Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes

Outcome of flexible fixation for acute isolated syndesmotic injuries

BACKGROUND

Management of syndesmotic injuries with screw fixation has potential disadvantages, which may lead to the loss of some of the ankle functions. The use of the suture-button system instead can overcome these disadvantages.

PATIENTS AND METHODS

In a prospective study, 32 patients with acute isolated syndesmotic injuries were treated with a suture-button device. Follow-up was for a minimum of 2 years, regarding the Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, patient satisfaction at 3, 12, and 24 months, and radiological assessment.

RESULT

A significant improvement regarding pain (VAS during rest 5.6 and during walking 6.1 preoperative improved to 0.1 and 0.2 postoperatively, respectively. (P values were < 0.0001 for both pain during rest and walking) and AOFAS score (improved significantly from 44 ± 7.5 pre- to 99 ± 8.7 points postoperatively (P value was 0.0034). The improved VAS and AOFAS scores of the repaired ankles gradually reached the values of the contralateral uninjured ankle (evaluated at 3,12, and 24 months, postoperatively). Radiographs and CT of both ankles - repaired and healthy ankles - were similar at the 3 months follow-up. Early full weight-bearing and early return to work and sport characterized all patients. There was no need for hardware removal.

CONCLUSION

Suture-button treatment for acute isolated ankle syndesmotic injuries leads to favorable clinical and radiological outcomes. Postoperative radiographs and CT denoted maintained ankle stability. Patients can do early full weight-bearing and early return to work and sport.

Midterm outcomes of the modified Lapidus arthrodesis using the Phantom® Intramedullary Nail System for the treatment of hallux valgus

BACKGROUND

Lapidus arthrodesis is one of the most commonly used techniques in the correction of moderate and severe hallux valgus. We analyzed the clinical and radiological outcomes after using the Phantom® Lapidus intramedullary nail to find an effective technique with low complications.

METHODS

We retrospectively analyzed data of 52 patients who underwent a modified Lapidus arthrodesis with an intramedullary nail at our center from November 2019 to September 2022. The mean follow-up period was 27 (range, 18-34) months. Clinical results were evaluated using the visual analog scale (VAS), the European Foot and Ankle Society score (EFAS) and the American Orthopaedic Foot and Ankle Society score (AOFAS); three different radiological measures were analyzed.

RESULTS

The mean AOFAS score increased from 44.8 to 82 points. The mean EFAS score increased from 11.2 to 20.1 points. The mean VAS score decreased by 4.7 points. The mean EFAS Sport score was increased from 9.2 (SD 4.6) to 12.6 (SD 5.4) points. The intermetatarsal angle decreased from 15° to 6.9° and the hallux valgus angle by a mean of 17.9°. The forefoot width reduced from 93.6 to 84.7 mm. All results were statistically significant (p < .001). One case of nonunion was recorded. No implant-related complications were observed.

CONCLUSIONS

This device was effective in correcting moderate to severe hallux valgus, with significant patient satisfaction. Its complication rate was not higher than that of other fixation devices. Correct compression of the arthrodesis, absence of extraosseous material, and multidirectional stability are important qualities of this implant for the correct treatment of this pathology.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ultrasound-guided infiltration with hyaluronic acid compared with corticosteroid for the treatment of Morton's neuroma

Aims

A local injection may be used as an early option in the treatment of Morton's neuroma, and can be performed using various medications. The aim of this study was to compare the effects of injections of hyaluronic acid compared with corticosteroid in the treatment of this condition.

Methods

A total of 91 patients were assessed for this trial, of whom 45 were subsequently included and randomized into two groups. One patient was lost to follow-up, leaving 22 patients (24 feet) in each group. The patients in the hyaluronic acid group were treated with three ultrasound-guided injections (one per week) of hyaluronic acid (Osteonil Plus). Those in the corticosteroid group were treated with three ultrasound-guided injections (also one per week) of triamcinolone (Triancil). The patients were evaluated before treatment and at one, three, six, and 12 months after treatment. The primary outcome measure was the visual analogue scale for pain (VAS). Secondary outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complications.

Results

Both groups showed significant improvement in VAS and AOFAS scores (p < 0.05) after 12 months. The corticosteroid group had a significantly greater reduction in VAS and increase in AOFAS scores compared with the hyaluronic acid group, at one, three, and six months, but with no significant difference at 12 months. There were no complications in the hyaluronic acid group. There were minor local complications in six patients (six feet) (25.0%) in the corticosteroid group, all with discolouration of the skin at the site of the injection. These minor complications might have been due to the three weekly injections of a relatively high dose of corticosteroid. No patient subsequently underwent excision of the neuroma.

Conclusion

An ultrasound-guided corticosteroid injection showed statistically significantly better functional and pain outcomes than an ultrasound-guided injection of hyaluronic acid for the treatment of a Morton's neuroma at many timepoints. Thus, a corticosteroid injection should be regarded as a primary option in the treatment of these patients, and the only indication for an injection of hyaluronic acid might be in patients in whom corticosteroid is contraindicated.

The evolution of patient-reported outcome measures after a first lateral ankle sprain: A prospective study

PURPOSE

A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain.

METHODS

A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test.

RESULTS

All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value <.0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value <.01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24.

CONCLUSION

The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies.

LEVEL OF EVIDENCE

Level II (prospective cohort study).

Reconstructing Quadriceps Tendon Disruptions in Post Total Knee Arthroplasty Patients with an Autogenous Peroneal Tendon Graft: A Viable Alternative

Purpose

Quadriceps tendon disruption post-total knee arthroplasty (TKA) is rare. Existing reconstruction procedures use allografts or synthetic meshes with varied success. This study evaluates outcomes with autogenous peroneal tendon grafts, a cost-effective alternative, compared to synthetic polypropylene mesh for quadriceps reconstruction.

Methods

16 patients who underwent extensor mechanism reconstruction between 2017 and 2021were retrospectively analysed. Parameters evaluated included type of reconstruction, extensor lag, IKDC (International Knee Documentation Committee) Score and AOFAS-Hindfoot-score (American Orthopaedic Foot and Ankle Society).

Results

At final follow-up, extensor lag for peroneal autograft group was 6.6° ± 1.5 and for synthetic polypropylene mesh group, 7.2° ± 0.7. Both groups improved in IKDC score (p < 0.01) AOFAS-Hindfoot-score was comparable for peroneal autograft patients with opposite side (p = 0.15).

Conclusions

Autogenous peroneal tendon graft for quadriceps reconstruction could be viable, cost-effective alternative to allografts or synthetic meshes, with good clinical outcomes.

Graphical Abstract

Graphical abstract depicting the harvesting of the peronei grafts and their passage through the quadriceps tendon. Sonographic image showing the preoperative presence of a gap in the quadriceps tendon which is reconstructed post-operatively.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01247-8.

A Novel Combination Strategy of Ultrasound-Guided Percutaneous Radiofrequency Ablation and Corticosteroid Injection for Treating Recalcitrant Plantar Fasciitis: A Retrospective Comparison Study

INTRODUCTION

The best treatment yielding clinical benefits was still equivocal and controversial for the treatment of recalcitrant plantar fasciitis (PF). This study aimed to propose a novel combination strategy of ultrasound-guided percutaneous radiofrequency ablation (RFA) and corticosteroid injection (CI) for recalcitrant PF, and to compare its therapeutic effects with CI alone and continued conservative management.

METHODS

We retrospectively reviewed consecutive patients with recalcitrant PF who underwent combined strategy (RFA + CI), CI alone, and continue conservative treatment at our institution between October 2021 and February 2023. The technical pearls were described elaborately. A comparison of demographic data and clinical outcomes, including visual analog scale (VAS), Ankle-Hindfoot Scale (AOFAS-AHS), and plantar fascia thickness, were conducted among the three groups.

RESULTS

Seventy-one eligible patients were enrolled in this study, with 17 in the combined strategy group, 25 in the CI group, and 29 in the continued conservative treatment group. Both the combined strategy group and the CI group showed significant improvements in VAS scores, AOFAS-AHS scores, and significant reductions in plantar fascia thickness during the 12-month follow-up period compared to those preoperatively (P < 0.05). The combined strategy group achieved comparable immediate pain relief to the CI group after the intervention ([25.7 ± 15.7] vs. [20.6 ± 17.6], P = 0.850). However, the combined strategy group demonstrated superior improvement in symptom and function compared to the CI group at the 3-month (VAS: [21.9 ± 13.5] vs. [39.6 ± 20.4]; AOFAS-AHS: [77.9 ± 12.4] vs. [60.5 ± 17.4], P < 0.05) and 12-month follow-up (VAS: [15.7 ± 12.0] vs. [56.8 ± 17.5]; AOFAS-AHS: [84.5 ± 10.7] vs. [53.8 ± 12.4], P < 0.05). Obvious adverse effects or complications were not identified in either group, while two cases (11.8%) in the combined strategy group and five cases (20.0%) in the CI group experienced unsatisfactory symptom remission.

