Objective: To compare the clinical efficacy of small incision oval forceps-assisted needle threading repair versus minimally invasive locking block modified Krackow technique for acute closed Achilles tendon rupture. Methods: A total of 25 patients with acute closed Achilles tendon rupture admitted to the Department of Traumatic Orthopedics between June 2018 and June 2021 were enrolled. Thirteen patients underwent small incision oval forceps-assisted needle threading repair (12 males, 1 female; mean age 36±7.4 years), and 12 received minimally invasive locking block modified Krackow technique (11 males, 1 female; mean age 39±8.6 years). The mean follow-up period was 29±2.4 months (range 24-36 months). Outcome measures included AOFAS score, ATRS, Arner-Lindholm rating, and ankle ROM. Results: All 25 patients completed follow-up. No statistically significant differences were found between the two groups (P>0.05). At 6 months postoperatively, ankle ROM recovered to over 90% of the contralateral healthy side in both groups. No major complications such as Achilles tendon re-rupture or sural nerve injury occurred in either group. Conclusion: Small incision oval forceps-assisted needle threading repair entails simpler procedures and shorter operative time. Minimally invasive locking block modified Krackow technique provides superior biomechanical stability and accelerates functional recovery.

Abstract Objective: To investigate the clinical efficacy of sled plate internal fixation for Herscovici type C medial malleolus fractures, and assess its clinical application value. Methods: Seventeen patients with Herscovici type C medial malleolus fractures admitted between February 2021 and May 2024 were enrolled. All diagnoses were confirmed by ankle X-ray and 3D CT reconstruction. The study comprised 10 males and 7 females, with a mean age of (42.3±5.7) years. Patients with severe comorbidities, multiple fractures, nerve or vascular injuries, and pathological fractures were excluded. All subjects underwent open reduction and sled plate internal fixation, combined with standardized postoperative rehabilitation. Follow-up was conducted to document fracture healing, ankle function recovery, and complications. Results: All patients completed 6-12 months of follow-up, with a mean duration of (8.5±2.3) months. All fractures achieved bony union within 8-12 weeks (mean 9.4±1.5 weeks). No severe complications, such as delayed union, nonunion, implant loosening or breakage, wound infection, or traumatic arthritis, were observed. At 6 months post-surgery, the AOFAS ankle-hindfoot score showed an excellent and good rate of 94.12%, with restored ankle mobility and unimpaired daily activities. Conclusion: Sled plate internal fixation is a reliable treatment for Herscovici type C medial malleolus fractures, with advantages of rigid fixation, high union rate, satisfactory functional recovery, and favorable safety. It is worthy of clinical promotion.

Foot drop caused by irreversible peroneal nerve injury is commonly treated with tibialis posterior tendon transfer (TPTT), yet no consensus exists on the optimal surgical configuration. Existing evidence relies on small cadaveric series and subjective clinical scores that fail to capture biomechanical differences between techniques. This study used musculoskeletal simulation to quantify the impact of three surgical variables on TPTT performance. A validated OpenSim Gait2392 model was modified to simulate 11 TPTT configurations. Variables included routing technique (interosseous versus circumtibial), rerouting height (5-11 centimetres above the medial malleolus), and insertion site (intermediate cuneiform vs cuboid). Dorsiflexion and inversion/eversion moment arms were computed across ankle and subtalar joint angles. Primary outcomes were peak moment arm, range-of-motion-weighted capacity, stability index, and joint angle at peak torque. Data were analysed using paired t-tests, Wilcoxon signed-rank tests, and polynomial regression modelling. The interosseous route produced significantly greater dorsiflexion leverage (0.0406 metres versus 0.0318 metres, p < 0.001) and reduced eversion bias compared with the circumtibial route. Rerouting height significantly influenced performance (Friedman test, p < 0.001), with an optimal zone at approximately 9 centimetres, beyond which gains plateaued. Classic insertion maximised dorsiflexion (0.0406 metres versus 0.0338 metres, p < 0.001), while modified insertion reduced inversion bias, reflecting a trade-off between torque and frontal-plane stability. This simulation-based framework identified interosseous routing at 9 centimetres with classic midfoot insertion as the biomechanically optimal TPTT configuration. This reproducible, data-driven approach enables objective comparison of surgical strategies and may support personalised preoperative planning for foot drop.

Introduction: Tailor's bunion is a lateral prominence of the fifth metatarsal head that frequently causes pain and discomfort with footwear. Multiple surgical techniques have been described for its treatment, including minimally invasive techniques. The objective of this study is to analyze the results of using a percutaneous sliding osteotomy for the treatment of tailor's bunion. The surgical technique is described. Materials and methods: Between December 2008 and April 2018, 42 cases (34 patients) of bunion were treated using percutaneous surgery with a minimally invasive sliding osteotomy. 27 patients were female and 7 were male. The average age was 46.5 years. Evaluation: Pre- and post-operative X-rays at 3 months. AOFAS scale pre- and post-operatively at 18 months. Coughlin scale post-operatively at 18 months. Average follow-up: 29.2 months. Results: Average improvement in the AOFAS score of 27.95 points. 90% excellent and good results according to the Coughlin scale. Periosteal consolidation at 3 months. Average correction of the MTP angle of 6.55°, average correction of the intermetatarsal angle of 8.85°, and average medial displacement of 3.2 mm. There were no infections or recurrences. There were 3 cases with delayed skin healing. Conclusions: The technique is safe and effective, does not require fixation, allows early weight-bearing, offers good cosmesis, and has few complications. It could be indicated in all 4 stages of the Fallat classification.

Introduction: Arthroscopy has become an important tool for treating several ankle pathologies. Like any surgical technique, it is not without complications. The objective of this study is to evaluate the early complications observed in anterior ankle arthroscopy and compare them with those described in world literature. Materials and Methods: This is a retrospective study in which 198 patients who underwent anterior ankle arthroscopy were evaluated. All patients underwent surgery performed by a single surgeon over a nine-year period, with a minimum postoperative follow-up of 18 months. Patients were evaluated using the AOFAS score. All complications, both intraoperative and early postoperative, were recorded. Results: There were 11,61% of cases of procedure-related complications. Included six cases of local cellulitis, four transient paresthesia of the superficial peroneal nerve, one permanent paresthesia, four cases of residual pain at the portal sites, two cases of septic arthritis, and one case of other complication. Seven patients experienced diffuse ankle pain, but these were the evolution of their pre-existing pain, and therefore not a complication. Discussion: These findings are comparable to results published in literature. In our series the post-surgical cellulitis and the superficial nerve injury were the most complications (47.8%). Most of the complications encountered can be avoided through knowledge of the anatomy of the region, proper asepsis, a meticulous technique with blunt entry through the skin portal, and careful handling of intra-surgical instruments. It´s not recommended to use joint traction devices. We must work in dorsiflexion to avoid injury to the anterior aspect.

Introduction: Posterior ankle arthroscopy allows the diagnosis and treatment of multiple pathologies with minimal trauma. The use of posterior portals, with or without mechanical distraction, provides good visualization of the posterior ankle, tendons of the region, and subtalar joint. The aim of this study was to evaluate the intraoperative and postoperative complications of posterior ankle and hindfoot arthroscopy without joint distraction and to compare them with those described in the literature. Materials and Methods: This retrospective study evaluated 49 patients who underwent posterior ankle arthroscopy for several pathologies. All patients were operated on by a single surgeon over a 7-year period. Results were analyzed using the visual analog scale (VAS) and the AOFAS score. Intraoperative and postoperative complications were recorded. The average follow-up was 28 months. Results: 33 men and 16 women (mean age 38.6 years). There were 7 complications (14.3%): 4 cases of paresthesia and/or hypoesthesia of the sural nerve, 2 cases of residual pain at one portal, and 1 case of scar dehiscence. The average improvement in the VAS score was 5.53 points. The average improvement in the AOFAS score was 35.78 points. Conclusions: Knowledge of the arthroscopic anatomy of the posterior compartment, careful use of instruments, and avoide distractions allow for the prevention of most complications. Distraction-free posterior ankle arthroscopy using the classic posterolateral and posteromedial portals is a safe technique with a low rate of major complications and low morbidity for the patient.

Introduction: Arthroscopy has become an important tool for treating various ankle conditions. In last fifteen years, arthroscopic treatment of chronic ankle instability has become increasingly popular, with two main techniques: the all-inside and the arthro-Brostrom. The objective of this study is to evaluate the functional outcomes and complications of arthroscopic treatment of chronic ankle instability using a modified arthro-Brostrom technique. Materials and Methods: Retrospective study of 28 patients with chronic ankle instability who did not respond to conservative treatment were evaluated using arthroscopic repair with the arthro-Brostrom technique. All patients were operated on by a single surgeon. over a five-year period. Minimum postoperative follow-up was 18 months. Patients were evaluated using the AOFAS score, the VAS scale, and their return to their usual sporting activity. Complications were also assessed, and the technique is described. Twenty-two patients underwent treatment for associated bone or soft tissue friction syndrome. Eight patients presented an osteochondral lesion treated with the same arthroscopy. Results: Mean age: 29,3 years. Mean follow-up: 32 months. Average improvement in the AOFAS score of 19 points and improvement in the VAS scale of 4.6 points. Complications were recorded in 17.8% (5 patients): residual pain in one; comparative plantar flexion limitation in another; superficial peroneal neuritis in two cases; and asymptomatic anchor malposition in the other case. Return to normal activity was achieved in 92.8% of cases. Conclusions: The arthroBrostrom ankle ligament repair was effective, without major complications, and with good functional results. Patients reported stability and returned to their activities.

Introduction: Total ankle replacement is a common surgical technique today. The appearance of periprosthetic bone cysts is a factor in the potential for implant loosening. The treatment of this condition prevents prosthetic loosening, subsidence, and decreased implant lifespan. The objective of this study is to present a surgical technique for stable ankle prostheses with signs of periprosthetic lysis, using mini approaches for its resolution. Materials and methods: Two cases of periprosthetic ankle lysis without prosthetic loosening are presented. The bone graft filling technique is described. The minimum follow-up was 24 months. Results: Prosthesis preservation was observed, with graft incorporation and no secondary lysis. Discussion: Periprosthetic osteolysis is often asymptomatic. Diagnosis is difficult because osteolysis occurs within the cancellous bone of the distal tibia and proximal talus, making it difficult to detect on plain radiographs. Computerized tomography (CT) with metal subtraction is the most sensitive method. The average size of the lesions detected on CT was three times smaller than those seen on radiographs. According to the literature, most asymptomatic lesions with small cysts should be treated conservatively and monitored regularly. Cysts that progress rapidly or begin to cause symptoms should be treated surgically with curettage and debridement, followed by grafting, with or without replacement of the polyethylene component. Conclusions: While there is no size that determines the surgical decision, publications with larger case series recommend evaluating surgery in the presence of symptoms, rapid progression of cysts that may result in loosening of the implant, which would change the therapeutic approach.

Background Supramalleolar tibial osteotomy (SMOT) is increasingly used as a joint-preserving procedure for ankle osteoarthritis. This experimental study analysed the effect of varus and valgus correction on intra-articular load distribution in the ankle joint using the centre of force (CoF). Methods Nine human lower leg specimens were tested in a servo-hydraulic system (Instron) under axial load (200 N). After SMOT, defined corrections of ±5° and ±10° were created using wedge osteotomies. Intra-articular pressure distribution was recorded with a TekScan sensor. The CoF was calculated relative to the neutral position. The talar surface was analysed in a two-region (medial/lateral) and a four-zone model. Statistical analysis was performed using R Studio. Results Varus correction resulted in a significant medial shift of the CoF (median 2.67 mm at 5°, 3.29 mm at 10°; p < 0.05) compared to native alignment. Additionally, increasing varus induced a posterior displacement. In contrast, valgus correction showed no consistent lateral shift and demonstrated high inter-individual variability, with mean values remaining close to the native position, particularly at 10° valgus. Four-zone analysis confirmed a shift towards the posteromedial quadrant under varus correction, most pronounced at 10°. Valgus correction showed a slight anterolateral tendency at 5°, but no directional pattern at 10°. Conclusion SMOT induces a correction-dependent shift in intra-articular load distribution. Varus correction leads to a predictable medial and posterior CoF shift, whereas valgus correction shows no consistent pattern and high variability. CoF analysis provides a detailed assessment of ankle joint biomechanics.

Background Supramalleolar tibial osteotomy (SMOT), alone or combined with calcaneal osteotomy (CO), is increasingly used as a joint-preserving treatment for ankle osteoarthritis. This study analysed correction-dependent changes in intra-articular load distribution using the centre-of-force (CoF). Methods Nine human lower leg specimens were tested in a biomechanical setup under axial loading (200 N; Instron). Based on a neutral ankle position, defined varus and valgus corrections were simulated, with and without additional CO. Intra-articular pressure distribution was recorded using TekScan sensors and analysed as CoF displacement relative to neutral in mediolateral and anteroposterior directions. Statistical analysis was performed using RStudio. Results SMOT for varus correction produced a consistent medial shift of the CoF across nearly all specimens, irrespective of additional CO. In contrast, valgus correction showed no uniform mediolateral shift and demonstrated high inter-individual variability without a reproducible directional pattern. In the anteroposterior plane, varus correction induced a pronounced posterior shift of the CoF, predominantly affecting posterior talar regions. Two-dimensional analysis confirmed a combined posteromedial displacement following varus correction, whereas valgus correction showed no consistent spatial pattern. Additional CO did not result in a systematic change in CoF position. No consistent additive effect was observed compared to isolated SMOT, and findings varied depending on the specific correction combination. Conclusion SMOT induces a reproducible, correction-dependent shift in intra-articular load distribution, particularly towards posteromedial regions. CoF analysis enables a more detailed assessment than peak pressure evaluation alone. Additional CO shows no consistent biomechanical benefit and should be considered on an individual basis.

Background: Total Ankle Arthroplasty (TAA) is an established treatment for end-stage ankle osteoarthritis. This study aimed to investigate the impact of initial component positioning on long-term clinical outcomes, hypothesizing worse results when alignment is suboptimal. Methods: A retrospective single-center cohort study was conducted, including all patients who underwent TAA with a minimum follow-up of 10 years. Demographic data and clinical outcomes at final follow-up were collected. First postoperative weight-bearing radiographs were evaluated to assess prosthetic alignment parameters. Patients were categorized into two groups based on the current literature: “within acceptable limits” and “beyond acceptable limits,” to examine the association between radiographic positioning and clinical outcomes. Results: Thirty-nine patients met the inclusion criteria (26 females, 13 males), with a mean age at surgery of 58 years (range, 25–79) and a mean follow-up of 15 years (range, 11–21). Among the evaluated parameters, only the talar center of rotation offset (Lateral Talar Station - LTS) showed a significant association with outcomes: patients with LTS values beyond the acceptable range reported higher VAS pain scores compared with those within the range (5.27 vs. 3.44; p = 0.031). Conclusions: Within the study limitations, LTS values beyond the acceptable range were associated with significantly higher patient-reported pain. These findings highlight the clinical relevance of restoring an appropriate talar center of rotation. Further studies are warranted to validate these results and clarify the impact of prosthetic positioning on long-term outcomes.

Background: Numerous surgical options have been proposed for ankle osteochondral lesions (OCLs), but the optimal treatment remains debated. This study aims to evaluate the clinical outcomes of a modified retrograde drilling (RD) for the management of ankle OCLs. Methods: All patients consecutively treated for ankle OCLs with RD augmented with a hyaluronic acid scaffold soaked in bone marrow aspirate were enrolled. Preoperative and postoperative clinical scores and imaging were registered. Results: Twenty-one patients (10 males, 48%; 11 females, 52%) were included with a mean age at surgery of 40.6 years (range, 19-61). Lesions were mainly located on the talus (17 medial, 81%; 3 lateral, 14%) and in one case on the tibia (5%). At a mean follow-up of 22.3 months (range, 15-31), the AOFAS score increased on average from 58.8 (range, 24-72) preoperatively to 85.2 (range, 68-100, p<0.001). The mean VAS score at rest and during activity improved from 2.6 (range, 0-5) and 8 (range, 6-10) to 0.5 (range, 0-3, p<0.001) and 2.5 (range, 0-6, p<0.001), respectively. No intraoperative complications occurred; one patient experienced delayed wound healing, completely resolved. Postoperative imaging showed good bone remodeling and reduction in bone edema. Conclusions: This technique combines the mini-invasiveness of RD with the regenerative properties of a biological scaffold soaked with bone marrow aspirate. Although further research is needed, it appears to be a promising option for treating subchondral cysts and osteochondral defects of the ankle.

