Background The aim of the study was to assess the 7-year-follow-up (7FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral defects at the first metatarsophalangeal joint (MTP1). Material and Methods In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at MTP1 that were treated with AMIC+PBC from April 1, 2009 from July 17, 2016 to May 21, 2017 were included. Size/location, Visual-Analogue-Scale Foot and Ankle (VAS FA), EFAS Score before treatment/5FU were analysed and compared with previous 2-/5-year-follow-up (2FU/5FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue. Results One hundred and ninety-eight patients with 228 chondral defects were included. In 21% of patients no deformities in the forefoot were registered. The average degree of osteoarthritis was 2.2. The chondral defect size was 1.0 cm2 on average. The most common location was metatarsal dorsal (22%), and in most patients one defect was registered (74%). Corrective osteotomy of the first metatarsal was performed in 79%. 176 (89%)/164 (82%)/159 (80%) patients completed 2FU/5FU/7FU VAS FA/EFAS Scores were preoperatively 46.8/11.9 and improved 74.1/17.1//75.0/17.2//72.8/17.5 at 2FU/5FU/7FU on average. No parameter significantly differed between 2FU/5FU/7FU (ANOVA, p>0.05). Conclusions In conclusion, AMIC+PBC as treatment for chondral defects at MTP1 as part of joint preserving surgery led to improved and high validated outcome scores at 7FU. The lack of significant differences between 2-year (2FU), 5-year (5FU), and 7-year (7FU) outcomes suggests plateaued benefits.

First metatarsophalangeal (MTP1) joint fusion is a well-established and effective procedure for advanced degenerative changes. The most stable method of fusion of this joint is considered to be dorsal plate fusion with a compression screw. However, the revision rate after MTP-1 joint arthrodesis is reported to be over 10%. A new fixation model for MTP1 arthrodesis was developed, using a medially positioned plate. A mathematical model of the MTP-1 joint was created. The last phase of gait was simulated to determine the strain and stress state for medially and dorsally positioned fixation plates. With the approval of the Bioethics Committee, a pilot clinical study on 20 patients was conducted to assess the safety and efficacy of the method. Fourteen patients (70%) rated their satisfaction with the procedure as very high, four as high (20%), two as low (10%), and no patient reported very low satisfaction with the procedure. In 19 patients (95%), radiological fusion was confirmed. Clinical results of MTP1 joint arthrodesis using a medially placed plate via a medial approach indicate that this method is effective, safe, and a valuable alternative to previously used methods.

Morton’s interdigital neuroma, resulting from chronic compression of the interdigital nerve, often requires surgical intervention when conservative measures fail. This retrospective study compares the outcomes of open neurectomy and percutaneous intermetatarsal ligament release (PILR), with particular focus on predictive factors influencing surgical success. Forty-six patients (58 feet) treated between 2012 and 2022 were included, with 24 undergoing open excision and 22 treated with PILR. Data collected included demographic information, MRI-measured neuroma size, postoperative complications, and need for revision surgery. Clinical outcomes were assessed using the Visual Analog Scale (VAS), Foot and Ankle Ability Measure (FAAM), and patient satisfaction scores. Results demonstrated that open neurectomy produced significantly better outcomes for neuromas larger than 7.40 mm, with lower VAS scores (2.3 vs. 3.9), higher FAAM scores (87 vs. 72), and greater patient satisfaction (3.2 vs. 2.1) compared to PILR. In the PILR group, neuroma width was a significant predictor of poor outcome, and a higher incidence of postoperative paraesthesia was noted (10% vs. 0%). These findings suggest that neuroma width is a key factor in surgical decision-making. Open excision remains the more effective option for larger neuromas, while PILR may be considered a viable, less invasive alternative in carefully selected patients with smaller lesions.

Objectives: The aim of this study was to evaluate the efficacy of the surgical method including the combination of proximal open wedge and distal closing wedge osteotomies for correction of the deformity in patients who underwent distal osteotomy and developed recurrence with increased DMAA. Patients and Methods: The study included patients who were treated for recurrent hallux valgus deformity with increased DMAA between 2018-2022. Preoperative and postoperative intermetatarsal angle (IMA), distal metatarsal joint angle (DMAA) and halluxvalgus (HVA) angles were measured and compared. The clinical outcomes of the participants were evaluated using the AOFAS score, The Manchester-Oxford FootQuestionnaire (MOXFQ) score and Maryland foot score. Results: The study included 10 female patients diagnosed with HV. Preoperative and postoperative HVA, IMA and DMAA were 32.4 to 14.6, 12 to 7.5, 19.3 to 9.7 degrees respectively. Aofas, Maryland and Moxfq scores were 49.4 to 96.4, 45.7 to 96.1, 39.6 to 6 respectively on final follow-up. Mean follow-up time was 33.1 months (24-78 months). Conclusion: The combination of distal closed wedge and proximal open wedge osteotomies for hallux valgus (HV) recurrence was emphasized as an effective surgical technique for correction of the deformity. Despite the limited sample size of our study, the data obtained provide valuable information about both short and long-term outcomes of surgical interventions. Supporting these results with larger patient groups and long-term follow-up in future studies will provide more comprehensive findings on the effectiveness of hallux valgus surgery.

Metatarsal pronation is an important component of Hallux valgus (HV) and contributes towards malreduction, recurrence and patient reported outcome measures. Metatarsal rotation can be assessed on radiographs and weight-bearing CT (WBCT), however there are no clinical tests for metatarsal pronation. This study therefore aimed to examine the relationship between clinical toe pronation and metatarsal pronation. Methods Single-centre, retrospective analysis over 5 years. Measurements were performed on WBCT images. First metatarsal rotation was measured using Metatarsal Pronation Angle as previously described. Toe rotation was measured by the Phalangeal Condylar Angle (PCA), the angle between the condyles of the proximal phalanx and the floor, and the Nail Plate Angle (NPA), the angle of the base of the nail plate to the floor. These were obtained from 50 Hallux valgus feet, and 50 controls. Results The HV group comprised 41 women and 9 men, mean age 52.4. Control group, 23 women and 23 male, mean age 40.25. Inter and Intra Observer reliability both excellent (ICC >0.95) for all measurements. When comparing HV vs control, MPA was 11.7 vs 6.0 (p<0.001), PCA 31.8 vs 4.7 (p<0.001), NPA 18.3 vs 6.0 (p<0.0001). NPA correlated with PCA. NPA and PCA correlate with Hallux valgus Angle (p<0.001), but not with MPA (p 0.567). Conclusion These results suggest that clinical toe pronation increases as HV angle increases but not with metatarsal pronation, which therefore cannot be used as a clinical marker. Toe pronation is similar at the base and at the nail, suggesting rotation happens at the MTPJ

INTRODUCTION: Minimally invasive or percutaneous surgery for hallux valgus correction has demonstrated excellent clinical and radiographic outcomes. However there are rare occasions where there is limited bone formation and remodelling despite successful union. This study investigated whether prophylactic bone graft augmentation could improve bone formation compared to standard percutaneous technique. METHODS: A retrospective comparative study of patients undergoing fourth-generation percutaneous hallux valgus correction with Bone Graft Augmentation (BGA) or without (NBG) demineralized bone fibre augmentation. Primary outcome was radiographic healing assessed at 6 weeks, 3 months, and 6 months using a validated classification system. Secondary outcomes included patient reported outcome measures (MOXFQ, EQ-5D-5L, VAS Pain), and radiographic parameters (intermetatarsal angle, hallux valgus angle). RESULTS: Between September 2022 and July 2024, 215 patients (191 female; 24 male; 316 feet) underwent fourth generation percutaneous metatarsal extra-capsular transverse osteotomy for hallux valgus correction. Patients were divided into bone graft augmentation (BGA;222 feet) and non-bone graft (NBG;94 feet) groups. Radiographic follow-up was available for 75.2% (167 feet) of BGA and 79.8% (75 feet) of NBG cases. The BGA group showed significantly improved radiographic union scores at 3 and 6 months (p=0.005-0.027) but not 6 weeks (p=0.06), with both groups achieving 100% union by 6 months. There were no significant differences between groups in terms of patient reported outcome measures or radiographic deformity correction (p>0.05). CONCLUSION: The addition of demineralized bone matrix to the lateral healing zone, led to significantly improved radiographic healing rates at three and six months following percutaneous hallux valgus surgery.

INTRODUCTION: Minimally invasive hallux valgus surgery can occasionally result in a distinct radiological finding termed the "Filament Union sign," characterized by a thin, filamentous bone bridge at the osteotomy <25% of the metatarsal head width and associated with minimal medial/lateral/central remodelling. We aimed to determine its prevalence and identify potential contributing factors. METHODS: A retrospective radiographic comparative study analyzed 726 feet that underwent percutaneous fourth-generation transverse osteotomy for hallux valgus correction between November 2017 and January 2023. The primary outcome was the presence of the filament union sign. Secondary outcomes included clinical patient reported outcome measure and radiographic deformity analysis. RESULTS: The filament union sign was identified in 24 feet (3.3%, 95% CI:2.0-4.6%) with 15 cases (62.5%) occurring in patients who underwent bilateral procedures. There was no significant difference in mean PROM follow-up between groups (1.7±0.8 vs 1.9±0.9 years, p=0.145). While both groups showed similar baseline characteristics, the filament union group demonstrated statistically but not clinically significant increased MOXFQ Index scores (20.6±16.9 vs 13.0±15.7, p=0.040) at final follow-up. There was no statistically significant difference in individual MOXFQ domains p>0.05. Preoperative hallux valgus angle was significantly associated with filament union (OR 1.08, 95% CI:1.02-1.15, p=0.006). No instances of fracture or metalwork failure were observed in the filament union group. CONCLUSION: The filament union sign is an uncommon radiographic finding occurring in 3% of cases. Its presence was associated with statistically but not clinically significant decreased functional outcomes and not associated with an increased rate of mechanical failure/fracture or revision surgery rate.

INTRODUCTION: There is increasing interest in the role of pronation as part of the deformity correction in hallux valgus (HV) especially with the advent of WBCT and percutaneous surgical techniques. This study aimed to assess coronal rotation of the first metatarsal before and after percutaneous HV surgery (META) using WBCT and correlate these findings with clinical outcomes. METHODS: A retrospective analysis of consecutive patients who underwent WBCT both before and after percutaneous distal transverse osteotomy for HV correction. The primary outcome was pronation correction on radiographic parameters; Hallux valgus angle, intermetatarsal angle, Metatarsal pronation angle, alpha angle, sesamoid rotation angle, arthritis and sesamoid position were assessed using WBCT. Secondary outcomes included pre- and post-operative clinical outcomes, including MOXFQ, EQ-5D-5L, Visual Analogue Scores and complications. RESULTS: 51 feet from 34 patients (32 Female, 2 Male, mean age 60.3±10.2 years) underwent META. Radiographic data was available for 94.4% of feet with mean follow-up of 12.1±3.2 months. There was significant improvement across all radiographic parameters including pronation correction (p<0.05). There was also a significant improvement in clinical foot function for all MOXFQ domains, EQ-5D-5L and VAS Pain outcomes (p<0.05). The complication rate was 1.9%. There was no significant correlation of post-operative outcomes with radiographic pronation parameters. Regression analysis did not identify any radiographic or clinical variables that predicted change in MOXFQ Index score. CONCLUSION: Percutaneous distal transverse osteotomy for hallux valgus deformity can significantly correct coronal plane pronation and improve patient-reported outcomes, although correction of pronation was not significantly correlated with clinical improvement.

INTRODUCTION Fourth-generation percutaneous valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of studies reporting the outcomes of transverse osteotomies, many of which have methodological limitations. The aim was to investigate percutaneous transverse osteotomies for hallux valgus deformity. METHODS A prospective series of consecutive patients undergoing fourth generation metatarsal extra-capsular transverse osteotomy (META) performed by a single surgeon between November 2017 and January 2023. The primary outcomes were radiographic deformity correction and clinical foot function assessed using the MOXFQ. Radiographic deformity (Hallux valgus angle (HVA) and Intermetatarsal angle(IMA), sesamoid position) were assessed. Secondary outcomes included VAS Pain and radiographic deformity recurrence (defined as HVA >20°). RESULTS: 729 feet from 483 patients (456 Female, 27 Male, mean age 57.9±11.9 years) underwent META. Radiographic data (minimum 12 months post-surgery) was available for 99 .7% of feet with mean follow up of 2.6±1.3 years (range 1.0-5.7). There was a statistically significant improvement (p<0.05) in both HVA; 29.5±8.5° to 7.3±6.7°, and IMA, 12.9±3.4° to 4.6±2.5°. All MOXFQ domains showed significant improvement (p<0.05); Index 36.9±18.9 to 13.4±15.8, Pain 40.5±22.0 to 17.2±18.3, Walking/Standing 32.3±23.1 to 12.0±18.2 and Social Interaction 40.4±20.4 to 11.0±15.2. The recurrence rate was 4.5% (n=33). The complication rate was 6.1% which included a screw removal rate of 2.9%. CONCLUSION: This is the largest consecutive series of any percutaneous osteotomy technique to correct hallux valgus deformity. This study demonstrates that the technique leads to significant improvement in clinical and radiographic outcomes with a low rate of recurrence.

INTRODUCTION: There is currently no standardised or validated radiographic classification to evaluate first metatarsal osteotomy healing following minimally invasive hallux valgus surgery. The aim was to validate a new radiographic classification system for assessing bone healing following MIS distal transverse osteotomy for hallux valgus. METHODS: A four-domain radiographic classification system based on callus formation, AP osteotomy line, lateral osteotomy line, and remodelling for MIS osteotomy healing was developed and tested on a cohort of 27 feet who underwent percutaneous transverse osteotomy for hallux valgus correction. Patients had simultaneous postoperative WBCT and radiographs following surgery. Five surgeons reviewed radiographs to evaluate interobserver reliability. WBCT was used to confirm union status and validate classification interpretation. RESULTS: The classification system demonstrated substantial interobserver reliability for lateral osteotomy line (Fleiss kappa = 0.671,95% CI:0.505-0.814) and AP osteotomy line assessment (Fleiss kappa = 0.664, 95% CI:0.459-0.811), with moderate agreement for callus formation (κ = 0.465) and remodelling (κ = 0.439). The classification showed strong correlation with WBCT findings, with an optimal threshold of 8 points identified to differentiate union from non-union, achieving an overall classification accuracy of 85.2%. Receiver operating characteristic analysis indicated an area under the curve of 0.832. At the optimal threshold, the classification demonstrated 90.0% sensitivity and 71.4% specificity for detecting union. CONCLUSION: This new classification provides a reliable, validated tool for assessing first metatarsal bone healing following MIS hallux valgus osteotomies, with substantial interobserver reliability. It offers a standardised approach for radiographic evaluation, supporting clinical decision-making and enhancing comparability across studies.

Objectives The optimal osteotomy technique (chevron versus transverse) for minimally invasive hallux valgus surgery remains unknown. This study aimed to explore the clinical and radiographic outcomes between chevron and transverse osteotomies in patients with severe hallux valgus deformity Methods: A retrospective cohort study was conducted including 110 patients (134 feet) who underwent hallux valgus correction using either PECA (n=46 patients, 53 feet) or META (n=66 patients, 81 feet) techniques. Radiographic parameters including hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured at baseline, 6-months, and final follow-up. Patient-reported outcome measures (PROMs) were assessed using the MOXFQ, VAS pain, and EQ5D-5L. Recurrence was defined as final HVA exceeding 20°. Complication rates and passive correctability were also analyzed. Result: Baseline characteristics were similar between groups, except for higher initial IMA in the PECA group (17.5° vs 15.8°,p=0.01). Both techniques achieved significant deformity correction. At final follow-up, the PECA group demonstrated a significantly lower HVA compared to the META group (11.5° vs 14.5°,p=0.03), while final IMA measurements were similar (5.1° vs 4.9°,p=0.87). Recurrence rates were significantly lower in the PECA group (9.4% vs 27.1%,p=0.01). Pre-operative passive correctability was higher in the PECA group (66.0% vs 46.9%,p<0.05), particularly among recurrent cases (80.0% vs 27.3%,p<0.05). No significant differences were observed in PROMs between groups. Complication rates were comparable (PECA: 13.2% vs META: 8.6%,p=0.40). Conclusion: Both PECA and META techniques provide effective correction of hallux valgus deformity. The higher recurrence rate seen in META is likely due to the lower rate of pre-operative passive correctability.

Objectives: There is increasing interest in minimally invasive (MIS) osteotomy techniques for bunionette correction. We aimed to assess for any difference between complete and incomplete osteotomies in clinical and radiographic outcomes following an unfixed MIS oblique distal osteotomy for bunionette deformity correction. Methods: 43 feet (mean age 54.2±17.1) underwent MIS oblique osteotomy for bunionette correction by a single surgeon over a course of 4 years. The primary outcome was presence of significant post-operative callus at the osteotomy site (greater than 150% of the width of the 5th metatarsal shaft). Secondary outcomes included radiographic parameters 4th-5th intermetatarsal angle (IMA), metatarso-phalangeal angle (MPA), and Patient Reported Outcome Measures (PROMs) of MOXFQ, EQ-5D-5L, and VAS(Visual Analogue Scale) Pain (minimum 12 months follow-up). Results: 30 patients had a complete osteotomy, 13 patients had an incomplete osteotomy with the lateral cortex remaining intact. For the complete osteotomy group, 60% of patients (p=0.0003) had callus equivalent to 150% of the metatarsal width or over at 6 weeks follow up, this reduced to 19% (p=0.31) at 6 months and 0% (p=1) at 12 month follow up. All PROMs showed significant improvements; IMA and MPA significantly reduced postoperatively. There was no significant difference between partial and complete osteotomy groups except for the MOXFQ walking/standing domain (p=0.014). Conclusion: Minimally invasive oblique osteotomy for bunionette deformity correction is a safe and effective procedure significantly improving radiographic and clinical outcomes. Whether or not the osteotomy is completed does influence callus formation but does not significantly affect the radiographic or clinical outcomes.

Objectives: Minimally invasive surgery (MIS) for hallux valgus (HV) deformity is gaining popularity. However, the transition from traditional open surgery to MIS techniques presents a significant learning curve for surgeons and poses potential challenges in training junior surgeons. This study compared radiographic outcomes, MOXFQ scores, operative time, and complications between cases performed by a consultant experienced in MIS HV versus trainees performing the same procedure under consultant supervision. Methods: We compared radiographic and prospective patient reported outcomes between 50 consecutive patients (mean age 55.3±15.6 years) who underwent MIS HV correction by a single consultant and 53 consecutive patients (mean age 60.7±15.9 years) operated on by four trainees under single consultant supervision. Primary outcomes included hallux valgus angle (HVA), intermetatarsal angle (IMA), and MOXFQ scores. Secondary outcomes included operative time and complications. Results: Both consultant and trainee groups achieved significant HVA reduction (consultant: 32.0±6.7° to 8.0±3.9°; trainee: 31.4±8.2° to 10.0±5.4°) and IMA reduction (consultant: 14.0±2.4° to 4.0±1.6°; trainee: 13.8±2.2° to 6.3±2.6°), all p<0.05. No significant differences were observed in radiographic outcomes or MOXFQ scores at 6 and 12 months (p>0.05). While operative time was increased in the trainee group, overall complication rates were similar, with minor variations in screw removal rates and delayed wound healing. Conclusion: Although operative time was increased in the trainee group, the comparable radiographic corrections, MOXFQ scores, and complication rates at 12 months suggest that MIS HV correction can be safely taught to surgical trainees in the elective foot & ankle setting under appropriate supervision.