CONCLUSIONS

We introduced and detailed a novel combination strategy involving ultrasound-guided percutaneous RFA and CI for treating recalcitrant PF. The strategy is both effective and safe in alleviating pain and enhancing function throughout the entire treatment course.

Is the occurrence of extra-articular calcaneal fractures of the joint depression type related to osteoporosis and aging?

PURPOSE

The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications.

METHODS

Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up.

RESULTS

Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery.

CONCLUSION

Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density.

LEVEL OF EVIDENCE

Level IV.

CASE SERIES

Allograft Screws as Fixation of the Scarf Osteotomy

Background: In comparison to titanium screws, novel cortical bone allograft screws may come with advantages in osseointegration and with avoidance of potential material removal surgery after scarf osteotomy. Methods: A scarf osteotomy with allograft bone screws as fixation was performed in 21 patients (30 feet). Clinical and radiological parameters were prospectively collected until one year after surgery. A retrospective control group, consisting of 75 patients (82 feet) after scarf osteotomy using headless compression screws, was used to compare clinical outcomes. Results: After fixation with allograft bone screws, the mean preoperative AOFAS score increased from 51.5 points preoperatively to 93.5 points one year after surgery. In radiological assessments, a continuous osseointegration with the remodeling of the bone screw was observed in all patients that finished follow-up. However, four metatarsal fractures occurred early postoperatively after fixation using allograft bone screws. There were only three material removal surgeries in patients treated with headless compression screws. Conclusions: Allograft bone screws display a safe fixation and are a biological alternative for scarf osteotomy. Enough distance between the screw and the proximal osteotomy should be ensured to avoid fractures.

Rehabilitation for ankle fractures in adults

BACKGROUND

Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.

OBJECTIVES

To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.

MAIN RESULTS

We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise. All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data. Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants) Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence). Removable versus non-removable ankle support (25 studies, 2206 participants) Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence). Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants). Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants) Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.

AUTHORS' CONCLUSIONS

Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.

Comparison of the Minimally Invasive Reverdin-Isham Lateral Translation Osteotomy Versus the Standard Reverdin-Isham Technique: A Pilot Prospective Cohort Study

Background/Objectives: Reverdin-Isham osteotomy is effective in correcting moderate hallux valgus deformity but has certain limitations when correcting a deformity in the sagittal plane. This study aimed to evaluate the impact on pain, functionality, and radiological measures of angular corrections, and the safety of the Reverdin-Isham lateral translation technique through minimally invasive surgery in the treatment of a moderate hallux valgus compared to Reverdin-Isham standard osteotomy. Methods: A pilot 6-month prospective cohort study was conducted on adults over 18 years old with a hallux valgus in at least one foot. The study exposure was the use of the Reverdin-Isham lateral translation technique. The outcome variables were pain and functionality through VAS and AOFAS scales, respectively, and radiological measurements of the first toe metatarsophalangeal angle (MPA), first space intermetatarsal angle (IMA), proximal articular set angle (PASA), distal articular set angle (DASA), metatarsal formula, and position of sesamoids in the AP projection. Results: The study involved 60 participants. Results indicate significant reductions in pain and radiological measures in both cohorts: MPA improved by 23.13 degrees, IMA by 5.93 degrees, and sesamoid position by 4.23 degrees in patients who underwent the lateral translation technique versus 13.20, 3.30, and 1.57 degrees, respectively, in patients who experienced the standard Reverdin-Isham technique. The lateral translation method showed greater reductions in these metrics compared to the standard Reverdin-Isham technique (p < 0.05). Conclusions: Percutaneous Reverdin-Isham techniques, both standard and with lateral translations, effectively corrected moderate hallux valguses. However, the lateral translation method provided greater reductions in MPA, IMA, and sesamoid positions, making it more suitable for deformities with IMAs over 15 degrees.

Surgical refinements and sensory and functional outcomes of using thinned sensate anterolateral thigh perforator flaps for foot and ankle reconstruction: A retrospective study

To improve the use of sensate anterolateral thigh (ALT) flaps for foot and ankle reconstruction, we employed a thinned nerve-selective harvesting technique. The data of 31 patients in whom sensate ALT perforator flaps were transferred for reconstruction of soft-tissue defects in the foot and ankle were reviewed. Flaps were elevated with 2 refinements. The first is the initial selection of the "true" sensory branch in the medial incision on the suprafascial plane. The second is flap thinning by keeping a cuff of thin deep fat surrounding the point where the perforator or nerve branch inserts into the superficial fat layer. The recipient site assessment consisted of complications, monofilament touch perception, sharp-blunt discrimination, axial circumference, and American Orthopedic Foot and Ankle Society score. After a mean follow-up of 31.7 months, all flaps survived uneventfully, except for marginal necrosis in 1 patient, infection in 1 patient, ulceration in 2 patients, and secondary thinning in 3 patients. The sensation of each flap was restored. A total of 87% and 90% of the patients exhibited 5 or more positive response points in the Semmes-Weinstein monofilament touch and sharp-blunt discrimination testings, respectively. The mean axial circumference of the reconstructed foot was 27.4 cm (the unaffected side was 25.8 cm). All patients achieved mobility in ordinary shoes with a mean functional score of 74.6. The thinned nerve-selective sensate ALT perforator flap can be a favorable option for foot and ankle reconstruction. This method also offers the possibility of preserving the nerve branch at the donor thigh.

Patient-reported outcome measures in studies on hallux valgus surgery: what should be assessed

INTRODUCTION

In recent years, there has been an increasing demand for patient-reported outcome measures (PROMs) to assess the outcome following orthopedic surgery. But, we are lacking a standard set of PROMs to assess the outcome of hallux valgus surgery. The aim of this study was to analyze the chosen patient rated outcome scores used in studies reporting on hallux valgus surgery.

MATERIALS AND METHODS

The study was based on a previously published living systematic review. Included were prospective, comparative studies of different surgical procedures or the same procedure for different degrees of deformity. Four common databases were searched for the last decade. Study selection, data extraction, and risk of bias assessment were made by two independent reviewers. Data assessed were the individual PROMs used to assess the outcome of hallux valgus surgery.

RESULTS

46 studies (30 RCTs and 16 non-randomized prospective studies) met the inclusion criteria. The most commonly used clinical outcome measures were the AOFAS (55%) and the VAS (30%). No differences were found between frequency of the individual scores per the level of evidence or the type of osteotomy.

CONCLUSION

Based on a systematic literature review, the AOFAS and VAS are the most frequently used outcome tools in studies assessing the outcome following hallux valgus surgery. Based on the literature available, the MOXFQ is a more valid alternative.

LEVEL OF EVIDENCE

Level I; systematic review of prospective comparative (level II) and randomized controlled trials (level I).

The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The effectiveness and safety of fibular intramedullary nail fixation (FINF) compared to plate fixation (PF) in treating ankle fractures among adults remains unclear. Therefore, we conducted a meta-analysis to assess the efficacy and safety of FINF versus PF, aiming to provide orthopedic surgeons with valuable insights when choosing between the two internal fixation methods for patient treatment.

METHODS

PubMed, EMBASE, and SCOPUS were systematically searched for articles comparing FINF and PF in ankle fractures among adults. Functional outcomes, complications, and bony union were compared between the implants.

RESULTS

A total of seven studies were included in the study, involving 586 patients. The results revealed no statistically significant differences in functional outcomes between two groups at 3, 6, and 12 months postoperatively. The outcomes favoring FINF comprised a lower infection rate (RR = 0.23, 95%CI, 0.11 to 0.47, P < 0.0001). Conversely, the PF group exhibited a superior performance in terms of hardware failure rate (RR = 2.05, 95%CI, 1.16 to 3.60, P = 0.01). A statistically significant difference was observed in the results of hardware failure rate in the subgroup of studies conducted in Europe (RR = 2.74, 95%CI, 1.45 to 5.18, P = 0.002). Comparable findings were also noted in a subgroup of older adults (RR = 4.25, 95%CI, 1.57 to 11.50, P = 0.004).

CONCLUSION

This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. Consequently, it is imperative to further delineate the surgical indications for both FINF and PF with precision to mitigate the risk of complications. Nevertheless, larger sample sizes and multi-center RCTs are imperative to corroborate this conclusion in the future.

Postural stability after operative reconstruction of the AFTL in chronic ankle instability comparing three different surgical techniques

Background

Chronic lateral ankle instability is a relatively frequent consequence after acute ankle sprain. In case of unsuccessful conservative treatment, surgical therapy is recommended to prevent osteoarthritis of the ankle joint. To date, different surgical methods have evolved. Yet, it remains unclear which approach reveals the best results. We hypothesized that the modified Broström-Gould procedure with suture anchor ligament fixation leads to superior postoperative results compared to the Broström-Gould procedure or the periosteal flap technique.

