Foot & Ankle International

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

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

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

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

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

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

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

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

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

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

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

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

First metatarsophalangeal joint arthrodesis is a reliable treatment for painful end-stage degenerative, inflammatory, and post-traumatic conditions and severe deformities of the first ray. Although long-term functional outcomes are well documented, the incidence and relevance of degenerative changes in adjacent joints of the medial column after first metatarsophalangeal joint (MTP1) fusion remain uncertain.

This exploratory single-center follow-up study included patients who underwent isolated MTP1 arthrodesis between 2012 and 2018. Preoperative and final follow-up weight-bearing radiographs were assessed for osteoarthritis progression in the interphalangeal (IP), tarsometatarsal (TMT1), naviculocuneiform (NC), and talonavicular (TN) joints using the Kellgren-Lawrence classification. Radiographic alignment parameters (hallux valgus angle, intermetatarsal angle, hallux-ground angle, and dorsal extension angle) were recorded. Clinical outcome was evaluated using American Orthopaedic Foot & Ankle Society hallux metatarsophalangeal-interphalangeal score (AOFAS HMI) score, Foot and Ankle Outcome Score (FAOS), Foot Function Index (FFI), and a study-specific questionnaire. Paired statistical tests and Pearson correlation analyses were performed.

Seventy-seven patients (45 female, 32 male) were available for follow-up at a mean of 106.9 ± 25.3 months. Radiographic osteoarthritis progression was significant in all assessed adjacent joints (P < .001) and was most pronounced in the IP joint (66 of 77 joints; 34 of 77 joints progressed by ≥2 grades). TMT1 progression occurred in 23 of 77 joints (≥2 grades in 5 of 77 joints), and NC or TN progression in 30 of 77 joints (≥2 grades: NC 6 of 77, TN 8 of 77). Radiographic alignment was not associated with adjacent-joint osteoarthritis progression, metatarsalgia, or patient-reported outcome. Overall, 90.9% reported good or excellent satisfaction. The mean AOFAS HMI score was 79.9 ± 9.1, FAOS 86.4 ± 15.2, and FFI 18.5% ± 9.3%. Wound healing complications were more frequent with dorsal plating than screw fixation. One nonunion required revision.

MTP1 arthrodesis provides excellent long-term satisfaction and functional outcomes with low revision rates. Although radiographic adjacent-joint degeneration, particularly involving the interphalangeal joint, may occur over time, these changes do not appear to influence clinical outcomes.

The objective of this study was to assess the types and rates of early complications following elective percutaneous surgery for hallux valgus (HV) in diabetic (DP) vs non-diabetic (NDP) patients.

This retrospective study was conducted at our institution between October 2017 and August 2020. During this period, 874 feet underwent percutaneous surgery for HV correction. All adult diabetic patients with controlled diabetes who underwent percutaneous distal metaphyseal osteotomy and had a minimum follow-up of 6 months were included. For each diabetic patient, 2 age-matched (±1 year) non-diabetic controls were randomly selected. Complications were defined as any deviation from the normal postoperative course and were systematically recorded. This work is a retrospective exploratory analysis of a matched cohort.

A total of 75 patients were analyzed, 25 DP and 50 NDP, with a mean follow-up of 10.8 months (range 6-48) months. There were no significant differences in demographic characteristics between groups, except for body mass index and Charlson Comorbidity Index, both of which were significantly higher in the DP group (P < .001 and P = .014, respectively). Although pre- and postoperative functional scale scores did not differ significantly between the groups, the postoperative radiographic angles showed a greater correction in the diabetic group.

The overall complication rate was 24% (n = 6) in the DP group and 18% (n = 9) in the NDP group (P = .553). Complications included infection, osteosynthesis discomfort, pseudarthrosis, residual pain, and metatarsalgia. In the DP group, all superficial infections were successfully managed with oral antibiotics.