Total ankle replacement (TAR) is increasingly used for end-stage tibiotalar osteoarthritis as an alternative to arthrodesis, which relieves pain at the cost of joint motion and may alter adjacent biomechanics. However, outcomes remain debated, with failures often linked to malposition, loosening, wear, pain, instability, and residual malalignment. Weight-bearing CT (WBCT) enables three-dimensional assessment of foot–ankle alignment under physiological load and may improve postoperative evaluation. This prospective study included 12 patients with unilateral end-stage ankle osteoarthritis undergoing TAR with a fourth-generation, three-component mobile-bearing prosthesis. WBCT scans in single-leg stance and clinical evaluations were performed preoperatively and at 12 months. Semi-automatic segmentation generated patient-specific 3D bone models, from which anatomical reference systems were defined using principal-component analysis. Absolute and relative orientations of bones across hindfoot, midfoot, and forefoot were quantified. A control group of seven healthy subjects was used for comparison. Preoperatively, patients showed increased sagittal alignment of the 2nd–4th metatarsals compared to controls (p≈0.02). These differences were no longer significant postoperatively (p≥0.05), indicating partial normalization. A borderline improvement in tibio-calcaneal sagittal alignment was observed (p=0.07), with postoperative values trending toward controls. Hindfoot alignment changes were limited. WBCT analysis suggests that TAR influences not only the ankle joint but also the global foot–ankle alignment under load. In particular, forefoot sagittal alignment and tibio-calcaneal relationships showed a shift toward more physiological patterns. Although preliminary and limited by sample size, these findings support the concept of TAR as a procedure capable of promoting partial global realignment. Larger, implant-specific studies are warranted.

Introduction: Osteochondral lesions of the talus (OLT) can result in chronic ankle joint pain. Around half of the cases require surgical intervention. The decision to operate depends on persisting symptoms, size and location of OLT. Various surgical techniques are available, but an optimal treatment strategy for Berndt & Harty (BH) stage IV and V lesions is lacking. This pilot study investigates the effect of a single-stage, matrix-augmented, autologous chondrocyte transplantation of the talus. Methods: This single-centre, retrospective pilot study included 8 patients with a median age of 32 years (IQR 20), treated with arthroscopic assisted surgery between 2022 and 2024 for MRI confirmed, symptomatic BH stage IV and V OLT with a median volume of 1 cm3 (IQR 1). Primary outcome is pain reduction during weight bearing (numeric rating scale, NRS 0-10), secondary outcomes are pain reduction at rest (NRS 0-10), postoperative satisfaction (scale 0-10) and the foot and ankle outcome score (FAOS-NL 0-100). Results: After a follow-up of 10 months (IQR 6) the pain during weight bearing decreased from 5 (IQR 1.5) to 2 (IQR 3.3). At rest the median pain decreased from 4.5 (IQR3.0) to 1.5 (IQR 1.8. The overall median postoperative satisfaction score was 6.5 (IQR 1.5) and the overall FAOS-NL had a median of 59 points (IQR 32). No surgical complications were reported. Conclusion: The early results of this pilot study suggest that single-stage, matrix-augmented, autologous chondrocyte transplantation of the talus is a safe and potentially effective treatment for OLT with BH stage IV and V.

Background. Total talus replacement (TTR) has emerged as a motion-preserving option for end-stage talar pathology. However, the indication for isolated talar replacement remains unclear, particularly with concomitant tibial plafond cartilage lesions. This study aimed to evaluate two-year outcomes of TTR and identify ideal candidates for isolated talar replacement based on preoperative radiographic assessment. Methods. Twenty-two consecutive TTR patients (May 2021 to February 2024; mean follow-up 32.7 months) were retrospectively reviewed. Preoperative radiographs were classified using a cascade-based staging system (Stage 0, no findings; 1, osteophyte; 2, sclerosis or cyst; 3, contour change; 4, destruction). Association with intraoperative tibial cartilage findings and clinical scores (visual analogue scale [VAS], Foot and Ankle Outcome Score [FAOS], range of motion [ROM], Foot Function Index [FFI], EuroQol-5 Dimensions [EQ-5D], EuroQol visual analogue scale [EQ-VAS], satisfaction) was analysed using Fisher's exact test, Cohen's kappa, and Kendall's tau-b. Results. All clinical parameters improved significantly (VAS 8.2 to 0.9; FAOS 19.5 to 83.3; FFI 84.3 to 10.5; all p<0.001). Two failures occurred, both in patients with preoperative tibial lesions and Stage 4 radiographs, presenting as superior prosthesis migration into compromised tibia. Preoperative staging showed near-perfect agreement with intraoperative tibial findings (sensitivity 91.7%, specificity 100%, kappa 0.909, p<0.001). Higher stage correlated with worse outcomes (Satisfaction tau=-0.495, p=0.012; FAOS tau=-0.369, p=0.027; EQ-VAS tau=-0.415, p=0.017). Conclusion. Patients with low radiographic stage and absent tibial lesions are ideal candidates for isolated TTR. Cascade staging may guide selection of candidates requiring tibial resurfacing. More granular lesion characterization is needed to refine surgical decision-making.

Background: Endoscopic flexor hallucis longus (FHL) tendon transfer addresses chronic Achilles tendon ruptures. Traditional percutaneous plantar incisions gain FHL length but risk neurovascular injury. This study evaluated the feasibility of an all-inside endoscopic FHL zone 1 tenotomy and transfer technique, which avoids plantar incisions by using zone 1 of the FHL tendon. We hypothesized that this technique would (1) provide sufficient tendon length, (2) avoid neurovascular damage, and (3) securely anchor the FHL tendon without tunnel blowout. Methods: Ten cadaveric all-inside endoscopic zone 1 FHL tendon transfers were performed without fluoroscopic guidance. Specimens were independently assessed post hoc by 2 board-certified orthopedic foot and ankle surgeons. Tendon length, anchor placement, tunnel integrity, and neurovascular bundle preservation were analyzed. Results: No neurovascular injuries or calcaneal tunnel blowouts occurred. Mean FHL tendon length for tunnel fixation was 17.5 (3.7) mm; 2 specimens had FiberLoop suture visible above the biotenodesis screw. Conclusion: Our study supports the feasibility, reproducibility and preliminary safety of an all-inside FHL zone 1 tenotomy and endoscopic transfer. These cadaveric findings support further clinical investigation of this technique for Achilles rupture repair. Clinical Relevance: This cadaveric study provides anatomical evidence that an all-inside endoscopic zone 1 FHL tendon transfer can be performed without neurovascular injury or tunnel blowout, offering preliminary support for future clinical investigation of this technique as a minimally invasive approach to Achilles tendon repair.

Introduction: Tibiotalocalcaneal arthrodesis is a well-established salvage procedure for advanced ankle and subtalar joint disease, including posttraumatic degeneration, rheumatologic conditions, neuropathy, congenital deformity, and failed previous procedures. Stable fixation remains challenging because these patients often present poor bone quality and high complication risk. Retrograde intramedullary nails and lateral locking plates with compression screws are commonly used, but comparative clinical evidence remains limited. Methods: This retrospective study reviewed adult patients who underwent tibiotalocalcaneal arthrodesis between 2005 and 2019 using either a retrograde intramedullary nail or a lateral locking plate associated with compression screws. Patients had at least 12 months of follow-up and no previous local osteomyelitis. Clinical records and radiographs were analyzed for demographic data, surgical indication, fusion, time to consolidation, infection, nonunion, residual deformity, implant-related complications, implant removal, and need for revision surgery. Results: Sixty-seven patients were included: 48 treated with retrograde intramedullary nails and 19 with locking plates and compression screws. Mean age was 48 years, and median follow-up was 64.3 months. The overall complication rate was 60.4% in the nail group and 52.6% in the plate group. Union occurred in 68.8% of nail cases and 73.7% of plate cases, without statistically significant difference. Infection, nonunion, implant removal, residual deformity, and repeated procedures were also similar between groups. Conclusion: Retrograde intramedullary nails and lateral locking plates with compression screws showed comparable complication and union rates for tibiotalocalcaneal arthrodesis. Implant selection should therefore consider patient factors, deformity pattern, soft-tissue condition, and surgeon experience.

Objective: Osteochondral lesions of the talus often lead to chronic pain and functional limitations due to the limited intrinsic repair capacity of articular cartilage. The autologous matrix-induced chondrogenesis (AMIC) procedure is a reliable single-stage surgical treatment. This study aims to evaluate long-term clinical outcomes and survivorship of the all-arthroscopic AMIC technique with a minimum follow-up of ten years. Methods: A retrospective case series was conducted on patients treated for lesions using the all-arthroscopic AMIC procedure between April 2013 and April 2016 (27 patients). The surgical technique involved debridement, microfractures, and implantation of a bilayer porcine collagen membrane. Clinical assessment was performed preoperatively and at 1, 5, and 10 years postoperatively using the Visual Analog Scale and American Orthopaedic Foot & Ankle Society score. The European Foot and Ankle Score and 17-item Italian Foot Function Index were utilized. Results: Analysis demonstrated significant improvements in VAS and AOFAS scores from baseline to 1 year and from 1 to 5 years (p < 0.001). These improvements were maintained with no significant differences between the 5-year and 10-year. Similarly, 17-IFFI and EFAS scores showed clinical stability and high patient satisfaction throughout the follow-up. No correlations were found between functional outcomes and age, BMI, lesion size, sex, or harvest type. The surgical failure rate was 7% at 10 years. Conclusions: The all-arthroscopic AMIC procedure is an effective, durable treatment for talus lesions. Clinical benefits achieved in the short term are successfully maintained up to ten years postoperatively, providing a reliable single-stage solution for joint preservation.

Background: Anterior talofibular ligament (ATFL) reconstruction is commonly performed for chronic ankle instability. Anatomical reconstruction aims to restore native anatomy and biomechanical function; however, detailed knowledge of ligament morphology and fascicular behaviour remains limited. The ATFL may consist of two anatomically and functionally distinct fascicles. This study evaluated ligament morphology and the influence of fascicle-specific reconstruction on ankle range of motion. Methods: Four fresh-frozen below-knee specimens were anatomically dissected to characterize ligament morphology, bundle configuration and footprint localization. Ligament lengths were measured in neutral position, plantarflexion and dorsiflexion. Ankle range of motion was assessed before and after sequential transection of the ATFL fascicles, followed by reconstruction of both fascicles, isolated inferior fascicle reconstruction, isolated superior fascicle reconstruction and non-anatomical reconstruction using FiberTape. Results: The superior fascicle demonstrated position-dependent length changes, lengthening in plantarflexion and shortening in dorsiflexion, whereas the inferior fascicle showed more isometric behaviour. FiberTape reconstruction reduced plantarflexion from 36.5 ± 3.4° to 18.8 ± 12.8° after two-fascicle reconstruction, 26.0 ± 14.7° after inferior fascicle reconstruction, 22.2 ± 12.9° after superior fascicle reconstruction and 16.0 ± 9.9° after non-anatomical reconstruction. Conclusion: This anatomical study supports the concept that the superior ATFL fascicle behaves in a non-isometric manner, whereas the inferior fascicle demonstrates more isometric characteristics. Reconstruction using a rigid FiberTape construct reduced plantarflexion, with a greater reduction following isolated superior fascicle reconstruction and non-anatomical reconstruction. These findings suggest that fascicle selection, footprint location and graft characteristics may influence restoration of native ankle biomechanics during ATFL reconstruction.

Background: Patient-specific instrumentation (PSI) has been developed to improve implant positioning in total ankle arthroplasty (TAA), but most studies have assessed accuracy using conventional radiographs. Three-dimensional evaluation with postoperative weightbearing CT (WBCT), particularly relative to clinically relevant anatomical landmarks, remains limited. Methods: This retrospective study included 54 patients who underwent INBONE II TAA using Prophecy PSI, with available preoperative planning and postoperative WBCT. Planned and postoperative measurements were compared for medial tibial component-to-medial malleolus distance, talar stem-to-subtalar joint distance, and talar cut angle relative to the horizontal floor axis. For distance measurements, excellent, acceptable, and poor accuracy were defined as <1, 1–2, and >2 mm, respectively. For angular measurements, the corresponding thresholds were <2°, 2–4°, and >4°. Interobserver reliability was assessed using intraclass correlation coefficients. Results: Distance-based parameters demonstrated high accuracy. For medial malleolar distance, 54% of cases were excellent, 26% acceptable, and 20% poor, with a mean absolute difference of 1.12 mm. For subtalar joint distance, 58% were excellent, 35% acceptable, and 7.7% poor, with a mean absolute difference of 0.98 mm. Directional analysis showed slightly greater postoperative medial malleolar and subtalar clearance than planned. The talar cut angle showed greater variability, with 39% excellent, 33% acceptable, and 28% poor, and a mean absolute difference of 2.91°. Interobserver reliability was good to excellent across all variables. Conclusion: INBONE Prophecy PSI demonstrated high accuracy for distance-based implant positioning on postoperative WBCT. However, sagittal talar component orientation remained more variable, suggesting that PSI does not fully eliminate factors influencing angular positioning.

Objectives: This prospective monocentric pilot study evaluated clinical-functional outcomes and return to sport after resurfacing surgery with second-generation customized talar implants for osteochondral lesions. Methods: Between October 2021 and July 2023, 20 patients underwent partial talar resurfacing. After exclusions and dropouts, 17 patients (13 males, 4 females; mean age 43 ± 14 years) completed follow-up (mean 19 ± 6 months, range 12–24). All had grade four osteochondral lesions. Nine patients (52.9%) reported previous ankle sprains, while eight (47.1%) had primary non-traumatic lesions. Clinical evaluation was performed preoperatively and at 3, 6, 12, and 24 months using pain, quality-of-life, and foot-and-ankle functional scores. Results: Significant improvements were observed across all outcomes. Mean pain score decreased from 6.16 ± 1.8 preoperatively to 0.08 ± 0.3 at 24 months. Quality-of-life score improved from 0.13 ± 0.2 to 0.86 ± 0.1, while Foot and Ankle Outcome Score increased from 58.6 ± 17% to 96.1 ± 6%. The sports and recreation subdomain improved from 41.8 ± 24% to 92.8 ± 16.8%. Mean time to return to sport was 20 ± 13 weeks. Complications occurred in three patients: one tendon injury, one delayed wound healing, and one implant failure requiring revision. Conclusions: Second-generation customized talar implants provided significant improvements in pain, function, quality of life, and return to sport. They represent a promising joint-preserving option for active patients with osteochondral lesions, although larger studies with longer follow-up are needed.

Background: Total ankle arthroplasty (TAA) relies heavily on intraoperative fluoroscopy, and adherence to As Low As Reasonably Achievable (ALARA) principles is increasingly important given the recognised occupational health risks of ionising radiation. While patient-specific instrumentation (PSI) has been widely adopted, the specific radiation burden of PSI-based TAA and the incremental effect of concurrent foot and ankle procedures have not been systematically quantified in an instrumentation-homogeneous cohort. Methods: A retrospective multicentre cohort study of 124 consecutive primary TAA procedures performed using the Infinity system with PSI was organised at two tertiary referral centres. Fluoroscopy time and dose-area product (DAP) were collected and compared between isolated and concurrent procedures using non-parametric tests. Concurrent cases were categorised into soft-tissue, tendon, and bony procedure subgroups. Results: Mean fluoroscopy time was 58.6 ± 28.4 seconds and mean DAP 17.12 ± 12.07 cGy·cm². Concurrent procedures significantly increased fluoroscopy time compared with isolated TAA (64.8 vs 52.6 seconds, +23.1%, P=0.008) without a corresponding increase in DAP (P=0.99). Tendon procedures increased fluoroscopy time by 33.1% (P=0.009) and bony procedures by 30.2% (P=0.035); soft-tissue procedures did not reach significance (+10.2%, P=0.30). Radiation metrics were comparable between the two centres. Conclusion: Concurrent tendon and bony reconstruction significantly increases intraoperative fluoroscopy time during PSI TAA. Fluoroscopy time is more sensitive than DAP for monitoring this cumulative radiation burden. Surgeons should anticipate higher fluoroscopic exposure when planning combined reconstruction and apply ALARA-based strategies accordingly.

Background: Chronic deltoid ligament insufficiency contributes to medial ankle instability, potentially coexisting with lateral instability or peritalar deformity. The optimal reconstruction strategy remains unclear. Methods: A systematic review following PRISMA 2020 guidelines searched MEDLINE, Embase and Scopus for studies reporting outcomes of deltoid ligament reconstruction for chronic insufficiency. Functional scores, radiographic stability and complications were extracted. Risk of bias was assessed using ROBINS-I. Results: Sixteen studies (326 patients, 331 ankles; mean follow-up 29.3 months) were included. Most were retrospective with moderate-to-serious risk of bias. Reconstructions included direct repair, tendon graft reconstruction and synthetic augmentation, predominantly via open approaches. Postoperative AOFAS scores and talar tilt measurements were consistently improved. Complications were predominantly transient sensory neuropraxias. Conclusions: Deltoid ligament reconstruction was consistently associated with improvements in pain, function and radiographic stability. Future comparative trials are needed to establish optimal surgical techniques, indications and long-term durability.

Introduction Total ankle arthroplasty (TAA) has become an established treatment option for end-stage ankle osteoarthritis. Transfibular implants may offer technical and biomechanical advantages, although evidence regarding their long-term survival remains limited. This study aimed to evaluate the long-term survival, clinical outcomes, and radiographic findings of a transfibular TAA design. Materials and Methods This retrospective single-center study included patients who underwent TAA with a transfibular approach using the TM Ankle prosthesis (Zimmer) between April 2013 and March 2016. Implant survival and complications were assessed according to the CROCS-COFAS classification system. Clinical evaluation included AOFAS, EQ-5D, and VAS scores, together with ankle range of motion (ROM) assessment at the latest follow-up. Radiographic analysis evaluated aseptic loosening, implant subsidence, peri-implant ossifications, and degenerative changes in adjacent joints. Results Of the 84 eligible patients, 64 completed follow-up. Five patients required revision surgery with implant removal and were classified as failures. Clinical, radiographic, and final statistical analyses are currently ongoing. Discussion Preliminary survival data appear encouraging. Most patients showed improvement in clinical scores and pain reduction compared with preoperative values, despite a decrease in ankle ROM. No cases of aseptic loosening were identified, whereas peri-implant ossifications were frequently observed and may be associated with ROM limitation. Conclusions Preliminary findings suggest that this implant may represent a reliable and safe option for the treatment of end-stage ankle osteoarthritis. Despite reduced joint mobility, improvements in clinical outcomes and favorable radiographic findings support its long-term use.