Material and methods

In a prospective study, we examined the three surgical techniques. For this purpose, we performed a matched-pair analysis with four groups according to age, sex, and body mass index: periosteal flap technique (G1), Broström-Gould procedure (G2), modified Broström-Gould procedure with suture anchor ligament fixation (G3), and a control group (G4). Results were compared with the American Orthopaedic Foot & Ankle Society (AOFAS) score, a functional analysis as well as measuring postural stability with the Biodex balance system.

Results

No significant differences were found between all four groups concerning AOFAS score, functional results, as well as postural stability.

Conclusion

All three surgical methods revealed satisfactory results. No significant differences could be detected in clinical and functional categories. The Broström-Gould method as well as the modified procedure with anchor can be recommended as surgical therapy for chronic lateral ankle instability. Additional anchors do not seem to have a significant positive impact on the results.

Tape-Fixation for the Treatment of a Dorsal Boss in Lisfranc Joints of an Elderly Patient

A dorsal boss, also known as a tarsal boss, is a bony prominence often associated with osteoarthritis (OA) of the tarsometatarsal (TMT) joints, leading to significant pain and a reduced quality of life (QOL) in elderly individuals. This condition frequently forces patients to abandon recreational activities and is typically resistant to conservative treatments. This report details a successful surgical intervention in an 83-year-old female patient with a dorsal boss and OA of the TMT joint, which involved osteophyte excision and semi-rigid fixation using ligament tape with an absorbable screw (Arthrex, Inc., Florida, USA). Post-surgery, the patient, who had experienced pain and deformity in the dorsal region of her right foot, showed significant improvement and returned to playing golf three months later. This case underscores the significance of considering a semi-rigid, flexible dorsal fixation approach in elderly patients with dorsal bosses and associated joint instability while preserving joint surfaces and facilitating early reintegration into society. The patient's favorable outcome highlights the potential advantages of this surgical method, particularly in managing dorsal boss cases that are resistant to conservative treatment.

Prospective randomized comparison of functional bracing versus rigid immobilization with early weightbearing after modified percutaneous achilles tendon repair under local anesthesia

OBJECTIVE

The optimal treatment and rehabilitation strategy for acute Achilles tendon rupture (ATR) remain a debate. This study aimed to compare the results of the two postoperative regimens after treatment for ATR with modified closed percutaneous repair under local anesthesia.

METHODS

In a 4-year study, 72 consecutive patients with acute complete ATR were randomized after percutaneous repair into a functional group (FG), using a modified brace (28 males, three females; mean age 41.9 [29-71] years) and an immobilization group (IG), wearing a rigid plaster (28 males, two females; mean age 42.2 [29-57] years), for a period of 6 weeks. Except for immobilization, they followed the same weight-bearing and rehabilitation protocols. The follow-up period was 3 years. The complication rate, active and passive ankle range of motion, standing heel-rise test, clinical outcome using the American Foot and Ankle Society (AOFAS) hindfoot-ankle score, return to the previous activity level, and subjective assessment were assessed.

RESULTS

There was one rerupture in the IG and two transient sural nerve disturbances in the FG and one in the IG, and one suture extrusion in the IG, with no other complications. The average AOFAS scores were 96.9 ± 4.3 and 96.0 ± 4.9 in the FG and IG, respectively. Patients in the FG reached a final range of motion and muscular strength sooner without limping and were more satisfied with the treatment. No significant differences could be detected between groups according to the results in any of the assessed parameters.

CONCLUSION

Early dynamic functional bracing in patients with ATR treated with modified closed percutaneous repair under local anesthesia resulted in earlier functional recovery with similar final results in terms of complications and functional outcomes, such as rigid postoperative immobilization with standardized rehabilitation and weight-bearing protocol.

LEVEL OF EVIDENCE

I, Prospective randomized study.

Lateral plantar fasciopathy: An frequently overlooked cause of atraumatic pain at the fifth metatarsal base

BACKGROUND

Lateral cord plantar fasciitis (LCPF) causes atraumatic pain at the fifth metatarsal base. This study assesses the outcomes of a conservative treatment (PRP + casting) on LCPF.

METHODS

Medical history, clinical diagnosis, and ultrasound imaging were used to determine LPCF. All patients received a leucocyte-poor PRP injection at the proximal part of the fifth metatarsal base, followed by three weeks in a walking cast. Follow-up questionnaires, encompassing NRS, AOFAS, and Foot Functioning Index (FFI), were administered at 6 weeks, 12 weeks, and 2 years post-treatment.

RESULTS

Ten patients were enrolled in the study. Ultrasound findings revealed hyposonant and thickened lateral fascia plantaris at the MT 5 insertion point with normal peronei tendons. There was a notable reduction in pain from pre-treatment (NRSrest 55.1 ± 29.6, NRSactivity 79.20 ± 15.5) to 6 weeks post-treatment (NRSrest: 22.4 ± 23.6, p = 0.03; NRSactivity: 38.6 ± 30.3, p = 0.005). FFI indicated an improvement between 12 weeks (25.7 ± 25.7) and 2 years (9.1 ± 8.5) compared to pre-treatment (42.6 ± 16.7).

CONCLUSION

Ultrasound stands out as the preferred diagnostic method for identifying LCPF. A PRP injection followed by a walking cast proves effective in relieving LCPF symptoms within six weeks with sustained relief up to two years.

LEVEL OF EVIDENCE

Level IV.

Postural Stability and Pedobarography After Reconstruction of Peroneus Brevis Tendon Split Lesion

PURPOSE

Lesions of the peroneal tendons are frequently overseen after ankle sprain. The symptoms consist of stress-dependent pain that extends from the inframalleolar to the proximal part along the course of the peroneal tendons as well as ankle instability and soft-tissue swelling. In case of unsuccessful conservative treatment, surgical therapy is recommended. The aim of the study was to evaluate the clinical and functional outcome after open reconstruction of the peroneus brevis tendon.

METHODS

13 patients were included in this retrospective study. All of them received a single reconstruction of the peroneus brevis tendon in open technique. Postoperative results were evaluated with the AOFAS score, a functional and perdobargraphic analysis as well as measuring postural stability with the Biodex balance system. The participants were matched with a healthy control group according to age, sex and BMI.

RESULTS

The results of the AOFAS score showed significantly convincing results in all subscores postoperatively. A bilateral comparison of the postural stability showed that the affected side had become functionally similar to the healthy side. No statistical significant difference was detected concerning both one-legged and two-legged standing with the control group. Pedobarographic results revealed no difference between the affected and contralateral side, as well as between the patients and the healthy control group.

CONCLUSION

Open reconstruction of the peroneus brevis tendon leads to significant better postoperative results and can be recommended after unsuccessful conservative treatment as promising option.

Use of computer-assisted hexapod external fixators for complex foot and ankle reconstructions - An analysis of functional outcomes and complications

INTRODUCTION

Foot and ankle pathology can often require complex surgical reconstruction. Until recently, circular external fixators such as the Ilizarov frame have proven to be useful, yet they fall short when progressive, precise corrections are required. Computer-assisted hexapod external fixators seek to address many of the shortfalls of traditional circular fixators. However, evidence for their use is scarce. The objective of this work was to evaluate the functional and quality of life outcomes and post-operative complications of patients treated with computer-assisted hexapod external fixation.

METHODS

A retrospective, observational study was conducted. All cases were treated with either a TrueLok hex (TL-HEX) or a Taylor Spatial Frame (TSF) fixator. Primary outcomes were post-operative improvement in 12-Item Short Form Survey (SF12) and American Orthopaedic Foot and Ankle Score (AOFAS) scores, and complications following Paley's classification.

RESULTS

A total of 59 patients with complex foot and ankle conditions using 64 external fixation frames were included. The median sum of both SF12 score domains improved from a preoperative score of 63.6 to 91.3 at last follow-up (p < 0.001). Median AOFAS improved from a preoperative score of 35 to 75.5 at last follow up (p < 0.001). Functional improvement was not affected by the choice of external fixator. Complications occurred in 49 cases (77 %). The most common post-operative complications included pin tract complications in 37 (58 %) cases, joint rigidity in 24 (38 %) and axial deviation in 9 (14 %).

CONCLUSIONS

Computer-assisted hexapod external fixation is an effective technique to correct complex foot and ankle deformities and leads to a marked improvement in post-operative functional and quality-of-life outcomes with a high minor complication rate.

