Foot & Ankle International

Supramalleolar osteotomy (SMO) enables deformity correction of the distal tibia, but the procedure remains technically demanding. Patient-specific instruments (PSIs) have the potential to mitigate the technical drawbacks associated with SMO that are performed free-hand, but their accuracy has not been investigated. Therefore, we aimed to perform a pre- vs post-operative comparison to assess the accuracy of PSI in the setting of SMO correction.

Eighteen patients (mean age = 47 ± 13.5 years) who underwent SMO with a PSI were prospectively recruited in a pre-post comparative study design. Inclusion criteria were correction of supramalleolar ankle varus or valgus deformity by a closing wedge SMO. Exclusion criteria consisted of biplanar SMO that required associated free-hand osteotomies. Clinical outcomes were collected by the American Orthopaedic Foot & Ankle Society (AOFAS), European Foot and Ankle Society (EFAS), and visual analogue scale (VAS) scores. Apart from the standard weightbearing radiographs, a weightbearing CT was performed to generate corresponding 3-dimensional (3D) bone models and measure the lateral distal tibia angle (LDTA) as main radiographic parameter.

The pre-operative radiographic parameters of the tibia joint alignment in patients with ankle varus (n = 12) deformity (LDTA_var = 96.5° ± 4.5°) and valgus (n = 6) deformity (LDTA_valg = 82.4° ± 2.5°) improved significantly relative to their post-operative equivalents (LDTA_var = 90.2° ± 3.2°); LDTA_valg = 90.9° ± 0.8°; P < .05). The pre-operative clinical outcome scores (AOFAS = 52.7 ± 22.9, EFAS = 15.1° ± 7.91°, VAS = 5 [2-8]) improved significantly relative to their post-operative equivalents (AOFAS = 75.5 ± 19.6; EFAS = 19° ± 7.6°; VAS = 3 [0-8]; P < .05). The mean simulated correction differed from the mean post-operative achieved correction within 1° (mean = 0.4°; range 0.1°-0.8°).

This study demonstrated an accurate correction of distal tibia deformities by SMO using PSIs. The achieved post-operative correction differed within the range of 1° from the pre-operatively simulated correction. This indicates that PSIs provide a precise execution of the pre-operative planning. Future studies should assess the added value of performing an SMO with PSI compared with former free-hand techniques towards clinical and radiographical outcomes.

Little is known regarding the circulating metal levels in patients following total ankle arthroplasty (TAA). Also unknown is the impact of implant modularity. The purpose of this study is to quantify the postoperative serum metal levels in patients who have undergone primary TAA and to evaluate the impact of tibial component design.

A cross-sectional study was conducted of patients who had undergone primary TAA during 2010-2023. Ten patients with the Stryker INFINITY System were included in the nonmodular tibia group, 10 patients with the Stryker INBONE System were included in the modular tibia group, and 21 patients without implants were included as a control group. Subjects attended a 1-time visit at minimum 12 months postoperative. Outcome measures included serum cobalt, chromium, and titanium levels measured by inductively coupled plasma mass spectrometry.

There were no differences in age, gender, body mass index, or follow-up between the nonmodular tibia, modular tibia, and control groups. Serum titanium levels were greater in the nonmodular tibia group (0.619 µg/L) and modular tibia group (0.993 µg/L) than in the control group (0.150 µg/L) (P < .001 and P < .001, respectively). Serum titanium levels were greater in the modular tibia group than in the nonmodular tibia group (P = .003). Serum cobalt and chromium levels did not differ between groups (P > .05). No associations were found between metal levels and clinical or radiographic outcomes.

Results from this study provide the first evidence that TAA is associated with elevated serum metal levels. Serum titanium levels were elevated, whereas chromium and cobalt levels were not. Patients with modular tibial implants had higher titanium levels than patients with nonmodular tibial implants. Possible explanations for these findings may be related to the greater surface area of the modular implants or greater release of metallic debris from tribocorrosion at the numerous modular junctions. These findings regarding implant modularity are hypothesis-generating and require further study.

Critical-sized defects (CSDs) of bone in the foot and ankle pose substantial surgical challenges because of high complication and failure rates. Three-dimensional (3D)-printed porous metallic implants (custom cages) have emerged as a potential alternative to traditional reconstruction techniques, offering theoretical advantages in stability and integration. However, current literature is limited by small sample sizes and short follow-up. This study reports the largest single-surgeon cohort to date, evaluating outcomes and complications of custom cage arthrodesis.

