Background: The optimal timing of weightbearing following surgical fixation of ankle fractures remains a topic of clinical debate. Although early weightbearing (EWB) may promote faster functional recovery, concerns about complication risks have limited its widespread adoption. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of EWB compared with LWB in adults undergoing ankle fracture fixation, using evidence from high-quality randomized controlled trials (RCTs) published since 2000.
Methods: A comprehensive literature search was conducted across 6 electronic databases (MEDLINE, Embase, CENTRAL, Scopus, CINAHL, and Web of Science) from January 2000 to May 2025. Only RCTs comparing EWB (initiated within 3 weeks postoperatively) to LWB (≥4 weeks) following surgical fixation of ankle fractures were included. Primary outcomes were functional recovery, primarily assessed by the Olerud-Molander Ankle Score (OMAS), and EuroQol 5-dimension visual analogue scale (EQ 5D VAS). Secondary outcomes included time to return to work and complication rates. Meta-analyses were conducted using fixed or random effects models based on heterogeneity.
Results: Five RCTs involving 1030 patients were included. OMAS at 6 weeks (5 studies) and 3 months (4 studies) favored EWB (6 weeks: MD 6.51, P < .00001; 3 months: MD 3.24, P = .005) and time to return to work (3 studies) was shorter with EWB. Complication rates were similar. Because several trials excluded patients with BMI >30, trimalleolar or syndesmotic injuries, and many enrolled patients were <65 years, these findings apply primarily to lower-risk patients treated with contemporary fixation.
Conclusion: EWB after ankle fracture fixation leads to improved early functional outcomes and quicker return to work, with no clear increase in complications, in primarily lower-risk patients.
Background: Tobacco use is known to have adverse outcomes in ankle open reduction and internal fixation (ORIF). Non-tobacco nicotine dependence (NTND), driven by the rising popularity of e-cigarettes and alternative nicotine products, is increasingly prevalent, but its relationship with ankle ORIF is unknown. This study evaluated the association of NTND on perioperative and long-term outcomes following ankle ORIF.
Methods: A retrospective cohort study was conducted using a large database to identify patients ≥18 years who underwent bimalleolar and trimalleolar ankle ORIF from 2004 to 2023. Patients were stratified into NTND, tobacco use, and non-nicotine control cohorts based on International Classification of Disease, Tenth Revision (ICD-10) coding. Propensity score matching (1:1) was performed to balance demographics and comorbidities. Outcomes were assessed at 90 days and 2 years. Odds ratios with 95% CIs and P values were calculated.
Results: 63 853 patients were eligible for analysis. A total of 4716 NTND patients were matched with 50 903 controls and 8234 tobacco users. NTND patients had higher odds of complications within 90 days, including stroke (OR 2.25, 95% CI 1.46-3.47), pneumonia (OR 1.81, 95% CI 1.27-2.58), surgical site infection (OR 1.82, 95% CI 1.37-2.41), wound dehiscence (OR 1.53, 95% CI 1.18-2.00), emergency department utilization (OR 1.68, 95% CI 1.47-1.92), and hospitalizations (OR 1.42, 95% CI 1.20-1.68). At 2 years, NTND patients showed higher rates of non‑union or mal‑union (OR 3.04, 95% CI 2.34-3.87), non‑union repair (OR 1.33, 95% CI 1.08-1.74), and hardware removal (OR 1.19, 95% CI 1.06-1.34) versus controls. Compared with tobacco users, NTND patients had increased odds of non‑union or mal‑union (OR 2.46, 95% CI 1.97-3.08) and hardware removal (OR 1.21, 95% CI 1.07-1.35).
Conclusion: NTND is associated with significantly increased short-term and long-term complications following ankle ORIF. These findings suggest NTND is not a benign alternative and may confer risks comparable to or greater than tobacco use, warranting further prospective investigation.
Background: Syndesmosis injury healing remains poorly understood, despite its high prevalence in ankle fractures. Unstable syndesmosis is commonly addressed with either syndesmosis screw (SS) or suture button (SB) fixation, and up to 20% of operated ankle fractures may require some form of syndesmosis fixation. However, in biomechanical studies no repair technique fully restores the preinjury rotational stability or the anatomical alignment of the tibiofibular joint.
Methods: In a study of 39 patients with operatively treated supination external-rotation type 4 and pronation external-rotation type 4 ankle fractures and fixation of an unstable syndesmosis, weightbearing cone beam computed tomography with rotational stress was performed on both ankles at a mean follow-up of 7.8 (range, 6.2-10.3) years to evaluate tibiofibular syndesmosis dimensions and fibular rotation. Sagittal translation of the fibula (ST), anterior width (AW) and posterior width (PW) of the syndesmosis, tibiofibular clear space (TFCS), and fibular rotation (RO) were measured in neutral position and in maximal internal and external rotation. Mean change in measurements between maximal rotations were calculated to represent range of motion of the fibula under rotational stress.ResultsTwenty-six patients had screw fixation (SS) and 13 had suture button (SB) fixation of the syndesmosis. Eight SSs had been removed and 3 were broken. No SBs had been removed. The mean Olerud-Molander Ankle Score was 84.7 (SD 20.3). Fibular rotation demonstrated a mean difference of 2.7 degrees (95% CI, 1.3-4.1; P < .05) compared with the patient's non-injured ankle. Other measurements showed no significant differences; however, we lacked statistical power to detect significant changes in ST, AW, PW, and TFCS.ConclusionExcess fibular rotation persists after healing of ankle fractures with fixed unstable syndesmosis. However, clinical relevance remains unclear and should be explored with larger patient groups.