With the available sample size, no statistically significant differences in the overall complication rate were detected between well-controlled diabetic and non-diabetic patients undergoing minimally invasive hallux valgus surgery. These findings should be interpreted as exploratory and hypothesis-generating, and require confirmation in larger studies.

This study aimed to demonstrate long term clinical follow-up and implant survivorship of Salto Talaris–type primary total ankle arthroplasty (TAA) by 1 foot and ankle–trained surgeon at a single institution.

Patients treated with primary Salto Talaris TAA were identified via Current Procedural Terminology (CPT) codes and included if they underwent primary TAA without history of arthrodesis and had complete imaging, clinical evaluation, and patient-reported outcomes preoperatively. Implant survivorship was calculated considering revision as requiring metal component explantation. Patient outcomes at final follow-up were compared to available preoperative values via paired t tests. P <.05 was considered significant.

A total of 154 patients met inclusion (55.8% female, mean age at surgery 63.3 ± 8.9 years). Mean follow-up was 9.7 years (range, 0.6-17.6 years). Estimated implant survival probability was 100% at 1 year, 97.2% at 3 years (95% CI 94.6-99.9), 94.9% at 5 years (95% CI 91.3-98.7), 91.6% at 10 years (95% CI 86.7-96.9), and 86.9% at both 12 and 15 years (95% CI 79.3-95.3); no component explantation events occurred between 12 and 15 years, with the final explantation recorded at 15.28 years postoperatively. Thirteen patients underwent revision. There was no significant change in dorsiflexion but a reduction in plantarflexion (Δ = –4.3°, 95% CI −6.0 to −2.6; P < .001) at final follow-up. No significant changes were observed comparing radiographs at 6-week and final follow-up, including tibial component coronal alignment, posterior tibial slope, and talar component position. Among 87 patients (91 TAA) with complete long-term data, VAS pain decreased (Δ = –26.5, 95% CI −33.0 to −20.0; P < .001), mean FCS 12 increased (Δ = +20.9, 95% CI 18.7-23.2; P < .001), and MCS increased (Δ = +5.2, 95% CI 2.9-7.5; P < .001). All FAOS subscales improved significantly (P < .001).

This cohort suggests that Salto Talaris–type TAA is associated with durable survivorship and patient outcomes at long-term follow-up in this single-surgeon series.

The European Foot & Ankle Society (EFAS) Score is a validated patient-reported outcome measure for the evaluation of postoperative foot and ankle outcomes. Yet, unlike the AOFAS, there is a dearth of literature defining the patient acceptable symptom state (PASS) for EFAS after hallux valgus surgery. This study aimed to determine the PASS for EFAS after hallux valgus surgery.

This was a retrospective cohort study using prospectively collected data of patients who underwent hallux valgus surgery between May 2017 and September 2023 in the authors’ institution. Patients were evaluated preoperatively and at 6 months and 2 years postoperatively, using functional outcomes such as EFAS and American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Rating System. PASS thresholds were determined with the Youden Index on receiver operating characteristic curves, with responses to an anchor question as the external criterion.

A total of 361 patients were followed up for 2 years. This included 324 (89.8%) female and 37 (10.2%) male patients. The mean age and body mass index (BMI) was 56.0 ± 14.0 years and 24.1 ± 4.6, respectively. Patients underwent various procedures including scarf-Akin osteotomy (n = 220, 60.9%), minimally invasive chevron-Akin osteotomy (n = 102, 28.3%), arthrodesis of first metatarsophalangeal joint (n = 15, 4.2%), scarf osteotomy (n = 14, 3.9%), Lapidus procedure (n = 7, 1.9%), and Bosch osteotomy (n = 3, 0.8%). The PASS for EFAS was determined to be 20.5 at 6 months (sensitivity 86.8%, specificity 70.4%) and 23.5 at 2 years (sensitivity 87.2%, specificity 72.0%). However, the PASS for AOFAS was determined to be 84.5 at 6 months (sensitivity 72.6%, specificity 75.0%) and 82.5 at 2 years (sensitivity 90.9%, specificity 63.4%).