A retrospective cohort study was performed on patients who underwent custom cage implant ankle arthrodesis. The primary outcome was reoperation for any reason. Demographic and perioperative data were extracted for each patient. Univariable and multivariable linear regression analyses were used to assess associations between reoperation and factors including body mass index (BMI), comorbidities, surgical history, and defect size.

Fifty-three patients were included in this study over a median follow-up of 620 days. At last follow-up, 83% of implants remained in situ and the nonunion rate was 15% at 1 year. Within the overall cohort, 19 patients (36%) required at least 1 reoperation. Of these 19 patients, 8 (42%) developed deep postoperative infection and 5 (26%) ultimately required below-knee amputation. Within the multivariable regression, prior ipsilateral limb infection (OR = 14.9, P = .01) was significantly associated with reoperation.

Custom cage ankle arthrodesis in this study achieved a relatively high overall fusion rate but was associated with a high complication rate. Deep postoperative infection was a major barrier to a successful outcome. As the use of custom cage arthrodesis increases, evaluation of outcomes and comparison to conventional treatments will be essential to advance CSD treatment in foot and ankle surgery.

There is an increasing role for joint-preserving surgery in hallux valgus (HV) management among patients with rheumatoid arthritis (RA). We compared radiologic and clinical outcomes after minimally invasive transverse distal metatarsal osteotomy (MITO) and a complete proximal phalangeal osteotomy for HV correction in patients with and without RA.

This retrospective cohort study included 16 RA patients (21 feet) who underwent MITO between July 2018 and June 2023 with a minimum follow-up of 24 months. In total, 53 non-RA patients (63 feet) were matched by propensity score matching (1:3 ratio) after consideration of age, sex, body mass index, follow-up duration, preoperative hallux valgus angle (HVA), first-second intermetatarsal angle (1-2 IMA), and tibial sesamoid position (TSP). Radiologic evaluation included HVA, 1-2 IMA, and TSP measurements. Clinical outcomes were assessed using visual analog scale (VAS) pain scores, Foot and Ankle Outcome Scores, and Medical Outcomes Study Short Form Health Survey-36 physical component summary scores.

The matched cohorts consisted entirely of female patients, with a mean age of 63.7 years in the RA group and 63.3 years in the non-RA group. The mean follow-up duration was 38.1 months (range, 24-85 months). All radiologic parameters significantly improved at the last follow-up (all P < .001). Postoperative mean HVA, 1-2 IMA, and TSP were 4.9°, 3.9°, and 3, respectively, in the RA group and 7.0°, 5.2°, and 3, respectively, in the non-RA group; with the numbers available, no significant difference could be detected. Similarly, no significant difference could be detected in the final functional scores, and VAS met the predefined noninferiority margin. Likewise, no significant difference could be detected in total complications (P = 1.000) or reoperation rates (P = .184).

MITO combined with a complete proximal phalangeal osteotomy yielded favorable radiographic improvements and noninferior pain relief in RA patients compared with non-RA patients. Our findings indicate that MITO with proximal phalangeal osteotomy may be a safe and effective minimally invasive joint-preserving surgical option for HV correction in RA patients without advanced first metatarsophalangeal joint destruction.

Next-generation DNA sequencing (NGS) has improved detection of bacterial species and expanded understanding of the microbiome’s influence on postoperative outcomes in orthopaedic patients. Although NGS has identified organisms linked to reoperations in shoulder surgery, its application in the foot and ankle remains unexplored. This study uses NGS to determine whether patients undergoing hardware removal exhibit a unique microbiome profile.

A prospective study recruited 34 patients undergoing hardware removal surgery from the foot or ankle during 2020-2023. Patients were excluded based on any concern for infection prior to surgery. During the operation, the surgeon collected the removed hardware for analysis at a CLIA (Clinical Laboratory Improvement Amendments of 1988)–licensed molecular diagnostic laboratory. Majority of patients underwent surgery for painful orthopaedic hardware (70.6%). The cohort was predominantly female (62.2%) and mean age was 53.3 years (range 17-78). The mean time from primary implantation to hardware removal was 40.1 months (range 2.8-276.6 months).

NGS identified bacterial DNA in 5 cases (14.7%), detecting 9 total organisms. Staphylococcus species were most common (44.4%), followed by Corynebacterium (22.2%). No significant associations were found between bacterial detection and patient demographics or with hardware removal performed for painful implants.