Background: Total ankle arthroplasty (TAA) is an increasingly popular treatment for end-stage ankle arthritis. Nerve injury is a recognized but underreported complication, which may result from direct trauma or indirect injury through retraction or instrumentation during the procedure. This systematic review aimed to evaluate the incidence of iatrogenic nerve injury in primary total ankle arthroplasty, identify the nerves most commonly affected, and describe patterns of management and recovery. Methods: A systematic literature search was conducted using the MEDLINE, EMBASE, PubMed, and Cochrane Library databases from January 2000 to November 2025, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. English-language studies reporting on nerve injury as an assessed outcome with sample sizes greater than ten were included. Methodological quality of included studies was assessed using the ROBINS-I tool. Results: Twenty-two studies incorporating 2771 TAA (2730 patients) were included. The nerve injury rate was 2.8% (77/2771); range, 0%-15%. The most commonly affected nerves were the tibial nerve, deep peroneal nerve, and superficial peroneal nerve. Five studies reported zero nerve injuries, although two of these did not systematically assess for this complication. The majority of cases were managed conservatively. Of 35 patients with documented recovery data, 14 (40%) achieved complete resolution, 11 (31%) experienced partial recovery, and 10 (29%) showed no improvement. Conclusion: Total ankle arthroplasty is associated with a clinically significant rate of iatrogenic nerve injury of 2.8%. A third of patients with nerve injury failed to improve.

Objectives: To compare the clinical outcomes and complication profile of the classic three-portal all-inside arthroscopic lateral ligament repair with a modified two-portal all-inside anatomical repair technique. We hypothesised that the two-portal approach would achieve equivalent outcomes without increased risk of complications. Methods: A multicentre retrospective cohort study was performed across two centres (London, UK and Brasilia, Brazil). A total of 69 patients with chronic lateral ankle instability underwent arthroscopic lateral ligament repair between 2020 and 2023. Thirty-six patients were treated using the modified two-portal technique and 33 using the classic three-portal technique. Outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOxFQ; walking/standing, pain, and social interaction domains) and the EuroQol-5D-5L (EQ-5D-5L). Complication rates, including superficial peroneal nerve injuries, were recorded. Statistical significance was set at p<0.05. Results: Both groups demonstrated significant improvement from baseline across all MOxFQ domains and EQ-5D-5L scores (p<0.001). No statistically significant differences were observed between groups in functional outcomes or health-related quality of life (p>0.05). Complication rates were comparable: three cases of temporary superficial peroneal nerve neuropraxia occurred in each group (8.1% vs. 8.8%, p=0.92). No re-ruptures or revisions were reported at mean follow-up of 22 months. Conclusions: The modified two-portal all-inside arthroscopic lateral ligament repair is a safe and effective alternative to the three-portal technique. Both approaches yield equivalent improvements in function and quality of life with similar complication profiles, suggesting the two-portal method offers a less invasive option without compromising outcomes or increasing surgical risk.

Minimally invasive repair of acute Achilles tendon ruptures aims to restore tendon anatomy while reducing surgical morbidity. This study evaluated functional outcomes, complication rates, and predictive factors for return to sports following PARS Knotless repair. A retrospective study was conducted on 27 patients (96.3% male; mean age 49.6 years) treated with the PARS Knotless technique. Demographic data, ankle range of motion (plantarflexion [PF] and dorsiflexion), and tendon elongation assessed by the relative Achilles Tendon Resting Angle (ATRA) were analyzed. Clinical outcomes were evaluated using the Achilles Tendon Total Rupture Score (ATRS). Statistical analysis included the Mann–Whitney U test and Spearman’s correlation coefficient, with significance set at p<0.05. The mean ATRS was 75.1 ± 24.1. The overall complication rate was 37%, with residual tendinopathy or persistent pain being the most frequent complication (25.9%). Complications were significantly associated with lower ATRS scores (p=0.004). Return to sports was achieved in 55.5% of patients and was associated with greater recovery of PF range of motion (38.3° vs. 23.3°; p=0.037). No significant association was found between return to sports and age or relative ATRA. Notably, 33.3% of patients with poor functional outcomes (ATRS <60) were still able to resume sports activities. Recovery of plantarflexion range of motion appears to be the main predictor of return to sports after Achilles tendon repair. Residual pain significantly impairs patient-reported outcomes but does not necessarily prevent sports participation. Rehabilitation strategies focused on restoring plantarflexion and preventing residual tendinopathy may help optimize clinical outcomes.

Introduction/Purpose: Ankle corticosteroid injections (CSI) are commonly used prior to ankle arthrodesis or total ankle arthroplasty (TAA). While preoperative injections in other joints have been linked to periprosthetic joint infection (PJI), ankle-specific evidence is limited. This study evaluated whether ankle CSI within six months prior to surgery is associated with postoperative infection, reintervention, or healthcare utilization. Methods: A retrospective cohort study used the TriNetX US Collaborative Network to identify adults undergoing ankle arthrodesis or TAA (2005–2025). Patients receiving preoperative CSI within six months were compared to those who did not, with 1:1 propensity matching for demographics, BMI, and comorbidities (1,918 matched pairs). Outcomes at 30 days, 90 days, 1 year, and 2 years included ED visits, opioid utilization, readmission, infection, implant removal, revision, amputation, and CRPS. Results: CSI was not associated with increased infection at any time point. CSI recipients demonstrated higher ED utilization at all time points (30d: 3.5% vs 2.0%; 2yr: 19.5% vs 14.8%) and greater opioid use through one year. At two years, the CSI cohort had higher rates of implant removal (12.8% vs 10.0%), revision/conversion to arthroplasty (2.9% vs 1.4%), and CRPS (1.4% vs 0.6%). Amputation was less frequent in the CSI group (0.5% vs 1.4%). Conclusion: Preoperative ankle CSI was not associated with infection risk but was associated with greater healthcare utilization, opioid use, implant removal, revision arthroplasty, and CRPS. Surgeons should weigh short-term symptomatic benefit against potential downstream morbidity when counseling patients before definitive ankle surgery.

Background: The pathophysiology of idiopathic talar avascular necrosis remains incompletely understood. Because the talus has a limited vascular supply, variations in extraosseous arterial anatomy may contribute to disease development. Purpose: To compare magnetic resonance imaging-based lumen diameters of the posterior tibial artery, deltoid branch, and sinus tarsi artery between patients with idiopathic talar avascular necrosis and matched controls, and to assess their relationship with disease severity. Methods: This two-center retrospective matched case-control study included 40 patients with idiopathic talar avascular necrosis and 40 healthy controls. Individuals aged 18 years or older with available ankle magnetic resonance imaging were eligible. Patients with systemic or local vascular risk factors, major trauma, talar fracture, chronic steroid use, rheumatologic disease, or inadequate image quality were excluded. Posterior tibial artery diameter, deltoid branch visibility and diameter, sinus tarsi artery diameter, talar morphology, disease stage, and percentage of necrotic volume were recorded. Measurements were performed by two blinded orthopedic researchers. Group comparisons, logistic regression, receiver operating characteristic analysis, and interobserver reliability assessment were used. Results: Patients with talar avascular necrosis tended to have smaller extraosseous arterial lumen diameters than controls. Distal posterior tibial artery measurements, deltoid branch visibility or diameter, and sinus tarsi artery diameter showed the clearest separation between groups. Smaller arterial diameters appeared to be associated with more advanced disease stage and greater necrotic volume. Conclusion: Extraosseous arterial lumen diameters may be associated with the presence and severity of idiopathic talar avascular necrosis. Magnetic resonance imaging-based vascular assessment may improve understanding of this condition.

Background: Posterior calcaneal tuberosity avulsion fractures, also known as calcaneal beak fractures, are rare injuries that require urgent treatment because of the continuous traction exerted by the Achilles tendon, which may lead to fragment displacement, skin compromise, and functional impairment. Case Presentation: A 68-year-old woman with no significant medical history presented with acute posterior heel pain following a forced dorsiflexion injury. Clinical examination revealed posterior heel tenderness, skin tension, and an altered Thompson test. Radiographs demonstrated a displaced avulsion fracture of the posterior calcaneal tuberosity consistent with a calcaneal beak fracture. Given the risk of soft-tissue complications, early surgical treatment was performed through a posterolateral approach. Anatomical reduction was achieved and stabilized using a 6.5-mm cannulated screw. The postoperative course was uneventful. Radiographic signs of union were observed at six weeks, with progressive recovery of plantarflexion. At three months, the patient was able to walk without pain and had regained approximately 70% of triceps surae strength. At six months, complete fracture union and excellent functional recovery were achieved without complications. Conclusion: Calcaneal beak fractures are unstable lesions requiring prompt surgical management to prevent skin complications and restore Achilles tendon function. In this case, fixation with a 6.5-mm cannulated screw provided stable osteosynthesis, successful bone healing, and excellent functional outcomes, supporting its use as a reliable treatment option for appropriately selected fractures.

INTRODUCTION: Hemophilic patients are at high risk of postoperative complications. This retrospective single-operator study reports TAR survival and outcome in these patients. MATERIAL: Between April 2006 and April 2023, 39 TARs (7 AES, 6 Hintegra, 25 Talaris-XT, 1 Quantum) were implanted in 33 men; mean age, 44.4 ±12.7(23-66) years. 69% had associated procedures (14 subtalar fusion, 9 Achilles lengthening, 4 ligament plasty, 2 preventive malleolar osteosynthesis). Functional, clinical and radiological follow-up was performed at 1, 2 then every 5 years, with CT preoperatively, and at 1 year and long-term. RESULTS: 39 TARs were analyzed at 69.8±53 months (1-17.2 yrs). The 5-year survival (Kaplan-Meier) was 87.5% reintervention-free, and 95.5% without TAR removal. Seven patients underwent reoperation: 1 arthrodesis for cysts, 1 cyst curettage-cementing, 2 Achilles lengthening, 1 early malleolar fracture osteosynthesis, 1 infection. Mean AOFAS score increased from 39.7 ± 12 (17-66) to 81.3 ±9 (59-97) at follow-up. Range of motion improved from 28.1±13.6° to 41.9±11.3°, with dorsiflexion improving from -1.54±9.8° to 10.2±4.5°. Radiologically, tibial implants were well positioned: alpha angle 90.3° (86°-93°), beta angle 88.6° (82°-94°), delta angle 90.2° (81°-109°). Overall radiological tibiotalar motion increased from 16.9±10° to 21.0±7°. Severe cyst rate on CT (>10mm) was 15.3% at last FU. 58.9% of patients showed no cysts or radiolucency on CT. DISCUSSION: In hemophilic patients, TAR has low revision and complication rates, and is an alternative to ankle arthrodesis.

Background: Fourth-generation total ankle replacement (TAR) reports survivorship of 92–98%, yet clinically significant complications persist, including heterotopic ossification rates of 55–70%, aseptic loosening, periprosthetic fracture, and revision procedures. The relationship between preoperative bone mineral density and TAR complications remains poorly characterized. CT-derived Hounsfield unit (HU) measurements from routine preoperative planning scans provide a validated, cost-neutral, radiation-free method for opportunistic bone quality assessment at TAR-specific fixation sites. Purpose: To determine whether preoperative CT-derived HU at the distal tibia, talar body, and calcaneus are independently associated with complications, component-specific failures, and patient-reported outcomes following primary TAR. Methods: This single-center retrospective cohort study includes 303 ankles in 300 unique patients undergoing primary fourth-generation TAR at Washington University in St. Louis. The cohort is 57% male with a mean age of 64 years and BMI of 31 kg/m². Smoking history included 63% never-smokers, 35% former smokers, and 2% active smokers. HU measurements at the distal tibia, talar body, and calcaneus are being performed using the validated Schreiber technique, and PROMIS Physical Function scores have been collected. All measurements and outcome analyses will be finalized prior to the meeting. Primary analysis will employ multivariable logistic regression adjusting for age, sex, BMI, deformity, and surgeon volume. Significance: This study provides the first comprehensive evaluation of ankle-specific CT bone quality as a predictor of the full TAR complication spectrum using fourth-generation implants, with direct implications for preoperative risk stratification, surgical decision-making, and patient counseling.

BACKGROUND Total ankle arthroplasty (TAA) is increasingly common, but the risk of amputation after TAA is poorly defined. METHODS TAA patients continuously enrolled in a commercial insurance database for 5 years were evaluated for subsequent lower extremity amputation. RESULTS A total of 6,439 patients underwent primary TAA; 2,134 (33.2%) had diabetes. Over 5 years, 39 major amputations occurred (0.60%). Patients with diabetes had a significantly higher risk of amputation than those without diabetes (0.98% vs. 0.42%; RR 2.35 [95% CI 1.26-4.40]; p = 0.0095). CONCLUSIONS The 5-year rate of major amputation following primary TAA is 0.60% overall. Among diabetic patients, the rate was significantly elevated at 0.98%. Careful patient selection and optimization of glycemic control remain essential when considering total ankle arthroplasty.

Background: Previous studies have suggested that total ankle arthroplasty (TAA) may reduce the risk of adjacent joint degeneration compared with ankle fusion (AF). We compared the incidence of subsequent hindfoot fusion after TAA and AF using a national database with verified long-term follow-up. Methods: Patients undergoing TAA or AF between 2010 and 2023 were identified in a United States commercial insurance database. Only patients with verified continuous enrollment for 10 years were included. Subsequent hindfoot fusion was assessed using Kaplan-Meier analysis. Results: Among 1,533 TAA and 4,404 AF patients with a verified 10-year follow-up, hindfoot fusion occurred in 4.24% and 4.06% of patients, respectively (p=0.765). Mean time to fusion was 3.8 years after TAA and 4.6 years after AF. Conclusion: The 10-year risk of subsequent hindfoot fusion was approximately 4% after both TAA and AF, with no significant difference between procedures. These findings do not support the commonly cited belief that TAA protects against symptomatic adjacent joint arthritis requiring hindfoot fusion.

Heterotopic ossification (HO), bone formation in extraskeletal tissues, is a common complication following Total Ankle Arthroplasty (TAA). However, its pathogenesis and risk factors remain poorly understood. This study investigated the incidence, distribution, and association of HO and clinical-demographic variables after TAA. A retrospective study was conducted on patients undergoing TAA. Radiographs obtained at 6 weeks, 12 months, and 24 months were evaluated for HO presence, location, and severity using the modified Brooker classification. Demographic characteristics, clinical variables, comorbidities (Elixhauser Comorbidity Index), chronic medications, and rehabilitation protocols were analyzed. Forty-seven patients were included (mean age 57.25 years). HO predominantly affected the posterior ankle compartment and progressed up to 24 months. Younger age and female sex were associated with lower HO grades. Surgical drainage, early mobilization, and early weight-bearing reduced HO formation. Lower comorbidity burden and polypharmacy were associated with less severe calcifications. Low-dose acetylsalicylic acid (ASA) and levothyroxine showed a protective effect. Swimming-based rehabilitation, combined with stationary cycling, was most effective in limiting calcification progression. All patients developed HO, which progressed up to 24 months without stabilization. Surgical drainage was associated with lower HO incidence, possibly through reduced postoperative hematoma. The protective effect of polypharmacy suggests modulation of inflammatory and osteogenic pathways. The benefit of swimming and cycling may be related to increased joint motion under partially loaded conditions. Factors associated with reduced HO incidence included early mobilization, polypharmacy, ASA and levothyroxine, and rehabilitation focused on mobilization. Conversely, higher postoperative activity and greater comorbidity burden were associated with increased HO risk.

Background: Total ankle replacement (TAR) is an established treatment for end-stage ankle arthritis, providing pain relief while preserving joint motion and avoiding the biomechanical limitations of arthrodesis. However, concerns remain regarding implant failure, revision surgery, and postoperative complications. Long-term survivorship data from non-designer centres are limited. This study reports 17-year implant survivorship following TAR at a UK non-designer centre. Methods: A retrospective cohort study was conducted at East Lancashire Hospitals NHS Trust. Demographic, radiographic, functional, and complication data were collected from electronic and paper records for TAR procedures performed between 2008 and 2025. Radiographic and functional outcomes were reviewed by orthopaedic surgical trainees. Results: Seventy-four TARs in 72 patients were analysed using three prosthesis designs (Mobility, Zenith, and Infinity). Mean age at surgery was 69.3 years (range 26–86), with osteoarthritis accounting for 85% of indications. Two patients (2.5%) required conversion to ankle fusion because of implant loosening. Satisfactory radiographic alignment was achieved in all cases. Mean ankle motion ranged from 10°–14° dorsiflexion and 25°–30° plantarflexion. Implant survivorship was 100% at 10 years and 94.9% at 17 years, comparable with published long-term outcomes. Conclusion: TAR performed in a UK non-designer centre demonstrated excellent long-term survivorship, satisfactory radiographic alignment, and favourable functional outcomes comparable with national and international data. Further analysis will evaluate the influence of implant design on patient-reported outcomes and survivorship.