Robot-assisted internal fixation of calcaneal fractures versus conventional open reduction internal fixation: a systematic review and meta-analysis

The aim of the study was to compare the efficacy and safety of robot-assisted (RA) percutaneous hollow screw fixation with traditional open reduction internal fixation (ORIF) for the treatment of calcaneal fractures through a systematic review and meta-analysis. An extensive search was conducted in the following databases-PubMed, CNKI, Embase, and the Cochrane Library-to gather research on patients with calcaneal fractures published up to July 2024. This search focuses on studies comparing the effectiveness of robot-assisted percutaneous cannulated screw fixation versus ORIF. We will include studies published in both English and Chinese. Our screening process adhered strictly to predefined inclusion and exclusion criteria, emphasizing randomized controlled trials (RCTs) and cohort studies. The ROBINS-I tool was utilized to evaluate the risk of bias in non-randomized studies. Meta-analysis was conducted using Review Manager 5.4.1. The final analysis incorporated six retrospective cohort studies comprising 247 patients-122 treated with robotic-assisted percutaneous cannulated screw fixation and 125 with conventional open reduction and internal fixation. The findings indicated that patients undergoing robotic-assisted percutaneous cannulated screw fixation experienced advantages over those receiving conventional treatment in terms of reduced hospital stay, lower estimated blood loss, and higher AOFAS scores at both 3 and 6 months. No statistically significant differences were observed between the two methods concerning operative time, fracture healing duration, or the frequency of intraoperative fluoroscopies. Robotic-assisted percutaneous cannulated screw fixation is a safe and viable treatment approach for patients with calcaneal fractures. When compared to ORIF methods, this robotic-assisted technique demonstrated significant benefits, including reduced hospital stay, lower estimated blood loss, and improved AOFAS scores at both 3 and 6 months.

Autologous osteoperiosteal transplantation for cystic osteochondral lesions of the talus: Bone reconstruction is essential

PURPOSE

Autologous osteoperiosteal transplantation (AOPT) is one of the most feasible and effective techniques for cystic osteochondral lesions of the talus (OLT). However, few reports have been reported about the process of graft-host bone healing and bone articular surface reconstruction, which help us to further understand the actual situation of bone healing and modify surgical methods.

METHODS

We retrospectively evaluated 33 osteochondral lesions in 30 patients undertaking AOPT for OLT with subchondral cysts from December 2016 to October 2021. According to CT observation, we used 4 variables to describe the bony articular repair, including the integration of the articular surface, the height of the bone filling, the status of bone union, and the appearance of bone resorption or cystic change. We also analyzed the demographic data and clinical function. Descriptive statistics were used for demographic and clinical variables. Normally distributed data were presented as mean ± SD, and non-normally distributed data were presented as median (Q1, Q3). Associations between these variables and the primary clinical outcomes were examined using t-test or one-way ANOVA test for continuous variables.

RESULTS

The patients' mean age was (41.7 ± 14.0) years old and the mean follow-up time was (29.6 ± 17.8) months. The chondral lesion size was (14.3 ± 4.1) mm. The cyst depth was (10.9 ± 3.7) mm. Significant improvements were observed in functional outcomes (according to the numeric rating scale for pain when walking and the American orthopedic foot and ankle society score) between the preoperative and latest follow-up evaluations, from 4.2 ± 2.1 to 2.2 ± 2.0 (p < 0.001), and from 66.8 ± 12.9 to 83.2 ± 10.4, respectively (p < 0.001). The overall satisfaction reached 8.3 of 10 points. All patients returned to sports and their median daily steps reached 8000 steps with 27 (81.8%) patients walking over 6000 steps daily. According to CT observation, "discontinuous bony articular surface and gap > 1 mm" was found in 27 grafts (81.8%), and "below the level of the adjacent articular surface, ≤ 1 mm" in a third of the grafts. Abnormal height of bone filling affected numeric rating scale score (p = 0.049) and American Orthopedic Foot and Ankle Society score (p = 0.027). Of note, bone resorption or cystic changes appeared in up to 13 autografts (39.4%).

CONCLUSIONS

AOPT is an effective and acceptable technique for cystic OLT. Bone reconstruction is essential for large cystic OLT. How to get better bony articular reconstruction and avoid cyst recurrence should still be paid more attention.

Arthrodesis using Iliac Crest autograft in revision surgery of the first metatarsophalangeal joint total arthroplasty for the treatment of Hallux Rigidus: a retrospective study

PURPOSE

The treatments for hallux rigidus (HR) encompass a wide spectrum, including conservative methods and surgical approaches such as arthroplasty and arthrodesis. This study aims to evaluate the outcomes of revision with arthrodesis following the failure of the first metatarsophalangeal joint total arthroplasty (MTPJ1TA).

MATERIALS AND METHODS

Patients who had surgery at two advanced orthopedic centers between January 1, 2020, and January 1, 2024, were reviewed. Those with at least 6 months of postoperative follow-up were assessed for demographics (gender, age, side), reoperation rates, complications, Visual Analogue Scale (VAS) scores, Foot and Ankle Disability Index (FADI) scores, and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal and Interphalangeal Scale (AOFAS-HMI) scores. Radiological evaluations included hallux valgus angle (HVA), intermetatarsal angle (IMA), dorsiflexion angle (DFA), and first ray length (FRL) in anteroposterior and lateral views.

RESULTS

Of 27 patients, 4 were male (15%) and 23 female (85%), with an average age of 56.18 ± 7.49 years (range 41-72). Arthrodesis was performed in 26 patients, with one requiring reoperation due to implant failure. Average VAS scores were 7.14 preoperatively and 3.55 postoperatively (p < 0.05). Average FADI scores were 50.51 preoperatively and 71.51 postoperatively (p < 0.05). Average AOFAS-HMI scores were 51.22 preoperatively and 70.59 postoperatively (p < 0.05). Average HVA was 19.7° preoperatively and 6.29° postoperatively (p < 0.05). Average IMA was 10.66° preoperatively and 11.37° postoperatively (p = 0.406). Average DFA was 34.14° preoperatively and 22.33° postoperatively (p < 0.05). Average anteroposterior FRL was 10.17 cm preoperatively and 10.77 cm postoperatively (p < 0.05). Average lateral FRL was 10.12 cm preoperatively and 10.42 cm postoperatively (p < 0.05). None of the patients in the study exhibited postoperative donor site complications or transfer metatarsalgia, while a 100% rate of bone union was observed.

CONCLUSION

We think that revision of MTPJ1TA with arthrodesis is a safe treatment option. Additionally, the use of an iliac crest autograft can be a viable option to restore bone stock and create a biological environment conducive to fusion. This study evaluates revision surgery with arthrodesis in the largest patient group with failed MTPJ1TA, highlighting its significance in the field. However, further studies are needed to determine the ideal surgical procedure.

Which type of supra-syndesmal fractures Weber C or Equivalent Weber C have the best reduction of the distal tibio-fibular syndesmosis? A prospective CT-scan investigation on 60 ankles

INTRODUCTION

The reduction of the distal tibiofibular syndesmosis (SyTFd) is a crucial factor in the functional prognosis following a suprasyndesmotic ankle fracture. Few studies have compared, using computed tomography (CT), the quality of SyTFd reduction in Weber C ankle fractures (WebC) and Equivalent Weber C (EqWebC) fractures, where there is a medial ligament injury instead of a bony malleolar lesion. This CT-based study aimed to answer the following questions: (1) Do Weber C fractures allow for better reduction of the distal tibiofibular syndesmosis compared to Equivalent Weber C fractures? (2) Are the functional outcomes one year postoperatively better for Weber C fractures compared to Equivalent Weber C fractures?

HYPOTHESIS

The hypothesis was that WebC fractures would present better reduction of the SyTFd than EqWebC fractures due to the restoration of bone anatomy, considering the bony nature of the medial ligament involvement.

MATERIALS AND METHODS

Since December 2021, all patients presenting with an ankle fracture were included in a database. Suprasyndesmotic fractures were extracted, and between December 2021 and February 2022, 60 patients underwent surgery for a suprasyndesmotic fracture (28 WebC - 32 EqWebC). All patients were operated on using the same technique and underwent a postoperative bilateral CT scan in axial slices with both ankles in a neutral position (foot at 90 ° to the leg). An analysis of 8 measurements was performed under the same conditions. Each fractured ankle was compared to the healthy contralateral ankle, and a delta was obtained for each measurement. The follow-up was standardized. At one year, an AOFAS Score and a Maryland Foot Score (MFS) were recorded. Statistical differences between the two groups were measured using the Student's t-test and Chi-square test.

RESULTS

There was a significant difference between the WebC and EqWebC groups for clinical scores at one year postoperatively: AOFAS: 92.0 ± 6.3 [78-100] vs. 80.1 ± 5.4 [62-100], p < 0.05; MFS: 90.9 ± 6.4 [78-100] vs. 81.6 ± 5.2 [64-100], p < 0.05. CT scan analysis of the SyTFd reduction found significantly better reduction in the WebC group.