Background: Although mosaicplasty has been a preferred surgery for osteochondral lesions of the talus (OLT), debriding the recipient bed may create interplug voids in larger defects. We evaluated clinical and imaging outcomes of mosaicplasty performed without recipient-site debridement.MethodsBetween March 2017 and August 2023, consecutive patients of OLT who were candidates for mosaicplasty were included in the study. Baseline demographics were recorded, and functional outcomes, including the American Orthopaedic Foot & Ankle Society (AOFAS), visual analog scale (VAS), and Lysholm scores, were assessed pre- and postoperatively. Imaging assessments, including radiography, computed tomography, and magnetic resonance imaging (MRI), were performed preoperatively to evaluate lesions and at 6 months postoperative and at last follow-up to assess cartilage integrity in all patients. Intraoperative lesion location or size and plug number were recorded.
Results: Thirty-two patients (mean age 36 years) completed follow-up (mean 35.8 months). AOFAS improved from 59 ± 16 to 85 ± 13 and VAS from 6.0 ± 1.6 to 1.6 ± 1.3 (both P < .001). Eight patients (25%) required hardware removal; 2 reported persistent ankle pain; and 1 had a clinically relevant decline in donor-knee Lysholm. Preoperative osteoarthritis predicted lower odds of AOFAS >80. The integrity of the autograft plugs at the follow-up MRI was found to be good for all patients.
Conclusion: Mosaicplasty, omitting recipient-site debridement, was associated with within-group functional improvement and MRI evidence of plug integrity. Findings should be interpreted cautiously, given the single-arm design, small sample size, and relatively short average follow-up of 3 years.
Background: The acquired flatfoot, often called progressive collapsing foot deformity, frequently includes attenuation or failure of the spring ligament. Reconstruction of the spring ligament has been proposed in conjunction with other bone and soft tissue reconstruction techniques. In this study, we compared a tendon-graft reconstruction with suture tape augmentation in a cadaveric flatfoot model.
Methods: Eight matched-pair fresh-frozen cadaver feet underwent flatfoot creation and reconstruction. The feet were cyclically loaded with 16,000 cycles from 200 N to 1.5× body weight at 1 Hz. Each foot was randomly assigned to undergo either suture tape or tendon graft reconstruction. Radiographic parameters and foot motion were measured at baseline, following creation of the collapsed arch deformity, and after repair.
Results: The cadaveric flatfoot model was successfully created, demonstrated by significant (P < .05) changes in Meary angle (mean change = +9.4 ± 6.4 degrees), talonavicular coverage angle (mean change = +15.6 ± 9.2 degrees), medial cuneiform height (mean change = -6.6 ± 4.1 mm), and calcaneal pitch (mean change = -2.6 ± 2.2 degrees). The tendon graft repair had significant improvements compared with flatfoot in the Meary angle (mean change = -6.4 ± 3.6 degrees), talonavicular coverage angle (mean change = -6.4 ± 5.2 degrees), calcaneal pitch (mean change = +1.9 ± 1.7 degrees), and medial cuneiform height (mean change = +3.7 ± 2.4 mm). The suture tape repair had significant improvements compared with flatfoot of talonavicular coverage angle (mean change = -8.1 ± 4.1) and calcaneal pitch (mean change = +2.9 ± 0.6). Inversion and eversion data showed hindfoot motion preserved from native to repair conditions. In load-to-failure testing, the tendon graft group had 1 failure at the interference screw and 1 midsubstance failure of the tendon graft. The suture tape group had 3 failures at the interference screws and 1 failure of the suture tape.
Conclusion: Both techniques restored arch alignment from the flatfoot condition and preserved hindfoot motion in a cadaveric flatfoot model.
Clinical relevance: Both techniques may provide a viable approach to restore alignment during flatfoot reconstruction. Both were mechanically stable under cyclic loading in this cadaver model; the tendon graft technique has a theoretical benefit of biological incorporation.
Background: Gastrocnemius tightness contributes to various foot and ankle pathologies. Although both proximal medial gastrocnemius release (PMGR) and the Strayer procedure (SP) are widely used, comparative data on their biomechanical effects are limited, particularly within the same specimen. This study aimed to compare dorsiflexion (DF) increase between PMGR and SP using a side-to-side cadaveric model.