Background: Total ankle replacement can be performed through a direct anterior approach or a lateral transfibular approach, but comparative evidence on perioperative burden and reoperation patterns remains limited. Purpose: To compare reoperation burden and perioperative outcomes between the direct anterior and lateral transfibular approaches for primary total ankle replacement. Study Design: Retrospective cohort study. Methods: Consecutive primary total ankle replacements performed at a single center between January 2016 and December 2021 were reviewed. Outcomes included reoperations, intraoperative and postoperative complications, operative time, length of hospital stay, and adjunctive procedures. Analyses were exploratory. Results: The cohort included 188 patients (120 anterior, 68 lateral). Length of hospital stay was 3.56 ± 1.49 days after anterior procedures and 3.67 ± 1.35 days after lateral procedures (p = 0.67). Overall complication rates were 31.67% and 30.88%, respectively. Operative time was longer in the lateral group (139.00 ± 34.17 minutes) than in the anterior group (115.00 ± 26.70 minutes). Reoperations per patient were higher and more heterogeneous in the lateral group (0.730) than in the anterior group (0.096). Adjunctive procedures were common; Achilles tendon lengthening was more frequent in anterior procedures (61.67% vs 47.06%, p = 0.025). Conclusions: In this cohort, the two approaches showed similar early length of stay and overall complication rates. The lateral transfibular approach required longer operative time and showed a more heterogeneous reoperation burden, potentially influenced by case complexity and adjunctive procedures.

Introduction/Purpose Intra-articular pathology is frequently associated with ankle fractures and may remain undetected during standard ORIF. Chondral lesions, soft-tissue impingement, and syndesmotic injuries may contribute to persistent pain and functional limitation despite satisfactory radiographic reduction. This study evaluated the role of ankle arthroscopy in the diagnosis and treatment of associated lesions in acute and subacute ankle fractures. Methods A retrospective single-center study was performed on 144 patients treated surgically for bimalleolar or trimalleolar ankle fractures between 2020 and 2024. Patients were divided into three groups: arthroscopically assisted ORIF performed acutely (AORIF), standard ORIF, and arthroscopic debridement performed for persistent symptoms (within 6–12 months after injury). Clinical outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), the European Foot and Ankle Society (EFAS) score, and ankle range of motion at a mean follow-up of 38 months. Results Patients undergoing arthroscopic debridement in the subacute phase demonstrated significant clinical improvement. Median FAOS improved from 61 preoperatively to 84.5 at final follow-up, with pain reduction and functional improvement reported in approximately 90% of cases. At final follow-up, the mean EFAS score was 34.0 ± 5.2 points. Arthroscopy performed during fracture fixation enabled direct visualization and treatment of associated intra-articular pathology, including chondral lesions, soft-tissue impingement, and syndesmotic injuries. Conclusion Ankle arthroscopy is a useful adjunct in the management of acute and subacute ankle fractures, allowing identification and treatment of associated intra-articular and syndesmotic lesions. Arthroscopic intervention may be particularly beneficial in patients with persistent symptoms during the early post-traumatic period.

Background: Mid to long term literature on the outcome of revision total ankle arthroplasty remains limited. We aimed to report clinical and radiographic outcomes of revision TAA at a high-volume centre in the UK. Methods: retrospective review of prospectively collected data of 82 patients who underwent 85 revision TAAs using the INBONE II Total Ankle System (Wright Medical Technology/Stryker). Demographic, radiographic, survivorship, reoperations, revisions and PROM data were analysed. Results: mean duration from primary TAA to revision 94.98 months (range 14 to 265 months). Mean age 68 years (range 33 to 86 years). Main indication was aseptic loosening after primary TAA (80%). Additional procedures required in 42.64% of ankles. At a mean follow-up of 64 months (range, 19 to 117 months), infection rate 2.35%, reoperation rate 8.23% and implant survival rate 95.29% (revision as end point). A significant postoperative improvement in radiographic component alignment measures was observed. The subsidence, loosening, and heterotopic ossification rates were comparable with those in other reports and did not influence the clinical outcome. A significant improvement was observed in Manchester-Oxford Foot Questionnaire (MOXFQ) in all domains and EuroQol-5 Dimensions (EQ-5D) in 3 domains at 24 months, 5 years and 10 years postoperatively. Conclusions: Revision TAA using the INBONE II prosthesis was associated with good short to mid-term survival and improvement in postoperative scores. Maintenance of the postoperatively improved alignment was documented at the follow-up. Results of this study support the notion that revision TAA is a satisfactory option for failed primary TAA in midterm FU.

Background: Mid to long term literature on outcome of revision total ankle arthroplasty remain limited. We aimed to report clinical and radiographic outcomes of revision TAA at a high-volume centre in the UK. Methods: This study was retrospective review of prospectively collected data of 45 patients who underwent 47 revision TAAs using INBONE II Total Ankle System (Wright Medical Technology/Stryker). Demographic, radiographic, survivorship, reoperations, revisions and PROM data were analysed. Results: Mean duration from primary TAA to revision 164 months (range 14 to 198 months). Mean age 66.87 years (range 33 to 83 years). Main indication was aseptic loosening after primary TAA (91.49%). Additional procedures required in 44.18% ankles. At a mean follow-up of 87 months (range 60 to 117 months), infection rate 4.25%, reoperation rate 10.63%, and implant survival rate 91.48 % (revision as end point). Significant postoperative improvement in radiographic component alignment measures was observed. Subsidence, loosening, and heterotopic ossification rates in this study were comparable with those in other reports and did not influence clinical outcome. Significant improvement was observed in Manchester-Oxford Foot Questionnaire (MOXFQ) in all domains and EuroQol-5 Dimensions (EQ-5D) in 3 domains at 24 months, 5 years and 10 years postoperatively. Conclusions: Revision TAA using INBONE II prosthesis was associated with good mid-term survival and improvement in postoperative scores at 5 – 10 years. Maintenance of postoperatively improved alignment was documented at follow-up. Results of this study support the notion that revision TAA is a satisfactory option for failed primary TAA in midterm follow-up.

Ankle arthritis causes chronic pain, impaired mobility, and reduced quality of life. Treatment options range from corticosteroid injections, offering short‑term relief, to total ankle arthroplasty, providing a longer‑term solution. Limited data directly compare longitudinal patient‑reported outcomes across these pathways. This study evaluates changes in PROMIS T‑scores: pain intensity, pain interference, physical function, and depression, among patients receiving injections versus arthroplasty to clarify expected recovery trajectories and inform treatment selection. Patients with ankle arthritis were identified at their initial visit, consented, and completed PROMIS questionnaires via RedCap at baseline, 3 months, 6 months, and 1 year. Participants were grouped by treatment: corticosteroid injection (n=25) or total ankle arthroplasty (n=15). Mean PROMIS T‑score changes from baseline were calculated for each timepoint and compared between cohorts using 95% confidence intervals with significance set at p<0.05 (IRB STUDYID:1200000109). Injection patients demonstrated significant improvement at 3 months in pain interference (Δ=–5.18; p=0.0047) and pain intensity (Δ=–4.17; p=0.0491). At 6 months, they showed further reductions in pain intensity (Δ=–5.93; p=0.0153) and interference (Δ=–6.24; p=0.001), with increased physical function (Δ=8.20; p<0.001). By 1 year, these gains reversed. Arthroplasty patients experienced early (3‑month) worsening in pain, function, and depression, but showed substantial improvement at 6 months and 1 year. At baseline, surgical patients reported lower pain and higher function than injection patients. These findings suggest that injections provide short‑term (3–6 month) symptom improvement but decline by 1 year, whereas arthroplasty patients experience early postoperative worsening followed by meaningful improvement by 6 months and sustained benefit at 1 year.

Introduction: Osteochondral lesions of the talus remain challenging, particularly when lesion size, location, or subchondral bone involvement limits the effectiveness of isolated arthroscopic treatment. This study compared clinical outcomes between arthroscopic debridement and bone marrow stimulation and open reconstruction with iliac crest osteoperiosteal grafting for larger or less accessible lesions. Methods: A retrospective comparative study was performed including 19 patients treated surgically for symptomatic osteochondral lesions of the talus between 2023 and 2026. Fourteen patients underwent arthroscopic debridement and bone marrow stimulation, while five patients with larger or technically inaccessible lesions underwent medial malleolar osteotomy and osteoperiosteal grafting harvested from the iliac crest. Clinical outcomes were assessed using the AOFAS score and VAS for pain preoperatively and at final follow-up. Results: Both groups demonstrated substantial clinical improvement. In the arthroscopic group, the mean AOFAS score improved from 62.4 preoperatively to 87.1 at final follow-up, while the meanVAS score improved from 6.8 to 1.6. In the osteoperiosteal grafting group, the mean AOFAS score improved from 55.8 to 89.4, while the mean VAS score improved from 7.4 to 1.2. No complications, graft-related morbidity, malleolar osteotomy complications, or revision procedures were recorded. Conclusion: Arthroscopic bone marrow stimulation remains effective for smaller and accessible osteochondral lesions of the talus. Iliac crest osteoperiosteal grafting appears to be a reliable joint-preserving option for larger, cystic, or inaccessible lesions, allowing anatomical reconstruction of the subchondral defect with favourable preliminary outcomes.

Background Focal osteochondral lesions of the talus remain a therapeutic challenge, particularly following failed cartilage repair procedures. While biological techniques are commonly applied to smaller defects, advanced lesions with subchondral involvement may require alternative joint-preserving strategies. Patient-specific partial talar prostheses have emerged as a potential option. This study aimed to evaluate one-year clinical outcomes following implantation of a customized partial talar prosthesis. Methods Between December 2024 and December 2025, five patients were enrolled in a prospective cohort study. Inclusion criteria were symptomatic focal osteochondral talar lesions, age ≥18 years, and BMI <30 kg/m² (men) or <26 kg/m² (women). All procedures were performed by a single surgeon and documented in the German Arthroscopy Registry (DART). Clinical outcomes were assessed preoperatively and at 12 months using the Foot and Ankle Outcome Score (FAOS) and the EFAS score. Statistical analysis was performed using SPSS. Results The cohort included 3 men and 2 women, with a mean age of 44.6 years and a mean BMI of 29.7 kg/m². Mean symptom duration was 46.8 months, and mean defect size was 13.6 × 11.4 × 7.2 mm. At one year, all outcome measures showed marked improvement. The EFAS total score increased from 5.8 to 17.0, and the EFAS sports score from 2.4 to 8.2. FAOS subscales demonstrated substantial improvements in pain, daily activities, and sports function. All patients reported they would undergo the procedure again. Conclusion Patient-specific partial talar prosthesis demonstrated substantial clinical improvement at one year and represents a promising joint-preserving option for selected patients.

Background Articular cartilage injuries are a major clinical challenge, particularly in weight-bearing joints, posing a significant global cause of disability. Existing clinical treatment have failed to induce articular cartilage regeneration of osteochondral defects (OCD) or prevent posttraumatic osteoarthritis. Previously we showed that Amelogenin, an enamel matrix protein, induced regeneration of acute osteochondral injury in rat and goat knee. This study reports the completed 24-month clinical&radiologic outcomes of a prospective first-in-human cohort treated with a commercially produced amelogenin based compound, during arthroscopic surgery for talar dome This open-label prospective study enrolled ten patients with isolated symptomatic talar dome OCD. All patients underwent arthroscopic synovectomy, debridement, and microfracture followed by single-dose Remelix injection into the prepared defect. Patients clinical and radiological outcomes were evaluated pre and post-surgery for 24 months. No complications nor side effects were noticed after the procedure and during the follow-up. A clear pattern of clinical improvement over time, with continued positive trends observed throughout the 24-month period was demonstrated. MRI assessments showed that the defect was filled with healthy subchondral bone and covered with tissue resembling hyaline articular caritlage. Ongoing and still evolving structural maturation was noted at the final follow-up. This completed 24-month analysis confirms the favorable safety profile of Remelix and demonstrates meaningful, durable clinical and radiologic improvement after a single injection delivered during arthroscopic treatment of talar dome OCD. These findings support progression to a multicenter randomized controlled trial to further evaluate Remelix as an innovative regenerative adjunct in cartilage repair surgery.

Background: Knee arthrodesis markedly alters lower limb biomechanics and creates a challenging scenario when associated with end-stage ankle osteoarthritis. No prior reports have specifically described treatment with total ankle replacement (TAR) in the presence of an ipsilateral fused knee. This study evaluated the feasibility and mid-term outcomes of TAR in this rare condition. Methods: Two patients with post-traumatic end-stage ankle osteoarthritis and long-standing knee arthrodesis underwent TAR using a lateral transfibular approach with a Zimmer Trabecular Metal™ implant. Surgical planning aimed to restore coronal and sagittal alignment. Postoperative management and rehabilitation were specifically adapted to the absence of knee motion, with emphasis on gait re-education. Clinical and radiographic follow-up was performed up to 36 months. Results: At final follow-up, both patients showed substantial pain reduction, improved ankle range of motion, and recovery of a stable, functional gait compatible with knee fusion. Imaging demonstrated well-aligned, stable components without loosening or subsidence. No major complications or reoperations occurred. Conclusions: Lateral transfibular TAR appears feasible and effective for end-stage ankle osteoarthritis in patients with ipsilateral knee arthrodesis, preserving ankle motion and supporting functional ambulation in this complex setting.

Background Artificial intelligence (AI) chatbots such as ChatGPT are increasingly used as sources of medical information. However, their reliability in foot and ankle surgery remains unclear. This study evaluated the accuracy and clinical relevance of ChatGPT responses to patient- and clinician-oriented questions regarding ankle osteoarthritis (OA). Methods Twenty-six frequently asked questions (20 patient-oriented, 6 clinician-oriented) were entered into separate ChatGPT-3.5 sessions (June 2025). Responses were independently graded using a standardized four-point scale (excellent to unsatisfactory) based on accuracy, completeness, and clinical relevance. Group comparisons were performed using the Mann–Whitney U test and Fisher’s exact test. Results Among patient-oriented questions, 16 of 20 (80%) were rated excellent or satisfactory with minimal clarification; 2 (10%) were unsatisfactory. In contrast, none of the clinician-oriented responses were rated excellent, and 3 of 6 (50%) were unsatisfactory. Median overall score was significantly worse for clinician-oriented questions (3.5 vs 2.0, p=0.019). The proportion of unsatisfactory responses was higher for clinician-directed questions (50% vs 10%; absolute difference 40%). ChatGPT performed well on general topics (epidemiology, treatment overview) but frequently provided outdated or overly generalized information regarding surgical indications, implant selection, and rehabilitation protocols. Conclusions ChatGPT provides generally accurate, patient-friendly information on ankle OA but lacks the precision and contemporary detail required for clinician-level decision-making. AI chatbots may support patient education but should not be relied upon for professional clinical guidance.

Background: Evidence on decade-long outcomes after lateral transfibular total ankle arthroplasty (TAA) with the Trabecular Metal™ (TM) fixed-bearing implant remains limited. This study evaluated 10-year survivorship, clinical outcomes, and weight-bearing computed tomography (WBCT) findings after lateral-approach TAA. Methods: A prospective cohort of 107 consecutive adult patients underwent transfibular TAA with the Zimmer TM Ankle between May 2013 and March 2016. Follow-up was performed at 6 months and annually thereafter, with a minimum follow-up of 120 months. Implant survivorship was assessed using Kaplan–Meier analysis, with revision for any reason as the endpoint. Clinical outcomes included pain, functional scores, and ankle range of motion. Final WBCT assessed component alignment and implant-related findings. Results: Mean age at surgery was 62.4 years, and 90.6% of cases were post-traumatic osteoarthritis. At final follow-up, 100 patients were available. Ten-year survivorship was 96.2% (95% CI 92.5–99.9), with four failures: two septic and two aseptic loosening. Pain and functional scores improved significantly and were maintained over time. WBCT confirmed stable alignment without loosening; radiolucencies and cysts were observed in 8% and 4% of cases, respectively, and were asymptomatic. Conclusion: Lateral transfibular TAA with the Trabecular Metal™ fixed-bearing implant demonstrated excellent 10-year survivorship, sustained clinical improvement, and stable WBCT alignment, supporting its reliability for end-stage ankle osteoarthritis.

Coronal alignment is a key determinant of outcomes in total ankle replacement (TAR), particularly in patients with varus deformity. Weight-bearing computed tomography (WBCT) combined with artificial intelligence (AI)–assisted planning may improve three-dimensional assessment and preoperative decision-making, although its clinical value remains incompletely defined. A retrospective cohort of 94 patients undergoing lateral-approach TAR for varus ankle osteoarthritis, with a minimum 2-year follow-up, was analyzed. All patients underwent pre- and postoperative WBCT scans. AI-assisted WBCT virtual planning was compared with expert manual measurements of coronal alignment parameters, including lateral distal tibial angle (α), tibio-talar surface angle (TTS), tibio-talar tilt (TT), and Saltzman 20° view angle. Agreement was assessed using intraclass correlation coefficients (ICC) and Bland–Altman analysis. Patients were stratified by preoperative talar tilt (<10° vs ≥10°). AI-assisted planning was integrated into a multidisciplinary workflow as a decision-support tool. AI-derived measurements demonstrated excellent agreement with manual assessment, particularly for talar tilt and hindfoot alignment (ICC 0.91–0.96). Bland–Altman analysis showed minimal systematic bias, with all mean differences within predefined clinically acceptable thresholds. AI-assisted planning influenced surgical strategy in 2 of 94 cases (2.1%), prompting additional procedures not identified through conventional planning alone. Severe talar tilt was associated with the use of adjunctive subtalar fusion, although this relationship was associative rather than predictive. AI-assisted WBCT planning provides reliable three-dimensional assessment of coronal alignment and may support surgical decision-making in selected complex varus TAR cases. Its value lies as a complementary decision-support tool integrated within expert-led clinical workflows.