DISCUSSION

WebC fractures showed better clinical scores associated with better SyTFd reduction on postoperative CT scans. The anatomical reduction related to the bone reduction criteria during surgery could explain our findings.

LEVEL OF EVIDENCE

III; Case-Control Comparative Study.

Ilizarov Distraction for Congenital Pseudoarthrosis of the Tibia in Adults

OBJECTIVE

The clinical evidence on the management for congenital pseudoarthrosis of the tibia (CPT) in adults is limited. The aim of this study is to assess the functional and radiological outcomes of Ilizarov distraction for treating CPT in adults.

METHODS

A retrospective analysis was conducted. Between 2013 and 2022, an Ilizarov distraction technique was performed on 14 adults (14 limbs) with CPT in our limb deformity center. There were seven females and seven males with a mean age of 33.7 (range, 18 ~ 53) years. The diagnosis of NF-1 was confirmed in seven (50.0%) patients. Eight patients had a history of previous surgical failure. The pseudoarthrosis occurred in the middle and lower tibia in all limbs (six left and eight right). The CPT was classified by Crawford classification and Paley classification. The surgical procedures, external fixation time (EFT), and all outcomes and complications were recorded. The Kolmogorov-Smirnov test was performed to test the normality of the data. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score at the preoperative and final follow-up was compared by using the Wilcoxon's signed-rank test. The limb-length discrepancy (LLD) and a self-made exercise capacity score at the preoperative and final follow-up were compared by using the student's t-test. The clinical and radiological outcomes were assessed by the Inan scale.

RESULTS

The mean EFT of Ilizarov fixator was 19.5 months (range, 7.3 ~ 39.1). At a median follow-up of 26.8 months (IQR, 20.2 ~ 34.3), bone union of the pseudarthrosis and consolidation of the distraction zone were achieved in all patients. The mean LLD was decreased from 11.3 cm (range, 3.4 ~ 17.3) preoperatively to 1.1 cm (range, 0.3 ~ 3.7) (p < 0.05). The mean or median AOFAS ankle-hindfoot score was improved from 53.5 (IQR, 26.5 ~ 60.5) preoperatively to 63.9 (range, 53 to 73) at final follow-up (p < 0.05). The mean score for exercise capacity were improved from 4.9 (range, 1 to 8) preoperatively to 9.6 (range, 7 ~ 12) at final follow-up (p < 0.05). According to the criteria described by Inan et al., the clinical results were classified as good in 10 and fair in 4, while the radiological results were classified as excellent in three, good in 8, and fair in 2. The success rate was 92.9%, as refracture was defined as treatment failure and occurred in one patient.

CONCLUSION

Ilizarov distraction provided a suitable treatment option for the CPT in adults, as it could achieve a high rate of bone union, a good correction of secondary deformity, a low risk of refracture, and consequently restore a relatively functional limb.

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates

INTRODUCTION

Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR.

MATERIALS AND METHODS

A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity).

RESULTS

The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%.

CONCLUSIONS

Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

Three dimensional analysis of factors affecting the prognosis of calcaneal fractures

PURPOSE

Analyzing the correlation between patients' basic information, three-dimensional parameters after calcaneal fractures, and the prognosis of calcaneal fractures.

METHODS

A retrospective analysis was conducted on 43 patients with calcaneal fractures who underwent surgical treatment in the Foot and Ankle Surgery, Xi'an Honghui Hospital, from September 2019 to August 2022. Patient demographics including gender and age were collected, as well as the preoperative posterior articular surface collapse area, number of fracture fragments, length, width, height, and volume of the calcaneus obtained from preoperative three-dimensional imaging. Patients were followed up for VAS, AOFAS, and SF-36 scores. Correlation analysis was performed on the obtained data.

RESULTS

All 43 included patients received complete follow-up, including 40 males and 3 females, with an average follow-up time of 35.37 ± 10.73 months, and an average age of 43.98 ± 12.08 years. All patients' VAS, AOFAS, and SF-36 scores at the last follow-up showed no correlation with patient age, gender, or the area of posterior articular collapse, number of fracture fragments, length, width, height, or volume of the calcaneus.

CONCLUSIONS

The prognosis of calcaneal fractures is unrelated to three-dimensional factors such as patient age, gender, length, width, height, volume of the calcaneus, area of the posterior joint, and number of fracture fragments.

Prone position fibula nail and tibia buttress plate for large Volkmann fracture-dislocations technical note and preliminary results on a short case series

Large posterolateral tibial fragments, known as Volkmann fractures, are common in ankle fracture-dislocations and typically require open reduction and fixation with interfragmentary screws and often buttress plates using a prone posterolateral approach. In this setting, fibula plating often necessitates dissection of the lateral window between the peroneal tendons and the skin, increasing wound-related complications. In recent years, intramedullary nailing of fibula fractures has gained popularity as a minimally invasive technique that allows load-sharing stabilization. However, this procedure has traditionally been performed in the supine position, which can pose challenges if a Volkmann-type fracture is present, requiring repositioning and losing access to the fibula through the posterolateral approach. Our objective is to describe a technique for fixing ankle fracture-dislocations with large posterolateral fragments using tibial buttress plates and fibula nails through a prone posterolateral approach without dissecting the lateral window. Additionally, we will present a case series with preliminary results.

Surgical treatment for medium-sized cystic osteochondral lesions of the talus: Autologous osteoperiosteal transplantation provides better clinical outcomes than bone marrow stimulation when cysts are deeper than 6 mm

PURPOSE

To compare clinical outcomes of autologous osteoperiosteal transplantation versus bone marrow stimulation (BMS) for medium-sized (100-150 mm2) cystic osteochondral lesions of the talus (OLTs) and assess the correlation between patient demographics and outcomes. It was hypothesised that autologous osteoperiosteal transplantation would provide better clinical outcomes than BMS for medium-sized cystic OLTs.

METHODS

Patients who underwent autologous osteoperiosteal transplantation or BMS for medium-sized cystic OLTs between 2014 and 2019 were retrospectively evaluated. According to their characteristics, a 1:1 propensity-score matching was performed and 33 pairs of patients were matched. The visual analogue scale, American Orthopaedic Foot and Ankle Society (AOFAS) score, Foot Ankle Outcome Score (FAOS) and Ankle Activity Score were collected preoperatively and at the last follow-up. In addition, a general linear model analysis was performed between patient demographics and clinical outcomes in two groups separately to detect potential risk factors.

RESULTS

Finally, 28 patients in the grafted group and 27 patients in the BMS group completed the follow-up and were enrolled with a mean follow-up period of 63.5 ± 13.9 months. Both groups showed significant improvement in all patient-reported outcomes (p < 0.01). At the final follow-up, no significant differences between groups were found in all postoperative scores except FAOS Pain (p = 0.02). Correlation analysis showed a moderate correlation between cyst depth and the postoperative AOFAS score in the BMS group (r = -0.48, p = 0.01). Based on the regression line, the patients in the BMS group with a cyst deeper than 6 mm showed a lower AOFAS score than the mean score (88.7 ± 9.5) of the grafted group.

CONCLUSION

Autologous osteoperiosteal transplantation and BMS are both safe and effective for medium-sized cystic OLTs. However, autologous osteoperiosteal transplantation is expected to provide better clinical outcomes than BMS when the cysts are deeper than 6 mm.

LEVEL OF EVIDENCE

Level III.

Validity and Reliability of the American Orthopaedic Foot and Ankle Society Score for the English-Literate Singapore Population With Hallux Valgus

BACKGROUND

This study aimed to evaluate the reliability and validity of the American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) score in patients with hallux valgus in Singapore.

METHOD

A total of 121 English-literate patients with hallux valgus identified between October 2017 and May 2020 were analyzed. Reliability was assessed via Cronbach α. Construct validity was evaluated through 20 a priori hypotheses by correlating the AOFAS MTP-IP score for hallux and lesser toes with other patient-reported outcome measures (PROMs). Standardized response means (SRMs) were calculated to evaluate responsiveness at 6 months postoperative. Structural validity was evaluated via confirmatory factor analysis (CFA) whereby a good fit was indicated when comparative fit index (CFI) is >0.95, Tucker-Lewis index (TLI) is >0.95 and standardized root mean residual (SRMR) is <0.08.

RESULTS

The AOFAS MTP-IP score demonstrated reliability with a Cronbach α of 0.837. Convergent construct validity was confirmed when all a priori hypotheses were fulfilled. Structural validity was established with our AOFAS MTP-IP score model that displayed good fit for a 1-factor structure (CFI = 0.988, TLI = 0.960, SRMR = 0.034). Responsiveness of the AOFAS MTP-IP score for hallux was demonstrated by an SRM score of 1.28.