This study found no consistent microbiome among patients undergoing hardware removal surgery, with Staphylococcus species being the most frequently detected organisms. These preliminary findings suggest that foot and ankle hardware does not consistently harbor bacteria detectable by NGS, although the small sample size limits generalizability and further investigation is warranted.

Fixed cavovarus foot deformity is characterised by a plantar-flexed first ray, hindfoot varus, and abnormal plantar loading, often resulting in pain, instability, and gait dysfunction. The surgical correction we performed involved a deformity-driven approach to address the structural apex and associated components. Evidence linking this multilevel correction strategy to objective biomechanical improvement remains limited.

This prospective case series evaluated outcomes following a uniform deformity-driven multilevel surgical correction protocol for fixed cavovarus deformity consisting of combined Cole midfoot osteotomy, Dwyer calcaneal osteotomy, and open Achilles tendon lengthening performed in all cases. Thirty-two relatively young skeletally mature patients (37 feet), predominantly with neuromuscular etiology, were included and followed for a minimum of 18 months. Primary outcome measures were patient-reported functional outcomes assessed using the Foot and Ankle Ability Measure Activities of Daily Living subscale (FAAM-ADL), radiologic alignment parameters on standardised weight-bearing radiographs, and objective gait and plantar pressure metrics. Secondary outcomes included postoperative complications. The Foot and Ankle Disability Index (FADI) was analysed as a secondary patient-reported outcome.

FAAM-ADL scores improved significantly from a preoperative mean of 45.2 to 77.2 at 18 months (P < .001). All radiologic parameters demonstrated significant correction, including Meary angle, calcaneal pitch angle, lateral talocalcaneal angle, anteroposterior talometatarsal angle, and talonavicular coverage angle (all P < .001). Gait analysis demonstrated a significant increase in comfortable walking speed (1.0 to 1.4 m/s, P < .001) and redistribution of plantar loading, with reduced lateral column pressures and increased midfoot contact area (all P < .001). The secondary FADI score also improved significantly over time (P < .001). Complications included transient postoperative pain during the first 12 months, 1 superficial wound infection, and 1 case of deformity recurrence.

In this prospective case series, deformity-driven multilevel surgical correction for fixed cavovarus deformity with a midfoot apex was associated with significant improvements in patient-reported function, radiologic alignment, and objective biomechanical parameters. These findings support the role of apex-targeted multilevel correction in appropriately selected patients with rigid midfoot-driven cavovarus deformity.

Weber B / Lauge-Hansen supination-external rotation 4b (SER4b) ankle fractures are unstable injuries characterized by complete deltoid ligament ruptures. Biomechanical studies suggest that fibular plate fixation alone is insufficient for SER4b fractures. Concurrent deltoid ligament repair seems necessary. This study explores how syndesmotic fixation, which is a simpler surgical approach, restores stability compared to deltoid repair or combined.

Eight fresh frozen human cadaveric ankle specimens were tested sequentially by a robot in all 5 states: native, SER4b injury model with anatomic fibular plate fixation only, or reinforced with a syndesmotic screw and/or deltoid ligament repair. Stability was measured in lateral translation (talar shift), valgus, and internal and external rotation during a constant 45-N axial load. The primary outcome was talar shift on fluoroscopic images. The minimal clinically important difference (MCID) was predefined as 1.0 mm.

Combined plate and syndesmotic screw fixation restored lateral translation stability. The mean difference in talar shift was −0.2 mm compared with native (95% CI −0.8 to 0.5, P = .57). However, talar valgus tilt increased by 18.1° (95% CI 16.1-20.0, P < .001) and external rotation by 15.9° (95% CI 12.6-19.2, P < .001). For combined plate fixation and deltoid ligament repair vs native, the mean difference in talar shift was 0.3 mm (95% CI −0.4 to 1.0), P = .37), also below the pre-defined MCID. Mean valgus and external rotation deviated less from native but were still significantly different, the respective mean differences were 2.7° (95% CI 0.8-4.7, P = .006) and 5.2° (95% CI 1.9-8.5, P = .002).

In this cadaveric SER4b injury model, both syndesmotic screw fixation and deltoid ligament repair restore lateral translational stability, when combined with fibular plate fixation. However, only deltoid ligament repair—addressing both the deep posterior and anterior deltoid components—substantially restored rotational and valgus stability, suggesting it provides more comprehensive joint stabilization than syndesmotic screw fixation alone.