Background: Charcot neuroarthropathy of the ankle and hindfoot is a limb-threatening condition characterized by progressive deformity, instability, ulceration, infection, and risk of amputation. Surgical reconstruction aims to restore alignment, achieve a stable plantigrade foot, and preserve limb function but is associated with substantial morbidity. Aim: To evaluate clinical outcomes, complications, amputation rates, and mortality following reconstructive treatment of Charcot neuroarthropathy of the ankle and hindfoot. Methods: This retrospective consecutive cohort study included all patients with Charcot neuroarthropathy of the ankle and hindfoot treated at Odense University Hospital between 2017 and 2026. Twenty-five patients were identified, of whom 24 (96%) underwent surgical reconstruction and one (4%) received non-operative treatment. Mean age was 58.7 years (range 38–77), mean BMI was 31.5 kg/m² (range 22–55), and 36% were female. At presentation, 48% were classified as Eichenholtz stage 1–2 and 52% as stage 3. Surgical techniques included intramedullary nailing (48%), screw fixation (20%), and plate fixation (28%). Results: Reoperation was required in 8% (n=2). Postoperative infection occurred in 28% (n=7), while wound complications were observed in 40% (n=10); all were managed with minor soft-tissue revision. The amputation rate was 12% (n=3), and all amputations were associated with deep infection. One-year mortality was 8% (n=2), increasing to 28% (n=7) at five years. Conclusion: Reconstruction of Charcot neuroarthropathy of the ankle and hindfoot is associated with high complication and mortality rates; however, limb salvage is achieved in most patients. Stable fixation and multidisciplinary management remain essential.

Introduction Determining when patient-reported outcome measures stabilize after surgery may help define the minimum follow-up required for clinical studies. However, revision procedures may occur substantially later. The purpose of this study was to determine when outcome scores stabilize after arthroscopic ankle fusion and to evaluate the timing of revision procedures. Methods Patients undergoing arthroscopic ankle fusion at a single institution between 2003 and 2023 were prospectively followed. Procedures were performed by four fellowship-trained orthopaedic foot and ankle surgeons. Annual follow-up included the Ankle Osteoarthritis Scale (AOS), expectation, satisfaction, stiffness, swelling, and Short Form-36 (SF-36) scores. Statistical analyses were performed to determine when outcome scores reached a steady state. Results A total of 190 arthroscopic ankle fusions were followed for a mean of 7.2 years (range 1-15 years). Mean age at surgery was 58 ± 12 years and mean body mass index was 28.9 ± 5.5 kg/m². Overall, 66% of patients were male, 11% had diabetes, and 6% were smokers. AOS scores improved at 6 months and 1 year and remained stable thereafter. Short Form-36 physical component scores and expectation scores stabilized at 6 months, whereas satisfaction, stiffness, and swelling scores stabilized at 1 year. Revision procedures occurred at a mean of 2.5 ± 2.8 years postoperatively. Conclusion Patient-reported outcomes after arthroscopic ankle fusion stabilize within 1 year after surgery, suggesting that this follow-up duration may be sufficient for outcome assessment studies. However, substantially longer follow-up is required to adequately evaluate revision procedures.

Background: In recent years, significant advances have been made in the field of personalized implant printing, enabling the management of complex bone defects . The integration of three-dimensional CT imaging and precise preoperative planning allows for the production of highly accurate patient-specific implants and the performance of direct reconstructive surgeries that were uncommon until recently. Objectives: Presentation of three case studies, demonstrating the clinical application of personalized 3D-printed implants for the reconstruction of complex bone defects of the foot and ankle and avoidance of amputation. Methods: The implants were designed based on CT imaging, using images of the healthy contralateral bone or anatomically tailored reconstructions. The implants were manufactured using 3D printing technology and used to replace the missing bones in dedicated surgical procedures. Results: Case 1: A 24-year-old female patient who lost the talus following a motor vehicle accident with an open fracture . A patient-specific 3D-printed talar replacement was performed, postoperatively returned to full function. Case 2: A patient with osteosarcoma of the calcaneus who, had A personalized 3D-printed calcaneal replacement. Case 3: A patient with complete talar loss and a fracture of the distal tibia. A patient-specific implant was printed to bridge the extensive bone defect, which preserved the montion of the talonavicular joint. Conclusions: Personalized 3D-printed implants provide innovative solutions for complex bone defects of the foot and ankle, with the potential for limb preservation, precise anatomical reconstruction, and significant functional improvement.

Introduction: Surgical reconstruction of Charcot foot is often the last resort to preserve limb function and prevent amputation. The purpose of this retrospective case-series study was to evaluate clinical and radiographic parameters and complications of patients with Charcot foot reconstruction. Material and Methods: Forty-three patients with forty-six feet underwent single or two stage Charcot foot reconstruction with internal fixation. All patients were operated by three consultants from January 2010 to January 2026 across 2 different District General Hospitals (DGH). Demographic characteristics, comorbidities, surgical details, radiographic parameters and postoperative outcomes were reviewed. Results: Mean age was 63,5±8,9 years and mean follow-up was 48,9±46,5 months. Single stage reconstruction happened in 33 feet and two stage in 13 feet. There were 34 midfoot reconstructions, 8 hindfoot and 4 midfoot/hindfoot reconstructions. Complications were developed in 32/46(69,6%) feet with the most common being ulcer recurrence 14/32(43,8%) and wound dehiscence 8/32(25,0%) and implant failure 5/32(15,6%). Complication-free period was 19,5±30,0 months. Amputation was needed for 2/46(4,3%) feet. Ulcer-free period was 25,4±27,6 months and the amputation-free period was 126 months. Average time to weight bear was 3,3±1,2 months and time to union was 5,0±2,5 months. Calcaneal pitch angle pre- and post-surgery was 5,2±10,6 and 10,0±11,1 mm respectively, Meary angle pre- and post-surgery was 121,0±11,1 and 139,8±58,5 degrees and cuboid height pre- and post-surgery was -6,0±8,2 and 1,0±8,5 mm respectively. All differences were statistically significant with p-value<0,001. Conclusion: Charcot foot reconstruction in a DGH setting is achievable and provides satisfactory clinical and radiographic outcomes despite the high complication rate.

Introduction: Pediatric transtibial amputation is rare but may be followed by distal bone overgrowth, causing pain, prosthetic intolerance, ulceration, and revision surgery. This study evaluated the frequency and timing of symptomatic bone spicule formation after transtibial amputation in children. Methods: A retrospective case series was performed including patients who underwent transtibial amputation before 12 years of age at a tertiary orthopedic institute between 1990 and 2021. Patients were followed at the foot and ankle outpatient clinic. Demographic data, indication for amputation, imaging findings, presence of symptomatic bone overgrowth, and need for revision surgery were analyzed. Patients with postoperative infection were excluded. Results: Twenty-seven pediatric transtibial amputations were included. There were 11 male patients and 16 female patients, with a median age of 43 months at the initial procedure. The main indications for amputation were congenital conditions in 14 patients, trauma in 6, infection in 6, and rheumatologic disease in 1. Symptomatic bone spicules requiring revision surgery developed in 18 patients, representing 66.66% of the cohort. The mean time to identify bone overgrowth was approximately 53 months after amputation, and revision surgery occurred at a mean of 62 months. Younger patients were more likely to develop spicules, although this difference was not statistically significant. Bone overgrowth occurred despite different surgical techniques. Conclusion: Symptomatic bone spicule formation is a frequent complication after pediatric transtibial amputation and commonly requires revision surgery. Awareness of this risk is essential for surgical planning, long-term follow-up, and counseling families regarding possible future procedures.

Cavus feet are commonly associated with neuromuscular conditions. They can often be challenging to treat and are associated with poor outcomes. A new method of approaching these patients using the Mosca algorithm aims to improve this. The post-operative outcomes of 24 patients with pes cavus were assessed by measuring pre- and post-operative angles of the feet and through self-reported post-operative outcomes measures (PROMS). Due to Mosca’s highly individualised technique with surgeries being tailored to the patient’s unique requirements, out of the 182 procedures on 36 feet, there were a total of 33 different procedures performed. The most common were peroneus longus-brevis transfer, plantar medial release and tendo-Achilles lengthening. The patients included had a median age of 22 and had a background of hereditary sensory-motor neuropathy, cord tethering or another syndrome. This audit found that, following surgery, patients had a more plantigrade foot, which contributed to improved gait, balance and mobility. The average angles post-operatively were: Meary’s angle 13 (from 21), Hibbs’ angle 133 (from 120) and calcaneal pitch 18 (from 18). Patients reported an average satisfaction of 7/10 at 26 weeks and 8/10 at 2 years. All responses to the PROMS questionnaire reported improvement at all stages. Given this, we would recommend the increased use of surgical intervention for correction of cavovarus feet using the Mosca algorithm

Background: Plantar fat pad atrophy is an under-recognised cause of heel pain and metatarsalgia, resulting in reduced plantar cushioning and increased mechanical load. Procedural interventions have been proposed, but their effectiveness remains unclear. Methods: A PRISMA-compliant systematic review of MEDLINE, EMBASE, and PubMed was conducted from inception to January 2026. Studies including adult patients with clinically or radiologically diagnosed plantar fat pad atrophy undergoing procedural intervention were included. Randomised controlled trials and observational studies were eligible. Risk of bias was assessed using RoB2 and ROBINS-I. Due to heterogeneity, results were synthesised narratively. Results: Thirteen studies (4 randomised controlled trials, 9 observational) including 247 patients (348 feet) were analysed. All RCTs had some concerns of bias, while observational studies ranged from moderate to critical risk. Autologous fat grafting demonstrated the most consistent improvements in pain and function, sustained up to 24 months (p<0.05), despite partial loss of ultrasound-measured thickness. Hyaluronic acid filler showed short-term pain reduction (VAS 6.86 to 3.50 at 24 weeks; p<0.001), though repeat treatment was often required. Evidence for allograft augmentation was limited and heterogeneous. No serious adverse events were reported. Conclusion: Current evidence is limited by small, heterogeneous, and predominantly non-comparative studies. Autologous fat grafting shows the most consistent benefit, but definitive conclusions cannot be drawn. Conservative management should remain first-line. High-quality comparative trials with standardised, clinically relevant outcomes are required.

Background:Talocalcaneal (TCC) and calcaneonavicular (CNC) coalitions are the most common tarsal coalition subtypes diagnosed in adulthood. Adults frequently present with pain, reduced range of movement, and functional limitation. When conservative management fails, surgical options include resection or arthrodesis. Arthrodesis is increasingly less favoured due to poorer functional outcomes, with ongoing concerns regarding recurrence and instability following resection. The optimal interposition material and role of arthroscopic approaches remain unclear. Aims:To evaluate clinical outcomes of tarsal coalition resection (with or without interposition arthroplasty) versus arthrodesis in adults. Methods:A PRISMA-compliant systematic review registered on PROSPERO was performed in December 2025. MEDLINE, Embase, and Cochrane Library were searched. Patient-reported outcomes, complications, revisions, and radiographic findings were extracted. Methodological quality was assessed using the MINORS tool. Narrative synthesis was performed using the SWiM framework. Results:Fifteen studies comprising 208 coalitions were included (MINORS scores 19–81%; mean 50%). Four studies reported 53 CNC resections via open approaches; outcomes were generally favourable, though complications occurred in 24.4% and subsequent arthrodesis was required in 8.9%. Interposition was used in 86.8% of cases. Nine studies reported 137 TCC resections with favourable results, although stiffness occurred in 27.5%. Three studies reported 16 TCC arthrodeses, with functional and pain improvements noted. Conclusions:High-quality evidence guiding treatment of adult tarsal coalition is critically lacking. Small cohorts, inconsistent outcome reporting, and methodological limitations preclude meta-analysis. Resection may provide symptomatic relief but carries notable complication rates. Future large, long-term studies using validated outcome measures are required.

Background: Ischemic diabetic foot wounds may progress to major amputation despite endovascular procedures or surgical bypass. In patients with insufficient distal perfusion after revascularization, transverse tibial transport may offer an additional limb-salvage option by improving distal microcirculation. Purpose: To evaluate 6-month limb-salvage outcomes of transverse tibial transport in ischemic diabetic foot wounds after failed or insufficient revascularization. Methods: This retrospective case series included 10 patients with ischemic diabetic foot wounds who underwent transverse tibial transport and had at least 6 months of follow-up. All patients had a history of failed or insufficient endovascular intervention, surgical bypass, or both. Demographic data, wound characteristics, minor amputations, wound closure method, Doppler ultrasonography findings, and clinical outcomes were reviewed. The primary outcome was limb preservation without major amputation at 6 months. Amputations proximal to the ankle were defined as major amputations; toe, ray, transmetatarsal, or more distal amputations were defined as minor amputations. Results: No patient required major amputation during follow-up. All patients underwent minor amputation for local infection or wound control. Wound closure was achieved primarily in 6 patients and with grafting in 4 patients. Follow-up Doppler ultrasonography suggested increased distal arterial flow compared with preoperative assessment. No procedure-related complication leading to limb loss was observed. Conclusion: Transverse tibial transport may support limb preservation in ischemic diabetic foot patients after failed or insufficient revascularization. Although it does not eliminate the need for minor amputation, it may help avoid major amputation when combined with appropriate debridement and wound closure.

Introduction: Charcot neuroarthropathy is one of the most severe complications of diabetic foot disease, characterized by progressive bone and joint destruction leading to deformity, dysfunction, and, in advanced cases, amputation. When conservative treatment fails, reconstructive limb-salvage surgery may be required. Because no single surgical technique has proven superior, treatment should be individualized according to deformity pattern, soft tissue status, infection risk, and patient needs. Methods: This retrospective case series reviewed five patients with Charcot neuroarthropathy treated at the Department of Orthopaedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kauno Klinikos. Results: All patients had diabetes mellitus and presented with Charcot-related deformities involving the midfoot and tarsal joints. Surgical reconstruction was performed using a common operative principle adapted to individual deformities and intraoperative findings. Procedures included corrective osteotomy, excision of sclerotic and nonviable bone, and multiple arthrodeses. Fixation was primarily achieved using intramedullary beams inserted through the metatarsals, with additional medial column plate fixation in most cases. Subtalar arthrodesis was performed in four patients. Most patients recovered without complications. One patient who underwent bilateral correction developed delayed wound healing, soft tissue necrosis, and subsequent plate exposure. Management included plate removal, surgical debridement, vacuum-assisted closure therapy, antibiotics, and skin grafting. The patient remains on antibiotic treatment with incomplete arthrodesis consolidation but no further complications. Conclusion: Charcot neuroarthropathy requires highly individualized management. Successful limb salvage depends on tailoring reconstruction to patient-specific factors and ensuring careful postoperative monitoring with prompt management of complications.

Background Critical-sized bone defects of the foot and ankle, arising from failed total ankle replacement, talar avascular necrosis, trauma, infection, Charcot arthropathy, and failed fusion, are traditionally managed with bulk structural allograft or major amputation. Patient-specific three-dimensional (3D) printed porous titanium implants offer an alternative, but evidence is fragmented. We systematically reviewed their clinical and radiographic outcomes. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and a pre-registered PROSPERO protocol, PubMed/MEDLINE was searched for clinical studies of adults undergoing reconstruction of complex foot and ankle defects with a patient-specific 3D-printed porous titanium implant. Two reviewers independently screened, extracted data, and assessed risk of bias. Primary outcomes were union, limb salvage, and major amputation. Outcomes were synthesised descriptively with pooled proportions. Results Twenty-two studies comprising 289 patients were included. The pooled limb-salvage rate was 92.6% and the major amputation rate 6.8%. Among 11 studies reporting patient-level union, the pooled union rate was 90.4%. The pooled reoperation rate was 29.8%, driven by deep infection; prior ipsilateral infection and neuropathy were independent predictors. Functional scores improved across heterogeneous instruments, including Foot and Ankle Ability Measure (33 to 60), Manchester-Oxford Foot Questionnaire (73 to 32), and visual analogue scale pain (59 to 34). Weighted mean follow-up was 24.7 months. Conclusion Patient-specific 3D-printed porous titanium implants achieve high limb-salvage and union rates with low major amputation, offset by a substantial reoperation burden from deep infection. Prospective comparative studies with standardised union definitions and longer follow-up are needed.