CONCLUSION

The AOFAS MTP-IP score displayed adequate reliability and validity among English-literate patients in Singapore with an operatively managed hallux valgus.

LEVEL OF EVIDENCE

Level III: Retrospective cohort study.

Syndesmotic screws, unscrew them, or leave them? A systematic review and meta-analysis of randomized controlled trials

Background

Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.

Methods

A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.

Results

Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.

Conclusion

Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.

Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study

INTRODUCTION

The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails.

MATERIALS AND METHODS

This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated.

RESULTS

Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each.

DISCUSSION

DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results.

CONCLUSIONS

DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.

Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique

OBJECTIVE

Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP.

METHODS

Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated.

RESULTS

The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P <0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters.

CONCLUSION

Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Modified Bösch Osteotomy Combined With a Percutaneous Adductor Tendon Release for the Treatment of Hallux Valgus Deformity: Learning Curve

PURPOSE

The expression "learning curve" indicates the relation between the time needed to learn a new technique and the technique-related outcome. Percutaneous surgery (also called "minimally invasive surgery") has experienced sustained and respectable growth, especially in forefoot deformities. The main purpose was to assess the number of feet necessary to become skilled in a specific minimally invasive surgery (MIS) procedure.

METHODS

From January 2015 to June 2018, 46 consecutive patients were evaluated and included in the study. Patients were divided into 2 groups according to the surgery period: first 30 feet (Group 1), and subsequent 30 feet (Group 2) from the whole population evaluated. Age, body mass index, and operative time were evaluated. Hallux valgus angle and the 1 to 2 intermetatarsal angle were also measured. Patients were assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) forefoot scale, the Foot and Ankle Ability Measure activities of daily living (FAAM ADL) subscale and the visual analog scale (VAS).

RESULTS

The comparison of the 2 groups showed statistically significant differences in hallux valgus angle (HVA) but not in intermetatarsal angle (IMA). The mean improvement between pre- and postoperative FAAM ADL, VAS, and AOFAS score in Group 1 were 12.83, 3.93, and 24.77 points, respectively. In Group 2, the mean improvement between pre- and postoperative FAAM ADL, VAS, and AOFAS scores were 15.19, 4.3, and 24.5 points, respectively. The differences between groups in FAAM ADL score was statistically significant (P = 0.0364). Group 1 showed a global complication rate of 16.67% (n = 5) while group 2 showed 3,3% (n = 1).

CONCLUSION

After the first 30 cases, radiographic, clinical, and functional outcomes substantially improved, and the level of the perioperative complications decreased. The results suggest that the learning curve plateau for performing a percutaneous subcapital osteotomy can be reached after 30 surgeries.

LEVELS OF EVIDENCE

Level III.

Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials

BACKGROUND

Intramedullary nail (IMN) and plate fixation are the most commonly used surgical modalities for distal tibia fractures. However, the superiority of their efficacy regarding functional outcomes and complications remains controversial. Here, we performed a systematic review and meta-analysis to compare the efficacy of these two modalities.

METHODS

Randomized controlled trials (RCTs) comparing the efficacy of IMN and plate fixation in distal tibia fractures were searched in PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Library up to January 31, 2024. Weighted mean difference (WMD) and odds ratio (OR) with corresponding 95% confidence interval (CI) were estimated using a random-effect model for continuous and categorical outcomes, respectively.

RESULTS

A total of 20 RCTs comprising 1528 patients were included. Compared with plate fixation, IMN significantly shortened surgery time (WMD=-10.73 min, 95%CI: -15.93 to -5.52), union time (WMD=-1.56 weeks, 95%CI: -2.82 to -0.30), and partial (WMD=-1.71 weeks, 95%CI: -1.91 to -0.43) and full (WMD=-2.61 weeks, 95%CI: -3.53 to -1.70) weight-bearing time. IMN was associated with markedly reduced risk of wound infection (OR = 0.44, 95%CI: 0.31-0.63) and secondary procedures (OR = 0.72, 95%CI: 0.55-0.95), but increased the risk of malunion (OR = 1.53, 95%CI: 1.02-2.30) and anterior knee pain (OR = 3.94, 95%CI: 1.68-9.28). The rates of nonunion, delayed union, and functional assessment scores did not significantly differ between the two groups. The percentages of patients obtaining an excellent functional outcome or an excellent and good functional outcome post-operation were comparable.

CONCLUSIONS

Both IMN and plate fixation are effective modalities for the surgical treatment of distal tibia fractures. IMN seems to be preferred since it confers more advantages, but the elevated rates of malunion and knee pain require attention. The decision on fixation modality should be tailored to the specific fracture, considering these pros and cons.

Dorsal Metatarsal Closed Wedge Osteotomy in the Treatment of Freiberg's Disease: A Prospective Observational Study

The aim of this study was to prospectively evaluate the clinical and radiological results of dorsal metatarsal closed wedge osteotomy and headless screw fixation in the surgical treatment of Freiberg's disease.Thirty-four patients who were treated with dorsal metatarsal closed wedge osteotomy (DMCWO) for Freiberg's disease between February 2018 and March 2022 were included in the study. Patients were staged according to the classification system described by Smillie. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society's (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the visual analog scale (VAS), the range of motion (ROM) of the metatarsophalangeal (MTP) joint, and a subjective patient satisfaction questionnaire. For radiological evaluation, the amount of preoperative shortening of the involved metatarsal, the amount of metatarsal shortening developed after osteotomy, and radiological recovery times were recorded.Thirty-two (94.1%) of the patients were female, and two (5.9%) were male. The average postoperative follow-up period for patients was 33.7 months (range: 24 months to 41 months). The mean AOFAS scores increased from 53.24 to 86.26 (p < 0.01). The mean VAS scores decreased from 8.59 to 1.79, and it was observed that the patients' pain improved significantly (p < 0.01). The mean ROM of the MTP joint increased from 48.76 degrees to 70.76 degrees (p < 0.01). An average of 2.5 mm (range 1 mm to 4.1 mm) of shortening of the metatarsal length developed postoperatively (p < 0.01). Arthrosis developed in 1 case (2.9%), and transfer metatarsalgia developed in 2 cases (5.8%).DMCWO is an effective treatment for both the early and advanced stages of symptomatic Freiberg's disease, leading to high patient satisfaction.

Osteosynthesis using a plate lacking the anterior component and canulated cancellous screws to treat an avulsion fracture of the calcaneal tuberosity: A case report

INTRODUCTION

Avulsion fractures of the calcaneal tuberosity with significant displacement can cause soft tissue complications in the heel. However, a treatment strategy for calcaneal tuberosity fractures with poor heel-skin condition is yet to be established. Here, we report a case involving avulsion fracture of the calcaneal tuberosity presenting with superficial skin necrosis that was treated with a plate lacking the anterior component and screws inserted percutaneously.

PRESENTATION OF CASE

A 74-year-old woman presented with progressive right heel pain following an injury to her heel sustained approximately six weeks previously. She had experienced difficulty walking due to heel pain and superficial necrosis was observed on the posterior surface of the heel. Radiography and computed tomography revealed an avulsion fracture of the calcaneal tuberosity with superior displacement. Open reduction was performed using a lateral L-shaped incision. After inserting two cancellous screws percutaneously into the calcaneal tuberosity, we fixed a plate lacking the anterior component to the lateral surface of the calcaneus. The superficial necrosis healed gradually post-operatively. Bone union was confirmed using radiography six months post-operatively.

DISCUSSION

We developed a novel surgical procedure to treat avulsion fractures of the calcaneal tuberosity with poor skin condition. The combination of a plate lacking the anterior component and the percutaneous insertion of canulated cancellous screws can reduce the risk of post-operative soft tissue complications while maintaining fixation of the fractured fragment.

CONCLUSION

Our findings provide a novel surgical method for the treatment of avulsion fractures of the calcaneal tuberosity with soft tissue complications.

Minimally invasive Chevron-Akin (MICA) osteotomies without Akin fixation in hallux valgus correction: a case series with 2-year follow-up

PURPOSE

The minimally invasive Chevron-Akin (MICA) is considered the third generation of minimally invasive hallux valgus (HV) surgery, and its original description included fixation of the Akin osteotomy with a screw. The aim of this study is to evaluate a series of patients undergoing HV correction using the MICA technique without screw fixation of the Akin osteotomy.

METHODS

We retrospectively evaluated 58 consecutive patients who underwent surgical correction for HV between August 2018 and March 2020. A total of 69 feet were evaluated with a minimum follow-up of 2 years. Clinical outcomes such as pain (VAS), function (AOFAS), range of movement, criteria personal satisfaction and complications were evaluated.