Syndesmotic screw fixation restores lateral translational stability as well as deltoid ligament repair when both are combined with lateral plate fixation. Complete deltoid ligament repair is superior to the syndesmotic screw in restoring overall stability in cadaveric SER4b ankle fracture models. Given their potential clinical relevance, these findings may be considered in future clinical studies and choice of treatment.

Flatfoot deformities are characterized by collapse of the medial arch due to tendinous and ligamentous dysfunction. The degree of deformity can be evaluated radiographically by measuring the talo–first metatarsal angle (Meary angle). These deformities have traditionally been corrected using a medial cuneiform dorsal opening wedge (Cotton) osteotomy; however, this procedure requires bone grafting to fill the osteotomy site and results in lengthening of the medial column. To address these concerns, the plantar closing wedge of the medial cuneiform bone, known as the reverse Cotton osteotomy (RCO), was developed. In this study, we aim to determine the effect of the RCO on the position of the first metatarsal, thus providing guidance and recommendations for surgeons employing the reverse Cotton osteotomy in the correction of adult-acquired flatfoot.

In this cadaveric study, we characterized the mean angular correction achieved by 1-, 2-, 3-, and 4-mm RCO by radiographically measuring Meary angle under simulated weight-bearing conditions. Secondary outcomes included radiographic measurements of the navicular-cuneiform incongruency angle (NCIA) and calcaneal pitch angle.

Statistically significant increases in Meary angle were observed following 1-mm (P = .020), 2-mm (P = .049), and 3-mm (P = .049) osteotomies but not following the 4-mm osteotomy (P = .081). The mean angular correction achieved by the 1-, 2-, and 3-mm wedge sizes was 0.97°/mm. With the numbers available, no significant increase in NCIA could be detected following any of the RCO wedge sizes, and calcaneal pitch increased significantly only after 2-mm RCO (P = .036).

The RCO was associated with significant (P ≤ .049) plantarflexion of the first ray in a cadaveric model; however, the authors recommend limiting the wedge size to a maximum of 3 mm, as larger wedges were not associated with further angular correction of the medial arch.

The findings of this study can guide surgeons performing RCO to correct flatfoot deformities, thereby potentially contributing to improved postoperative outcomes.

Accurate evaluation of tibiotalar alignment is essential for staging and surgical planning in progressive collapsing foot deformity (PCFD), yet plain radiographs are limited by their 2-dimensional nature and variability in beam angulation. This study pursued 3 objectives: to quantify discrepancies in tibiotalar tilt (TT) between plain radiographs (XRs) and weightbearing CT (WBCT), to compare the prevalence of significant valgus tilt between modalities, and to identify features associated with underrecognized deformity on XRs.

One hundred thirty-eight PCFD patients (mean age: 55.1 years) who underwent both WBCT and ankle XRs were reviewed. On weightbearing ankle XRs, tibiotalar tilt (TT_XR), medial distal tibial angle (MDTA_XR), and talus-ground surface angle (Tal-GS_XR) were measured. On WBCT, corresponding parameters (TT_WBCT, MDTA_WBCT, and Tal-GS_WBCT) were assessed at 25% (anterior), 50% (middle), and 75% (posterior) of the joint. The degree of tibiotalar tilt and prevalence of significant valgus tibiotalar tilt (≥4°) were compared. Bland-Altman plots evaluated agreement between XRs and WBCTs. Patients were classified into Discrepancy (TT_XR < 4°, TT_WBCT ≥ 4°) and No-discrepancy groups, and group characteristics were compared. Interobserver and intraobserver reliability were assessed using intraclass correlation coefficients (ICCs).

Mean TT_XR was 1.5°, and mean TT_WBCT was 4.1°, indicating a 63% underestimation on radiographs. Significant valgus tilt (≥4°) was present in 10.1% of radiographs vs 37.7% of WBCT scans. Radiographs correlated best with the middle WBCT slice. Discrepancy group patients showed greater anterior TT_WBCT values. On multivariable logistic regression, anterior tibiotalar tilt on WBCT was the predictor of XR-WBCT discrepancy (odds ratio, 33.0; 95% CI, 5.6-114.7; P < .001), suggesting anterior deformities visualized on WBCT are not reliably captured on radiographs. Interobserver reliability ranged from 0.80 to 0.86 and intraobserver reliability from 0.88 to 0.89 (ICC).