Background: Charcot midfoot deformity is associated with instability, ulcer formation and a high risk of amputation. Reconstruction with superconstruct device has been available since 2017 at our Hospital. Aim: To present our results after midfoot reconstrution with a mean follow up of 5.6 years. Methods: A consequtive series of 29 patients with 30 severely deformed charcot feet were operated from 2017 until 2026. Mean age was 56 years, 18 males and 11 females were reconstructed. Mean BMI was 33. Fourteen patients presented with an ulcer, they were immobilized in a total contact cast for mean 11 weeks. During surgery all joints were prepared and fused with 7.0 TwinCF screws and supplementary plate. Mean operation time was 215 minutes, in all cases medial column was fixed, in 18 cases lateral column was fixed. Postoperatively immobilization was 16 weeks in total contact cast. Results: Fifteen patients developed postoperative ulcerformation, 9 cases required secondary surgery. All patients healed. Four patients had below knee amputation, all due to deep infection related to surgery or later deformity. 27 patients were mobilized in orthopedic shoes at one year follow up. Five patients developed secondary Charcot, requiring surgery in 3 cases. Five year mortality rate was 0%. Five patients died mean 6.2 year after surgery. Conclusion: Despite there is a high postoperative complication rate we achieved good results, most patients were mobilized in orthopedic shoes after one year and a low mortality rate. We can recommend bridging reconstruction with superconstruct device for severely displaced midfoot charcot deformity.

Background: Large area deep wounds (LADWs) in the lower extremities typically require flap grafting. In this study, we introduce Tibial Cortex Transverse Transport (TTT) as a novel treatment for LADWs and evaluate its efficacy in treating such wounds, providing indications for TTT use. Methods: We conducted a retrospective review of consecutive patients with LADWs in the lower extremities who underwent reconstruction using TTT from January 2018 to June 2021. Inpatient follow-ups occurred one month after surgery, while outpatient follow-ups were performed at 3, 6, and 12 months after surgery. We assessed ulcer healing and healing time, recurrence rate, major amputation rate, and complications during the one-year follow-up. All patients underwent computed tomography angiography (CTA) one-month post-surger y to evaluate changes in the lower extremity small blood vessels. Results: The study included 36 patients (21 males, 15 females) with a mean age of 62.5 years. Wound etiologies included infected skin defects (20 cases), traumatic skin defects (9 cases), tumor resection skin defects (6 cases), and burns (1 case). The healing rate was 94.4%, with an average healing time of 6 months. No recurrences, nail tract infections, osteomyelitis, incisional infections, or related complications were observed. Conclusion: TTT proved to be a safe and effective treatment for LADWs in the lower extremities. The procedure is relatively simple and does not require grafting, making it a promising alternative for treating extensive skin defects in the lower extremities.

Background The purpose of this study was to assess the benefit of using WBCT instead of R and/or CT as the standard imaging modality, evaluating image acquisition time, radiation dose, and cost-effectiveness. Methods All patients who obtained WBCT from July 1, 2013 until January 31, 2026 (12.5 years) were included. Image acquisition time (T), radiation dose (RD) per patient, and cost-effectiveness were analyzed and compared between the time period using WBCT (yearly average) and the parameters from 2012, i.e. before the availability of WBCT (RCT group). Results 25,143 WBCT scans were obtained from 10,945 patients (10,945 scans (43.5%) before treatment; 14,198 scans (56.5%) at follow-up). On a yearly average, 2,011 WBCTs and an additional 11.5 CTs were obtained (WBCT group). In 2012, 1,850 Rs and 254 CTs were obtained from 885 patients (RCT group). The mean yearly RD was 4.3/4.8uSv for WBCT/RCT (mean difference of 0.5 uSv; decrease 10% for WBCT group; p<.01). Yearly mean T was 117/494 hours in total (3.5/16.0 minutes per patient) for WBCT/RCT groups (mean difference 376 hours; 76% decrease for the WBCT group; p<.01). Yearly cost-effectiveness was a mean profit of 64,404/-723 Euro for WBCT/RCT groups (60.0/-1 Euro profit per patient).cost-effectiveness was a mean profit of 64,404/-723 Euro for WBCT/RCT groups (60.0/-1 Euro profit per patient). Conclusions 25,143 WBCT scans from 10,945 patients over a period of 12.5 years at a foot and ankle department resulted in 10% decreased RD, 76% decreased T, and increased financial profit (61 Euros per patient) for the institution.

Venous thromboembolism (VTE) is a significant complication of surgery. Prior to 2025 we provided anti-embolic stockings (AES) for the contralateral leg on discharge to patients for up to 6 weeks. NICE guidelines (2018) do not specifically suggest the need for AES in foot and ankle patients, and evidence for their efficacy is lacking. AES may cause unnecessary patient discomfort and are associated with significant additional costs (£63 Million/year in the UK). In 2025 we stopped providing AES routinely. Our primary objective was to identify whether this change in practice would result in an increase in post-operative VTE rates. Secondary objectives included the complication rate associated with AES. This was conducted as a single-centre, completing 2 audit cycles. In Cycle 1, patients were given AES on discharge (2024), in Cycle 2 (2025), no AES were given. Data was collected for 265 patients in Cycle 1 (12 months retrospectively) and 478 patients in Cycle 2 (12 months prospectively). In Cycle 1 there were no episodes of VTE and one AES related complication (blistering, 0.3%). In Cycle 2, there were one reported PE at nine weeks post-surgery. At 6 weeks there was no evidence of VTE at clinical review (overall VTE rate of 0.2%). Our VTE rate did not increase after discontinuing AES and remained comparable to previous literature. AES after discharge may not be routinely indicated for thromboprophylaxis following foot and ankle surgery, although larger studies are required. This may result in cost savings and avoid the risk of AES related complications.

Osteoarthritis (OA) is the most prevalent musculoskeletal disorder, affecting multiple joints including the ankle. Although AC has traditionally been considered aneural, proprioceptive mechanoreceptors have been identified within joint tissues, and proprioceptive impairment has been described in cartilage pathology. However, the neuroanatomical role of ankle AC in OA remains poorly investigated. This study aimed to assess the presence and distribution of proprioceptive mechanoreceptors in human ankle cartilage and their relationship with inflammation, considering age and sex differences in patients undergoing total ankle arthroplasty (TAA). In this prospective study, 23 of 40 patients with unilateral end-stage tibiotalar OA undergoing primary TAA were analyzed. Clinical evaluation included VAS, AOFAS, and SF-12 scores. Osteochondral specimens collected intraoperatively were processed and examined using histological (hematoxylin–eosin, Gomori trichrome), histomorphometric (OARSI score on Safranin O/Fast Green), and immunohistochemical analyses (S100, p75, PGP9.5). Preliminary data showed advanced cartilage degeneration (OARSI 20–26), consistent with end-stage OA, with inflammatory infiltration and extracellular matrix disruption. Pacinian and Ruffini corpuscles were identified within osteochondral tissue. Immunohistochemistry revealed consistent PGP9.5 positivity, discontinuous p75 expression, and moderate S100 staining, confirming the persistence of neural elements in degenerated cartilage. These findings suggest an association between cartilage degeneration, inflammation, and altered proprioceptive innervation. End-stage ankle OA is characterized not only by severe cartilage damage but also by persistence of proprioceptive neural structures. These alterations, together with local inflammation, may contribute to proprioceptive dysfunction and symptom severity, identifying ankle cartilage as a potential target for future research.

Introduction: Rocker-bottom shoes are widely used to redistribute plantar pressure and reduce forefoot overload, but their effects on three-dimensional running kinematics in healthy runners remain unclear. This study aimed to compare lower-limb kinematic parameters during treadmill running with conventional and rocker-bottom footwear. Methods: A cross-sectional biomechanical study was conducted with 20 healthy volunteers, including 12 men, with a mean age of 27.9 ± 4.8 years and mean body mass index of 23.7 ± 2.1 kg/m². Participants ran on a treadmill using two types of shoes: a conventional flat, flexible shoe and a rigid rocker-bottom shoe. Three-dimensional kinematic data were collected using an eight-camera Vicon motion analysis system. Paired comparisons were performed using paired t-tests or Wilcoxon tests, according to data distribution, with significance set at p < 0.05. Results: Rocker-bottom footwear significantly reduced peak ankle eversion during stance compared with conventional shoes (5.1 ± 2.6° vs. 7.8 ± 5.1°; p = 0.047; Cohen’s d = -0.67). The time to peak eversion was also significantly shorter with rocker shoes (11.2 ± 3.0% vs. 19.8 ± 4.9% of the gait cycle; p < 0.001; d = -2.12). Peak eversion velocity was significantly greater with rocker shoes (99.2 ± 33.9°/s vs. 66.6 ± 39.8°/s; p = 0.010; d = 0.88). No significant differences were observed in cadence, stance time, or hip and knee kinematics. Conclusion: Rocker-bottom footwear modifies ankle kinematics during running, reducing peak eversion and time to peak eversion while increasing eversion velocity, without relevant changes in proximal lower-limb joints.

Introduction: Tibial hemimelia is a rare congenital anomaly characterized by partial or complete absence of the tibia, often associated with severe deformity and functional impairment. In severe cases, limb reconstruction may not be feasible, and early amputation can facilitate prosthetic adaptation and motor development. Plantar soft-tissue coverage may provide a durable, sensate, weight-bearing stump. Methods: We report the case of a 4-year-old female patient with right tibial hemimelia, severe limb shortening, varus deformity, and a cavovarus-supinated foot. Radiographs confirmed severe tibial deficiency, classified as Jones type 2. Due to the impossibility of reconstruction, knee disarticulation was indicated. A pedicled plantar fillet flap based on the posterior tibial neurovascular bundle was used for distal femoral coverage. The technique included medial dissection and preservation of the posterior tibial artery, vein, and tibial nerve, preparation of the plantar flap, knee disarticulation, and fixation of the flap to the distal femur. Results: The postoperative course was uneventful, with adequate wound healing and no infection or dehiscence. Rehabilitation progressed from early hip motion exercises to edema control, strengthening, and terminal weight-bearing training after stump maturation. A rigid-knee prosthesis was prescribed between the fourth and fifth postoperative months. At 8 months, the patient walked independently with the prosthesis and performed age-appropriate activities without complaints. Conclusion: Knee disarticulation with a pedicled plantar fillet flap is a feasible option for severe tibial hemimelia, providing durable sensate coverage, terminal weight-bearing potential, and satisfactory medium-term function.

Introduction: Primary actinomycosis of the foot is a rare chronic infection caused by anaerobic Gram-positive filamentous bacteria. Due to its slow progression and nonspecific presentation, diagnosis is often delayed or mistaken for neoplastic, granulomatous, or fungal disease. This report describes a rare case of primary plantar actinomycosis of the foot, highlighting clinical presentation, imaging findings, treatment, and long-term follow-up. Methods: A 37-year-old woman presented with a slowly progressive plantar mass in the left forefoot. She reported a penetrating trauma seven years earlier, followed by a painless callosity near the fifth metatarsal head. Examination revealed a 6-cm plantar mass without drainage, inflammatory signs, lymphangitis, or neurovascular deficit. Radiographs showed plantar soft-tissue thickening without bone involvement. Magnetic resonance imaging demonstrated heterogeneous plantar tissue and the “dot-in-circle” sign, suggesting mycetoma. Excisional biopsy was performed, and samples were sent for culture and histopathology. Results: Surgery revealed a well-circumscribed, capsulated lesion limited to superficial tissues, with hematic content and yellowish granules. Cultures were negative, but histopathology showed inflammatory aggregates and multifilamentous bacteria suggestive of Actinomyces spp. The patient was treated with oral amoxicillin for three months after complete excision. Healing was uneventful, with complete clinical recovery and no recurrence after three years of follow-up. Conclusion: Primary plantar actinomycosis is rare and challenging to diagnose. MRI, especially the dot-in-circle sign, combined with biopsy and histopathology, is essential. Complete excision followed by antibiotic therapy may provide excellent long-term outcomes.

Background: Plantar fat pad atrophy is an under-recognised cause of heel pain and metatarsalgia, resulting in reduced plantar cushioning and increased mechanical load. Procedural interventions have been proposed, but their effectiveness remains unclear. Methods: A PRISMA-compliant systematic review of MEDLINE, EMBASE, and PubMed was conducted from inception to January 2026. Studies including adult patients with clinically or radiologically diagnosed plantar fat pad atrophy undergoing procedural intervention were included. Randomised controlled trials and observational studies were eligible. Risk of bias was assessed using RoB2 and ROBINS-I. Due to heterogeneity, results were synthesised narratively. Results: Thirteen studies (4 randomised controlled trials, 9 observational) including 247 patients (348 feet) were analysed. All RCTs had some concerns of bias, while observational studies ranged from moderate to critical risk. Autologous fat grafting demonstrated the most consistent improvements in pain and function, sustained up to 24 months (p<0.05), despite partial loss of ultrasound-measured thickness. Hyaluronic acid filler showed short-term pain reduction (VAS 6.86 to 3.50 at 24 weeks; p<0.001), though repeat treatment was often required. Evidence for allograft augmentation was limited and heterogeneous. No serious adverse events were reported. Conclusion: Current evidence is limited by small, heterogeneous, and predominantly non-comparative studies. Autologous fat grafting shows the most consistent benefit, but definitive conclusions cannot be drawn. Conservative management should remain first-line. High-quality comparative trials with standardised, clinically relevant outcomes are required. PROSPERO No:CRD420261304287

Background: Interpreting patient-reported outcomes (PROMs) is enhanced by establishing clinical threshold values. This study determined the minimal important change (MIC), patient acceptable symptom state (PASS), treatment failure (TF) thresholds and responsiveness for the Self-reported Foot and Ankle Score (SEFAS) and the EuroQol 5 Dimensions (EQ-5D) in patients from the Swedish National Foot and Ankle Register (Swefoot). Aim: 1) determine the MIC, PASS, and TF thresholds for the SEFAS and EQ-5D and 2) the responsiveness for the same PROMs in patients from the Swedish National Register who underwent surgery for foot and ankle pathology. Methods: This retrospective register-based study included 139 randomly selected patients from Swefoot between 2021 and 2024 (mean age 55 years; 60% women). Patients underwent surgery for forefoot or ankle/hindfoot pathology. MIC, PASS and TF thresholds were estimated using anchor-based adjusted predictive modelling with logistic regression. Responsiveness was evaluated using effect size (ES), calculated as the mean postoperative change divided by the preoperative standard deviation. Results: For forefoot disorders, SEFAS thresholds were: MIC 7.2, PASS 36.3 and TF 30.7. For ankle/hindfoot disorders, corresponding thresholds were: MIC 8.8, PASS 33.7 and TF 32.5. EQ-5D thresholds for forefoot disorders were: MIC 0.09, PASS 0.67 and TF 0.70; for ankle/hindfoot disorders: MIC 0.16, PASS 0.77 and TF 0.76. SEFAS responsiveness was 1.31 for forefoot and 1.64 for ankle/hindfoot; EQ-5D responsiveness was 0.69 and 0.97, respectively. Conclusion: SEFAS and EQ-5D demonstrated good responsiveness and established MIC, PASS and TF thresholds for SEFAS and EQ-5D in patients undergoing foot and ankle surgery.

Introduction: Running is one of the most widely practiced sports worldwide, and advanced footwear technology (AFT) has substantially transformed running performance. These shoes combine a rigid carbon-fiber plate with resilient energy-returning foam to reduce metabolic cost and optimize propulsion during stance phase. However, concerns have emerged regarding altered lower-limb biomechanics and their association with foot and ankle overuse injuries. This systematic review aimed to synthesize clinical evidence regarding the kinematic, kinetic, and metabolic adaptations associated with AFT use and their possible role in foot and ankle pathologies. Methods: A systematic search following PRISMA guidelines was conducted in PubMed, Embase, and Google Scholar through April 2026. Clinical studies evaluating biomechanical adaptations and foot/ankle injury patterns associated with AFT use were included. Eight studies involving 102 runners met the inclusion criteria. Outcomes included running economy, kinematic and kinetic parameters, and reported injury profiles. Results: AFT consistently improved running economy by 2–3%. However, its use was associated with increased rearfoot eversion, reduced cadence, decreased ankle plantarflexion moment, longer stride length, greater horizontal ground reaction forces, and a more anterior foot-strike pattern. These adaptations may increase mechanical loading across the medial midfoot and adjacent structures. Navicular bone stress injury was the most frequently reported overuse pathology. Conclusion: Current evidence suggests that AFT improves running economy while modifying lower-limb biomechanics and redistributing loads, particularly across the medial midfoot. Although evidence supports association rather than causation, clinicians should remain vigilant for injury risks in runners presenting with medial midfoot pain or navicular stress injuries.

Background: Patient-reported outcome measures (PROMs) are widely used to assess outcomes following foot and ankle surgery, with clinically meaningful change conventionally defined using the Minimum Clinically Important Difference (MCID). The Patient Acceptable Symptom State (PASS) is a complementary state-based benchmark, but its comparative performance against MCID has not been established in foot and ankle surgery. Methods: A retrospective observational cohort study of 232 patients undergoing foot and ankle surgery at a tertiary orthopaedic centre with matched pre-operative and 12-month post-operative MOXFQ and EQ-5D scores. Patients were classified into a 2×2 framework based on MOXFQ Pain MCID achievement and binary satisfaction status. PASS thresholds were derived from post-operative absolute scores using ROC analysis and compared head-to-head with MCID thresholds. Results: 156 patients (67.2%) reported satisfaction and 120 (51.7%) achieved MOXFQ Pain MCID. PASS thresholds outperformed MCID across all domains (AUC 0.826–0.853 versus 0.753–0.796). A distinct Discordant A phenotype was identified — 17 patients (7.3%) who achieved meaningful pain improvement but remained dissatisfied — characterised by failure to reach PASS (10/17, 58.8%), markedly poorer walking and social recovery, and high rates of procedural complexity (41.2%), complications (29.4%), and revision surgery (29.4%). Conclusion: PASS outperformed MCID in predicting satisfaction, establishing absolute post-operative symptom state as a stronger determinant of outcome than magnitude of change. The 2×2 framework identifies an improved-but-dissatisfied phenotype invisible to conventional reporting, with direct implications for preoperative counselling and outcome assessment.