The PASS for EFAS established in this study can be used for the clinical interpretation of future hallux valgus studies. A potential ceiling effect of the EFAS was identified, and the revised AOFAS PASS thresholds may warrant consideration.

Modified Lapidus procedure is well established for severe hallux valgus (HV). Nonetheless, postoperative recurrence remains a clinical concern. Peroneus longus (PL) functions as a dynamic stabilizer of the first ray, and its insertion at the base of the first metatarsal may be partially resected during osteotomy. Notably, PL dysfunction may contribute to recurrence by contributing to postoperative first ray instability. Nevertheless, extent of PL insertion resection during modified Lapidus procedure has not been quantified. This study aimed to evaluate the extent of resected PL insertion during modified Lapidus procedure.

We retrospectively reviewed 80 feet from 74 patients with severe HV. We simulated 2 osteotomy methods: lateral wedge osteotomy at the base of the first metatarsal (M-method) and lateral wedge osteotomy at the distal medial cuneiform (C-method). On radiographs, resected lateral edge length of the first metatarsal (rM1-length) to correct intermetatarsal angle (IMA) to 0° was measured. Based on the rM1-length, 3-dimensional computed tomography models were used to measure whole PL insertion length, resected PL insertion length (rPL-length), and percentage of resected PL insertion (%-rPL). These parameters between the M-method and the C-method were compared. Cutoff value of the IMA for diagnosing feet with %-rPL greater than 50% using the M-method was evaluated.

rM1-length, rPL-length, and %-rPL were significantly greater with the M-method than with the C-method (all P < .001). Notably, the mean %-rPL with the M-method exceeded 50%. The IMA cutoff value was 21.4°; however, with the numbers available, no statistically significant difference was detected in the rPL-length and %-rPL with the C-method above and below this cutoff.

Lateral wedge osteotomy at the first metatarsal may result in substantial PL insertion resection during the modified Lapidus procedure. Lateral wedge osteotomy of the medial cuneiform bone may better preserve PL insertion and potentially have implications for first ray stability.

Limited dorsiflexion (DF) after total ankle arthroplasty (TAA) is a challenge that has been associated with worse functional outcomes and lower patient-reported satisfaction. The purpose of this study was to identify predictive variables for limited DF following TAA.

A retrospective cohort study was conducted on patients who underwent elective primary TAA between 2013 and 2023 by a single surgeon. Postoperative range of motion (ROM) was assessed using weight-bearing lateral radiographs obtained in maximal DF and plantarflexion (PF). Limited DF was defined as <20° and preoperative DF was based solely on clinical assessment (C-DF). Demographic variables, medical comorbidities, surgical history, and adjunctive procedures, including gastrocnemius recession and tendo-Achilles lengthening (TAL), were collected and compared between patients who achieved full vs limited postoperative DF. Additionally, Foot and Ankle Ability Measure activities of daily living subscale (FAAM-ADL) and visual analog scale (VAS) scores were collected. Multivariable logistic regression was performed to identify independent predictors of final DF.

A total of 175 patients were included in this study, with 111 (63.4%) demonstrating limited postoperative DF and 64 (36.6%) achieving full DF at a mean 3.3 years. Age was significantly greater in the full DF group (65.5 vs 61.5 years, P = .013). No significant associations were identified between body mass index / weight, tobacco use, diabetes, sex, medical comorbidities, polyethylene size, or adjuvant procedures and postoperative DF following TAA. Prior open reduction internal fixation was more prevalent in patients with limited DF (P < .05), whereas postoperative FAAM-ADL scores were more favorable in the full DF group (70.0 vs 86.9, P = .010). Multivariable regression analyses identified full C-DF as the only significant independent predictor of improved postoperative DF following TAA.