Plain radiographs underestimate valgus tibiotalar tilt compared with WBCT, mainly because of limited visualization of the anterior joint. Surgeons should recognize that reliance on XRs alone may lead to underrecognition of ankle valgus alignment in patients with PCFD. As WBCT is not universally available, optimizing XR projection angles may better capture anterior tibiotalar alignment and improve preoperative planning.

Level III, retrospective diagnostic.

Several radiographic and cadaveric studies have suggested that specific anatomical features of the Lisfranc joint complex, including a shallower medial mortise of the second metatarsal (M2), shorter M2 length, or pes cavus alignment, may be associated with ligamentous Lisfranc injuries. These associations have largely been derived from 2-dimensional imaging or post-injury assessments. Weightbearing computed tomography (WBCT) enables 3-dimensional evaluation of midfoot anatomy under physiologic load and allows a more robust reassessment of these proposed anatomical associations.

This retrospective matched case-control study compared WBCT scans of the uninjured contralateral feet of 34 patients with low-energy ligamentous Lisfranc injuries to those of 34 matched controls. Groups were matched 1:1 for sex and side, and within a tight caliper for age and body mass index. Manual WBCT-based measurements included M2 length, M2 base height, medial and lateral mortise depths, foot length, and derived ratios. Overall foot and ankle alignment parameters were assessed using semi-automatic and automated WBCT tools. Paired statistical analyses were performed with correction for multiple comparisons.

No significant differences were identified between groups for M2 length (74.5 ± 7.1 mm vs 75.2 ± 6.8 mm, P = .42), medial mortise depth (7.1 ± 1.5 mm vs 7.3 ± 1.4 mm, P = .31), lateral mortise depth (6.9 ± 1.6 mm vs 7.0 ± 1.5 mm, P = .48), or any calculated ratios. Of 23 additional alignment parameters, the sagittal first tarsometatarsal angle showed a nominal unadjusted difference with lower values in the Lisfranc group (8.33° vs 9.63°, P = .02); this difference did not persist after FDR correction (P_FDR = .53) and is of uncertain clinical relevance. Intraobserver reliability was good to excellent across all manual measurements, whereas interobserver reliability ranged from moderate to excellent.

WBCT did not identify anatomical features involving the second metatarsal, Lisfranc mortise morphology, or global foot alignment that were consistently associated with ligamentous Lisfranc injuries. These findings challenge previously proposed anatomical associations and underscore the value of standardized, weightbearing 3D imaging when evaluating midfoot anatomy.

Ankle arthrodesis (AA) has historically been the gold standard surgical treatment for end-stage ankle arthritis, providing reliable pain relief at the expense of motion. Total ankle arthroplasty (TAA) has emerged as a motion-preserving alternative with improving survivorship and functional outcomes. However, large-scale comparative data evaluating complications, reoperation rates, opioid utilization, and health care costs remain limited. This study compared outcomes following AA and TAA using a national administrative database.

A retrospective cohort study was performed using a national claims database. Adult patients undergoing primary TAA or AA were identified, excluding cases involving trauma, infection, or malignancy. Propensity score matching (1:1) was performed based on age, sex, year of surgery, insurance type, and comorbidities. Thirty-day complications, 2-year outcomes, postoperative opioid utilization, and cumulative health care costs were assessed. Categorical variables were compared using χ² testing and continuous variables using independent-samples t-tests.

A total of 15 898 patients met inclusion criteria (9271 AA; 6627 TAA). After matching, 6627 patients remained in each cohort. At 2 years, TAA demonstrated lower rates of any reoperation compared with AA (3.1% vs 7.7%, P < .001), driven by lower rates of revision (1.1% vs 3.3%), hardware removal (1.3% vs 5.5%), and infection-related reoperations (1.3% vs 1.9%) (all P < .05). Diagnosis-based endpoints, reported separately, similarly favored TAA. Within 30 days, TAA was associated with fewer complications (1.0% vs 2.3%, P < .001). Although index costs were modestly higher for TAA, cumulative costs at 2 years were lower ($7225 vs $8043, P < .001). Early opioid use was slightly higher following TAA but converged by 1 year.

In a propensity-matched national cohort, TAA demonstrated lower reoperation rates, fewer early complications, and lower cumulative costs at 2 years compared with AA, supporting TAA as a durable treatment option.