Background: Hallux valgus (HV) is a common foot deformity affecting around 19% of adults. Finite element analysis (FEA) is a valuable computational tool for investigating the complex biomechanics of foot deformities. This systematic review evaluates FEA studies investigating HV biomechanics, surgical correction techniques and fixation methods. Methods: Medline, EMBASE, PubMed, and Cochrane Library databases were searched from inception to 2025. Included studies employed FEA to investigate HV biomechanics, with or without surgical intervention. An adaption of the ROBFEAD tool was used to assess bias. Results: 19 studies met inclusion criteria (12 surgical, 7 biomechanical). All studies demonstrated moderate to high risk of bias. Biomechanical analyses revealed increased lateral metatarsal loading (40-55% higher stress) and medial shift of peak pressures at the MTPJ. Surgical technique analyses demonstrated metatarsal shortening up to 6 mm could be accommodated before significantly altering foot loading patterns. Fixation studies showed superiority of dual fixation methods in minimally invasive surgery. Conclusions: FEA provides valuable insights into HV biomechanics and surgical optimization. The data supports dual fixation approaches, precise osteotomy parameters, and caution regarding post-operative protocols.

Aims: Minimally invasive hallux valgus (HV) correction techniques, including percutaneous Chevron-Akin (PECA) and metaphyseal extra-articular transverse and Akin (META) osteotomies, offer favourable outcomes but occasionally are complicated by unpredictable metatarsal fractures. This study identifies predictive factors for first metatarsal fractures following minimally invasive HV surgery. Methods: This retrospective case-control study analysed 370 patients (499 feet) who underwent minimally invasive HV correction between November 2017 and August 2024 at a tertiary orthopaedic centre. Cases from the learning curve, revision procedures and patients lost to follow-up were excluded. Cases were categorised based on the presence or absence of first metatarsal fracture within 6 weeks of surgery. Logistic regression analysis was then performed to identify risk factors for first metatarsal fracture within 6 weeks of surgery. Results: First metatarsal fractures occurred in 5.4% (27 feet) of cases, with Type II fractures being most common (40.7%). Advanced age and/or simultaneous bilateral surgery were significantly associated with fracture risk (p<0.05). Logistic regression showed that fracture risk increased by 7.6% per year of age (OR: 1.076, 95% CI: 1.006–1.160, p = 0.042) and was significantly higher in patients undergoing bilateral surgery (OR: 3.70, p = 0.002). Bone mineral density (BMD) of the femur and lumbar spine did not correlate with fracture risk. Conclusion: Advanced age and bilateral surgery are predictive factors for metatarsal fractures following minimally invasive HV correction. Tailoring surgical and postoperative strategies, especially in elderly patients, may help mitigate fracture risk. Further research should explore metatarsal-specific bone density, surgical biomechanics, and younger patient cohorts.

Introduction Total joint arthroplasty is a recognised and ever-increasing method of treating end stage hallux rigidus. The Toefit Plus implant has a fixed bearing UHMWPE fixed to the phalangeal component. This study was mainly concerned with the long term survival of the Toefit Plus total joint replacement. Method It is a retrospective study which entailed the latest clinic letters and radiographs were compiled for every patient who had the Toefit Plus total joint arthroplasty performed at The University Hospitals of Derby and Burton from the accurate database of the senior author and double checked with the theatre log. A telephone interview survey was conducted for surviving patients using the MOXFQ [1]. Results There were a total of 70 Toefit Plus total joint replacements performed in our Institution between 2006 to 2013. This consists of 57 patients (46 females, 11 males), average age 62 years (range 42-82 years). The average MOXFQ score at the latest follow up telephone consultation was 7.4 (range 0-59, 95% CI 7.4 ± 4.4). The Kaplan-Meier survival curve graphically represents the survival rate of the implant to revision. Conclusion In TKR and TAR it has been proposed that mobile bearing UHMWPE were developed with the intension of reducing wear and improving range of movement . These 2 reasons lead us to conclude that Toefit Plus causes early phalangeal failure which may not be symptomatic, reflected in a false impression of longevity.

Background and Objectives: Hallux rigidus is a degenerative condition of the first metatarsophalangeal (MTP) joint, causing pain and limited dorsiflexion. In early stages (grades I–II), joint-preserving procedures like dorsal cheilectomy and Moberg osteotomy are commonly used. Minimally invasive techniques have recently gained popularity, potentially reducing soft tissue trauma and improving recovery. This study compares clinical outcomes, postoperative pain, and complication rates between open and percutaneous Moberg osteotomy, both combined with dorsal cheilectomy. Methods: A retrospective review was conducted on 96 patients with grade I–II hallux rigidus who underwent either open (n=43) or percutaneous (n=53) Moberg osteotomy with dorsal cheilectomy. All patients had failed at least three months of conservative treatment. Outcomes were evaluated using the Visual Analog Scale (VAS), Foot Function Index (FFI), and opioid use (oxycodone tablets) over the first two postoperative weeks. Complications and reoperation rates were also recorded. Results: Both groups showed significant improvements in VAS and FFI scores with no significant difference between techniques. However, the percutaneous group had significantly lower opioid use (3.6 vs. 13.3 tablets; p < 0.0001). Complication rates were low in both groups, with no wound issues reported in the percutaneous cohort. Conclusions: Percutaneous Moberg osteotomy with dorsal cheilectomy is a safe and effective option for early-stage hallux rigidus. It provides similar clinical outcomes to the open approach, with the added benefit of reduced postoperative opioid use and potentially fewer wound-related complications.

Metatarsophalangeal (MTP) joint fusion is a surgical procedure for end-stage hallux rigidus. Recent advances in minimally invasive surgery (MIS) techniques have increased adoption, yet comparative evidence with traditional open approaches remains limited. Methods: A comprehensive literature search was conducted across PubMed, CINAHL, Cochrane Library, and Google Scholar for systematic reviews, meta-analyses, randomized controlled trials (RCTs), and comparative studies . Primary outcomes included fusion rates, complication profiles, functional outcomes, and radiographic parameters. Results: Fusion rates were consistently high for both techniques, with MIS demonstrating rates of 96-100% compared to 94-95% for open approaches, without statistically significant differences (p>0.05). Overall complication rates were comparable between techniques (20-23%), though MIS approaches showed fewer wound-related complications but similar hardware-related issues. Meta-analysis of RCTs revealed higher functional scores for MIS techniques, while both approaches demonstrated similar long-term pain outcomes. MIS techniques were associated with shorter operative times, reduced hospitalization, and advantages in certain radiographic parameters, particularly with newer generation techniques. Conclusions: MIS approaches may offer advantages in early post-operative pain, functional outcomes, surgical efficiency, and specific radiographic parameters. However, the quality and quantity of available evidence remain limited, with few high-quality RCTs and meta-analyses specifically addressing MTP joint fusion. Reference:Duggan JL, Guild TT, Stanwood KC, Miller CP. (2024). Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results. Foot Ankle Int, 45(7), 723-727. Ji L, Wang K, Ding S, Sun C, Sun S, Zhang M. (2022). Minimally Invasive vs. Open Surgery for Hallux Valgus: A Meta-Analysis. Front Surg, 9, 843410.

Background: Rotational malalignment of the first metatarsal is increasingly recognized in hallux valgus, but the reliability of radiographic rotation markers remains uncertain. This study evaluated inter- and intraobserver reliability of four common radiographic parameters: metatarsal pronation angle (MPA), tibial sesamoid position (TSP), lateral head shape (LHS), and round head sign (RH). Methods: In this prospective reliability study, three senior clinicians independently assessed weight-bearing anteroposterior and axial sesamoid radiographs of 75 hallux valgus cases on two occasions. MPA was analyzed as a continuous variable using intraclass correlation coefficients (ICC). TSP, LHS, and RH were graded on ordinal scales and analyzed using weighted kappa statistics (κ). Subgroup analyses explored effects of deformity severity and increased distal metatarsal articular angle (DMAA >10°). Results: MPA showed excellent agreement (ICC 0.81–0.94). TSP also demonstrated high reliability (κ 0.88–0.98), though its utility as a rotation marker may be limited. LHS showed moderate to substantial agreement (κ 0.59–0.85), while RH had fair to moderate reliability (κ 0.35–0.66). RH was least reliable in mild deformities. Reliability for other markers remained stable across subgroups, with slightly lower values in elevated DMAA. Conclusions: Conventional radiographs provide reliable assessment of MPA and TSP. LHS shows acceptable reproducibility, whereas RH is less consistent. These findings support selective use of radiographic markers and suggest further validation against 3D imaging and standard grading frameworks.

Objectives: The minimally invasive hallux valgus (HV) surgery has developed in recent years and provides advantages compared with traditional technique. The aim of the study was to evaluate short-term outcome of patients with moderate and severe HV after third-generation minimally invasive surgery. Methods: A retrospective study of patients, operated by using third-generation Chevron-Akin minimally invasive osteotomy from November 2024 to February 2025, was conducted. Pre-operative and short-term postoperative radiological examination results and patients' satisfaction were analyzed. Results: Short-term outcome was evaluated in 9 patients (8 female, 1 male) (11 feet), mean age 58.3 (26 - 77) years, mean three months after operation. Six feet had moderate HV and 5 ̶ severe HV. Pre-operative mean hallux valgus angle (HVA) was 39.080, intermetatarsal angle (IMA) 14.40, distal metatarsal articular angle (DMAA) 38.20; postoperative mean HVA was 11.50, IMA 8.20, DMAA 15.30 (p<0.05). Mean grade of the medial sesamoid position pre-operatively was 2.7, postoperatively ̶ 1,9. The mean pre-operative AOFAS MTP-IP score was 43 points, postoperatively ̶ 90.5 points. Eleven patients (100%) were satisfied with surgery. One patient had non-union of the proximal phalange of first toe. Discussion/conclusions: Patients with moderate and severe HV in short-term after minimally invasive HV surgery demonstrated improvement of HVA, IMA, DMAA postoperatively, showing good functional results. All patients were satisfied with outcome. Patients are suggested to be informed about disadvantages and risks of the surgery.

Tranexamic acid (TXA) is widely used in orthopaedic surgery to minimize blood loss and wound-related complications. The use of topical tranexamic acid has shown promising results in hindfoot surgery, particularly in calcaneal fractures (Zhong 2021, Huang 2022); however, its role in forefoot procedures remains less established as a strategy to minimize postoperative bleeding and its associated complications. In 2024, our department implemented a protocol for the topical application of TXA after forefoot surgeries to reduce postoperative bleeding and associated complications. This study aimed to evaluate whether topical TXA reduced bleeding-related complications and facilitated earlier suture removal. A prospective observational study was conducted on consecutive patients undergoing forefoot surgery between September and December 2024 (31 patients), comparing them to a retrospective cohort from 2022 (56 patients), before TXA implementation. Outcomes included postoperative bandage staining and time to suture removal. The study was approved by the institutional ethics committee EOM017/24. Written informed consent was obtained from all subjects before the study. All participants completed follow-up. Both groups had comparable baseline characteristics. No significant differences were found in postoperative bleeding, assessed via bandage staining. However, a statistically significant reduction in time to suture removal was observed in patients treated with topical TXA. The study's limitations included the comparison with a historical cohort and the lack of homogenization in forefoot surgery types, which may impact result interpretation. Considering the promising results of this study, we believe that selecting groups of participants who undergo the same procedures will be essential for further refining the findings.

Introduction: Morton’s neuroma (MN) is a painful compressive neuropathy, typically involving the third intermetatarsal space. Ultrasound-guided alcohol injection (USGAI) has emerged as a minimally invasive option, yet its efficacy versus surgical neurectomy remains under evaluation. This retrospective study compares pain and functional outcomes of USGAI and neurectomy in patients with MN, with a minimum 2-year follow-up. Methods: Thirty-three patients with US-confirmed MN refractory to conservative management were included. Seventeen under-went USGAI (Group A) and sixteen surgical neurectomy (Group S). Outcomes were assessed using the Foot and Ankle Disability Index (FADI), Visual Analog Scale (VAS), and a 4-point Likert satisfaction score. Mean follow-up was 29.2 ± 6.8 months (range: 24–48). Statistical analysis used Student’s t-test and Pearson correlation; significance was set at p < 0.001. Results: Both groups showed significant FADI functional improvement (Group A: +33.4 ± 5.6; Group S: +25.4 ± 6.2; p < 0.001) and pain reduction (Group A: 3.5 ± 1.2 to 9.3 ± 0.9; Group S: 3.2 ± 1.0 to 9.3 ± 0.8; p < 0.001). VAS scores decreased from 7.4 ± 1.0 to 1.9 ± 1.3 in Group A, and from 7.6 ± 0.9 to 1.5 ± 1.1 in Group S (p = 0.062). Satisfaction was high (Group A: 87.6%; Group S: 94.1%). No surgical complications occurred; one transient ischemic event followed alcohol extravasation in Group A. Conclusion: USGAI and neurectomy both provide effective long-term relief in MN. USGAI offered greater functional gains, while neurectomy showed slightly superior—but statistically comparable—pain relief.

Introduction: In the surgical treatment of hallux valgus, in addition to correction at the level of the first metatarsal, an Akin osteotomy (medial wedge-closing osteotomy of the proximal phalanx) is frequently associated. It is secured with staples, screws, wire, or transosseous sutures; it occasionally causes discomfort and requires removal. Objective: The objective of this retrospective study is to evaluate the use of periosteal suture fixation of the Akin osteotomy with 0 absorbable suture. Methods: Retrospective, descriptive, single-center cohort study. We describe a large cohort of Akin fixed with periosteal suture (265 feet). Lateral cortical disruption (additional stabilizer of the osteotomy), postoperative osteotomy displacement and delayed- and non union rates were recorded. Results: Between 2013 and 2018, 240 patients, 265 feet (124 left, 141 right) were evaluated. Displacement in the first 6 weeks was noticed in 9.43% (25/265 cases) of cases. Only 1 (0.38%) required reoperation for instability of Akin osteotomy. All cases achieved fusion at 3 months but in 49 cases (16.23%), we observed delayed consolidation. Conclusion: Surgical correction with the periosteal suture fixation for Akin osteotomy is an useful option for managing would appear not to impair osteotomy healing and complication rates, diplaying similar dates to those present in the literature about other fixation systems.

Müller-Weiss Syndrome (MWS) is a rare, idiopathic pathologic condition of the navicular bone in adults, characterized by chronic midfoot pain, deformity, and progressive functional limitation. Due to its complex biomechanics and varying stages of degeneration, surgical treatment remains a challenge. This study presents a comparative analysis of two surgical interventions: calcaneal osteotomy and talonavicular fusion, both aimed at alleviating pain and restoring foot alignment and function. A retrospective review was conducted on patients diagnosed with MWS, treated with either calcaneal osteotomy or talonavicular fusion. A total of 16 patients (21 feet) were included in the study. Surgeries were performed by the same 3 foot and ankle surgeons between 2016 and 2025. Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and visual analog scale (VAS) for pain. All patients reported symptomatic improvement postoperatively. The arthrodesis group demonstrated slightly better scores (AOFAS 59.75±31.63; VAS 5.0±4.14) compared to the osteotomy group (AOFAS 64.08±11.65; VAS 7.08±1.75), though the osteotomy results were more consistent. Nevertheless, no statistically significant differences were detected between the two surgical procedures for the AOFAS and VAS measures. Preliminary results suggest comparable outcomes for both procedures. The existing literature often describes better preservation of foot mobility and faster postoperative recovery with the calcaneal osteotomy, whereas talonavicular fusion provides more robust structural correction in advanced deformities. These results reinforce the importance of patient-specific factors in the surgical decision-making process. More studies are needed to further extend the knowledge and comprehension of MWD treatment.

As one of the three pillars of the foot tripod, the first column plays a key role in maintaining overall alignment. This study aimed to evaluate the effect of a bunion correction procedure (first metatarsal distal Chevron osteotomy) on hindfoot alignment, hypothesizing that lateralization of the first metatarsal head would induce compensatory hindfoot valgus. This retrospective study included 39 patients (58 feet) with symptomatic hallux valgus. The mean age at surgery was 54.8 ± 15.1 years, with an average follow-up of 3.3 ± 1.1 months. All patients underwent pre- and postoperative weight-bearing CT scans. Assessed parameters included: intermetatarsal angle (IMA), sesamoid rotation angle (SRA), distal metatarsal articular angle (DMMA), hallux valgus angle (HVA), sagittal Meary’s angle, and Foot and Ankle Offset (FAO). FAO values significantly increased from 2.22 ± 2.51 preoperatively to 2.97 ± 2.48 postoperatively (p = 0.003), and Meary’s angle from 6.86° ± 7.53 to 8.75° ± 7.73 (p = 0.007). All other radiographic parameters improved significantly (p < 0.001). Subgroup analysis revealed a morphology-dependent FAO change (p = 0.047): cavus feet (preop FAO < –0.5) showed a mean FAO increase of 2.15 ± 2.07; neutral feet (FAO between –0.5 and 5.2) increased by 0.61 ± 1.76; and flatfeet (FAO > 5.2) showed a decrease of –0.05 ± 1.48. We observed that Chevron osteotomy led to a significant shift toward increased hindfoot valgus. This effect was more pronounced in cavo-varus feet and marginal in neutral or flatfoot cases, potentially relevant in borderline cases with preexisting signs of PCFD.

Background: First Metatarsophalangeal (MTP) joint arthrodesis is a commonly performed procedure for hallux rigidus and severe hallux valgus with osteoarthritis. Despite its commonality, post-operative weight bearing protocols vary widely. To date, no prospective randomised controlled trials have directly compared outcomes between immediate weight bearing as tolerated (WBAT) and non-weight bearing (NWB) following 1st MTP fusion. Methods: A prospective randomised controlled trial was conducted with 68 patients undergoing isolated 1st MTP fusion, allocated to WBAT or NWB groups. Standardised surgical technique and fixation (screws or plate) were performed by two fellowship-trained foot and ankle surgeons. Primary outcomes were pain measured by the Visual Analogue Scale (VAS) and function measured by the Foot & Ankle Ability Measure, (FAAM–ADL subscale) at a minimum 12-months. Secondary outcomes included non-union, complications, and patient satisfaction. Statistical analysis used t-tests, chi-squared, or Fisher’s exact tests, with significance at p<0.05. Results: Sixty-eight patients (33 WBAT, 35 NWB) completed the study. Both groups demonstrated significant improvements in pain and function. No significant differences were found in VAS scores (2.97+/-2.215 vs 2.54+/-2.147; p=0.423), FAAM scores (81.31+/-16.028 vs 85.02+/-18.863; p=0.387), or patient satisfaction (8.00+/-2.76 vs 8.34+/-2.52; p=0.594). Complication rates were comparable, with one case of hardware irritation in each group (p=0.739). Conclusions: Immediate weight bearing following 1st MTP fusion is safe and results in equivalent pain relief, function, satisfaction, and complication rates, compared to traditional NWB protocols. These findings support a shift toward more permissive postoperative strategies, with potential benefits for patient mobility, independence, recovery time, and healthcare resource use.

