100,000 patients). There were relatively low rates of all medical and orthopedic complications assessed.

Conclusions: ATR repair incidence, which is especially high among young men, is increasing. Low medical and orthopedic complications rates support the safety and good functional outcomes of ATR repair.

Background: Autogenous bone grafting is a useful tool for the foot and ankle surgeon to augment their arthrodesis procedures. Distal tibial graft has been shown to be increasingly useful with the benefit to those with limited scope of practice while maintaining low morbidity. While techniques of harvest are surgeon dependent, no study has assessed optimal anatomic location of obtaining distal tibial graft.

Purpose: The primary goal of this study was to evaluate zones of distal tibial graft harvest to assess the location of optimal graft volume while also identifying structures at risk through a percutaneous approach with the use of powered bone graft harvesting instrumentation.

Study design: Twenty individual (ten-matched pairs) fresh-frozen cadaveric below-knee specimens were used. The distal tibia was subdivided into three equal zones.

Methods: A 7mm bone graft harvester was inserted perpendicular to the tibia to allow for graft harvest from each respected zone. Post harvest dissection was performed to assess structures at risk.

Result: A significant increase (p<0.001) in autogenous harvest was found in the medial zone (zone 3) with a mean harvest of 1.12 grams, while also found to be closest in proximity to the tibialis posterior tendon as well as saphenous vein and nerve. The lateral zone (zone 1) was significantly closer to the tibial crest and tibialis anterior tendon.

Conclusion: Distal tibial autograft remains a safe means for obtaining autogenous graft, our findings suggest that harvest planning closest to the medial malleolus (zone 3) may yield greater graft volume.