RESULTS

The AOFAS score (mean ± standard deviation) significantly improved from 57.0 ± 8.6 preoperatively to 93.9 ± 8.7 postoperatively (p < .001) with a minimum follow-up of 2 years. The VAS score improved from 6.0 ± 1.8 preoperatively to 0.6 ± 1.4 at 2-year follow-up (p < .001), and the hallux valgus angle reduced from 39.7 ± 6.9 to 8.9 ± 9.0 (p < .001). The majority of patients (95.6%) reported the result as excellent or good, and the most common complication was the need to remove the screw (7.2%).

CONCLUSIONS

The use of MICA without Akin osteotomy fixation resulted in successful correction of hallux valgus with improvements in clinical and radiographic parameters.

LEVEL OF EVIDENCE

IV, case series.

Primary Isolated Arthrodesis of the First Metatarsophalangeal Joint for Hallux Rigidus: Clinical, Radiologic, and Pedobarographic Evaluation

Background

Arthrodesis of the first metatarsophalangeal joint is an effective treatment of advanced hallux rigidus. Numerous options have been described for performing this intervention. The aim of this study was to evaluate the outcomes following a consistent surgical technique of joint preparation with hand tools and fixation with 2 crossed screws and a dorsal compression plate.

Methods

Thirteen patients (16 feet) who underwent primary isolated arthrodesis of the first metatarsophalangeal joint between March 2019 and June 2021 were available for clinical, radiologic, and pedobarographic evaluation at a minimum of 12 months after surgery. American Orthopaedic Foot & Ankle Society scores, numerical pain rating scale, the radiologic hallux valgus and intermetatarsal 1-2 angles as well as the distribution of plantar pressure during gait were compared between the pre- and postoperative conditions.

Results

After an average follow-up period of 26 months, union was achieved in all cases and the mean AOFAS score raised significantly by 39 points. All the patients were satisfied with the result. Only 1 patient complained of mild residual pain at walk. Hardware removal was performed in 2 cases. The mean hallux valgus angle dropped from 12.3 to 6.3 degrees. The mean postoperative dorsiflexion angle was 21.6 degrees. After the procedure, peak pressure was significantly higher beneath the first metatarsal head and heel, whereas pressure-time integral was significantly lower beneath the hallux and medial lesser toes.

Conclusion

Arthrodesis of the first metatarsophalangeal joint with 2 crossed screws and a dorsal compression plate is a safe and effective treatment of advanced hallux rigidus. This procedure provides adequate pain relief and functional improvement of gait.

Level of Evidence

Level IV, therapeutic, retrospective case series.

Validity and reproducibility of the ARL-RSI score to assess psychological readiness before returning to sport after lateral ankle sprain

Purpose

Although multiple scales exist to evaluate psychological readiness before returning to sport post-lateral ankle sprain (LAS), no score has been validated specifically for LAS or chronic ankle instability. The main aim of the study is to evaluate the validity and reproducibility of the ankle ligament reconstruction-return to sport injury (ALR-RSI) scale in assessing psychological readiness after LAS and its ability to identify patients who can return to their preinjury level.

Methods

A total of 64 patients (35 females and 29 males; 33.8 ± 13.2 years) who recently experienced an acute LAS were included in this study. All patients participated in a predictive validation component of the study and were assessed at 2 and 4 months following an LAS. The ALR-RSI was completed twice by 20 patients at a 7-day interval to evaluate the reliability of the score in patients suffering from LAS.

Results

The ALR-RSI was significantly (p < 0.001) and positively correlated with the other scores. The correlation was strong with the Foot and Ankle Ability Measure Sports: r = 0.77; 95% confidence interval [CI]: 0.78-0.83) and moderate with the American Orthopaedic Foot and Ankle Society (r = 0.69; 95% CI: 0.60-0.78) and the Foot and Ankle Ability Measure Activities of Daily Living Scores (r = 0.63; 95% CI: 0.51-0.72). Two-month ALR-RSI scores had good ability for predicting nonreturners at 4 months (area under the curve = 0.76; 95% CI: 0.6-0.9; p = 0.005). A Youden index of 0.51 was observed at an ALR-RSI score of 46%, corresponding to a sensitivity of 67% and specificity of 83%. Test-retest reliability of the ALR-RSI was excellent, with an ICC of 0.98 (95% CI: 0.96-0.99), a standard error of measurement of 3.02% and a minimum detectable change of 8.37%.

Conclusions

The results of the current study validated the ALR-RSI as an important questionnaire to assess psychological readiness to return to sport after LAS.

Level of Evidence

Level II prospective cohort study.

Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus surgery

INTRODUCTION

The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery.

METHODS

551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: (1) non-frail: patients without any of the 5 comorbidities, (2) pre-frail: patients with one comorbidity and (3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded.

RESULTS

In the study period 772 percutaneous surgeries were performed to correct hallux valgus deformity, 551 patients were included with a median age of 60 (IQR 48-70). 389 patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (p=0.11). Frailty patients had worse AOFAS scores at final follow up (p=0.011).

CONCLUSION

The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Long-term donor site outcome after second toe transfer for congenital hand differences

This study evaluates the long-term donor site outcomes after second toe transfers for congenital hand differences performed during childhood. In total, 25 toe transfers in 18 patients were followed up for a mean period of 17.4 years. We examined the patients clinically, radiologically and with a gait analysis system. Patient-reported outcome measures were collected. The patients were asymptomatic and there were no problematic clinical or radiological findings. Patients expressed high levels of satisfaction. The results were consistent, regardless of the resection level in the toe transfer or whether the operation was unilateral or bilateral. No postoperative complications or late reoperations on the foot were observed.Level of evidence IV.

Effects of tendon elongation on plantar pressure and clinical outcomes: A comparative analysis between open repair and minimally invasive surgery

PURPOSE

The aim of this study was to assess whether variances in Achilles tendon elongation are linked to dissimilarities in the plantar pressure distribution following two different surgical approaches for an Achilles tendon rupture (ATR).

METHODS

All patients who were treated with open or minimally invasive surgical repair (MIS) and were over 2 years post their ATR were eligible for inclusion. A total of 65 patients with an average age of 43 ± 11 years were included in the study. Thirty-five patients were treated with open repair, and 30 patients were treated with MIS. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and ATR Score (ATRS). Achilles tendon elongation was measured using axial and sagittal magnetic resonance imaging scans. Plantar pressure measurements for the forefoot, midfoot and hindfoot during gait were divided into percentages based on total pressure, measured in g/cm2 for each area.

RESULTS

The average AOFAS score was found 'excellent' (93 ± 2.8) in the MIS group, while it was found 'good' (87.4 ± 5.6) in the open repair group. In addition, the MIS group showed significantly superior ATRS scores (78.8 ± 7.4) compared to the open repair group (56.4 ± 15.4) (p < 0.001). The average tendon elongation in the MIS group was 11.3 ± 2 mm, while it was 17.3 ± 4.3 mm (p < 0.001) in the open repair group. While the open repair group showed significantly higher plantar pressure distribution in the initial contact and preswing phases compared to uninjured extremities, there was no significant difference between the uninjured extremities and the MIS group.

CONCLUSION

In conclusion, the findings of this study demonstrated that minimally invasive surgery was associated with less tendon elongation, more proximity to the plantar pressure distributions of the uninjured extremity and superior clinical outcomes compared to open surgical repair. Therefore, minimally invasive surgery may be considered a more suitable option for acute Achilles tendon repair to achieve overall better outcomes.

LEVEL OF EVIDENCE

Level III.

Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus percutaneous surgery

INTRODUCTION

The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery.

METHODS

551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: 1) non-frail: patients without any of the 5 comorbidities, 2) pre-frail: patients with one comorbidity and 3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded.

RESULTS

In the study period 772 percutaneous surgeries were performed to correct HV deformity, 551 patients were included with a median age of 60 (IQR 48-70). Three hundred eighty-nine patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (P=.11). Frailty patients had worse AOFAS scores at final follow up (P=.011).

CONCLUSION

The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Comparison of instep and non-instep flap in the reconstruction of the weight-bearing portion of the forefoot and heel

BACKGROUND

Instep flaps are commonly used for the reconstruction of weight-bearing areas of the foot. However, in cases of large defects or damage to the instep area, non-instep flaps such as reverse sural flaps (RSF) or free anterolateral thigh flaps (ALTF) can be employed. Previous studies have primarily focused on heel reconstruction when comparing different flaps, without considering the forefoot. This study aims to verify the clinical outcomes of these flaps and determine the appropriate donor site for weight-bearing areas of the foot including forefoot reconstruction.