Introduction The choice of surgical technique for hallux valgus correction remains debated. We aimed to compare the radiographic correction of three surgical techniques—guided-Percutaneous Extraarticular Transmetatarsal Osteotomy (PETA), classic Scarf, and screwless Maestro Scarf. Materials and Methods This retrospective cohort study included 120 patients (40 per group). Guided-PETA was executed with an intraoperative guide. We measured Distal Metatarsal Articular Angle (DMAA), Intermetatarsal Angle (IMA), Hallux Valgus Angle (HVA), sesamoid position, and metatarsal length. Group comparisons were performed using ANOVA or Kruskal–Wallis with Bonferroni-adjusted. Results Preoperative DMAA was similar across groups. The guided-PETA group had significantly higher preoperative IMA (p = 0.001) and HVA (p = 0.017) than Maestro. All techniques significantly improved radiographic parameters postoperatively. Classic Scarf achieved superior IMA correction compared to guided-PETA and Maestro (both p = 0.001) and superior HVA correction compared to guided-PETA (p = 0.001). Postoperative DMAA was lower in guided-PETA than Maestro (p = 0.048), but not different from Scarf (p = 1.0). DMAA correction was greater in guided-PETA than Maestro (p = 0.018), with no difference compared to Scarf (p = 0.377). Guided-PETA led to significantly less metatarsal shortening than Scarf techniques (p < 0.05). Guided-PETA showed the lowest standard deviation for DMAA correction (Levene’s test, p < 0.05). There was no significant difference in sesamoid position correction among the three techniques. Conclusion Guided-PETA provided more consistent DMAA correction and minimized shortening, while classic Scarf achieved the greatest angular correction. Technique selection should be guided by the deformity’s characteristics.

Introduction: Post-operative swelling (POS) is a significant concern in forefoot surgery, leading to complications such as pain, stiffness, or wound breakdown. Swelling assessment could improve monitoring and rehabilitation. Traditional volumetric methods require additional equipment. Cone-beam weightbearing CT (WBCT), increasingly used for radiographic evaluation, offers opportunistic swelling assessment without added burden, though its role remains unexplored. This study aimed to evaluate edema using WBCT in forefoot surgery, hypothesizing an increase in swelling at 1-month post-op and a decrease by 3 months. Methods: This retrospective, IRB-approved, paired study included 29 feet with WBCT imaging pre-operatively, at 1 month, and at 3 months post-operatively. Procedures included mini-open Chevron osteotomy; 17.2% underwent additional percutaneous lesser toe realignment, and 58.6% had distal metatarsal metaphyseal osteotomies (DMMO). CubeVue software measured standard Hallux Valgus angles. Slicer 3D segmented soft tissue (ST, -500 to +500 HU) and bone plus soft tissue (BST, -500 to +3000 HU). Friedman’s and Nemenyi’s tests were used for statistical analyses. Results: Mean age was 58.5 ± 14.2 years. ST volume increased by 9.25% (95% CI 6.37–12.14) at 1 month, then decreased by 4.02% (95% CI -6.7 to -1.33) at 3 months (p < 0.001). Swelling was greatest in DMMO cases (12.4%) compared to isolated first ray (4.3%, p=0.02). At 3 months, cases with IMA >14° had more residual swelling than IMA <14°. Conclusions: WBCT enabled objective swelling assessment without additional equipment, potentially enhancing post-operative monitoring and guiding targeted rehabilitation strategies. This opportunistic use may improve post-operative monitoring in forefoot surgery.

INTRODUCTION Hallux Valgus (HV) is a complex deformity with multiplanar components. Weight-bearing computed tomography (WBCT) has enhanced deformity assessment, while 3D-printed models offer a tangible representation of foot anatomy. This study evaluated the correlation and reliability of angular measurements between WBCT and 3D-printed models, focusing on pronation and the distal metatarsal articular angle (DMAA), and examined how deformity severity influences consistency. METHODS Sixteen HV patients were evaluated. Two foot and ankle surgeons performed inter- and intra-rater assessments on WBCT and 3D models. Intraclass correlation coefficients (ICCs) assessed reliability for pronation and DMAA. Digitally reconstructed radiographs were used to measure hallux valgus angle (HVA) and intermetatarsal angle (IMA). Pearson correlations examined the association between WBCT and 3D measurements. Deformity severity was categorized into tertiles based on HVA and IMA. Linear regression and interaction analyses assessed consistency across severity groups. RESULTS High inter- and intra-rater ICCs were found for HVA and IMA. Pronation measurement on 3D models showed lower reliability (inter-rater ICC = 0.507; intra-rater ICC = 0.643). Correlations between WBCT and 3D were moderate to high for pronation (r = 0.55–0.75) and strong for DMAA (r = 0.89–0.91). Deformity severity had no significant impact on measurement consistency (p > 0.05). CONCLUSION WBCT remains the gold standard for foot deformity assessment. 3D-printed models offer strong DMAA correlation and consistent results across severity levels. They may be useful adjuncts in surgical planning, though further refinement is needed for reliable pronation assessment.

Introduction: The distal metatarsal articular angle (DMAA) remains a controversial parameter in hallux valgus (HV) Coronal rotation of the first metatarsal has been proposed as a potential contributor. This study aimed to compare DMAA and related parameters between HV and control feet using weight-bearing CT (WBCT), and to identify factors associated with DMAA. Methods: WBCT scans of 28 feet with HV (HVA > 20°) and 28 control feet were analyzed. Measured parameters included intermetatarsal angle (IMA), hallux valgus angle (HVA), DMAA, and alpha angle. Group comparisons with independent t-tests. Multiple linear regression was used to identify predictors of DMAA within HV and control groups. Interobserver reliability was assessed using intraclass correlation coefficients (ICC). Results: Compared to controls, HV feet demonstrated significantly greater IMA, HVA, and DMAA (10.75° vs 4.69°, all p < .001). The alpha angle did not differ significantly between groups (p = .44). In the HV group, HVA and IMA were the only significant predictors of DMAA (p = .001 and p = .031), explaining 61.7% of the variance. The alpha angle was not a significant predictor (p = .905); each one-degree increase in alpha angle was associated with a -0.02° change in DMAA. Interobserver reliability was almost perfect (ICC > 0.81). Conclusion: DMAA is independently associated with both HVA and IMA severity, suggesting that increased DMAA may reflect the extent of angular deformity rather than a distinct anatomical abnormality. DMAA may be an independent morphological characteristic of global deformity rather than a consequence of a rotational anomaly.

Introduction The guided percutaneous extra-articular transverse axis (PETA) osteotomy is a minimally invasive technique designed to address hallux valgus deformity while minimizing soft tissue disruption. This study aimed to evaluate the radiographic and functional outcomes of guided PETA in patients with moderate to severe hallux valgus. Materials and Methods Seventeen patients (mean age 41.2 ± 15.6 years) underwent guided PETA osteotomy. Radiographic parameters—intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMAA)—were measured pre- and postoperatively. Functional outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ) at baseline and at mean follow-up of 12.7 months (range 6 - 29 months). Paired-sample t-tests were used to assess changes, with significance set at p < 0.05. Results Significant radiographic improvements were observed postoperatively: • IMA: 10.99 ± 1.50° → 7.34 ± 0.86° (p = 0.001) • HVA: 19.4 ± 2.94° → 5.82 ± 4.43° (p = 0.002) • DMAA: 7.73 ± 6.63° → 1.25 ± 0.58° (p = 0.01) MOXFQ scores improved over time, with significant changes: • Pain: from 48.9 to 5.5 (p = <.001) • Function: from 37.8 to 7.14 (p = <.001) • Social interaction: from 33.455 to 4.7 (p = 0.002) • Total score: from 42.24 to 6.51 (p = <.001) Conclusion Guided PETA osteotomy provides effective radiographic correction and substantial functional improvement at 1 year, as demonstrated by both clinical scores and radiographic parameters. These findings support its use as a reliable, minimally invasive technique for the correction of moderate to severe hallux valgus.

Aim Osteoarthritis of the first metatarsophalangeal joint (MTPJ) is a common forefoot problem affecting patients in later years. Treatment is controversial, Arthrodesis remains the gold standard but it has its own complications. The aim of this study was to analyze the outcome of silastic joint arthroplasty for end-stage hallux rigidus. Methods This retrospective analysis included 117 consecutive first MTPJ silastic arthroplasties done between January 2016 and February 2023 for end-stage hallux rigidus. There were 77 females and 40 males with a mean age of 65 years. Radiological and clinical assessments were performed, and patient-reported outcome measure data (PROMS) and visual analogue scale (VAS) scores were collected pre- and post-operatively. Results Findings showed 99.1% survivorship following a silastic joint arthroplasty with a mean follow-up of four years. The MOXFQ score improved from a mean of 81 (59.8-100) to 13 (0-57). The mean VAS scores improved from 7.2 (5-10) to 1.5 (0-7) postoperatively. Five patients were lost to follow-up. Two patients developed deep infection and one required revision. In total 10 patients (8.9%) developed complications, out of which eight patients responded to simple treatments. Conclusion Results have shown good to excellent outcomes following a silastic arthroplasty of the first MTPJ. The survivorship at a mean follow-up of four years was 99.1% and the patient satisfaction rate was 90.1%. As historically reported, we did not see any soft tissue reaction or progressive osteolysis in any of our patients. It provides comparable and predictable outcomes to joint fusion for end-stage arthritis.

Aim Osteoarthritis of the first metatarsophalangeal joint (MTPJ) is a common forefoot problem affecting patients in later years. Treatment is controversial, Arthrodesis remains the gold standard but it has its own complications. The aim of this study was to analyze the outcome of silastic joint arthroplasty for end-stage hallux rigidus. Methods This retrospective analysis included 117 consecutive first MTPJ silastic arthroplasties done between January 2016 and February 2023 for end-stage hallux rigidus. There were 77 females and 40 males with a mean age of 65 years. Radiological and clinical assessments were performed, and patient-reported outcome measure data (PROMS) and visual analogue scale (VAS) scores were collected pre- and post-operatively. Results Findings showed 99.1% survivorship following a silastic joint arthroplasty with a mean follow-up of four years. The MOXFQ score improved from a mean of 81 (59.8-100) to 13 (0-57). The mean VAS scores improved from 7.2 (5-10) to 1.5 (0-7) postoperatively. Five patients were lost to follow-up. Two patients developed deep infection and one required revision. In total 10 patients (8.9%) developed complications, out of which eight patients responded to simple treatments. Conclusion Results have shown good to excellent outcomes following a silastic arthroplasty of the first MTPJ. The survivorship at a mean follow-up of four years was 99.1% and the patient satisfaction rate was 90.1%. As historically reported, we did not see any soft tissue reaction or progressive osteolysis in any of our patients. It provides comparable and predictable outcomes to joint fusion for end-stage arthritis.

Introduction and objectives The Scarf osteotomy is widely used as diaphyseal surgical technique, for correcting hallux valgus deformities of the first metatarsal, due to its versatility and safety. However, it is not without complications. Nonunion (pseudoarthrosis) is a rare but significant one Material and methods We report a case of a 51-year-old female, smoker as only known risk factor, who underwent a Scarf osteotomy for right hallux valgus, fixed by using two cannulated screws. Posoperative evolution was poor, both clinically and radiographically, with persistent pain, crepitus, and swelling, severely affecting daily life. Imaging showed aseptic nonunion at proximal osteotomy site. Ten months after surgery, she underwent revision surgery. Intraoperatively, lack of healing was confirmed at the proximal osteotomy site, while distal site had consolidated. Screws were removed and analyzed with sonication. Tissue samples were also studied. Nonunion site was treated by refreshing and adding autograft bone harvested from minor metatarsal osteotomies, needed for metatarsal pain during surgery. A low-profile compression plate was used for stabilization. Results: Postoperatively, cultures revealed Shingomonas paucimobilis, for which she received two months of oral antibiotics. There were no wound complications, and the patient showed significant clinical improvement. Six months later, she was walking pain-free in regular shoes, and imaging showed early signs of bone healing. Conclusion: Although nonunion after Scarf osteotomy is rarely reported, risk factors like smoking or biomechanical misalignment. Infection must always be considered and ruled out as a primary cause. Early recognition and appropriate surgical revision can yield successful outcomes.

Aims/Objective: First metatarsophalangeal (MTP) joint fusion is a common procedure for treating hallux rigidus and other degenerative toe pathologies. While traditional cigarette smoking is a known risk factor for postoperative complications, the impact of non-tobacco nicotine dependence (NTND), such as through vaping or e-cigarettes, remains poorly understood. This study evaluates whether NTND is associated with increased postoperative complications following 1st MTP fusion. Methods: A retrospective cohort analysis was conducted using the TriNetX database. Patients undergoing 1st MTP joint arthrodesis (CPT 28750) were stratified into NTND users (nicotine dependence without concurrent tobacco product use), and nonsmokers. 1:1 propensity score matching was performed based on demographics and comorbid status. Postoperative complications were assessed within 90 days and 2 years using ICD-10 and CPT codes. Risk ratios (RR), absolute risk differences, and 95% confidence intervals (CI) were calculated. Results: After matching, 1,416 patients were included in each cohort. Compared to nonsmokers, NTND patients had significantly higher 90-day rates of opioid prescriptions (RR 1.17, 95% CI: 1.09 – 1.26, P < 0.001) and aspiration pneumonia (0.7% absolute risk increase, P = 0.002). At 2 years, pseudoarthrosis was significantly more common in NTND users (RR 1.33, 95% CI: 1.07 – 1.64, P = 0.009). No other major short- or long-term complications differed significantly between groups. Conclusions: These findings mirror known effects of tobacco smoking and underscore that nicotine’s adverse effects may extend to vaping. Surgeons should consider NTND use in preoperative risk assessment and reinforce cessation guidelines regardless of nicotine delivery method.

First metatarsophalangeal (MTP) joint arthrodesis is a valid surgical treatment for advanced or end-stage hallux rigidus, including cases where other techniques have failed. Although most published series report a mean patient age between 55 and 60 years, the proportion of older patients who remain physically active and interested in returning to sport is increasing. We retrospectively evaluated consecutive patients treated with first MTP arthrodesis for grade IV hallux rigidus between August 2021 and March 2025 at Policlinico Campus Bio-Medico in Rome. Of 44 treated patients, 35 met inclusion criteria (mean age 64.7 years [48–87]). Clinical outcomes were assessed using VAS and FAAM (Activities of Daily Living), preoperatively and at final follow-up. Among 23 patients engaged in regular sports, RTS time, FAAM Sport, and EFAS scores were recorded. Mean follow-up was 30.7 months [10–49]. Preoperative VAS averaged 8.6 and decreased to 1.6 (p < .005). FAAM ADL averaged 71.1. Of the 23 sporting patients, 20 (87%) returned to regular activity at a mean RTS of 10.9 months, with a mean FAAM Sport of 25.2 and EFAS of 25.9. Complications included one superficial infection and three cases of hardware intolerance, resolved by plate removal. Alhough the literature on return to sport after first MTP arthrodesis is limited and mainly involves younger cohorts, our findings indicate that this procedure can effectively relieve symptoms and support resumption of physical activity—even in older, active patients. Further studies with larger and more diverse cohorts are warranted to guide patient counseling and surgical decision-making.

Modified Lapidus arthrodesis is a surgical option for the treatment of severe hallux valgus, particularly effective in cases with marked deformity and first ray hypermobility. Fusion of the first tarsometatarsal (TMT) joint allows triplanar correction of the deformity and addresses its underlying biomechanical causes. Between December 2021 and January 2024, 24 modified Lapidus arthrodeses were performed at the Fondazione Policlinico Universitario Campus Bio-Medico in Rome using a plate and compression screw construct. Eighteen patients were treated (mean age 57.36 years [33–77]; 22 females, 2 male), with 13 right-sided, 9 left-sided, and 1 bilateral procedure. Deformity severity was assessed via hallux valgus angle (HVA) and intermetatarsal angle (IMA) measured on pre- and postoperative weightbearing radiographs. Clinical outcomes included pre- and postoperative VAS and AOFAS scores. All patients followed a 6-week non-weightbearing protocol using a postoperative boot. Mean follow-up was 29.10 months [13–47]. Mean VAS decreased from 8.73 to 1.21 (p<0.001), and AOFAS scores improved from 59.4 to 93.8 (p<0.05). HVA improved from 17.5° to 9.6°, and IMA from 40.1° to 10.8°, both statistically significant (p<0.05). Radiographic union was achieved in all patients within 3 months, with full weightbearing resumed thereafter. No complications were reported. Modified Lapidus arthrodesis using plate and compression screw fixation demonstrates strong corrective potential and low recurrence by stabilizing the first ray and correcting metatarsus primus varus. These preliminary results are promising, though larger cohorts and longer follow-up are needed to confirm long-term outcomes.

Hallux valgus (HV) surgery is one of the most frequently performed procedures on the forefoot. The aim of this study was to analyze which preoperative factors can predict outcomes in the surgical treatment of hallux valgus (HV), including the risk of complications and recurrence. A retrospective analysis was conducted on patients admitted for surgical treatment of HV. A total of 102 patients were included in the study, with a mean follow-up of 12 months. Statistical analysis was performed using SPSS v.27 Mean age was 54.2 years; 90.2% were female. Average BMI was 25.9 and Charlson Comorbidity Index (CCI) was 1.6. Bilateral deformity occurred in 70.6%, and pes planus in 79.2%. HV severity was mild in 17.5%, moderate in 60.4%, and severe in 22.1%. Mean corrections achieved were: hallux valgus angle (HVA) 15.5°, intermetatarsal angle (IMA) 2.75°, and DMAA 0.83°. AOFAS scores improved from a mean of 76.1 preoperatively to 93.0 postoperatively. Complication rate was 35.1% (most commonly hallux rigidus and recurrence), recurrence rate was 13.6%, and reoperation rate 6.5%. No significant associations were found for demographic factors, bilateral deformity, or pes planus with outcomes. Higher preoperative angles were associated with worse preoperative AOFAS scores but greater postoperative improvement. Only increased preoperative HVA (OR=1.237, p<0.001) and a positive “round sign” (OR=2.97 for recurrence; OR=2.26 for complications) were significantly associated with recurrence and complications. Identifying such predictors may guide surgical planning and improve patient outcomes and satisfaction.

Introduction Metatarsus adductus (MA) complicates hallux valgus (HV) surgery as the second and third metatarsals interfere with correction of the varus deformity of the first ray. Thus, it is crucial to understand the anatomy of MA to improve patient outcomes. The primary aim of this study was to analyze differences in metatarsal angular rotation between HV patients with and without MA. Methods The study cohort study consisted of 124 patients with a primary diagnosis of HV between 2017 and 2023 and both preoperative weightbearing AP radiographs and CT scans of the foot. Patients with previous ipsilateral forefoot surgery were excluded. All radiologic measurements were completed by two independent raters. MA was defined as a Sglarato angle of greater than 20°. Reliability of novel measurements was assessed using Intraclass Correlation Coefficients (ICC). Differences in radiologic measurements between patients with MA and those without MA were compared using the difference between means. Results Moderate to good intra- and inter-rater reliability was observed for measurements of metatarsal angular rotation. Compared to patients without MA, patients with MA had a significantly larger HVA (Difference: 3.36°; CI, 2.13-8.25°) but no difference in IMA. MA patients had greater supination of both the first and second metatarsals (Differences: 2.33° CI, 0.29-3.57° and 2.14°; CI, 0.16-4.12°, respectively). Conclusion Our study found only small differences in metatarsal rotation between HV patients with MA compared to HV patients without MA. Consequently, MA is primarily an axial plane deformity with minimal rotational deformity in the coronal plane.