Introduction: Understanding and accurately reporting surgical complications is fundamental to safe practice, informed consent, and shared decision-making. This study aimed to review the type and quality of complication reporting in clinical papers in leading journals. Methods: A systematic review was conducted in accordance with PRISMA guidelines. A total of 690 papers published in 2021 across Foot and Ankle International, Foot and Ankle Surgery, and Journal of Foot and Ankle Research were screened. Inclusion criteria required papers to be clinical surgical studies of humans reporting outcomes in more than five patients. After applying exclusion criteria, 213 papers were included for analysis. Data extracted included study design, primary pathology, complication rate, use of a classification system, tabulation of complications, and reporting of ten pre-specified specific complications. Results: Of the 213 papers analysed, 190 (89.2%) reported complications. However, only 53 (24.9%) reported a total complication rate, and just 21 (9.8%) used a formal classification system. Among those using a system, 12 different frameworks were identified. Return to theatre was the most commonly reported specific complication (60.1%), while nerve injury (13.6%) and loosening/osteolysis (14.6%) were least frequently reported. Complications were tabulated in only 35.2% of studies. Conclusion: Significant heterogeneity exists in complication reporting across foot and ankle surgical literature. Fewer than 10% of studies employed a classification framework, and considerable variation was observed between systems used. These findings support the adoption of a standardised, validated classification system such as the modified Clavien-Dindo classification to enable consistent, comparable complication reporting across foot and ankle surgery.

Background:Reporting complications following foot and ankle surgery lacks standardisation. Lewis et al. (2022) proposed a foot and ankle-specific modification of the Clavien-Dindo classification, introducing A/B subcategories to grades I–III. No validated version exists. As a preparatory step to a formal Delphi consensus study, we surveyed clinicians to assess how complications are currently graded relative to the published classification. Methods:An online survey was distributed via BOFAS and international networks. 51 consultant-level surgeons rated 25 complications on a six-point severity scale and indicated which should be included in a standardised system. Mean scores were compared to published grade equivalents. Results:51 clinicians responded (46 foot and ankle orthopaedic surgeons; 87% UK-based; 51% >10 years' experience). Clinicians systematically rated several complications above their published grade: symptomatic non-union (IIB, mean 4.27/6), nerve pain requiring long-term medication (IIB, mean 4.06), intraoperative plan change affecting recovery (IB, mean 2.49), and wound infection requiring antibiotics (IB, mean 2.37). Scar revision (IIIA) was the only complication rated lower than published (mean 2.76). Near-universal inclusion agreement (≥90%) was achieved for Grade IIA and above. Agreement was lowest for intraoperative hardware adjustments (18–37%) and life-threatening events including death (54%) and organ failure (25%). Complex regional pain syndrome was the most commonly suggested omission (10 respondents, 20%). Conclusions: Significant discordances exist between clinician perception and the published classification, particularly at Grades IB and IIB. CRPS represents an important omission. These findings will inform a three-round Delphi consensus study (IRAS 361163) to formally validate the classification and produce national reporting standards.

Background:Informed consent requires disclosure of material risks. The Montgomery ruling (2015) reinforced that disclosure must be patient-centred. In foot and ankle surgery, no consensus exists on which complications require routine disclosure. The modified Clavien-Dindo classification provides a structured framework to assess this threshold. Methods:51 consultant-level foot and ankle surgeons and podiatric surgeons completed an online survey, rating 30 complications across the Clavien-Dindo spectrum on a six-point severity scale and on whether each should be included in a standardised consent framework. Strong consensus was defined as ≥90% agreement for inclusion. Results:Strong consensus for inclusion (≥90%) was achieved for 16 of 30 complications, encompassing all Grade IIA and above: persistent pain, stiffness, neuropraxia, residual deformity, non-union, deep infection, periprosthetic fracture, and nerve injury. Minor intraoperative technical events (Grade IA) had the lowest agreement: hardware adjusted intraoperatively (18%) and extra fixation without protocol change (37%). Life-threatening complications also showed unexpectedly low agreement: organ failure (25%), stroke (46%), heart attack (49%), and death (54%), likely reflecting their extreme rarity in elective surgery. Complex regional pain syndrome was identified by 10 respondents (20%) as a significant omission requiring consent disclosure. Amputation and recurrence of deformity were also highlighted. Conclusions:Foot and ankle surgeons draw an effective consent threshold at approximately Grade IIA of the modified Clavien-Dindo classification. Grade IA intraoperative events are not considered consent-worthy. Life-threatening events, despite their severity, are also frequently excluded. CRPS represents a gap in both the classification and current consent practice.

Background Pes equninovarus (PEV) is a complex congenital foot disorder requiring long-term treatment during childhood. Symptoms can persist into adulthood and affect quality of life. Known risk factors include parental PEV, maternal smoking, and breech presentation. PEV is also associated with developmental dysplasia of the hip (DDH). We investigated the overlap between these disorders in the Norwegian Mother-Father-Child Cohort Study (MoBa). Methods A total of 106,876 children were included in the analysis after excluding syndromic cases. PEV was identified in the Norwegian Patient Registry using ICD-10 code Q66.0. Additional data were acquired from the Medical Birth Registry of Norway and questionnaires from the MoBa study. Data were analysed using descriptive statistics and logistic regression in SPSS version 31.0. Results We identified 199 children with PEV, with a prevalence of 0.19%. PEV was more common in males and first-born children and was associated with shorter gestational age and lower birth weight. These findings contrast with the established risk profile of DDH. However, PEV was associated with both breech presentation and DDH. Thirteen of 199 children with PEV (6.5%) had DDH, compared with 3.2% of children without PEV. After adjustment for sex, parity, gestational age, birth weight, and breech presentation, PEV remained independently associated with DDH (adjusted OR 2.49, 95% CI 1.40–4.42). Conclusion PEV was associated with male sex, breech presentation and an increased risk of DDH. Children with both PEV and DDH displayed a risk-factor profile that differed from isolated DDH, supporting the hypothesis of a distinct DDH subgroup.

Mid‑substance Achilles tendinopathy (MAT) is a common cause of posterior ankle pain, characterized by impaired tendon healing within the hypovascular region 2–6 cm proximal to the calcaneal insertion. This review synthesizes current evidence on the epidemiology, pathophysiology, diagnosis, and management of MAT. Diagnosis remains primarily clinical, supported by ultrasound findings such as tendon thickening, hypoechoic change, and neovascularization. The Victorian Institute of Sport Assessment‑Achilles (VISA‑A) score provides a validated measure of symptom severity and functional limitation. Eccentric loading programmes represent the most effective first‑line treatment, demonstrating consistent improvements in pain and function. For patients who fail to respond, high‑volume image‑guided injection (HVIGI) offers a safe and effective second‑line option, with extracorporeal shockwave therapy (ESWT) serving as a useful adjunct. Evidence for platelet‑rich plasma, corticosteroid injections, low‑level laser therapy, and therapeutic ultrasound remains weak or inconsistent, and these modalities are not recommended. Surgical intervention is reserved for the 20–29% of patients with persistent symptoms despite structured conservative therapy. Options include gastrocnemius recession, plantaris excision, minimally invasive or endoscopic debridement, and tendon transfer for large defects. While reported outcomes are generally favourable, the lack of high‑quality comparative trials limits the ability to define an optimal surgical algorithm. This review proposes a staged, evidence‑based treatment pathway emphasizing eccentric rehabilitation, selective use of HVIGI and ESWT, and minimally invasive surgery for refractory cases.

Background: Conventional fabrication of custom-made foot orthotics, for reducing plantar pressures in patients with diabetes-related foot disease, remains largely empirical, with limited quantitative dose-response insights linking orthotic geometry and material properties to biomechanical outcomes. 3D-printed foot orthotics potentially offers patient-specific control of orthotic design parameters. Objective: To evaluate the dose-response effect of custom-made segmented 3D-printed foot orthotics (CSFOs) on plantar pressure in people with diabetes and a central forefoot pressure pattern (CFPP) (metatarsal 2-3; high-resolution barefoot peak pressure >400 kPa), with emphasis on reducing peak pressure in this region. Methods: A prospective monocentric interventional study was conducted in ten participants with diabetes (Risk 0-3(a)) and a CFPP. Following baseline shoe-only condition (BFS), participants were tested with four CSFO designs varying in segmentation, geometry, and gyroid infill density. Plantar pressure was measured during walking, using an in-shoe system. Data were analysed using repeated-measures ANOVA with Holm-adjusted post-hoc tests. Results: Peak plantar pressure in the metatarsal 2-3 region differed significantly across orthotic conditions (F(4,36) = 39.36, p < 0.001, ηp² = 0.814). Mean peak pressure decreased from 402.0 ±109.4 kPa at BFS to 288.7 ±78.2 kPa in the most effective CSFO, corresponding to a 27.9% reduction in plantar pressure. These reductions were accompanied by a redistribution of load towards adjacent plantar regions, indicating a measurable dose-response relationship. Conclusion: CSFOs significantly reduced central forefoot plantar pressure in people with diabetes. These findings provide quantitative insights into the relationship between 3D-printed orthotic design characteristics and plantar pressure redistribution, supporting more personalised pressure offloading strategies.

Objective: This study reports preliminary results of a minimally invasive first metatarsal base osteotomy for chronic plantar DFUs. Methods: Eight consecutive patients with neuropathic DFUs under the first metatarsal head, unresponsive to at least six weeks of conservative treatment, were enrolled. Patients with severe ischemia, osteomyelitis, or significant soft tissue loss were excluded. All underwent a dorsomedial percutaneous incomplete wedge osteotomy of the first metatarsal base, performed by a single surgeon. Ulcer care and postoperative follow-up were conducted according to standardized protocols. Results: All ulcers healed within weeks, with no cases of radiographic nonunion, transfer lesions, or recurrence at a mean follow-up of 12 months. One superficial infection resolved with oral antibiotics. Conclusion: These preliminary findings suggest that minimally invasive first metatarsal base osteotomy may be a feasible surgical option for selected patients with chronic plantar DFUs refractory to conservative care. Larger, controlled studies are warranted to validate its safety, effectiveness, and long-term outcomes. Level of evidence: IV, Case series

Objective: Complex regional pain syndrome type I (CRPS-I) is a debilitating pain disorder that can develop after trauma or surgery. This systematic review aims to evaluate the association between prophylactic oral vitamin C supplementation and the development of CRPS-I after foot and ankle fractures or surgery. Materials and methods: This systematic review was conducted according to the PRISMA guidelines. A comprehensive literature search of the PubMed, Embase and Cochrane databases was performed up to the 30th of April 2026. Four studies evaluating vitamin C for the prevention of CRPS-I following foot or ankle fractures or surgeries were therefor included. RoB 2 and NOS were used to evaluate the methodological quality of the studies. Results: Interventions consisted of oral vitamin C supplementation, after elective surgery, operative and non-operative fracture management. Vitamin C supplementation was consistently associated with a lower incidence of CRPS-I, ranging from 1.28% to 4.9% compared with 9.6% to 21.7% for the control group. Multivariate analyses of two studies identified vitamin C intake as an independent protective factor against CRPS-I. One study evaluating adjunctive therapies including vitamin C reported lower postoperative complication rates. Reported independent risk factors for CRPS-I included previous history of CRPS-I, cast immobilization and alcohol abuse, whereas female sex, smoking, diabetes mellitus and psychological factors were not independently associated factors for CRPS-I. Conclusion: Available evidence suggests the preventive role of vitamin C supplementation against CRPS-I following foot and ankle trauma or surgery, although further research based on foot or ankle orthopaedic patients is necessary.

Progressive Collapsing Foot Deformity (PCFD) is a degenerative condition characterized by ligament failure and progressive arch collapse, producing pain, deformity, and impaired mobility. Quantifying deformity severity on radiographs is essential for diagnosis and treatment planning, yet existing radiographic parameters lack simplicity and reproducibility. This pilot study evaluated a novel radiographic metric: the arch height index (AHI)—as a potential measure of arch integrity and compared it with established alignment parameters. Two independent observers measured the AHI on weight‑bearing radiographs from 30 subjects previously classified clinically as neutral, planus, or cavus by a fellowship‑trained foot and ankle surgeon. The AHI was defined as the ratio of the height of the first metatarsal base to that of the fifth metatarsal. Inter‑rater reliability was compared with the Meary’s angle, the most reproducible current radiographic measure of arch height. Mean AHI values were 0.40 ± 0.15 (neutral), 0.22 ± 0.28 (planus), and 0.78 ± 0.55 (cavus). ROC analysis showed that an AHI threshold of 0.2 provided 50% sensitivity and 92% specificity for distinguishing planus from neutral alignment, whereas a threshold of 0.5 was fully sensitive but poorly specific. Inter‑rater reliability for AHI was 0.97, substantially higher than the 0.71 observed for Meary’s angle. These findings suggest that the AHI is a simple, intuitive, and highly reproducible radiographic measure of arch collapse that may be useful for diagnosis, clinical decision‑making, and postoperative assessment in PCFD. Further work with larger datasets is needed to refine cutoff values distinguishing neutral, planus, and cavus foot types.

Introduction. Traumatic osteochondral fractures of the metatarsal head are exceptional injuries. Since the first case described by Heckman in 1984, only thirteen cases have been reported in the literature, with the second and fourth metatarsal heads being the most commonly affected (Missaoui 2022). This case highlights that diagnostic delay can occur even when the lesion is visible on plain radiographs, and that surgical fixation can achieve good outcomes depite that delay. Patient concerns and clinical findings. A female patient presented with left forefoot pain, swelling and limited range of motion following a fall from two metres, initially diagnosed with a subcapital fourth metatarsal fracture at another centre. At five weeks, joint locking was the predominant finding. Diagnosis, interventions and outcomes. Plain radiographs at our centre revealed a displaced osteochondral fracture of the fourth metatarsal head with a free intraarticular fragment. Open reduction and internal fixation with a 1.7mm cannulated screw was performed urgently, followed by weight-bearing in a rigid-sole shoe for six weeks and rehabilitation. At one-year follow-up, complete bone union was achieved with no avascular necrosis. Mild digital flexion stiffness was the sole residual finding. Conclusion Osteochondral fractures of the lesser metatarsal heads require a high index of clinical suspicion as they can be missed despite being radiologically visible. Tanaka (1995) and Mereddy (2007) both emphasized anatomical reduction as the key prognostic factor, and our case supports this, achieving good functional outcomes despite the five-week diagnostic delay. Early specialist management is essential to optimize functional otucomes.

Background: Distal tibiofibular syndesmotic injuries frequently accompany rotational ankle fractures, but the prevalence and risk factors of anterior inferior tibiofibular ligament (AITFL) avulsion fractures are still undetermined. This study aimed to determine the prevalence of AITFL bony avulsion, either Wagstaffe or Chaput avulsion fractures, and identify its associated risk factors. Methods: A retrospective review of 156 surgically treated ankle fractures was conducted. Demographic and clinical data, including BMI, injury mechanism, medical history, and ASA grade, were collected. Fractures were classified using the Weber/OTA and Lauge-Hansen systems. Each Wagstaffe or Chaput avulsion fractures were confirmed on CT scan, then categorized by the modified Wagstaffe classifications. The prevalence and risk factors for AITFL fractures were analyzed. Results: AITFL-related anterior malleolar fractures were identified in 77 patients (49.4%) on CT. Among these, 49 (63.6%) were isolated Wagstaffe fractures, 18 (23.4%) isolated Chaput fractures, and 10 (13.0%) combined lesions. AITFL fractures were more common in rotational ankle fractures. Most isolated Wagstaffe fractures (98.0%, 48/49) occurred in Weber B/SER-type fractures, while isolated Chaput fractures (61.1%, 11/18) were mainly seen in Weber C/PER-type fractures. No type 1 injuries were observed by modified Wagstaffe classification. Multivariate analysis identified age (OR = 1.04) and posterior pilon fractures (OR = 3.52) as independent risk factors for AITFL avulsion fractures. Conclusion: AITFL injuries appeared more commonly in ankle fractures than previously thought, and were frequently overlooked clinically. Recognizing AITFL fractures associated with ankle fractures through CT imaging is imperative and our findings provide clinicians with further insights on such injuries

Complex fractures of the talar body are rare injuries associated with a high risk of complications, including avascular necrosis, post-traumatic arthritis, and functional impairment. The aim of this study was to evaluate the long-term clinical and radiographic outcomes of a case series of patients affected by complex talar body fractures treated with open reduction and internal fixation using bioabsorbable implants through a single surgical approach. Five patients with displaced complex fractures of the talar body underwent surgical treatment with anatomical reduction and internal fixation using bioabsorbable osteosynthesis devices. In all cases, fracture fixation was achieved through a single surgical approach tailored to the fracture pattern. Postoperative management included protected weight-bearing and serial clinical and radiographic evaluations. Patients were followed for a minimum of 2 years and a maximum of 21 years. Clinical outcomes were assessed in terms of pain, ankle and subtalar joint function, return to daily activities, and radiographic evidence of fracture healing and degenerative changes. All fractures healed and reconstructed fragments was revascularized, without secondary surgeries request. Satisfactory functional outcomes were observed in all patients, with preservation of joint congruity and acceptable range of motion. No implant-related complications or need for hardware removal were recorded. Although post-traumatic degenerative changes were noted in all cases, long-term results remained clinically satisfactory. The use of bioabsorbable fixation devices for complex talar body fractures can represent an effective treatment option, allowing sufficiently stable fixation and surprising satisfactory long-term outcomes when combined with accurate reduction and careful surgical planning.