Methods: A total of 15 full-body non-embalmed cadaveric specimens were included. Each specimen underwent a randomized side-to-side comparison: one leg received PMGR and the other the SP. Passive ankle DF was measured before and after intervention by a masked observer using a standardized 10-kg load and an electronic goniometer. Relative changes in DF were also calculated. All procedures were performed by a single orthopaedic surgeon; measurements were performed by a masked observer.
Results: Baseline DF was similar between limbs (PMGR: median -18.5 degrees; SP: -19.0 degrees, P = .776). Post-surgery, the SP resulted in significantly greater DF (median -3.4 degrees vs -9.0 degrees, P < .001). Absolute DF gain was higher in the SP group (median 14.7 degrees vs 8.0 degrees, P = .001), as was relative increase (14.9% vs 7.4%, P < .001). No correlation was found between increase and age, sex, or BMI.
Conclusion: The distal procedure (SP) resulted in significantly greater DF gain compared with proximal release (PMGR) within the same specimen. The difference was observed across absolute and relative dorsiflexion gains. These cadaveric experimental findings support the hypothesis that the level of recession influences the extent of correction in ankle dorsiflexion, whereas clinical decision making should take into account the risks of each procedure.
Background: Nicotine and cannabis use are increasingly relevant in surgical planning, but their effects on postoperative complications following ankle fracture open reduction and internal fixation (ORIF) remain unclear. This study evaluates associations between recent substance use and postoperative complications across multiple time points.
Methods: We queried a nationwide database, TriNetX, for patients aged ≥18 years who underwent ORIF for ankle fractures between 2011 and 2023. Five independent 1:1 propensity-matched cohort analyses were performed based on substance use in the year prior to surgery: (1) dual use vs neither, (2) nicotine use vs neither, (3) cannabis use vs neither, (4) dual vs cannabis use, and (5) dual vs nicotine use. Patients with overlapping exposures were excluded from single-substance groups. Groups were 1:1 propensity score matched. Primary outcomes included 90-day wound disruption, surgical site infection (SSI), and hardware removal at 1 and 3 years.
Results: Nicotine use was associated with higher 90-day wound disruption (odds ratio [OR] 1.4 [1.2-1.6]) and SSI (OR 1.4 [1.2-1.6]) compared to nonusers. Dual users also showed increased SSI vs neither-use (OR 1.6 [1.1-2.3]), whereas wound disruption trended higher (OR 1.4 [0.99-2.0]). Cannabis use alone was not associated with higher complication rates (all P > .05). Compared to cannabis-only users, dual users had higher 90-day wound disruption (OR 2.0 [1.1-3.4]) and SSI (OR 1.7 [1.01-2.8]), though outcomes were similar between dual and nicotine-only users (all P > .05). Hardware removal rates did not differ across groups (all P > .05).
Conclusion: Nicotine use was associated with increased postoperative complications after ankle fracture ORIF, whereas cannabis use alone was not. When evaluating dual substance users, complication rates were largely comparable to nicotine-only users. Further studies are needed to clarify the isolated and combined perioperative effects of cannabis and nicotine.
Background: Osteochondral lesions (OCLs) of the talus involve damage to both the articular cartilage and underlying subchondral bone, which may range from compression injury to complete fragment separation. Treating large lesions may necessitate osteochondral allograft transplantation (OCA) to ensure cartilage congruence and minimize articular step-off. However, current allograft selection techniques rely largely on gross size estimation rather than precise contour matching, which may increase the risk of graft incongruity and suboptimal clinical outcomes. This study evaluates the correlations between the talar dome posteromedial (PM) and central lateral (CL) radii of curvature (ROC) with age, articular width (AW), and articular length (AL) in a young patient group to optimize graft selection and matching.
Methods: Twenty-nine patients, aged 9-18 years, and 30 ankles were included. Magnetic resonance imaging was used to measure talar dome ROC, AW, and AL. The ROC was measured on sagittal images at the PM and CL regions, whereas AW and AL were measured on coronal and sagittal planes, respectively. Three independent reviewers assessed all measurements using Sectra PACS software. Reliability was evaluated using intraclass correlation coefficients (<0.50, poor; 0.50-0.75, moderate; 0.75-0.90, good; >0.90, excellent). Correlations (R2) between ROC with age, AW, and AL were assessed.
Results: The mean PM ROC was 20.55 mm and CL ROC 17.20 mm. The mean AW and AL were 27.84 mm and 36.25 mm, respectively. Intraobserver reliability was good to excellent for PM ROC and AW, and moderate to excellent for CL ROC and AL. Interobserver reliability was good to excellent for PM ROC and AW, and moderate to good for CL ROC and AL. For PM ROC, R² values were 0.29 (age), 0.18 (AW), and 0.62 (AL); for CL ROC, R² values were 0.06 (age), 0.54 (AW), and 0.78 (AL).
Conclusion: Articular length demonstrated stronger correlations with talar dome PM and CL ROCs compared with AW and age. AL may be a useful parameter for optimizing graft selection, particularly contour and size matching, in OCA.
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