Introduction Hallux valgus (HV) is a complex three-dimensional deformity of the first ray. Recurrence after surgical correction remains high and may be linked to unrecognized midfoot instability. While previous studies have identified the first tarsometatarsal (TMT1) joint as a possible source, other medial column joints such as the middle-medial intercuneiform (IC) and medial naviculocuneiform (NC) joints may also contribute. This study aimed to evaluate differences in medial column joint spaces between HV patients and controls using 3D distance maps (DMs) derived from weightbearing CT (WBCT) scans. Methods Twenty HV patients were retrospectively identified and matched with 20 controls. WBCT scans were segmented using Disior Bonelogic, and 3D bone coordinate systems were generated in Geomagic Design X via a published Matlab code. Joint regions were divided anatomically: dorsal/plantar for TMT1, proximal/distal for IC, and medial/lateral for NC. Minimum joint distances were calculated from DMs. Results No significant differences were found in TMT1 (dorsal or plantar), distal IC, or lateral NC regions (p>0.10). However, HV patients showed significantly increased minimum distances at the proximal IC region (0.95mm vs. 0.61mm, p=0.004) and the medial NC region (1.23mm vs. 1.11mm, p=0.005) compared to controls. The hallux valgus angle was significantly correlated with DMs at the proximal IC region and medial NC region. Conclusion Widening at the proximal IC and medial NC joints in HV patients suggests valgus alignment of the medial cuneiform, possibly as compensation for first metatarsal varus. These findings highlight the potential role of more proximal medial column joints in HV pathogenesis.

Aims: Bony correction in complex cavovarus deformities is challenging. To correct deformity at the CORA a multiplanar wedge tarsectomy (WT) may be required. We examine our results of WT using patient-specific instrumentation (PSI). Methods: This single-centre, prospective cohort study evaluated non-correctable cavovarus feet undergoing PSI-guided WT. Accuracy of PSI guides/plans, surgical duration and adjunctive procedures were recorded. Pre- and postoperative weight-bearing CT (WBCT) measurements and PROMs (at 1 year) were compared. Data was normally distributed and analysed with paired t-tests and Pearson correlation. Results: 11 patients had tri-planar deformities with a CORA at the Chopart or navicular-cuneiform joint. Mean surgical time was 135 minutes. Planned correction was achieved in all cases. Two cases required minor adjustments to initial osteotomy. Nine patients required adjunctive procedures. Postoperative radiological measurements significantly improved including sagittal and axial Meary’s angle (p=0.039, p=0.010), talonavicular coverage (p<0.001) and coronal forefoot arch angle (p=0.001). All patients fused by 3 months. MOxFQ-Walking scores improved post-operatively, with a greater improvement with increasing correction of adduction (p=0.047, r=0.67). Improvements were noted in other PROMs but were not statistically significant. One patient had residual hindfoot varus and underwent subsequent calcaneal osteotomy. Two patients had delayed wound healing. One patient had transient neuropathic pain and one developed CRPS. Conclusion: PSI-guided wedge tarsectomy is safe and achieves predictable multiplanar correction. Our unit’s experience has been excellent, with significant improvement in patients’ walking, particularly with larger deformity corrections.

Hindfoot fusion is commonly performed to relieve pain and restore function in patients with end-stage ankle and hindfoot conditions. However, its impact on specific aspects of health-related quality of life is not well established. This study aimed to evaluate changes across individual SF-36 domains following hindfoot fusion and assess their correlation with clinician-reported outcomes. A retrospective review was conducted on 98 patients who underwent ankle-hindfoot fusion, focusing on SF-36 subdomains: Physical Functioning (SFPF), Role Physical (SFRP), Bodily Pain (SFBP), General Health (SFGH), and Vitality (SFVI). Scores were recorded preoperatively and at 6 months postoperatively. Paired t-tests were used to determine statistical significance of change, and Pearson correlation coefficients assessed relationships with changes in AOFAS and VAS scores. At 6 months, patients reported significant improvements in SFPF (+12.9, p < 0.001), SFRP (+15.5, p = 0.002), and SFBP (+25.5, p < 0.001). No significant changes were observed in SFGH or SFVI. Improvements in AOFAS scores were moderately correlated with gains in SFPF (r = 0.402), SFBP (r = 0.381), and SFRP (r = 0.289). Pain reduction measured by VAS correlated negatively with SFBP improvement (r = –0.275). In conclusion, hindfoot fusion leads to significant gains in physical and pain-specific domains of patient-reported outcomes. These improvements moderately align with changes in traditional clinician-reported scores, reinforcing the utility of using both SF-36 and AOFAS/VAS to capture recovery more holistically. Incorporating patient-reported outcomes enhances evaluation of surgical effectiveness and promote patient-centered care.

Introduction: Achilles tendinopathy is often managed conservatively, but surgery, such as secondary reconstruction, is required in refractory cases. Obesity has been linked to higher complication rates in foot and ankle surgery. However, its impact on postoperative outcomes following Achilles tendon secondary reconstruction is unclear. This study assess the association between obesity and early postoperative outcomes following secondary reconstruction for Achilles tendinopathy. Methods: Using the National Surgical Quality Improvement Program database (2013–2022), patients undergoing secondary Achilles tendon reconstruction were identified via ICD and current procedural terminology codes. Patients were categorized as non-obese (BMI<30) or obese (BMI≥30). Primary outcomes included 30-day postoperative mortality, readmission, and reoperation; secondary outcomes included wound complications, thromboembolism, and cardiopulmonary or renal events. Compensation was assessed via work relative value units (wRVUs), operative time (OT), wRVU/hour, and reimbursement rate ($/hour). Results: 688 patients were analyzed (183 non-obese; 505 obese). Obese patients had significantly higher rates of diabetes (16.9% vs. 8.7%, P=.0115) and hypertension (50.1% vs. 38.8%, P=.0095) and higher ASA class. Obese patients underwent more concomitant procedures (1.20 vs. 0.97, P=.003). No significant differences were observed in mortality, readmission, reoperation, or secondary complications. Compared to the non-obese group, the obese group showed higher wRVU/hour (14.42 vs. 13.46), and reimbursement rates ($466.42 vs. $435.22), but they did not show significant differences. Conclusion: Our results showed that obesity was not associated with worse early postoperative outcomes following Achilles tendon secondary reconstruction. However, the current reimbursement system may not fully account for the increased surgical workload in obese patients.

Aims To examine the relationship between sagittal plane alignment and patient-reported outcomes measures (PROMs) in patients undergoing ankle / tibiotalocalcaneal (TTC) arthrodesis. Methods: A retrospective review of 42 patients undergoing ankle or TTC arthrodesis over 8 years was conducted. Sagittal and coronal alignment parameters—including anterior/medial distal tibial angles (aDTA/mDTA), talar tilt, tibial-sole angle (TSA), tibio-talar angle (TTA), and tibio-calcaneal angle (TCA)—were measured using weightbearing CT at baseline, 3, and 12 months. Comparisons were made with 50 normal controls. PROMs (MOxFQ) were recorded pre- and post-operatively, along with subjective alignment patient feedback. Results: Mean age was 56±12.9 years; mean BMI was 30.5±5.1. Ankle arthrodesis was performed in 83.3% of cases. Pre-operative sagittal or coronal deformity >10° was seen in 19% of patients. Compared to controls, post-operative TSA was similar (p=0.058), while TTA (5.0°, p<0.001) and TCA (2.9°, p=0.037) were lower. Fixation method, approach, and pre-op deformity had no impact on final sagittal alignment. All MOxFQ domains improved significantly (p<0.01). A lower TSA was predictive of a subjective dorsiflexed foot (p=0.021, Exp(B)=0.472). Conclusions Regardless of pre-operative deformity, Ankle/TTC arthrodesis is effective at restoring sagittal alignment and improves PROMs. There is some variation in TTA, TCA may compensate partially for this resulting in a balanced foot (TSA). TSA influenced perceptions of sagittal balance, particularly when dorsiflexed. It is important to strive for optimal sagittal alignment in ankle and TTC arthrodesis, which may be judged intra-operatively by the TSA.

Background: Hindfoot fusions are effective for managing end-stage arthritis and deformity, but the impact of obesity on clinical outcomes remains inadequately defined. Methods: We retrospectively analyzed 103 patients who underwent open or arthroscopic hindfoot fusions, stratifying them into BMI categories based on WHO guidelines: Normal (n=32), Overweight (n=37), and Obese (n=33). One underweight patient was excluded due to inadequate sample size. Demographic comparability was confirmed across BMI groups (age p = 0.059; sex p = 0.632). Functional outcomes at 6 months were assessed using VAS, AOFAS Hindfoot Score, and SF-36 subdomains. Statistical comparisons included Kruskal-Wallis and Mann-Whitney U tests for between-group differences, and Wilcoxon signed-rank tests for pre- vs. post-operative improvement. Results: There were no significant differences in 6-month postoperative VAS scores (p = 0.980), AOFAS scores (p = 0.733), or SF-36 subdomains across BMI groups. Pairwise post hoc analysis similarly showed no significant differences between Normal, Overweight, and Obese patients. All BMI groups demonstrated statistically significant pre- to post-operative improvements in VAS (Normal: –3.44, Overweight: –4.76, Obese: –5.58; all p < 0.001) and AOFAS scores (Normal: +27.31, Overweight: +31.97, Obese: +34.34; all p < 0.001). Improvements in SF-36 physical function and bodily pain were also significant in most groups. Conclusion: BMI does not appear to impact 6-month postoperative functional outcomes following hindfoot fusion adversely. Patients across all BMI strata achieve significant pain relief and functional improvement, supporting the procedure's efficacy even in obese populations.

Objectives: There is increasing interest in the percutaneous dorsal closing wedge Zadek calcaneal osteotomy (ZO) for treatment of insertional Achilles tendinopathy (IAT). This study aims to investigate the clinical efficacy and radiographic outcomes of ZO in patients with and without pes cavus foot morphology. Methods: A multicentre observational study of patients undergoing ZO for IAT. Patients were stratified into cavus (calcaneal pitch angle >20°) and non-cavus (calcaneal pitch angle ≤20°) groups. The primary outcome was radiographic parameters, including the X/Y ratio and calcaneal pitch. Clinical outcomes were assessed using the MOXFQ, VAS pain, and EQ-5D scores. Results: Between April 2022 and December 2024, 49 feet (47 patients; 20 male, 27 female) with mean age 56.2±12.7 years underwent percutaneous Zadek osteotomy with a mean clinical follow up of 12±7 months and mean radiographic follow up of 6±4 months. The cohort included 39 cavus feet and 10 non-cavus feet. Radiographic analysis showed significant increase in the X/Y ratio in both groups (cavus:2.46±0.27 to 3.11±0.44, p<0.01; non-cavus:2.43±0.34 to 3.10±0.66, p<0.01). Calcaneal pitch angle changed significantly in the cavus group (55.3±8.1° to 47.1±7.9°, p<0.05) but remained relatively unchanged in the non-cavus group (17.9±1.7° to 19.4±5.4°, p=0.32). Clinical outcomes demonstrated significant improvement in MOXFQ, VAS Pain, and EQ-5D scores in both groups (p<0.05), with no significant between-group differences. No non-unions were reported in either group. Conclusion: Percutaneous Zadek calcaneal osteotomy is a safe and effective procedure for IAT in both cavus and non-cavus feet, associated with significant improvements in foot function and pain relief.

Background: While hindfoot fusion is an established surgical procedure for end-stage arthritis and deformity, individual recovery outcomes vary. Identifying preoperative predictors of functional improvement may aid surgical planning and patient counseling. Methods: A retrospective cohort study was conducted on 98 patients who underwent ankle-hindfoot fusion, with functional outcomes evaluated preoperatively and at 6 months postoperatively. Primary outcomes were change in AOFAS hindfoot score (ΔAOFAS) and change in pain score (ΔVAS). Multivariable linear regression analyses were performed using age, BMI, surgical approach (open vs arthroscopic), and baseline scores as independent variables. Results: The regression model for ΔAOFAS showed a moderate fit (R² = 0.428, p < 0.001). Preoperative AOFAS score was the only significant predictor (β = -0.691, p < 0.001), indicating that patients with lower baseline function experienced greater improvement. Age, BMI, surgical technique, and baseline VAS were not significant. For ΔVAS, the model demonstrated good fit (R² = 0.452, p < 0.001). Preoperative VAS was a strong inverse predictor of pain improvement (β = -0.840, p < 0.001), suggesting that patients with higher baseline pain benefitted more. Other variables were not significant. Conclusion: Preoperative functional and pain scores are the strongest predictors of postoperative improvement in patients undergoing hindfoot fusion. Neither BMI nor surgical technique significantly influenced outcomes. These findings support individualized preoperative counseling based on baseline scores.

Minimally invasive arthroscopic techniques are increasingly used for hindfoot and midfoot arthrodesis, offering potential advantages over traditional open surgery. This retrospective study compared early postoperative outcomes between open and arthroscopically assisted fusion, focusing on pain relief, functional recovery, and achievement of the minimum clinically important difference (MCID). Fifty-eight procedures were analyzed (26 arthroscopic, 32 open), with similar baseline characteristics and preoperative scores across groups. Both techniques resulted in significant improvements in the American Orthopaedic Foot & Ankle Society (AOFAS) and European Foot & Ankle Society (EFAS) scores, as well as VAS pain reduction (p < 0.001 within groups). The arthroscopic group showed greater mean improvements in AOFAS (34 ± 8 vs 28 ± 10) and VAS (5.8 ± 1.5 vs 5.0 ± 1.8) compared to the open group, although these differences were not statistically significant (p = 0.16 and p = 0.22). At follow-up (~10 months), final AOFAS and EFAS scores were slightly higher in the arthroscopic group, and a greater proportion achieved MCID for AOFAS (90% vs 75%), EFAS (88% vs 69%), and pain relief (100% vs 94%), though again, not statistically significant. Patient satisfaction and radiographic union rates were high in both groups. Notably, the arthroscopic group had no wound complications, while the open group had a 9% incidence of superficial wound issues. Overall, arthroscopic arthrodesis offered outcomes equivalent to open surgery, with trends favoring greater clinical improvement and fewer wound-related issues. Larger studies are needed to confirm these early findings.

Background and Objectives: The Zadek osteotomy, a dorsal closing-wedge procedure of the calcaneus, is frequently used to treat insertional Achilles tendinopathy in patients who fail conservative treatment. Minimally invasive surgical (MIS) techniques may offer advantages such as reduced soft tissue damage and quicker recovery. However, limited visualization raises concerns about potential injury to the sural nerve. This cadaveric study investigates the anatomical proximity of the sural nerve to the MIS Zadek osteotomy to evaluate the risk of iatrogenic nerve injury and define a surgical safe zone. Methods: Twenty fresh-frozen human lower limbs underwent a standardized MIS Zadek osteotomy using a 3 × 30-mm Shannon burr via a lateral percutaneous approach under fluoroscopic guidance. Following the procedure, anatomical dissections were performed to identify the sural nerve and measure its distance from both the anterior and posterior arms of the osteotomy using digital calipers (precision: 0.1 mm). Two independent observers recorded all measurements. Results: The sural nerve was identified in all specimens, with no cases of transection or visible damage. The mean distance from the osteotomy to the sural nerve was 11.95 mm (range: 8.3–15.4 mm; SD: 2.18 mm). These measurements indicate a consistent anatomical buffer between the osteotomy and the nerve. Conclusions: The MIS Zadek osteotomy appears to carry a low risk of sural nerve injury when performed with adherence to defined anatomical landmarks. The identification of a reproducible safe zone supports the procedure's safety and effectiveness for insertional Achilles tendinopathy. Further clinical studies are needed to confirm these cadaveric findings

Aims: Weight-bearing computed tomography (WBCT) has set a new standard for the assessment of foot and ankle alignment in patients with progressive collapsing foot deformity (PCFD). Principal component analysis (PCA) models are currently used for a detailed 3D shape analysis, but are not able to take in to account non-linear (e.g. rotational) anatomical variance, which is particularly relevant in PCFD. Innovative advances in geometric morphometrics by principal polynomial shape analysis (PPSA) are now able to overcome this challenge. Therefore, the objective of this study was to evalute the use of PPSA to identify in patients with PCFD under weight-bearing conditions. Methods: In this retrospective comparative study, 43 feet from 23 PCFD patients imaged by WBCT were confirmed eligible for analysis. PPSA was applied on the 3D foot models to identify and delineate morphology variations in foot shape between the PCFD and control group. Results: Automated classification of PCFD by LDA using the PPSA model yielded a sensitivity of 91% and specificity of 91% . Furthermore, PPSA revealed distinct foot morphology components in the PCFD group. Anatomical differences were significant and most pronounced at the level of the talocalcaneonaviclar joint, with prominent internal and plantar rotation of the talar bone (p < 0.05). Conclusion: This study is the first to apply PPSA in patients with PCFD. The findings validate distinct 3D spatial position alterations compared to control subjects. More specifically, it is demonstrated that the talocalcaneonaviclar joint is the most significant affected structure.

Tarsal coalitions in adults are uncommon, often underdiagnosed, and sparsely reported in the literature. Their management is particularly complex when associated with severe pes planovalgus This study aims to evaluate the outcomes of a one-stage surgical approach combining medial talocalcaneal coalition resection with fat interposition and a triple C osteotomy of calcaneus-cuboido-cuneiforme for correction of the associated deformity. Between 2013 and 2023, 11 patients (14 feet) with painful and severe hindfoot valgus (>25°) underwent a single-stage procedur e at our institution. The surgical technique consisted of Achilles and peroneal tendon lengthening, medial coalition resection with fat interposition, and three bony corrections: calcaneal, cuboid, and medial cuneiform osteotomies, following Rathjen and Mubarak’s principles. The mean age at surgery was 22.5 years (range: 16–35). Pre- and postoperative assessments included radiographic evaluation and the AOFAS score, with an average follow-up of 6 years. Outcomes showed excellent correction of deformity, significant pain relief, and functional improvement. The mean AOFAS score increased from 40 to 99. Ten coalitions were cartilaginous and four were osseous. No recurrences or major complications were observed. The 3C osteotomy proved essential to fully correct the valgus component. While treating hindfoot valgus during coalition surgery is known, the innovative aspect of this study lies in the systematic use of the 3C osteotomy in adults. This combined approach addresses both the structural and functional pathology, and stands as a reliable, durable alternative to triple arthrodesis in well-selected patients.

Subtalar distraction arthrodesis is a surgical procedure aimed at addressing hindfoot deformities with isolated subtalar joint arthritis. Initially observed by Fitzgibbons in 1996, in some cases hindfoot fusion appeared to be associated with the development of tibiotalar valgus tilt. Since then, few studies have addressed this issue. The purpose of this study was to investigate whether the modified Grice-Green technique is associated with the onset of tibiotalar joint frontal or sagittal modifications. Patients who underwent subtalar distraction arthrodesis via modified Grice-Green procedure were included. The patient records were reviewed to extract demographic data and weight-bearing foot and ankle radiographs were assessed to measure the talar tilt angle and the tibiotalar ratio. A total of 69 patients met the criteria for inclusion. The mean talar tilt increased from 1.46 ± 1.62 preoperatively to 1.93 ± 2.19 at minimum 8 months postoperatively. However, the difference was not statistically significant (p = 0.47). The average preoperative tibiotalar ratio significantly increased from 33.4 ± 4.4% to 35 ± 4% postoperatively (p = 0.007), although remaining within the normal range. In conclusion, this study demonstrates that the modified Grice-Green procedure does not have a statistically significant influence on the talar tilt angle. However, this technique may lead to an increase in tibiotalar ratio values, although these remain within the normal range. This effect is likely a consequence of restoring the physiological coverage of the posterior facet of the subtalar joint by re-establishing normal talocalcaneal alignment.