The Fifth metatarsal base avulsion fractures are common injuries, frequently resulting from inversion mechanisms with traction by the peroneus brevis tendon and plantar fascia. While minimally displaced fractures can be managed nonoperatively, surgical fixation is indicated for displaced, comminuted, or symptomatic nonunion. Traditional fixation methods using screws, metallic tension-band constructs, or hook plates are associated with hardware irritation, breakage, and the potential need for secondary removal. A metal-free, high-strength suture tension-band construct may provide stable fixation while minimizing implant-related complications. A retrospective case series was conducted, including patients with displaced or comminuted fifth metatarsal base avulsion fractures treated using suture-based tension-band technique. Demographic data, fracture characteristics, time to union, complications, and functional outcomes were recorded. Radiographic union was assessed using serial follow-up radiographs. Clinical outcomes included time to weight-bearing, return to activity, pain scores, and AOFAS midfoot scores. All patients achieved radiographic union without loss of reduction. The mean time to union was 8 weeks. Patients were able to initiate protected weight-bearing at a mean of 2 weeks and returned to full activity at a mean of 8 weeks. Functional outcomes were favorable, with a mean AOFAS midfoot score of 97.5 at final follow-up. No cases of implant failure, hardware irritation, or reoperation were observed. Metal-free suture tension-band fixation for fifth metatarsal base avulsion fractures provides stable fixation, reliable union, and excellent functional outcomes. This technique may be particularly advantageous in fractures with small or comminuted fragments, as it avoids complications associated with metallic implants. Further comparative studies are warranted.

Acute Achilles tendon rupture remains challenging because treatment must restore function while minimizing complications related to open surgery and percutaneous nerve injury. This case series evaluated functional outcomes, quality of life, and complications after repair of acute noninsertional Achilles tendon ruptures using a modified minimally invasive Dresden technique. Patients treated at a tertiary orthopedic institute between 2015 and 2024 were reviewed. Adults with acute ruptures within 2 weeks, located at least 2 cm proximal to the calcaneal insertion, underwent repair by two senior surgeons trained in the Dresden technique, followed by a standardized functional rehabilitation protocol. Outcomes included FAOS, ATRS, EQ-5D-5L, PROMIS Physical Function, Physical Activity Scale, heel-rise testing, calf circumference, ankle range of motion, gravitational equinus angle, and postoperative complications. Statistical analysis used descriptive methods, Spearman correlations, and paired Wilcoxon tests. Thirty-one patients completed follow-up. Mean age was 37.0 ± 10.55 years, and 64.5% were male. Mean scores were FAOS 99.03 ± 1.73, ATRS 98.29 ± 2.64, EQ-5D-5L 0.98 ± 0.03, and PROMIS 61.0 ± 0.51. Twenty-four patients maintained single-leg heel-rise support. No infection, wound dehiscence, rerupture, or deep vein thrombosis occurred. Two transient sural nerve symptoms resolved within 2 months. Range of motion was comparable between sides, while calf circumference was 1.08 cm smaller on the operated side. Modified minimally invasive Dresden repair provided excellent functional outcomes, high quality-of-life scores, preserved ankle motion, and very low complication rates. These findings support this tissue-sparing technique as a safe, reproducible alternative for selected acute Achilles tendon ruptures.

Posterior tibial tendon dislocation is a rare and frequently overlooked ankle injury, especially when associated with more evident traumatic lesions. This report describes an uncommon case of posterior tibial tendon dislocation occurring concomitantly with an acute Achilles tendon rupture, highlighting diagnostic challenges and simultaneous surgical management. A 37-year-old male sustained a right ankle injury during a soccer match after forced dorsiflexion and inversion, with an immediate snapping sensation. Initial assessment identified a complete Achilles tendon rupture. Persistent medial ankle pain and edema prompted further evaluation by a foot and ankle specialist. Magnetic resonance imaging demonstrated an Achilles tendon rupture 5.5 cm proximal to the calcaneal insertion, medial dislocation of the posterior tibial tendon, and detachment of the flexor retinaculum. Surgical treatment was performed in a single session, combining reduction of the posterior tibial tendon, repair of the flexor retinaculum to the medial tibia with transosseous sutures, and minimally invasive Achilles tendon repair using the Dresden technique. Postoperative rehabilitation included early protected weight-bearing, progressive range-of-motion exercises, and staged strengthening while respecting both tendon repairs. The patient progressed without complications. At seven months postoperatively, he had no pain or edema, restored posterior tibial tendon stability, recovered plantar flexion and inversion strength, and returned to previous sports activities. Posterior tibial tendon dislocation should be suspected in patients with medial malleolar pain and swelling after ankle trauma, even when another major injury is evident. Early MRI-based diagnosis and tailored simultaneous surgical repair can restore anatomy, prevent chronic tendon damage, and allow excellent functional recovery.

Introduction: Subtle Lisfranc injuries are challenging to diagnose, particularly in high-demand athletes, because conventional radiographs, computed tomography, and magnetic resonance imaging may fail to demonstrate functional instability under physiologic load. Weight-bearing computed tomography (WBCT) may improve assessment by allowing three-dimensional evaluation of the tarsometatarsal complex during loaded positions. Methods: This technical tip describes a 17-year-old professional ballerina with an isolated ligamentous Lisfranc injury after an eversion trauma. Initial radiographs showed no fracture or displacement, while MRI demonstrated Lisfranc ligament injury without clear evidence of instability. Bilateral WBCT was performed in sitting, regular weight-bearing, and demi-pointe positions before treatment. After treatment, the same protocol was repeated with the addition of pointe-position WBCT. Measurements were obtained between the medial cuneiform and second metatarsal base (C1-M2), medial and intermediate cuneiforms (C1-C2), and first and second metatarsals (M1-M2). Results: Pre-treatment WBCT showed no significant increase in Lisfranc spacing compared with the contralateral foot, including during demi-pointe loading. Based on the absence of dynamic instability, nonoperative treatment was selected, consisting of protected weight-bearing in a foam walker boot with midfoot arch support for eight weeks. The patient became asymptomatic, progressed to full weight-bearing, and returned to sport within 12 weeks. Follow-up MRI demonstrated ligament healing, and repeat WBCT confirmed maintenance of stable measurements, including in pointe position. Conclusion: WBCT using sport-specific loaded positions may help distinguish stable from unstable subtle Lisfranc ligament injuries. In this case, WBCT supported successful nonoperative management and safe return to ballet.

Introduction Malleolar fractures are common ankle fractures with prevalence around 10% and a risk factor for ankle osteoarthritis. Bimalleolar fractures are inherently unstable and ORIF is the standard care. Anatomic reduction is the single most important modifiable factor determining long-term outcomes. Case Report A 29-year-old man presented with pain and limited range of motion following primary ORIF for a closed bimalleolar fracture. CT-scan confirmed non-anatomic reduction and nonunion of both malleoli. The patient underwent revision surgery with hardware removal, non-viable bone debridement, accurate anatomic reduction and application of a synthetic bone substitute fixed with a lateral plate and two medial screws. At 3 months postoperatively, the patient was completely asymptomatic, fully weight-bearing, and imaging confirmed complete consolidation. Discussion: This case demonstrates that precise anatomic reduction is paramount for achieving optimal clinical and radiological outcomes. Conversely, poor primary reduction is a critical risk factor for bimalleolar nonunion, chronic pain and a strong independent predictor of long-term post-traumatic osteoarthritis and poor functional outcomes. Biomechanically, just 1 mm of lateral talar shift reduces the tibiotalar contact area by 42%, drastically increasing joint stress. When primary fixation fails, revision surgery combining accurate anatomic re-reduction with synthetic bone substitutes is a highly effective strategy to successfully manage nonunion, relieve pain, and preserve long-term joint function.

Chronic Achilles tendon rupture is commonly treated with V–Y advancement or tendon transfer according to tendon gap length. However, in many cases, the gap reflects tendon retraction and fibrotic elongation rather than true tendon loss. We hypothesized that direct end-to-end repair with gradual postoperative stretching could achieve satisfactory outcomes without complex reconstruction. Fourteen patients with chronic Achilles tendon rupture (>3 months) treated at Nowon Eulji University Hospital between 2014 and 2025 underwent direct end-to-end repair. Cases with infection or major tendon loss were excluded. Fibrotic tissue was debrided and direct repair performed despite dorsiflexion limitation. Postoperatively, serial splint and cast immobilization with gradual stretching toward neutral ankle position was maintained for 6 weeks. Functional outcomes were evaluated at final follow-up. Mean age was 60.6 ± 13.0 years. Injury mechanisms included sports activity (8), stair injury (2), and falls (4). Mean MRI gap was 34 ± 11 mm, and mean interval from injury to surgery was 22 ± 13 weeks. Eleven patients completed final evaluation. Walking discomfort was absent in 8 and mild in 3 patients. Dorsiflexion limitation was absent in 9 and mild in 2 patients. Single heel-rise recovered fully in 5 patients, and running ability recovered fully in 5 patients. Mean time to comfortable ambulation was 26 ± 17 weeks. In selected chronic Achilles tendon ruptures with preserved tendon length, direct end-to-end repair combined with gradual postoperative stretching may provide satisfactory recovery without tendon transfer or other reconstructive procedures.

Background Early surgery within 36 hours of admission improves outcomes in hip fracture patients and recommended by NICE CG124 and the Best Practice Tariff (BPT). DOACs are increasingly prescribed in older adults and may contribute to surgical delays due to concerns regarding bleeding risk and variation in perioperative management. National data from the HASTE collaborative has demonstrated longer times to theatre and reduced compliance with the 36-hour target in anticoagulated patients. Aim To determine whether hip fracture patients receiving DOACs experience delays to surgery compared with non-anticoagulated patients and to assess compliance with local and national guidance. Methods A retrospective audit of consecutive hip fracture admissions between 1 August and 31 October 2025 was conducted at the University Hospital of North Tees. Data were collected from the National Hip Fracture Database, electronic patient records, and prescribing systems. Variables included DOAC status, renal function, time to theatre, documented reasons for delay, and anaesthetic technique. Outcomes were benchmarked against NICE CG124 and local perioperative anticoagulation guidance. Results Of 121 patients identified, 34 receiving DOAC therapy underwent operative management. Mean time to theatre was longer in the DOAC cohort than in non-anticoagulated patients (2.57 vs 1.96 days). Only 23.6% of DOAC patients underwent surgery within 36 hours. Among delayed cases, 46.2% were attributed to anticoagulation status, with 83.3% inconsistent with local guidance. Conclusion DOAC therapy is associated with clinically significant surgical delays in hip fracture patients. Simplified guidance, improved documentation and earlier anaesthetic involvement may reduce unnecessary delays improving compliance with national standards.

Introduction: Delayed unions or non-unions of fractures or fusions represent daily orthopedic challenges, specially around the foot and ankle. This literature review aims to evaluate the clinical and radiological outcomes of extracorporeal shock wave therapy (ESWT) on foot and ankle surgery. Our goal was to determine if ESWT can serve as a reliable, lower-morbidity alternative to surgery, accelerate recovery, and ease return to sports and daily activities. Methods: Electronic databases (Embase, Cochrane Library, PubMed, Google Scholar) were used to look for all the clinical studies evaluating the use of ESWT in foot and ankle surgery. Analyzed protocols compared ESWT (2000–4000 impulses per session, with energy flux densities ranging from 0.06 to 0.84 mJ/mm² across 1–5 sessions), with surgical treatment. Results: Overall union rates reached 86% for delayed unions and 73% - 75.7% for non-unions. Focused ESWT achieved higher union rates compared with radial ESWT (94.7% vs. 77.8%) in an comparative study. Among elite athletes, return to play occurred within 4–7 weeks in ballet dancers following stress fractures of the second and third metatarsal bases. In football players, return to sport was reported after approximately 12–13 weeks following fifth metatarsal stress fractures. Morphologically, trophic non-unions demonstrated a healing rate of 69.9%, compared with only 33.3% in atrophic non-unions. Conclusion: ESWT represents a highly promising, non-invasive treatment option that achieves fracture/fusion union rates and return-to-sport timelines comparable to surgery, in selected patients.

Fractures of the posterior malleolus play a crucial role in maintaining ankle stability and strongly influence long-term functional outcomes in complex ankle injuries. The posterolateral rim fragment constitutes a bony avulsion of the posterior syndesmotic complex. Anatomical reduction and stable fixation of this fragment are essential for restoration of the fibular notch, posterior tibiotalar stability, and syndesmotic integrity. We present a modified minimally invasive inside-out fixation technique using the example of a geriatric patient with a trimalleolar ankle fracture with a Bartoníček type 2 posterior malleolar fragment. The procedure was performed under intraoperative three-dimensional imaging guidance. Stabilization of the posterior malleolar fragment was achieved using a posterior-to-anterior headless double-threaded compression screw. The medial malleolus was treated with two parallel partially threaded cannulated cancellous screws, whereas the distal fibular fracture was stabilized using a reamed intramedullary locking nail. Surgical technique, potential complications, and postoperative treatment strategy are outlined in detail. By combining the biomechanical benefits of direct posterior malleolar fixation with a minimally invasive approach that preserves soft tissues, this technique provides a stable and dependable construct for the management of complex ankle fractures, particularly in geriatric patients and patients with compromised soft-tissue conditions.

Introduction: Unstable ankle fractures and fracture-dislocations require prompt reduction. Temporary external fixation (EF) provides mechanical stability and soft-tissue protection prior to definitive surgery, but its impact on waiting times and clinical outcomes remains debated. This study compared postoperative complications and functional outcomes between patients managed with temporary EF versus direct definitive surgical fixation. Methods: A retrospective case-control study was conducted on patients undergoing definitive fixation for ankle fractures or fracture-dislocations. Patients initially managed with temporary EF (study group) were compared in a 1:2 ratio with a control group managed without EF. Demographic characteristics, fracture patterns, time to definitive surgery, complications, and functional satisfaction were analyzed. Results: Overall, 69 patients were included (mean age 60 years; 57% female), with 23 (33.3%) in the EF group. Trimalleolar fractures and fracture-dislocations predominated (78%). The median waiting time for definitive surgery was significantly longer in the EF group (14 vs. 5 days). Postoperative complications occurred in 26.1% of patients, with no statistically significant difference between groups (p=0.144). The most common complication was hardware removal (13% EF vs. 9% control), followed by infection. High functional satisfaction was reported by 52% of patients, while 9% were dissatisfied, with no significant differences between treatment groups. Conclusion: Temporary external fixation significantly increased the time to definitive surgery but did not lead to higher postoperative complication rates or worse functional satisfaction. EF remains a safe, effective measure for soft-tissue protection, yielding comparable outcomes to direct surgical fixation.

Introduction: Malleolar ankle fractures represent one of the most frequent orthopedic injuries requiring surgical fixation. Despite advances in fixation techniques, early postoperative complications remain a relevant concern. This study aimed to determine the early complication rate and identify risk factors in a consecutive surgical series. Methods: A single-centre retrospective cohort study of 121 consecutive patients undergoing operative fixation of malleolar ankle fractures by a dedicated Foot and Ankle team over 18 months. The primary outcome was any complication within 3 months: wound healing problems, infection, or unplanned revision surgery. Secondary outcomes included individual complication rates and comparison between syndesmotic fixation methods. Fisher's exact test was used (p<0.05). Results: Mean age was 55.6±16.4 years; 70.2% were female. Fracture distribution: trimalleolar 54.5%, bimalleolar 38.8%, unimalleolar 6.6%. Comorbidities: smoking 14.0%, diabetes mellitus 10.7%, open fracture 4.1%. Syndesmotic fixation was performed in 43.0% (elastic suture-button device 80.8%; transsyndesmotic screw 19.2%). The overall early complication rate was 19.8% (24/121): wound healing problems 14.9%, revision surgery 3.3%, infection 2.5%. Open fracture was the strongest predictor (100% vs 16.4%; p=0.0002). Diabetes mellitus was independently associated (46.2% vs 16.7%; p=0.022). Smoking (p=0.744), age ≥65 years (p=0.228), sex (p=1.000), fracture type (p>0.49), and syndesmotic fixation (p=0.820) did not reach statistical significance. No significant difference was observed between syndesmotic fixation methods (p=1.000). Conclusions: Open fracture and diabetes mellitus are the primary risk factors for early complications after malleolar ankle fracture surgery. These findings support proactive preoperative patient optimisation and heightened postoperative surveillance in high-risk individuals.