METHODS

In a retrospective study, 39 patients who had undergone flap reconstruction of weight-bearing area defects in the foot with a follow-up period of ≥1 year were included. The patients were categorized into two groups: Group A (n = 19) using instep flaps, and Group B (n = 20) using non-instep flap including RSFs and ALTFs. Surgical outcomes were assessed based on the success of the flap, the presence of partial necrosis, the number of additional surgeries, and complications related to the donor site. Clinical evaluation included visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score, and the occurrence of ulcers.

RESULTS

All flaps were successful, while partial necrosis occurred in one case in Group B. There were three reclosures after flap border debridement in both groups and one donor site debridement in Group A. The VAS scores during weight-bearing were 2.0 ± 1.1 and 2.2 ± 1.5 for Groups A and B, respectively (p = .716). The AOFAS scores were 52.8 ± 6.8 and 50.2 ± 12.7 for Groups A and B, respectively (p = .435). The occurrence of ulcers was 0.4 ± 0.9 times for Group A and 0.3 ± 0.7 times for Group B, with no significant difference between the two groups (p = .453).

CONCLUSION

There was no difference in clinical outcomes between the types of flaps after reconstruction of the forefoot and hindfoot. Therefore, it is recommended to choose the appropriate flap based on factors such as the size of the defect, its location, and vascular status rather than the type of flap.

Treatment of a Brodie's abscess manifesting as persistent pain after a twisting ankle injury: A case report

INTRODUCTION

Cystic lesions in long bones are the radiological presentation of various bone pathologies, they can easily be misdiagnosed and thus mistreated; treatment varies from observation to aggressive surgical interventions based on the nature and characteristics of the lesion.

CASE PRESENTATION

A 25-year-old male had a twisting injury to his ankle and his radiographs showed a cystic lesion in the distal tibia that was asymptomatic until he injured his ankle. he had persistent pain since then. and after conservative methods failure, a two-stage surgical intervention was done; first, we curetted the lesion and filled it with antibiotics cement; then the cement was removed with autologous bone grafting. The patient eventually healed and returned to his normal activity level.

DISCUSSION

Brodie's abscess has a similar radiological appearance to other bone neoplasms and tumor-like lesions. Clinically, it is minimally symptomatic, and often initially misdiagnosed; surgical treatment is very effective, but it depends on the size, location, and aggressiveness of the lesion; the goal is to eliminate the infection, refill the residual gap, and restore the normal function, especially in weight-bearing bones.

CONCLUSION

Brodie's abscess is a hideous lesion that is hard to diagnose. It could mimic other tumor-like lesions. However, applying bone cement and a second stage of bone grafting might help maximize the treatment efficiency.

Arthroscopic Resection of Symptomatic Ossicles of the Medial Malleolus Combined With Deltoid Ligament Repairs in Athletes: A Report of Three Cases

We report three cases of young athletes with symptomatic ossicles of the medial malleolus who underwent arthroscopic resections of the ossicle combined with deltoid ligament repair. A differential diagnosis of the ossicles beneath the medial malleolus, accessory ossification center, avulsion fracture resulting in pseudoarthrosis, and accessory bone such as os subtibiale has been proposed. However, it is difficult to differentiate them clearly. Most of these ossicles are asymptomatic, although they can cause chronic medial ankle pain, especially in young athletes who require surgical treatment. All three patients had pain in the distal part of the medial malleolus, which restricted their sports activities. Plain radiographs of all three cases revealed a well-defined, round-shaped bony lesion beneath the medial malleolus. Ultrasonographic imaging, magnetic resonance imaging, and arthroscopic findings revealed that ligament attachment to the ossicle varies in volume and type according to the cases. In other words, the mechanisms through which the existence of the ossicles affects the stability of the ankle joint and foot alignment are different in each case, indicating that deltoid ligament repair is necessary according to the cases. In all three cases, we performed arthroscopic resections of ossicles combined with deltoid ligament repairs, achieving favorable short-term clinical outcomes.

Peritendinous Submembrane Access Technique for Management of Acute Ruptures of the Achilles Tendon: A Retrospective Study of 249 Cases

OBJECTIVE

Percutaneous repair is an alternative to open surgical repair of the Achilles tendon with comparable, functional results and low re-rupture and infection rates; however, sural nerve injury is a known complication. The purpose of this study is to design a new surgical procedure, the minimally invasive peritendinous submembrane access technique (MIS-PSAT). It offers optimal results, with excellent functional outcomes, and with minimal soft tissue complications and sural nerve injury.

METHODS

This retrospective study included 249 patients with acute closed Achilles tendon ruptures treated at our institution between 2009 and 2019. All patients underwent MIS-PSAT at our institution and were followed up for 8-48 months. Functional evaluation was based on the Achilles tendon total rupture score (ATRS) and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS), associated with local complications and isokinetic tests.

RESULTS

None of the patients had infection, necrosis, or sural nerve injury. Re-rupture occurred in two cases. The average times to return to work and sports was 10.4 and 31.6 weeks, respectively. The average ATRS and AOFAS-AHS scores were 90.2 and 95.7, respectively, with an excellent rate of 99.5%. Isokinetic tests showed that ankle function on the affected side was comparable with that on the healthy side (p > 0.05).

CONCLUSION

The MIS-PSAT for acute Achilles tendon rupture is easy to perform with few complications. Importantly, the surgical technique reduces the risk of sural nerve injuries. Patients have high postoperative satisfaction, low re-rupture rates, and muscle strength, and endurance can be restored to levels similar to those on the healthy side.

External Versus Internal Fixation Techniques for Ankle Arthrodesis: A Systematic Review and Meta-analysis

Ankle arthrodesis is an effective surgical intervention for end-stage arthritis or severe ankle joint deformity. Both internal (IF) and external fixation (EF) techniques are valid options, but there is controversy regarding the most effective technique. This study compares the safety and efficacy of EF and IF fixation techniques for ankle arthrodesis. A systematic review and meta-analysis was conducted according to the Preferred reporting items for systematic reviews and meta-analyses (PRISMA) Guidelines. A literature search of electronic databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL), was performed to identify all studies directly comparing the two techniques. Both fixed and random effects models of analysis were used depending on heterogeneity. Odds of union in the EF and IF groups were comparable (OR = 0.60, CI 0.36-1.02, p = .06) however, EF was associated with greater odds of deep hardware infections (OR = 3.67, 1.97-6.83, p < .05) and amputations (OR = 3.17, CI 1.06-9.54, p = .04). Odds of revision surgery and superficial wound complications were similar between groups. EF techniques had significantly longer operation times (MD = 31.23, CI-25.11-37.34, p < .05) and intraoperative blood loss (MD = 44.1, CI 28.77-59.43, p < .05). No significant difference was noted in pain and functionality scores. IF and EF techniques have reasonable union rates with similar postoperative outcomes.

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint

INTRODUCTION

Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge.

METHODS

This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score.

RESULTS

Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002).

CONCLUSION

This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

Evaluation of Functional Outcome in Surgically Managed Tibial Pilon Fractures

Background Pilon fractures are infrequent and among the most challenging to manage. One reason is the extensive soft tissue injury surrounding the distal tibia. Second, the articular surface of the distal tibia with a complex fracture pattern needs anatomic reduction. These fractures occur due to high energy impaction of the talus into the distal tibia. The fracture patterns and extent of soft tissue involvement vary based on the intensity of the impact's energy. The management needs to be patient-specific to prevent complications. Proper pre-operative planning with the help of computer tomography scans aids in choosing the approach and proper reduction. Either single-stage early definitive fixation or two-staged protocols involving the application of spanning external fixation to maintain length and allow soft tissue healing followed by definitive open reduction and internal fixation is done. However, complications still remain inevitable in a significant subset of patients. Objective To evaluate the functional outcome in surgically managed tibial pilon fractures using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Methods This prospective observational study included 20 patients who underwent surgery for pilon fractures of the tibia at Nizam's Institute of Medical Sciences between November 2020 and September 2022. The patients were between 18 and 65 years old and consented to participate in the study group. After undergoing patient-specific surgical management, all patients are followed for a minimum of six months. Their functional outcome is evaluated after fracture union and scheduled physiotherapy sessions every four weeks using the AOFAS scoring system. Ankle range of motion (ROM) is also evaluated. Results The average age of the patients was 40 years, and male predominance was present. Most of the patients (60%) underwent internal fixation. According to the AOFAS scoring system, six patients had an excellent outcome, 11 had a good outcome, and three had a fair outcome. Most of the patients (11 patients) had excellent to good ankle ROM. Complications were encountered in two patients with ankle stiffness and one with wound dehiscence. Conclusion Pilon fractures are more common in young adults due to road traffic accidents. The most common type of pilon fracture is a closed fracture, which can be treated with definitive internal fixation after the soft tissue has healed. Definitive internal fixation has shown excellent and good functional outcomes (according to the AOFAS score) with improved ankle ROM and no complications when compared to external fixation, which can result in ankle stiffness and delayed union.