INTRODUCTION Triple arthrodesis is a common procedure for correcting rigid hindfoot deformities. However, a high rate of complications has been described, with malunion being one of the most frequent. The correction of residual deformities, reported in up to 78% of long-term follow-up series (Saltzmann, 1999), represents a clinical challenge. OBJECTIVE Resolution of a clinical case based on a literature review. MATERIALS AND METHODS A 44-year-old patient presented with ambulation supported by the outer edge of the right foot and antialgic gait after a triple arthrodesis performed due to a comminuted cuboid fracture. Radiologically, varus consolidation of the hindfoot and midfoot supination were confirmed. A review of the literature focused on malposition following triple arthrodesis was conducted. Haddad (1997) provides a treatment algorithm for satisfactory correction, and his systematic approach has been cited in subsequent publications. RESULTS The previous osteosynthesis material was removed, and a derotational osteotomy was performed at the fusion site, along with a valgus osteotomy of the calcaneus. After three months, the patient returned to work with a plantigrade foot and showed improvement in the Manchester-Oxford questionnaire (MOXFQ) score, from 78 to 28. CONCLUSIONS There are few publications on this complication, with reported incidences of 6% (Bibbo, 2001; Galeote, 2012) and 7% following revision surgery (Seybold, 2017). The key to successful treatment lies in the precise identification of the deformity through clinical assessment and imaging studies.

Introduction The literature has demonstrated that ankle osteoarthritis is a disabling condition, comparable to that of hip osteoarthritis. To date, there is no evidence analyzing the extent of disability caused by subtalar osteoarthritis. Methods Patients were recruited from the same hospital between 2003 and 2023. Subtalar and ankle osteoarthritis patients were respectively recruited from a prospective randomized controlled trial and a prospective cohort study involving individuals who required a subtalar fusion or an ankle replacement. The AOS score was compared using the Mann-Whitney test, and a generalized linear regression was performed to adjust for potential confounders and analyze for interactions. Results In 234 individuals (178 with ankle osteoarthritis vs. 56 with subtalar osteoarthritis) statistically significant differences were observed in the baseline characteristics age (median ankle osteoarthritis: 67.1 ± 11.4 versus subtalar osteoarthritis: 59.0 ± 13.2, p-value 0.01), and BMI (median ankle osteoarthritis: 27.4 ± 5.0 versus subtalar osteoarthritis: 29.5 ± 6.5, p-value 0.04). There were no significant univariate associations between these variables and the AOS score. There was no significant difference in the AOS score by osteoarthritis location (median ankle osteoarthritis: 59.9, IQR 46.3–72.6 versus subtalar osteoarthritis: 57.6, IQR 46.8–69.7; p-value 0.81). With the linear regression, BMI showed a positive association with the AOS score. Conclusions This study revealed that subtalar osteoarthritis causes a level of disability comparable to ankle osteoarthritis. In addition, higher BMI was independently associated with greater discomfort and disability.

Introduction: Hindfoot arthrodesis is a well-established procedure for treating severe arthritis and deformities. Minimally invasive techniques such as arthroscopic fusion have gained popularity due to presumed lower complication rates. This study presents a five-year retrospective review of hindfoot arthrodesis outcomes in a small county hospital, focusing on surgical approach and fixation method. Materials and Methods: We retrospectively analyzed 21 hindfoot arthrodesis procedures performed between 2019 and 2024: 12 subtalar, 6 tibiotalar, and 3 double arthrodeses. Eleven were performed using an open approach and nine arthroscopically. Consolidation and infection rates were compared, and subgroup analysis was conducted for subtalar arthrodesis based on screw count and surgical technique. Results: Postoperative infection occurred in three open cases and none of the arthroscopic ones. While not statistically significant (Fisher’s exact test, p = 0.218), the odds of infection were 7.8 times higher in open surgery. Consolidation was achieved in 89% of arthroscopic cases and 55% of open cases (p = 0.157; OR = 0.21). Among subtalar arthrodeses, one-screw fixations showed higher non-union rates (75%) compared to two-screw fixations (50%), with improved consolidation when combined with an arthroscopic approach (66%). All tibiotalar and double arthrodeses achieved consolidation; only one double arthrodesis developed an infection, managed with debridement. Conclusion: Arthroscopic hindfoot arthrodesis is associated with lower infection rates and improved consolidation, although statistical significance was not reached due to the small sample size. In subtalar cases, using two screws and an arthroscopic approach may improve outcomes. Further research with larger cohorts is warranted.

Clubfoot equinovarus is one of the most common congenital deformities in children. The problem lies in feet that have already been operated on and which present with residual deformities or even recurrences. The objective of this presentation is to show the surgical difficulties faced with the complexities of deformities. This is a prospective study between 2021 and 2024 including children with severe foot deformities, non-reducible stiffness already operated on for congenital equinovarus clubfoot. Thirty children (40 feet: 10 bilateral and twenty unilateral), mostly male, the average age is 7.9 years, the average follow-up is 25 months. The surgical technique performed always combines a soft tissue release procedure and a bone procedure. Significant improvements were observed in radiological parameters and functional outcomes. for a foot that has already been operated on, the complexity of the deformations is due first of all to the pathology itself and then to the consequences of the initial intervention which did not sufficiently or too much correct the deformations, thus generating an imbalance of the musculo-tendinous balance and significant retractions of the soft parts, as well as a disorganization of the bone structure, around a laterally dislocated talus, with biomechanical disturbances and stiffness, added to this is the growth of the child which will aggravate this disorganization. The challenge is to restore alignment and provide plantar support. Multi-operated clubfoot constitutes a real problem for surgical management, especially on a stiff foot and a structured deformity.

Introduction: When treating Progressive Collapsing Foot Deformity (PCFD), Lateral Column Lengthening (LCL) osteotomies such as Evans (EO) and Hintermann osteotomy (HO) are commonly used. The EO involves a cut proximal to the calcaneocuboid joint (CCJ), while HO starts at the angle of Gissane. Due to anatomical variations, the entry point and obliquity for LCL can vary, often leading to iatrogenic injury to articular facets. This study aims to identify a single ideal entry point for LCL to enable reliable cuts between the anterior/middle or middle/posterior facets. Methods: Retrospective-cohort study, 70 PCFD patients underwent weightbearing CT. Calcaneus was segmented, and the anterior (AF), middle (MF), and posterior facets (PF) were marked. Traditional entry points for EO and HO were measured, along with the distances and angles relevant to each facet. An ideal entry-point was then determined on the lateral wall of the calcaneus to optimize angulation tolerance for performing either EO or HO. Results: Use of traditional EO points risked injuring 91% of MFs. The ideal entry-point was found to be on average 19.4mm posterior to the CCJ and just 0.7mm anterior to the Angle of Gissane. This position allows for an average angulation range from the ideal entry-point to AF/MF of 7.4° and to MF/PF of -7.4°. Conclusion: This study identifies an optimal entry-point for LCL osteotomies that maximizes angulation tolerance and minimizes the risk of injuring articular facets. This finding provides valuable guidance for surgical planning in PCFD, potentially improving the accuracy of LCL osteotomies and patient outcomes.

This retrospective study compared clinical and radiographic outcomes of joint-sparing reconstructive procedures for flexible (Stage 1) Progressive Collapsing Foot Deformity (PCFD) and hindfoot fusions for rigid (Stage 2) PCFD. We hypothesized that fusions would provide greater radiographic correction, while joint-sparing procedures would yield superior clinical short-term outcomes. Fifty-four adult PCFD patients (33 female, 21 male, mean age 54.2 years, mean BMI 32.2) treated by a single surgeon were analyzed. Thirty-six patients with Stage 1 PCFD underwent joint-sparing reconstruction, and 18 patients with Stage 2 PCFD underwent hindfoot fusions. Minimum follow-up was six months (mean 11.2 months). Pre- and three-month postoperative weightbearing CT (WBCT) scans assessed alignment. PROMIS Physical Function (PF) and Pain Interference (PI) scores were collected at baseline, three, and six months. Groups were similar for gender and BMI; reconstruction patients were younger (48.9 vs. 64.7 years, p=0.001). Complication rates were similar. PROMIS scores improved significantly in both groups by six months (p<.05). At three months, PROMIS-PI was significantly lower in the fusion group (p=0.026), but this difference was not sustained at six months. WBCT parameters improved significantly in both groups (all p-values <0.05), with fusions achieving greater correction of abduction and longitudinal arch collapse. Multivariate regression revealed that postoperative alignment/sinus tarsi impingement/age significantly influenced PROMIS-PF (p=0.0002, R2 0.84), while sinus tarsi impingement/BMI/gender significantly influenced PROMIS-PI (p<0.0001, R2 0.82). Both joint-sparing reconstruction and hindfoot fusion improved radiographic alignment and clinical outcomes. Longer-term studies are needed to compare durability and functional outcomes between these surgical treatments.

Introduction: Conventional radiographic (CR) parameters are frequently used to evaluate Progressive Collapsing Foot Deformity (PCFD), but threshold values for classifying deformity types are not well defined. This study aimed to identify the specific measurements and cut-off values that influence orthopaedic foot and ankle surgeons’ staging of PCFD across its five classes: A (hindfoot valgus), B (midfoot/forefoot abduction), C (arch collapse), D (peritalar subluxation), and E (valgus talar tilt). Methods: Five fellowship-trained foot and ankle surgeons independently assessed clinical and CR images from 96 PCFD patients (108 feet), including anteroposterior (AP) and lateral foot views, AP ankle view, hindfoot alignment view, and posterior clinical heel view. Observers made class determinations visually without measurements. A sixth investigator recorded radiographic metrics: hindfoot moment arm (HMA, Class A), talonavicular coverage angle (TNCA) and talus–first metatarsal angle in the axial plane (TFMA-A, Class B), calcaneal inclination angle (CIA) and talus–first metatarsal angle in the sagittal plane (TFMA-S, Class C), subtalar impingement (STI) and subfibular impingement (SFI, Class D), and talar tilt angle (TTA, Class E). Results: Interobserver agreement was high: 0.98 (A), 0.88 (B), 0.77 (C), 0.74 (D), and 0.96 (E). Class A was present in 100% of feet, followed by B (96.3%), C (82.4%), D (37.0%), and E (6.5%). Key thresholds influencing classification included: TFMA-A >13.31° (AUC = 0.90), TFMA-S >16.45° (AUC = 0.90), absence of STI (88.5% predictive of no Class D), and TTA >0.52° (AUC = 0.92). Conclusion: Specific CR thresholds reliably influence PCFD classification and may guide more objective, standardized staging.

The Foot and Ankle Offset (FAO) is a validated 3D biometric tool to assess hindfoot alignment based on weight-bearing CT. Traditionally, FAO is calculated using a reference point at the central, proximal aspect of the talar dome. However, in the presence of talar tilt or joint incongruency, this point may not represent the actual biomechanical center of the ankle. This study aimed to assess how different anatomical reference points affect FAO in patients with tibio-talar misalignment. We retrospectively analyzed 39 weight-bearing CTs from patients with symptomatic varus or valgus deformity and ≥2° of talar tilt. Three FAO measurements were compared: TD-FAO (talar dome), TM-FAO (midpoint of tibial plafond), and CP-FAO (center of tibio-talar contact). FAO values varied significantly between methods and alignment type (p<0.001). In valgus cases, CP-FAO deviated more from TM-FAO (10.86 ± 7.97 vs. 15.83 ± 4.77; p=0.001) than TD-FAO did (p=0.006). A similar trend was observed in varus (–9.77 [IQR 6.04] vs. –16.69 [IQR 4.17]; p<0.001), while TD-FAO was closer to TM-FAO (p=0.23). A three-way comparison confirmed significant differences among all three methods (p<0.001). These results indicate that traditional FAO based on the talar dome may overestimate malalignment in the setting of joint incongruency. Among the tested methods, the tibial midpoint may offer the most consistent approximation of the normal ankle joint center, especially in deformed joints, and may therefore represent a more reliable reference for quantifying the relationship between the foot tripod and the ankle joint center.

Introduction Coronal plane differences in talar shape between patients with progressive collapsing foot deformity (PCFD) and controls are well documented. However, axial rotation of the lower limb can significantly affect subtalar alignment on imaging, raising the question of whether axial differences contribute to coronal discrepancies. We hypothesize that axial alignment differs between PCFD and controls and impacts talar morphology. Methods WBCT scans from 42 PCFD patients and 27 controls were analyzed. Measured angles included: inferior talar facet vs. horizontal (inftal-hor), inferior vs. superior talar facets (inftal-suptal), bimalleolar axis vs. coronal plane, talar inclination, Meary’s angle, and foot and ankle offset (FAO). Two observers measured all variables; reliability was assessed with intraclass correlation coefficients (ICC). Linear regression evaluated the contribution of Meary’s angle, FAO, bimalleolar axis, and talar inclination to inftal-suptal and inftal-hor variance. ANOVA tested the effect of ±10° axial rotation. Normalized measurements were compared post-adjustment for axial and sagittal alignment. Results All angles differed significantly between PCFD and controls (p < .001). Axial rotation of ±10° significantly changed inftal-hor and inftal-suptal (p < .001). Regression showed bimalleolar axis and talar inclination as key predictors of inftal-suptal variance (64.9%, p < .001); Meary’s angle and FAO were not significant. Differences remained significant after normalization (p < .001). Conclusion Axial talar rotation significantly affects subtalar morphology measurements. Differences persist despite normalization. Standardized WBCT positioning protocols should be enforced to reduce variability. Future studies should explore the clinical impact of incorporating rotational alignment into PCFD corrective strategies.

The Zadek Osteotomy (ZO) is a surgical technique employed in the treatment of Insertional Achilles Tendinopathy (IAT). The effectiveness of this procedure may be influenced by the position and orientation of the osteotomy wedge. This study aims to investigate whether variations in these parameters affect the bone correction power. A retrospective analysis was conducted using Disior Bonelogic™ software (Zimmer Biomet, Warsaw, IN, USA) to perform virtual ZO on WBCT-derived 3D models from 60 asymptomatic patients, stratified by foot type based on calcaneal pitch. For each case, nine osteotomy configurations—combining three wedge positions and three inclinations—were simulated, and their effects assessed using key radiographic parameters: calcaneal pitch, talocalcaneal angle, hindfoot moment arm, hindfoot alignment angle, Fowler–Philip angle, and calcaneal length ratio. The inclination of the wedge did not significantly affect any of the measured variables (p=.99). However, the position of the osteotomy hinge showed a marked impact. When the hinge was placed anterior to the calcaneal tuberosity, a significant decrease in calcaneal inclination angle was observed from 16.22°±7.94 to 14.12°±7.72 (p<.001). Placement of the hinge at the level of calcaneal tuberosity resulted in a significant increase in both the Fowler-Philip angle and the calcaneal length ratio (p<.001). Similar findings were observed in the subgroup analysis based on foot type. These findings highlight the relevance of osteotomy hinge positioning in influencing radiographic outcomes, suggesting that individualized planning based on foot morphology may enhance surgical effectiveness.

INTRODUCTION: Progressive Collapsing Foot Deformity (PCFD) determinants are multifactorial, originating from bony and soft-tissue involvement. PCFD classification relies on staging as flexible (1) or rigid (2), based on clinical examination: subjective and influenced by experience and patient-specific factors. An objective, data-driven approach could enhance staging accuracy. Automated measurement reports can be generated from Weightbearing CT (WBCT) images, and machine learning (ML) offers potential for analyzing these datasets. This study aimed to evaluate the staging accuracy of WBCT-based ML in PCFD cases, hypothesizing substantial agreement with clinical staging. METHODS: This retrospective cross-sectional study analyzed 73 feet staged as flexible or rigid, using WBCT datasets. Reports included 37 automated measurements per foot. Demographics were recorded. Data were normalized (mean=0, SD=1), and Principal Component Analysis (PCA) reduced dimensionality, retaining 17 components explaining 95% of cumulative variance. Machine learning models applied included Logistic Regression, Random Forest, Voting Classifier, and Support Vector Classifier. An 80/20 training-validation split was used, evaluating performance via F1-score, precision, recall, accuracy, and Area Under the Curve (AUC). Models with F1-score >0.80 were considered successful. RESULTS: Mean age was 59.2±15.6 years, BMI 32.6±6.4 kg/m², and Foot Ankle Offset was 10.6%±4.9. There were 39 flexible and 34 rigid feet. CatBoost achieved the highest performance (F1-score 0.84, precision 0.89, recall 0.80, accuracy 0.80, AUC 0.76). SVC had the best AUC (0.82) and recall (1.0). CONCLUSIONS: ML models accurately staged PCFD using automated WBCT-derived 3D measurements. This objective method could support clinical evaluations, although future research should explore larger, multicenter datasets.

Background: Subtalar arthrodesis is commonly performed to treat hindfoot arthritis, deformities, and instability. Prior ankle arthrodesis may negatively impact subtalar fusion due to altered biomechanics and vascular supply, though evidence is limited. This study examines fusion outcomes following subtalar and ankle arthrodesis in patients with and without prior ipsilateral fusion. Methods: Using the TriNetX Research Network, we identified patients who underwent subtalar fusion with (ankle-subtalar) or without (subtalar-only) prior ankle fusion. The ankle-subtalar group was stratified by the outcome of the prior ankle fusion (successful vs failed). A secondary analysis examined patients who underwent ankle fusion with (subtalar-ankle) or without (ankle-only) prior subtalar fusion, similarly stratified by fusion outcome. Propensity score matching (1:1) was performed based on age, sex, BMI, and comorbidities. Primary outcomes included one-year nonunion and hardware removal rates. Results: Before matching, 265 patients were in the ankle-subtalar cohort and 12,635 in the subtalar-only group. The ankle-subtalar group had significantly higher hardware removal (20.2% vs 10.3%, p=0.002) and nonunion (30.5% vs 18.7%, p=0.002) rates. Failed ankle-subtalar patients had a threefold higher risk of nonunion (RR 3.0, 95% CI 1.79–5.02). In the secondary analysis, 171 patients were in the subtalar-ankle group and 6,801 in the ankle-only group. Hardware removal was higher in the subtalar-ankle group (17.5% vs 6.4%, p=0.002), while nonunion rates were similar. Failed subtalar fusion was associated with a 2.4-fold increased risk of ankle nonunion (RR 2.4, 95% CI 1.30–4.42). Conclusion: Fusion success, not prior fusion status alone, significantly influences nonunion risk in subsequent hindfoot procedures.

Background: Venous thromboembolism (VTE) is a potentially life-threatening complication following orthopedic surgery. While prophylaxis is routine in joint arthroplasty, its role after Achilles tendon repair remains controversial. Despite being a soft-tissue procedure, prolonged postoperative immobilization increases VTE risk, with symptomatic rates reported as high as 7%. However, the cost-effectiveness of pharmacologic VTE prophylaxis in this population has not been previously studied. Methods: A literature review and TriNetX Research Network data were used to estimate 30-day symptomatic VTE rates following primary Achilles tendon repair without prophylaxis. VTE treatment costs were derived from published data and adjusted to 2025 U.S. dollars. Drug prices were obtained from an online pharmacy database. A break-even analysis was conducted to determine the absolute risk reduction (ARR) and number needed to treat (NNT) at which aspirin (81mg and 325mg), warfarin (5mg), enoxaparin (40mg), and rivaroxaban (20mg) become cost-effective. A sub-analysis compared postoperative bleeding and transfusion rates between patients who did and did not receive chemoprophylaxis. Results: Among 8,935 patients without chemoprophylaxis, 47 developed symptomatic VTE (0.526%). Aspirin and warfarin were cost-effective across all VTE rates (NNTs 9,217–10,547); warfarin remained cost-effective with INR monitoring. Enoxaparin and rivaroxaban were only cost-effective at the highest VTE rate (7.2%), with NNTs of 131 and 390, respectively. No significant differences in bleeding or transfusion rates were observed with prophylaxis. Conclusion: Aspirin and warfarin are cost-effective for VTE prophylaxis after Achilles tendon repair. Enoxaparin and rivaroxaban are not cost-effective under most scenarios. Prophylaxis decisions should consider patient risk and cost-effectiveness.

Surgical treatment for flexible (Stage 1) Progressive Collapsing Foot Deformity (PCFD) preserves triple joint mobility and typically includes osteotomies, tendon transfers, and ligament reconstructions to correct hindfoot valgus (Class A), forefoot/midfoot abduction (Class B), forefoot varus/medial column instability (Class C), and peritalar subluxation (Class D). We hypothesized that joint-sparing surgery would achieve significant radiological correction across all PCFD classes. This retrospective cohort study included 43 adult PCFD patients (24 females, 19 males; mean age 47.8 years, mean BMI 31.0). All underwent joint-sparing reconstruction by a single surgeon, with at least three months of follow-up (mean 9.3 months). Postoperative care included six weeks of nonweightbearing followed by progressive weightbearing. Pre- and three-month postoperative WBCT scans assessed alignment using semiautomated and manual measurements representing PCFD classes A-D (Foot and Ankle Offset, Hindfoot Moment Arm, Talonavicular Coverage Angle, Forefoot Arch Angle, Sagittal Talus-First Metatarsal Angle, and Middle Facet Subluxation). Performed surgical procedures and complications were recorded. All radiographic parameters improved significantly postoperatively (all p-values <0.01). Most common procedures were Cotton or Lapicotton for plantarizing the first ray (100%), Medial Displacement Calcaneal Osteotomy (93%), Peroneus Brevis to Longus transfer (86%), Posterior Tibial Tendon procedure (84%), Gastrocnemius/Achilles lengthening (81%), and Spring Ligament reconstruction (67%). Three patients (7%) had complications, including two nonunions. This study highlights the potential of joint-sparing PCFD reconstruction, demonstrating promising short-term radiographic outcomes. Longer follow-up with WBCT is needed to assess the durability of correction. Additionally, studies evaluating clinical outcomes after joint-sparing procedures are warranted.

Introduction: Stress fractures of the 5th metatarsal are common in individuals engaging in repetitive impact activities or patients with preexisting deformities. Compared to traumatic fractures, outcomes are often worsened by delayed unions, non-unions, or recurrence. Risk factors such as hindfoot varus and foot adduction have been identified, but specific anatomical and bone density characteristics of the 5th metatarsal remain underexplored. This study aimed to analyze alignment and bone density patterns associated with 5th metatarsal stress fractures using weight-bearing computed tomography (WBCT). Methods: This retrospective case-control study analyzed 15 feet with stress fractures and 15 control feet using WBCT. Fifth metatarsal offsets, orientations, and foot alignment were assessed from Digital Imaging and Communications in Medicine (DICOM) datasets. Segmentation and normalized bone density (Hounsfield Units [HU]) measurements were performed. Results: No significant differences existed between groups for age, BMI, sex, or laterality. Fracture cases exhibited lower 5th metatarsal base height (p=0.045), increased ground contact frequency (p<0.001), and longer metatarsal length (p=0.038). Hindfoot varus and foot adduction were significantly associated with stress fractures. Although absolute HU values showed no difference, fracture cases demonstrated a mean 50% increase in normalized HU values (p<0.001). A metatarsal-to-talus HU ratio of 1.2 predicted stress fractures with 80% sensitivity and 94% specificity. Conclusions: Stress fractures of the 5th metatarsal are associated with distinct alignment patterns, including reduced base height, increased plantarflexion, longer length, and higher bone density, suggesting potential indicators for early preventive measures.

The surgical management of paediatric flatfoot includes various techniques, with calcaneal osteotomy, particularly the Evans procedure. This technique elongates the lateral column of the foot without compromising remaining growth. Traditionally, cortical bone autografts or allografts are used as wedges to achieve the desired mechanical correction. Recently, synthetic alternatives such as porous titanium wedges have been introduced, offering precise elongation and inclination control while promoting osteointegration and eliminating donor site morbidity. This study aims to evaluate the short- and medium-term clinical and radiological outcomes of porous titanium wedges in paediatric patients undergoing Evans osteotomy for flatfoot deformity. Twelve feet from nine pediatric patients (three bilateral) with a mean age of 12 years were included. Five patients presented with comorbid conditions, including agenesis of the corpus callosum, cerebral palsy, and hydrocephalus. All participants had open growth plates. In three cases, a simultaneous Cotton osteotomy using porous titanium wedges was performed. At one-year follow-up, significant improvements were observed in pain and functional outcomes, as assessed by the EVA and GSTT scales. Quality of life, measured using the EuroQol-5D scale, also improved. Radiographic evaluation demonstrated complete bone consolidation in all cases. Postoperative correction was assessed using the Kite angle, talo-first metatarsal angle, and Moreau-Costa-Bartani angle, with all but one case achieving improved alignment. Postoperative complications were minimal; one patient required surgical debridement due to delayed wound healing. Porous titanium wedges provide favorable clinical and radiological outcomes in paediatric Evans osteotomy, with significant pain reduction, improved quality of life, and effective consolidation while minimizing complications.

INTRODUCTION Diabetes mellitus affects the treatment of lower extremity pathologies, including Achilles tendon disorders. Non-enzymatic glycosylation leads to tendon stiffening and altered gait mechanics. While the effects of diabetes on Achilles tendon structure are well-studied, its impact on Insertional Achilles Tendinopathy with Haglund deformity (IAT-HD) remains unclear. This study compares surgical and patient-reported outcomes between diabetic and non-diabetic patients undergoing IAT-HD repair. METHODS This retrospective cohort study included adult patients who underwent insertional Achilles tendon repair with Haglund's deformity between 2017 and 2022. Patients were stratified by the presence of diabetes mellitus. Key demographic factors, surgical characteristics, and comorbidities were collected. The primary outcome was functional improvement, measured by FAAM scores at 1- and 2-year follow-ups. Secondary outcomes included readmissions, revisions, time to weight-bearing, physical therapy, and complications. RESULTS A total of 18 diabetic patients and 132 non-diabetic patients were included. Baseline demographics and surgical characteristics were similar between groups. Diabetic patients showed higher rates of 90-day and more than 90-day readmissions, revisions, debridement, retear, and a decrease in FAAM score at 1-year, although these differences were not statistically significant. CONCLUSION Patients with diabetes exhibited similar surgical and patient-reported outcomes after operative management of IAT-HD compared to non-diabetic patients. These findings suggest that surgical intervention for IAT-HD is safe in diabetic patients, providing valuable information for preoperative counseling and risk stratification.

INTRODUCTION Haglund deformity often requires surgery, with treatment and outcomes potentially influenced by insurance coverage. This study examines how insurance type affects treatment decisions, complications, and recovery in patients with Haglund deformity, aiming to identify disparities and improve healthcare delivery. METHODS We retrospectively analyzed 172 patients with Haglund deformity, grouped by insurance type: Medicare, PPO/HMO, and Other. Continuous data are presented as mean (standard deviation), and categorical data as count (percentage). For two-group comparisons, T-tests or Mann-Whitney U tests were used; ANOVA or Kruskal-Wallis tests were applied for three-group comparisons. Chi-Square or Fisher’s Exact tests were used for categorical variables. Variables analyzed included age, race, sex, BMI, comorbidities, length of stay, DCI scores, preoperative treatments, surgical details, and postoperative outcomes. Statistical significance was set at p < 0.05. RESULTS Medicare patients were significantly older (67.2 vs. 52.5 years, p < 0.001) and had higher Charlson Comorbidity Index scores (p = 0.002) than PPO/HMO and Other groups. No significant differences were observed in race, sex, BMI, or length of stay. Readmission rates were similar (p = 0.058), but revision surgery rates were significantly higher in the Other insurance group (12.2%, p = 0.038). No significant differences were found in postoperative outcomes, including weight-bearing time, FAAM VAS scores, or rehabilitation (1-year p = 0.162; 2-year p = 0.705). CONCLUSION While Medicare patients had more comorbidities, outcomes were similar across groups. The Other insurance group had higher revision rates, but no significant differences in functional recovery were identified.

INTRODUCTION Total talus replacement (TTR) is an emerging alternative to tibiotalar and subtalar fusion for patients with talar avascular necrosis, nonunion, or trauma, offering the advantage of motion preservation. However, data on failure rates, functional outcomes, and predictors of poor results remain limited. This study evaluates functional outcomes, reoperation rates, and risk factors for complications following TTR. METHODS A retrospective review identified patients who underwent isolated elective TTR between 2017 and 2023. Patients who received total ankle arthroplasty or tibiotalar fusion were excluded. Demographic variables (age, sex, BMI, comorbidities) were collected. Functional outcomes were assessed using Foot and Ankle Outcome Scores (FAOS), including pain, symptoms, ADL, sports/recreation, and QOL domains. Complications, revision rates, and additional surgeries were analyzed. RESULTS Thirty-one patients underwent TTR (mean age 41.6 ± 15.4 years; 71.2% female; mean BMI 29.7 ± 7.0). Mean follow-up was 1.7 ± 0.9 years. Diabetes was present in 12.9% of patients. Significant improvements were observed across all FAOS domains (p < 0.001), including pain (42.0 ± 17.3 to 75.3 ± 18.6), symptoms (42.0 ± 19.1 to 66.4 ± 22.9), ADL (54.5 ± 23.5 to 84.3 ± 18.6), sports/recreation (26.8 ± 31.4 to 36.5 ± 28.4), and QOL (10.4 ± 14.5 to 42.8 ± 21.2). Two patients (6.4%) required revision surgery; four (12.9%) underwent additional procedures. CONCLUSION TTR significantly improved functional outcomes and preserved joint motion with low early revision rates. It represents a promising option for appropriately selected patients seeking to avoid fusion procedures.

Charcot neuroarthropathy is a rare but severe diabetic complication characterized by progressive joint and bone destruction, often leading to deformity, ulceration, and amputation. Conservative treatments have shown high failure rates, prompting a shift toward surgical approaches aimed at restoring a stable, plantigrade foot. This study evaluates a minimally invasive technique combining arthroscopic debridement with retrograde intramedullary nail arthrodesis. We conducted a retrospective review of 15 patients treated between January 2022 and January 2024. Inclusion criteria were hindfoot Charcot neuroarthropathy and a minimum follow-up of 6 months. Clinical and radiographic outcomes were assessed using the AOFAS score, time to wound healing and bone fusion, ambulation status, and complications. The mean age was 53 years; all patients had insulin-dependent diabetes. Preoperative findings included rocker-bottom deformity (100%), recurrent ulcers (30%), and ankle or subtalar instability (36%). The mean AOFAS score improved from 23.5 preoperatively to 75 at 6 months. All patients achieved skin healing and radiological consolidation within a mean of 5 months. Ninety percent regained walking ability; one patient remained wheelchair-bound. No revision surgeries were needed. Complications were limited to one case of tibial cortical breach. This combined minimally invasive technique appears to offer a valuable alternative to amputation in selected patients with Charcot foot, achieving both mechanical stability and soft tissue healing. These results are encouraging and suggest that early surgical intervention may significantly improve outcomes in this challenging condition. Further long-term studies are needed to confirm durability and functional benefit.

Aims/Objectives: Hindfoot arthrodesis, while routinely performed for arthritis, trauma, and deformity correction, carries risks of several postoperative complications. Cigarette smoking is a well-established risk factor for impaired bone healing, but the effects of non-tobacco nicotine dependence (NTND), such as from vaping and related behaviors, are poorly understood. This study aims to evaluate the association between NTND and postoperative complications following hindfoot fusion. Methods: This retrospective cohort study utilized the TriNetX database to identify patients who underwent hindfoot arthrodesis. Patients were categorized into NTND (ICD-10: F17, excluding tobacco-specific codes) and nonsmoker cohorts. 1:1 propensity score matching was performed to balance demographics and comorbidities. Outcomes were assessed at 90 days and 2 years postoperatively using risk ratios (RR) with 95% confidence intervals (CI). Results: After matching, 2,172 patients were included in each cohort. NTND patients had significantly higher 90-day rates of opioid prescriptions (RR 1.20), emergency department visits (RR 1.31), hospitalizations (RR 1.20), postoperative infections (RR 1.61), wound complications (RR 1.68), and pneumonia (RR 2.19) (all P < 0.05). At 2 years, NTND patients experienced increased rates of pseudoarthrosis (RR 1.52), mechanical implant failure (RR 1.42), infection-related implant failure (RR 1.39), and periprosthetic fractures (RR 1.59) (all P < 0.05). No differences in revision arthrodesis rates were observed. Conclusions: NTND is associated with increased short- and long-term complications following hindfoot fusion. These findings suggest that vaping may negatively impact bone healing and surgical recovery. Surgeons should incorporate NTND considerations in preoperative risk assessments and promote cessation strategies to optimize patient outcomes.

Background: Osteoid osteoma (OO) is a benign bone tumor that rarely occurs in the sinus tarsi, where its non-specific symptoms can make diagnosis difficult. Arthroscopic excision is a minimally invasive treatment option, though it has been reported in only a few cases involving this location. Case Presentation: We report the case of a 45-year-old male with 18 months of persistent left foot pain misdiagnosed as sinus tarsi syndrome. Despite conservative treatment, symptoms persisted. Imaging eventually revealed a lesion consistent with OO in the calcaneus at the sinus tarsi floor. Arthroscopic resection was performed using standard instruments, and histopathological analysis confirmed the diagnosis. Postoperative recovery was uncomplicated, with complete symptom resolution. Conclusion: Arthroscopic excision of OO in the sinus tarsi is a feasible and effective treatment option that enables precise tumor removal with minimal disruption to surrounding structures. This case contributes to the limited body of literature on this approach and supports its use as a viable alternative to open surgery or ablative techniques.

Background: Insertional Achilles tendinopathy is a frequent condition among physically active individuals. Extensive intratendinous pathologies may require partial tendon detachment, debridement and reconstruction of the tendon footprint. Positive functional outcomes are reported after the procedure, but literature on postoperative sport function is limited. Methods: Pre- and postoperative sports capability and ankle function were assessed in 25 patients undergoing Achilles tendon debridement and double-row footprint reconstruction. Results: The mean VAS score for pain during sport decreased significantly from 7.4 (SD, 2.5) to 1.2 (SD, 2.0) postoperatively (p < 0.001). Sports ability and subjective fitness levels increased significantly from 3.6 (SD 3.0) and 3.5 (2.2) to 8.8 (2.4) and 8.8 (2.2), respectively (p < 0.001). A trend from high-impact sports to low-impact sports was observed postoperatively. The subjective surgical outcome was good or excellent in 96 %. Conclusion: Our study shows improvement in postoperative sports ability and high patient satisfaction after insertional Achilles tendon debridement, and double-row tendon footprint reconstruction.

Introduction Pickleball is one of the fastest-growing sports in the United States, particularly among the aging population. With its rising popularity comes concern for related injuries. The purpose of this study was to evaluate clinical outcomes and return to sport (RTS) following acute Achilles tendon rupture in this unique patient group. Materials & Methods A retrospective analysis was performed of patients who sustained an acute Achilles tendon rupture while playing pickleball from 2013 to 2023. Patients were contacted via telephone to confirm the mechanism of injury and collect data regarding duration of pickleball participation prior to injury, RTS, and Achilles Tendon Rupture Score (ATRS). Results A total of 42 patients with a pickleball-related Achilles tendon rupture were identified; 28 were successfully contacted and included in the study (67% response rate). The mean age was 63.9 years (range 36–81). Sixty-eight percent sustained the injury within the first month of playing, with 32% injured on their first day. At a mean follow-up of 4.7 years, there were no significant differences in ATRS or RTS rates between operatively and nonoperatively treated patients. The overall RTS rate was 47%, with a mean return at 1.6 years. Among patients who did not return, all but one cited fear of reinjury as the primary reason. Discussion/Conclusion Pickleball-related Achilles tendon ruptures are rising among older adults. Despite favorable long-term outcomes regardless of treatment modality, fewer than half of patients return to play, most commonly due to fear of reinjury.

Introduction: Insertional Achilles tendon injuries present unique challenges in orthopedic and sports medicine. Surgical repair options include direct tendon repair or reconstruction using a graft, each providing risks and benefits. Although this condition typically affects older populations, there is a decrease in the age of this population as recreational sports become popular in the elderly. This study aims to evaluate demographics of patients who receive a graft repair for insertional Achilles tendinitis (IAT). Methods: This was a retrospective multi-surgeon single-institution cohort study reviewing demographics of patients who had an IAT repair. Demographics, medical history, surgical details, and patient-reported outcomes were recorded. We excluded patients with a BMI>30. Patient-reported outcomes were assessed using the Foot and Ankle Ability Measure Visual Analog Scale (FAAM-VAS) score. Results: 753 patients were identified (557 without vs 196 with graft). Individuals receiving grafts were older (45.5 vs 40.0 years, p<0.001) with higher BMIs (26.8 vs. 26.0, p=0.010) and CCIs (0.82 vs. 0.42, p<0.001). The reinforcement group had more females (24.0% vs. 16.7%, p=0.035) and experienced significantly longer time to surgery (58.8 vs. 21.4 days, p<0.001). Preoperative physical therapy and steroid injections were more common in the reinforcement group (p<0.001). There were no significant differences in revision, readmission, or need for additional treatments. Postoperative function, measured by the Delta-FAAM-VAS score, showed greater improvement in the non-reinforcement group (-18.30 vs. -1.39, p=0.033). Discussion: Our findings indicate that age, sex, BMI, CCI, and exhaustion of conservative treatments influence the decision to implement a graft in an IAT repair.

INTRODUCTION Both first and second generation cephalosporins are recommended as prophylactic antibiotics for orthopedic trauma surgery. A comparative study between both generations of cephalosporins has not been conducted before. The current retrospective study was designed to compare surgical site infection rates between both prophylactic antibiotics. METHODS Cases were included from an anonymised registry from a level one trauma center if the met the following criteria: age between 18 and 70 years and hospitalisation for at least 24 hours. During the study period, prophylactic antibiotic protocols were changed from first-generation to second-generation cephalosporins. We analysed SSI infection rates and compared patients who underwent surgery during the period when first-generation and second-generation cephalosporins were the standard. RESULTS A total of 2,269 cases have been included, of whom 1,168 were selected for the FIRST and 1,101 in the SECond cohort. SSI-infection rates dropped from 2,8 to 2,6 pct after the shift from FIRST to SECond generation cephalosporins. This was mainly due to less gram positive infections. In the SECond cohort, deep infections (with osseous/implant involvement) were diagnosed in 41% of cases. CONCLUSIONS A shift from first to second generation cephalosporins is associated with decreased SSI-rates in patients <70yrs undergoing trauma orthopedic surgery. This is mainly due to reduced occurrence of Gram-positive infections. More detailed studies are required to identify which specific trauma patients benefit most from altering prophylactic antibiotics routines.

Introduction Some patients insist not to sacrifice the knee joint for treatment of ischemic and/or infectious foot and ankle disease in the state of obvious proximal progression. In these cases, amputee end should be left open and managed following below knee amputation (BKA). We aimed to report the result of open below knee amputation in surgical treatment of ischemic and/or infectious foot and ankle disease Method We retrospectively reviewed medical records in 3 hospitals and found 16 patients among 317 with open BKA from Oct. 2012 to Jan. 2025. 17 factors including demographics (gender, age, walking capability, social support, smoking), underlying disease (diabetes, atherosclerosis obliterans, chronic kidney disease (CKD), ischemic heart disease, cerebrovascular disease, diabetic foot) laboratory data (hemoglobin A1c, white blood cell count, hemoglobin, serum protein, serum albumin, C-reactive protein). Knee joint salvaged and sacrificed/deceased patients were assigned to group 1 and 2 respectively. Mann-Whitney and Fisher’s exact test were adopted to analyze for continuous and categorical variables, respectively. Results Incidental infection over the amputee end was found in 9 patients. Knee joint was preserved in 9 patients 3 patients resulted in above knee amputation (AKA). 3 patients were expired while managing open amputee end within 3 months. Significant difference was only observed in chronic kidney disease between group 1 and 2 (p= 0.028). Conclusion The effort to salvage the knee joint with open amputee end should be conducted for the patient’s quality of life. CKD is significant risk factor to lose the knee joint on open BKA management

Introduction Diabetic foot infections (DFI) are the most common diabetes-related complication requiring hospitalisation. Over the past year, the Newcastle Hospitals NHS Foundation Trust (NUTH) have utilised absorbable calcium sulphate antibiotic carrier (CSAC) (primarily Stimulan®) to treat acute DFIs in the diabetic foot clinic. A review of current literature does not show any recorded use of CSACs in an outpatient setting, therefore the aim of this study was to assess the outcomes of patients receiving this intervention. Methodology Patient selection included DFI with underlying osteomyelitis. All patients underwent thorough debridement, sampling, and application of CSAC. Patients were then followed up in weekly diabetic foot clinic to monitor progression. Results 34 patients were included in the study. 59% of patients healed fully with an average healing time of 84 days. 17% of patients had definitive surgical management. 12% of patients’ infections resolved, but wounds did not heal. Fourteen patients were treated without hospital admission, with eleven patients’ wounds fully healing. Staph aureus was the most common causative micro-organism. Discussion The main benefit of CSACs is the delivery of high-dose antibiotics to the source of infection, circumventing the circulatory system. Our data demonstrated that CSACs can be used in an outpatient setting with a fully healed rate of 59%. Additionally, 45% of patients were treated without requiring hospital admission, benefiting the patient and minimising healthcare resources. However, future research is needed to assess the efficacy of local antibiotic treatment in the outpatient setting compared to treatment post-debridement in theatre.

Introduction Diabetic foot ulcers are a common complication of diabetes that significantly reduce quality of life and functional mobility. One contributing factor is equinus contracture, which increases forefoot plantar pressure, impeding ulcer healing and increasing recurrence risk. Surgical offloading techniques, particularly gastrocnemius release (GR), have shown promise in mitigating these effects. The present study evaluates whether adding GR to diabetic foot surgery improves outcomes by reducing further surgical intervention and enhancing foot survivorship, defined as the absence of additional surgery or amputation on the same foot. Method This retrospective cohort study included diabetic patients who underwent GR alongside surgical treatment for diabetic foot pathology between May 2021 and February 2024. Eligible patients were adults with diabetes who received GR in addition to a planned excision or amputation. Data collected included demographics, comorbidities, ulcer details, presence of peripheral vascular disease (PVD), and six-month readmission rates. Results Twenty-four patients met the inclusion criteria (87.5% male; mean age 58.4 years). Most had type 2 diabetes (87.5%), with the remainder having type 1 diabetes mellitus. Within six months of their initial surgery, 5 out of 24 patients (20.8%) were readmitted. Readmission was more frequent among patients with PVD (3 of 6, 50%) compared to those without PVD (2 of 18, 11.1%). No patients required major amputation, and limb preservation was achieved in all but one case. Conclusion The study suggests GR may improve outcomes in diabetic foot surgery by enhancing foot survivorship and lowering readmissions. Prospective studies are warranted to confirm these findings.

Aims The optimal marker for evaluating glycemic control before diabetic foot surgery is still unclear. This study aimed to evaluate the effectiveness of glycated albumin versus glycated hemoglobin (HbA1c) in predicting early complications after amputation and to identify the threshold level. Patients and Methods Patients were assessed for glycated albumin and HbA1c levels within 30 days before surgery. Complications, including uncontrolled infection, wound issues, re-amputation and re-operation were monitored for 4 weeks post-surgery. The ROC curve was employed to establish the cut-off values for glycated albumin and HbA1c linked to complications. Additionally, two HbA1c thresholds, 6.5% and 7.5%, were compared with glycated albumin to evaluate their effectiveness in predicting complications. Results In total, 79 patients (63 men, 16 women) participated in the study. A glycated albumin level of 22.8% was identified as the optimal cut-off for predicting complications. Patients above 22.8% were 2.86 times more likely to develop uncontrolled infections compared to those with lower levels (p = 0.001). The rates of re-amputation and re-operation were 2.4 and 3.6 times higher, respectively, in patients with glycated albumin above the threshold (p = 0.006 and p = 0.037). These associations remained statistically significant in multiple regression analysis. In contrast, an HbA1c level above 7.5% was significant correlation with complications. Conclusion Glycated albumin is a reliable and highly effective predictor of complications following amputation in diabetic foot patients. These findings advocate for screening all patients with glycated albumin, and for those with levels above 22.8%, strict glycemic control before surgery is crucial.

Introduction: Calcaneal osteomyelitis accounts for 3-11% of all bone infections. The definitive way of treating this condition is a below-knee amputation (BKA), which has associated complications such as increased risk of contralateral amputation; 39–80% mortality within 5 years; and adverse psychosocial impacts including loss of job, restricted social engagement and low mood. This is a retrospective review of patients who underwent a combination of surgical debridement with insertion of Cerament bone-void filler containing antibiotics as an alternative to BKA. Objectives: To review whether combining insertion of Cerament with surgical debridement to treat calcaneal osteomyelitis enables limb salvage. Methods: A retrospective review of 15 patients who underwent surgical debridement and insertion of Cerament containing vancomycin and gentamicin over a 4-year period was undertaken. They were reviewed weekly by a multi-disciplinary team comprising of Orthopaedics, Infectious Diseases, Podiatry and Diabetes. Negative pressure dressings and podiatry debridement were used in conjunction. The goal was to achieve wound closure and avoid recurrence once antimicrobials were discontinued. Results: Of the 15 eligible patients, 3 patients’ calcaneal ulcers healed and no longer required antibiotics; 7 had residual ulcers requiring Podiatry input but stopped antibiotics; 2 required BKA; 3 unfortunately died, unrelated to surgery. In total, 10 out of 12 of the surviving patients (83.3%) avoided BKA. Conclusion: A combination of antibiotic Cerament with surgical debridement provides an exciting prospect for limb salvage in this difficult to manage condition, at a rate of 83.3%, compared to the almost certain outcome of amputation with current mainstay treatment.

Introduction Infections of the distal tibia and ankle are challenging, especially in cases with open fractures or prior failed treatments. This study presents our clinical experience using a multidisciplinary approach several combining surgical techniques and targeted antibiotic therapy. Materials and Methods We retrospectively analyzed 17 patients (71.4% male; mean age 53.4 years; mean BMI 28.4). Treatment included the Masquelet technique, external fixation, bone fusion, bone grafting, and pathogen-specific antibiotics. Open fractures were present in 66.7% of cases. Follow-up lasted ≥24 months. Results Bone consolidation was achieved in all patients, with no infection recurrence. Re-interventions were more frequent in open fracture cases. Only one patient underwent limb amputation. Mean healing time was 30.2 weeks. No major complications were observed. Conclusion A multidisciplinary approach appears effective in managing distal tibia and ankle infections. An early diagnosis, accurate planning, and correct use of the fixation devices are mandatory to reach good outcomes.

Introduction: Osteochondral defects of the ankle and metatarsophalangeal joints are often associated with sports injuries, Freiberg’s disease, hallux valgus, and hallux rigidus. This study aims to evaluate mid-term functional and radiological outcomes following AMIC, combined with microfracture and bone grafting, in managing osteochondral defects of the talus and metatarsal heads. Methods: A retrospective analysis was conducted on 74 patients treated for osteochondral lesions of the talus and metatarsal heads using open debridement, microfracture, bone grafting, and AMIC membrane application. Functional outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOxFQ) and EQ-5D scores. Patients were followed for a mean duration of 7.6 years (range 6–8 years). Radiological outcomes recorded. Results: There were 24 (32.4%) talar lesions, 27 (36.5%) of first,16 (21.6%) of second, and 7 (9.6%) third metatarsal head lesions. The mean patient age was 41.5 years. At final follow-up, mean MOxFQ scores improved significantly from 59.4 (95% CI: 48.2–89.4) to 18.3 (95% CI: 10.1–34.7) for talar lesions, and from 43.75 (95% CI: 33.75–75.2) to 7.19 (95% CI: 4.63–18.2) for metatarsal head lesions. EQ-5D scores improved from 12.6 (95% CI: 8.1–18.4) to 9.3 (95% CI: 4.4–11.2) for talar lesions and from 11.2 (95% CI: 7.9–17.6) to 6.1 (95% CI: 5.1–10.0) for metatarsal lesions. Radiological assessment demonstrated progressive cartilage remodelling in younger patients. No post-operative complications were observed. Conclusion: AMIC with bone grafting and microfracture provides reliable and sustained improvement in pain, mobility, and function for osteochondral defects of the talus and metatarsal heads. Radiological remodelling is more consistent in younger patients.

Introduction: The Progressive Collapsing Foot Deformity (PCFD) classification system categorizes foot deformities into five classes but lacks established measurement thresholds for reliable classification. This study aimed to determine cut-off values for PCFD measurements for Classes A to D using a large cohort of patients and controls. Methods: We analyzed two cohorts: a prospective group of 197 asymptomatic volunteers (103 females/94 males, average age 41.7 years, BMI 28.9) and a retrospective group of 321 PCFD patients (136 females/185 males, average age 50.7 years, BMI 29.8). Both groups underwent weight-bearing computed tomography scans of the foot and ankle, with semi-automatic bone segmentation and automatic measurement of parameters related to PCFD classes. Receiver Operating Characteristic curves and Youden's Indexes helped identify diagnostic thresholds. Results: Significant findings (all p-values < 0.0001) included a Hindfoot Moment Arm of 13.9mm or more for Class A, Talonavicular Coverage Angle of 38.7° or higher and Talus-First Metatarsal Angle Axial of 20.3° or higher for Class B, Forefoot Arch Angle of 8.7° or lower and Talus-First Metatarsal Angle Sagittal of 18.7° or higher for Class C, and Coverage values for Middle Facet of 73.5% or lower, Posterior Facet of 84.5% or lower, and Sinus Tarsi of 25.7% or higher for Class D. Conclusion: This study establishes normative thresholds for PCFD measurements, enhancing the classification system's reliability and reproducibility, with high diagnostic accuracy for determining the presence or absence of specific deformities.

Introduction: Peritalar Subluxation (PTS) significantly influences Progressive Collapsing Foot Deformity (PCFD), primarily manifesting through external rotation and dorsolateral subluxation around the Interosseus Talocalcaneal Ligament (ITCL). Traditional PCFD surgeries like calcaneal and Cotton osteotomies indirectly correct PTS by adjusting foot positioning, yet direct ITCL repair is seldom performed due to its complexity. This study aimed to develop and assess a new surgical technique combining ITCL and spring ligament (SL) reconstruction, evaluating its effect on PTS and hindfoot kinematics during simulated walking. We hypothesized that this ITCL-SL reconstruction would rectify PTS and improve joint movements. Methods: Using ten cadaveric matched-pair specimens (20 limbs), we simulated the walking stance phase with a six-degree-of-freedom robot, following established protocols. We assessed talonavicular and subtalar joint kinematics (indicators of PTS) and performed Weightbearing CT (WBCT) imaging under three scenarios: intact, post-PCFD simulation, and after ITCL-SL repair. The surgical approach involved tape reconstruction with bone tunnel fixation at the talar neck and sustentaculum. Results: Post-ITCL-SL reconstruction, significant enhancements in PTS and hindfoot kinematics were observed under simulated PCFD conditions (all p-values <0.05). Notably, subtalar joint eversion and talonavicular joint abduction were considerably reduced, with slight under-correction compared to the intact state. WBCT measurements showed an average improvement in Foot and Ankle Offset (FAO) by 1%±1.4%. Conclusion: The novel ITCL-SL reconstruction technique for PCFD demonstrated notable improvements in hindfoot kinematics and PTS during simulated walking. This method effectively reduced key deformity indicators and enhanced foot alignment without traditional bony realignment surgeries.

INTRODUCTION: Flatfoot can be a normal condition, but a worsening flatfoot is not. This prospective comparative study recruited patients with asymptomatic flatfoot and controls with normal foot alignment, comparing them to patients with Progressive Collapsing Foot Deformity (PCFD). We hypothesized that deformity and collapse measurements—Class A (hindfoot valgus), Class B (midfoot/forefoot abduction), and Class C (longitudinal arch collapse)—would progressively increase from controls to asymptomatic flatfoot to PCFD patients. However, only symptomatic PCFD patients were expected to show Peritalar Subluxation (PTS) or Class D deformity. METHODS: IRB-approved study, recruited adult volunteers with either normal foot alignment or flatfoot morphology. We included 88 controls (98 feet), 66 asymptomatic flatfoot patients (132 feet), and a retrospective cohort of 306 symptomatic PCFD patients (311 feet). All underwent Weightbearing Computed Tomography (WBCT), and alignment and collapse were compared across groups. RESULTS: Measurements for Classes A, B, and C were significantly more pronounced in asymptomatic flatfoot and PCFD patients compared to controls (p<0.0001). PTS measurements were similar in controls and asymptomatic patients but significantly more pronounced in symptomatic PCFD patients. Notably, PCFD patients showed decreased coverage in posterior and middle subtalar joint facets and increased sinus tarsi coverage compared to asymptomatic patients (p<0.0001). A partition predictive model showed that sinus tarsi distances below 1.9mm predicted an 89% chance of symptomatic PCFD. CONCLUSION: This study highlighted significant differences in foot alignment and collapse between normally aligned feet, asymptomatic flatfoot, and symptomatic PCFD, identifying Class D Deformity (Peritalar Subluxation) as a potential primary symptom driver in PCFD patients.

Background: Total ankle arthroplasty (TAA) failure presents complex challenges, particularly in patients with concomitant hindfoot pathology. This report details a novel revision strategy for failed TAA in a patient with talonavicular joint ankylosis.
Case Presentation: A 61-year-old female with rheumatoid arthritis and a failed TAA (initially implanted 12 years ago) presented with severe pain on walking. Imaging revealed talar component subsidence and talonavicular ankylosis.
Intervention: Revision surgery was performed using a custom total talar prosthesis (TTP) combined with the tibial component of TAA. 
Outcomes: At 5-year follow-up, the patient achieved significant pain relief, improved ambulation, and radiographic evidence of stable implant positioning.
Conclusion: TTP may be a viable option for revising failed TAA in select patients with concurrent talonavicular ankylosis.

Introduction: Ankle fractures are among the most common orthopaedic injuries, frequently requiring surgical management through open reduction and internal fixation (ORIF). While the negative impact of cigarette smoking on bone healing is well established, the effects of non-tobacco nicotine dependence (NTND) remains poorly understood. This study aims to evaluate the impact of NTND on postoperative outcomes following ankle ORIF. Methods: A retrospective cohort study was conducted using the TriNetX database. Patients undergoing ankle ORIF (CPT: 27766, 27792, 27814, 27823) were divided into two cohorts: NTND (ICD-10: F17, excluding tobacco-specific subcodes) and nonsmokers (no history of nicotine use). Following 1:1 propensity score matching for demographic and comorbid conditions, postoperative outcomes were analyzed at 90 days and 2 years using risk ratios (RR) with 95% confidence intervals (CI). Results: After matching, 7,549 patients were included in each cohort. At 90 days, NTND patients experienced significantly higher rates of opioid prescriptions (RR 1.30), emergency department visits (RR 1.54), inpatient hospitalizations (RR 1.27), infections (RR 1.44), wound complications (RR 1.48), and pneumonia (RR 1.58) (all P < 0.005). Over 2 years, NTND patients had increased risk of pseudoarthrosis (RR 2.49), mechanical implant failure (RR 1.42), infection-related implant failure (RR 1.39), and periprosthetic fracture (RR 1.38) (all P < 0.005). Conclusions NTND is associated with significantly higher rates of short- and long-term complications following ankle ORIF. These findings highlight the importance of preoperative screening and cessation counseling for patients with NTND to optimize surgical outcomes.

Aims/Objectives: Non-tobacco nicotine dependence (NTND), such as vaping, has become increasingly prevalent. While the negative effects of cigarette smoking on bone healing are well established, the impact of NTND on surgical outcomes remain unclear, particularly in foot and ankle surgery. This study aimed to evaluate the effect of NTND on short- and long-term postoperative complications following midfoot arthrodesis, a procedure commonly performed for arthritis, trauma, and congenital deformities. Methods: This retrospective cohort study was conducted utilizing the TriNetX database. Patients undergoing midfoot arthrodesis were identified and stratified into NTND (ICD-10: F17, excluding tobacco-specific codes) and nonsmoker cohorts. 1:1 propensity score matching was performed based on demographic and comorbid variables. Postoperative complications were assessed at both 90 day and 2 years utilizing risk ratios (RR) and 95% confidence intervals (CI). Results: After matching, 1,235 patients were included in each cohort. At 90 days, NTND patients had significantly higher rates of opioid prescriptions (RR 1.18), emergency department visits (RR 1.52), hospitalizations (RR 1.59), postoperative infections (RR 1.95), and wound complications (RR 1.72) (all P < 0.05). At 2 years, NTND was associated with increased rates of pseudoarthrosis (RR 1.27) and mechanical implant failure (RR 1.39) (both P < 0.05). Conclusions: NTND is associated with significantly increased risk of both early and late postoperative complications following midfoot arthrodesis. These findings suggest that vaping may adversely affect bone healing and implant integrity. Surgeons should incorporate NTND screenings and cessation counseling into preoperative planning to optimize patient outcomes.

Introduction Management of periprosthetic joint infection (PJI) in patients with previous tumor resection and proximal tibial replacement (PTR) is a major challenge in orthopedic oncology. We report the case of a patient with tibial adamantinoma treated with a two-stage revision and a custom-made megaprosthesis, including a tailored talar component. Case Presentation A 75-year-old patient with a history of left total hip arthroplasty, left nephrectomy for neoplasm, and PTR with MUTARS megaprosthesis for adamantinoma of the tibial shaft presented one year postoperatively with acute pain and swelling in the right ankle. Joint aspiration revealed coagulase-negative Staphylococcus. Subsequently, a fistula developed, and Corynebacterium jeikeium was isolated in three cultures. The patient had previously undergone revision of the PTR due to Staphylococcus lugdunensis infection, treated with Linezolid and Oxacillin. A two-stage surgical treatment was performed. First stage: removal of the MUTARS prosthesis and implantation of a custom-made antibiotic-loaded tibial spacer. Cultures were negative. Antibiotic therapy with minocycline and cotrimoxazole continued for 7 months. Second stage: implantation of a new custom-made tibial megaprosthesis including knee and ankle joints. At 4-year follow-up, the patient was in good clinical condition with full recovery of joint function. A revision of the talar component was performed due to mechanical wear, and a custom-designed talar module was implanted. Conclusion In patients with tibial bone tumors treated with megaprostheses, a multidisciplinary and staged approach is essential in the event of PJI. Custom-made prosthetic designs, including tailored modules for joint reconstruction, can offer durable infection control and functional recovery.

Objectives: A retrospective review of operated ankle fracture cases at our institution was performed to analyse their risk factors for major and minor complications. Methodology: Cases were identified using surgical logs. Patient demographics, fracture classification, surgical method and complications data were identified. Logistic regression analysis was performed to identify risk factors for complications. Results: 531 cases were identified for the period of 2016-2022. 81% of patients were below 60 years of age and 51% were male. The open fracture rate was 2%. Definitive fixation in 84% of cases was plating, 4% intramedullary fixation, external fixation 1% and other implants 11%. 91% of patients were ASA 1 and 2. The overall complication rate was 37% with 29.8% minor complications 7.3% and major complications. Major complication included revision surgery n=26 (4.9%), deep infection n=10 (1.8%),amputation n=1 (0.18%), thromboembolism n=2 (0.37%). The 1 year mortality rate was 0.37% (n=2). Risk factors identified for overall complications include female sex (OR 1.4, p=0.04), open fracture (OR 5.2, p=0.02), intramedullary fixation (OR 2.29, p=0.014), ASA 3 (OR 3.3, p<0.001), Weber C (OR 1.7, p=0.005), diabetes mellitus (OR 2.1, p=0.002), renal disease (OR 4.3, p=0.007) and peripheral vascular disease (OR 14.09, p=0.001). Multivariate regression for major complications found the use of intramedullary fixation (OR 10.18, p<0.01) ,diabetes (OR 3.72, p=0.012) and open fracture (OR 24.7 p<0.001) to be significant risk factors. Conclusions: Our cohort has a complication rate comparable to the published literature. Major complications following ankle fracture surgery remain low despite a high overall complication rate.

Introduction: In equivalent quadrimalleolar ankle fractures Posterior inferior tibio fibular ligament remains attached to the posterior malleolus which fractures. In some cases when interosseous and anterior inferior tibio fibular ligament are injured, syndesmotic instability can be treated with anchor suture anterior inferior tibio fibular repair. Methods: Case series of 14 patients with equivalent quadrimalleolar ankle fractures with surgical treatment in two health centaers between 2021 and 2024. All of them with pre and postoperative 6 week follow up CT-Scan, evaluating post operative syndesmotic reduction quality. We used the same diagnose and repair pathway in all patients: After lateral, medial and posterior fixation a syndesmotic stress was applyied, if possitive we proceed to repair or reattach AITFL in the footprint with 3.5mm anchor. Then post fixation syndesmotic stress was applyied to establish syndesmotic stability. Results: 14 patients, 8 men and 6 women, mean age 40 yo (26-61). 7 posterior malleolus fractures were Rammelt II, 5 Rammelt III. Anchor insertion was placed in fibular footprint in 9 cases and in tibial footprint in 5 cases. Results: 100% of anatomic syndesmotic reduction evaluated at 6 weeks postoperative CT-scan. No complications in 2 years mean follow up.

Background: The Lisfranc ligament’s role in maintaining midfoot stability is well established; however, the specific contributions of the First Cuneo metatarsal (C1-M1) ligaments, in conjunction with the Lisfranc ligament, to the stability of the C1-M1 joint have not been thoroughly investigated. This study aims to evaluate the importance of the Lisfranc and C1-M1 ligament in the stability of the C1-M1 joint. Methods: Six cadaveric below-knee specimens were used in this study. Metal pins were placed dorsally and medially at the C1-M1 joint to measure displacement and angulation. The specimens were divided into two groups: Group 1 underwent progressive sectioning of the C1-M1 ligaments, followed by sectioning of the Lisfranc ligament. Group 2 had the Lisfranc ligament sectioned first, followed by progressive sectioning of the C1-M1 ligaments. Axial and abduction stress was applied before and after each ligament section, with angulation and translation measured in both planes. Final measurements were taken after Lisfranc screw fixation. Results: Sequential transection of first C1-M1 and Lisfranc ligaments led to a progressive increase in angulation and translation of the C1-M1 joint. Instability was significantly higher when the Lisfranc ligament was sectioned. Lisfranc screw fixation achieve better stability of C1-M1 than natural Lisfranc ligament. Conclusions: Lisfranc ligament is the principal stabilizer of the C1-M1 joint. Screw fixation confers greater stability compared to specimens with sectioned C1-M1 ligaments and an intact Lisfranc ligament.

Background: Current literature lacks comprehensive information comparing primary tibiotalocalcaneal (TTC) hindfoot nailing and open reduction internal fixation (ORIF) in the ankle fractures in the elderly population. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of two surgical techniques, primary TTC nailing and ORIF, for ankle fractures in the elderly. Methods: Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included total infection, deep infection, superficial infection, hardware problems such as painful hardware and hardware protrusion/pullout, nonunion/delayed union, reoperation, length of stay, and return to preoperative mobility level. Results: Total five studies were included in this study. In aggregate, 127 (42.9%) patients underwent TTC nailing, while 169/296 (57.1%) patients underwent ORIF. A lower rate of superficial infection was reported for the TTC nailing group: 2.1% (2/95) in TTC nailing versus 10.2% (14/137) in ORIF, with a relative ratio of 0.26 (95% CI, 0.08 to 0.85). The other outcome measures were not significantly different between groups. Conclusions: Based on our review of these studies that reported mostly early follow-up data, it appears that primary TTC nailing may be a viable alternative to ORIF for ankle fracture fixation in the elderly population. However, these findings should be interpreted cautiously due to heterogeneity across the included studies.

INTRODUCTION Minimally invasive surgery became the standard of care for foot fractures, but complex cases remain challenging. The introduction of intra-operative CT imaging has improved outcomes, and navigation-assisted surgery may offer additional benefits. This study aims to assess the feasibility of navigation-assisted surgery for foot trauma. METHODS Following the PRISMA-guidelines, the PubMed database was searched for clinical studies on computer-assisted/navigated foot and ankle fracture surgery by the utilization of MeSH-terms. Patient and fracture characteristics as well as surgical techniques and outcome were analyzed. No language restrictions were applied. RESULTS 37 studies on navigated fracture care for foot injuries were identified, with 4 selected for analysis. A total of 53 fractures were described, including calcaneal (n=33), talar (n=10), and 5th metatarsal (n=10). Patient age ranged from 20 to 51 years, and 75% of studies used 3D navigation. Reference guides were attached to the calcaneus. Mean operation time ranged from 13 to 61 minutes, none of the navigated screws was misplaced and no conversion to open surgery was required. Moreover no complications or infections have been reported. CONCLUSION Navigation-assisted fracture treatment of foot injuries is a promising technique that allows for more precise screw placement, less soft tissue injury, and improved outcomes with fewer complications. Fractures of the calcaneus, talus and metatarsals can be treated in isolation or in combination. Prospective comparative studies are needed to further explore the feasibility of this technique in trauma cases.

Background: Ankle fractures are highly prevalent orthopaedic injuries frequently involving the posterior malleolus. The critical role of the posterior malleolus in syndesmotic stability and ankle function is increasingly recognised. The aim of this study was to assess the outcomes of operatively managed posterior malleolus fractures, including functional outcome and return to sports. Methods: A retrospective review of consecutive patients with posterior malleolus fracture, that underwent operative fixation, was conducted in a single institution in the UK. Fractures were classified using the Mason classification. Primary outcome was functional outcome assessed using the Olerud and Molander (OM) score. Secondary outcomes were return to sport, union rates, complications and Visual Analog Pain Score (VAS) during the last follow up. Results: Between May 2019 and May 2021, 238 patients underwent operative fixation of an ankle fracture of which 61 patients underwent fixation of the posterior malleolus. Mean age was 45.2±14.5 with mean follow up of 14.2±4.3 months. Mean OM score was 79.3±16.9 and mean VAS score was 1.2±1.7. 29 (54.7%) patients reported some level of residual pain(VAS >1). 18 (35%) and 12 (23%) patients reported persistent ankle stiffness and swelling respectively. Out of 43 patients doing sports pre-operatively, 28 (65.1%) returned to their preoperative level, while 11 (25.6%) returned to a lower level and 4 (9.3%) patients were unable to return to sports. Conclusion: The majority of patients undergoing operative management of posterior malleolar fractures have satisfactory functional outcomes. Residual symptoms and functional limitations must be emphasised to patients to manage postoperative expectations.

Starting in 2007, we developed a standardized minimally invasive concept for treating all types of calcaneal fractures. To evaluate the radiological and clinical outcomes, we conducted a retrospective study encompassing 159 procedures performed between 2015 and 2020. In 138 cases, exclusively stab incisions were used; 16 fractures were treated via a sinus tarsi approach, and 5 involved open fractures. The Sander’s classification was as follows: 48.21% were type II, 33.33% type III, 10.11% type IV, and 8.35% were unclassifiable. Surgery was performed within one day in 117 cases (73.6%). In addition to the use of raspatories, bone tamps, and Schanz screws, fracture reduction was frequently supported by a specialized calcaneal distractor. For osteosynthesis we use static 7.3 mm fully threaded screws and 4.0 mm lag screws. Plaster casts were occasionally applied until 2019, from that point onward, early functional mobilization began on the first postoperative day. Böhler's angle improved from a preoperative average of 8.52° to 25.00° postoperatively. There was one deep infection associated with an open fracture and three cases of superficial infection. The AOFAS score was recorded in 73 patients, with an overall average of 91.41 points (Sanders II: 94.29, Sanders III: 89.00, and Sanders IV: 78.00). Secondary fracture dislocations occurred in four cases, each attributed to technical error. Minimally invasive techniques can show excellent clinical results even when done completely covered and with screw-only osteosynthesis. Advantages are early surgical timing, minimal complication rate and scarring, fixation-free functional aftertreatment and uncomplicated removal of hardware if necessary.

Introduction: Wagstaffe-Le Fort fractures and avulsion injuries at the fibular insertion of the anterior inferior tibiofibular ligament (AITFL) are often underdiagnosed in ankle fractures, though identifying them is crucial due to potential syndesmotic instability needing surgical intervention. This retrospective study examined the prevalence, detection methods, morphology, associations with fracture classifications, and clinical significance of fragment sizes. Methods: From 1022 patients treated for distal lower limb fractures at a level I trauma center between January 2016 and June 2024, 573 patients were included after excluding those without suitable imaging or non-ankle/pilon fractures. Radiologists and orthopedic surgeons independently reviewed imaging (X-rays and computed tomography [CT]). Results: Wagstaffe-Le Fort fractures were identified in 116 patients (20.2%), with significantly higher detection via CT (68%) compared to X-rays (13.4%). Type 2 fractures were predominant (82.8%), associated with supination-external rotation (SER) and Weber B patterns, while type 4 fractures linked to pronation-external rotation (PER) and Weber C. Fragment sizes showed substantial variability, appearing larger on radiographs (median 18.5 mm) versus CT (median 12.0 mm). The study proposes revising surgical fixation thresholds, recommending ≥15 mm instead of the traditional <5 mm. Discussion and Conlusion: Wagstaffe-Le Fort fractures are more common and better detected by CT, underscoring the need for advanced imaging. The study advocates updating existing classification and fixation criteria, incorporating fragment morphology and size to enhance clinical decision-making.

Introduction: Timely diagnosis of Lisfranc injuries is crucial to reduce complications and improve outcomes. Chronic injuries, often due to delayed or inadequate treatment, can cause instability, degeneration, and chronic pain. Management aims to restore foot stability and function; TMT arthrodesis has shown good results. Clinical case report: A 27-year-old woman sustained a severe injury to her right foot in a work accident, involving a Lisfranc injury, soft tissue damage, tendon rupture, and open fractures of the 1st and 2nd cuneiforms (Gustilo-Anderson IIIB). Initial management included debridement, antibiotics, tendon repair, and soft tissue coverage with a free flap. The TMT joints were treated conservatively. Ten months later, she presented with disabling midfoot pain and instability. Imaging (rx, CT) revealed post-traumatic osteoarthritis of the 1st and 2nd TMT joints, diastasis between the 1st and 2nd metatarsals, and elevation of the 1st metatarsal head. Surgical treatment involved 1st TMT arthrodesis with plantarflexion of the 1st metatarsal. Postoperative recovery included early mobilization and progressive weight-bearing. At six weeks, clinical and radiological outcomes were favorable. Follow-up is ongoing. Discussion: Isolated 1st TMT arthrodesis proved effective and safe in a complex case, improving function and reducing the need for broader intervention. Despite 2nd TMT osteoarthritis, this approach stabilized the midfoot and redistributed load, avoiding further surgery. The case underscores the impact of delayed diagnosis and the need for early intervention. Conclusion: Chronic Lisfranc injuries are challenging. In TMT instability and arthritis, isolated 1st TMT arthrodesis may offer an effective, individualized treatment option with good clinical results.

Introduction Deltoid repair as part of acute ankle fracture fixation is a controversial topic debated in the literature. Repairing the injured deltoid may help rehabilitate patients faster and prevent pes planus in the future, with minimal morbidity. Aim Our objective was to review patient outcomes across 2 centres, focusing on post-operative morbidity associated with deltoid repair. Methods A retrospective review of patients undergoing ankle fracture fixation was performed across 2 centres (1 Major Trauma, 1 Trauma Unit). Patients undergoing deltoid repair were identified and intra-operative and post-operative data were collected from patient electronic records. Only patients who attended post-operative follow up were included. Results 87 patients had their deltoid repaired during ankle fracture fixation. The average age of patients undergoing deltoid repair was 36 (range 19-68). Decision to repair the deltoid was consistently based on either intra-operative screening or medial malleolus tip avulsion fracture not amenable to bony fixation. 12 patients underwent end to end suture repair of the deltoid, while 75 patients underwent deltoid repair using suture anchors. Post-operative morbidity was low and the majority of patients made a full recovery. 3 patients (3%) experienced medial wound superficial infections, all successfully treated with antibiotics. 2 (2%) patients experienced chronic medial pain. Conclusion Deltoid repair during ankle fracture fixation is associated with minimal morbidity for potential significant gain. Integrity of the deltoid should be routinely screened intraoperatively and surgeons should have a low threshold to acutely repair the deltoid given the low complication risk.

Introduction To assess the clinical and radiographic outcomes of OR/IF and arthroscopic procedure in chondral injuries associated with intra-articular ankle fractures, and to identify factors influencing the occurrence of chondral injury. Materials and methods Fifty-five patients treated by OR/IF were included retrospectively. Radiographic examination using the Van Dijk criteria (grade 0: normal joint or subchondral sclerosis; grade I: presence of osteophytes without joint space narrowing; grade II: joint space narrowing with or without osteophytes; grade III: (sub) total disappearance or deformation of the joint space. Second-look arthroscopy was applied during implant removal. Results The amount of displacement noted on ankle mortise plain radiograph was decreased from 6.4 mm ± 10.4 to 2.4 mm ± 1.3 (p = 0.000). Post-traumatic osteoarthritis was progressed in twenty- two patients (40.0%). Thirty-two patients had concomitant chondral injury, with 24 cases treated by bone marrow stimulation and the remaining eight patients treated by debridement of injured cartilage. Preoperative medial clear space widening (> 10 mm) was significantly associated with the risk of chondral injruy (p = 0.045; odds ratio (OR): 11.0, 95% confidence interval (CI): 2.034–52.124). Postoperatively, 28 treated patients were evaluated by second-look arthroscopy; 19 had healed completely and nine had healed partially. However, the majority of findings based on arthroscopic evaluation were classified as ICRS grade 1 or 2. Conclusion Chondral injury is frequently combined with intra-articular ankle fracture, in correlation with more than 10 mm of joint translation. OR/IF with arthroscopic procedure could achieve good outcomes.

Purpose Various surgical techniques have been introduced to achieve accurate anatomical reduction in intra-articular calcaneal fractures. While the traditional extensile lateral approach remains widely used, minimally invasive techniques have gained attention for reducing postoperative complications while providing comparable outcomes. However, optimal criteria for internal fixation following reduction remain unclear. This study reports the initial outcomes of internal fixation using a multidirectional locking plate via a minimally invasive sinus tarsi approach. Methods Twenty patients with intra-articular calcaneal fractures (Sanders type II and III) underwent surgery between June and December 2022. Postoperative imaging included lateral radiographs to measure Bohler and Gissane angles and CT scans to assess articular step-off and fracture gap. Clinical evaluations included VAS for pain, length of hospital stay, and postoperative complications. Results The mean time to bony union was 7.8 weeks (range, 6–12). One patient required implant removal due to irritation. Postoperative calcaneal length and width remained within 10% of the contralateral side. No cases of nonunion or infection were observed. CT scans showed a step-off >1 mm and gap >3 mm in two cases. The average hospital stay was 4.6±1.8 days. Conclusions Despite the short follow-up period, minimally invasive reduction via the sinus tarsi approach with multidirectional locking plate fixation demonstrated favorable radiologic and clinical outcomes, reduced complication rates, and shorter hospital stays in intra-articular calcaneal fractures.

Lisfranc injuries pose diagnostic challenges, particularly in evaluating joint stability. Conventional Weightbearing CT (WBCT)-based distance measurements of the medial cuneiform-second metatarsal (C1-M2) interval fail to account for the second metatarsal’s triplanar orientation, potentially leading to inaccuracies. This study introduces a new 3D-corrected triplanar measurement method correcting for axial, coronal, and sagittal alignment to improve diagnostic accuracy. In this retrospective study, the initial bilateral WBCT scans of 31 patients with acute Lisfranc injuries were evaluated. Injuries were defined based on radiographic findings in the first to third tarsometatarsal joints and the C1-M2 interval. Two foot and ankle surgeons independently performed manual measurements using a previously described uniplanar method and a new triplanar technique, applied proximally and distally in the C1-M2 interval. Intra- and interrater reliability were assessed via intraclass correlation coefficients (ICCs), and side-to-side differences were compared using paired statistical tests. Triplanar measurements demonstrated higher ICCs compared to the uniplanar method, with measurements in the distal C1-M2 interval showing near-perfect reliability (intra- and interrater ICCs 0.87-0.97, compared to 0.74-0.91). In 22.6% of injured feet, the original method erroneously measured the M1-M2 instead of the intended C1-M2 interval. All six measured variables showed significant differences between injured and contralateral feet (P<.05). The triplanar method applied distally in the coronal plane yielded the greatest side-to-side difference (1.81mm, SD 1.60, P<.0001). The proposed triplanar alignment method improves WBCT-based assessment of the Lisfranc interval. It offers higher reliability and avoids pitfalls of previous techniques, with the distal C1-M2 interval showing the greatest diagnostic utility.