Preoperative clinical dorsiflexion was the only significant independent predictor of postoperative dorsiflexion following TAA. A thorough preoperative discussion regarding anticipated postoperative motion can help establish appropriate expectations and potentially enhance patient satisfaction following TAA.

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

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

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

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

Level III, retrospective diagnostic.

Lateral lengthening calcaneal osteotomy (LLOT, Evans and Hintermann) is widely used to treat progressive collapsing foot deformity (PCFD). In the Evans osteotomy, the cut is performed proximal to the calcaneocuboid joint, carrying a risk of violating the anterior or middle subtalar facet. Hintermann proposed a modified technique placing the osteotomy between the middle and posterior facets to reduce risks. Although anatomical studies have shown potential facet involvement, clinical data on the actual incidence and its impact on long-term outcomes remain scarce. This study aimed to determine the incidence of subtalar facet penetration after LLOT and to evaluate its effect on clinical and radiographic results.

All patients aged ≥18 years who underwent LLOT (Evans or Hintermann osteotomy) at our institution between January 1, 2010, and December 31, 2020, were included. Postoperative computed tomography (CT) was performed 6 weeks after surgery to assess possible subtalar facet violation. At a minimum follow-up of 5 years, magnetic resonance imaging (MRI) was obtained to evaluate cartilage and ligament integrity. Clinical outcomes at the time of MRI were assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot & Ankle Society (AOFAS) score. Demographic variables, including type of osteotomy and outcome measures, were compared between patients with and without facet penetration.

Thirty-one patients met inclusion criteria. Subtalar facet penetration was detected in 11 patients (35%) on postoperative CT. No significant differences were observed between groups with respect to demographic variables. MRI analysis revealed no relevant differences in cartilage degeneration. FFI and AOFAS scores were comparable between groups.

Subtalar facet penetration occurred in one-third of patients after LLOT (Evans and Hintermann). With the numbers available, no significant differences in clinical or radiographic outcomes were detected at a minimum 5-year follow-up, suggesting that minor facet violations may have limited clinical relevance.

Level III, retrospective cohort study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patients treated with an Ilizarov external fixator often feature risk factors that impair wound healing such as diabetes, peripheral arterial disease, obesity, and renal insufficiency. A 2-staged approach, with initial bony correction (Kirschner wire or hybrid) followed by delayed Ilizarov application by 5 days, is intended to support wound healing by allowing for reduction of soft tissue swelling and enhancing postoperative wound care. We hypothesized that this method is associated with fewer wound complications but increased use of resources.

A retrospective review of 98 cases treated with an Ilizarov fixator (2004-2024) was conducted. Surgical management included 2-stage (n = 53, 54%) and single-stage (n = 45, 46%) procedures. Baseline characteristics and risk factors for compromised wound healing were recorded. Patients were stratified into 3 subgroups to enable comparative analysis: infection-related reconstructions (IRR), Charcot arthropathy (CA) and other applications. Preoperative presence of infection and ulceration was recorded. Primary endpoints were rates of impaired wound healing and wound revisions within 3 months post removal. Secondary endpoints were hospital length of stay after bony fixation, and total hospitalization costs.

Wound revision rates were significantly lower in the 2-stage group (9% vs 36%; OR 5.3, 95% CI 1.8-17.9; P = .0025) particularly in the CA subgroup (0% vs 38%; P = .010) or when an infection was present (14% vs 44%; OR 4.6, 95% CI 1.2-22.3, P = .0138). Impaired wound healing was significantly lower in patients with a 2-stage procedure (30% vs 55%; OR 2.9, 95% CI 1.3-6.6, P = .021). As an exploratory secondary outcome, no statistically significant difference in length of hospital stay or total hospitalization costs was observed.

Two-stage Ilizarov ring fixator application in high-risk foot and ankle surgery was associated with lower rates of impaired wound healing and wound revisions, particularly in CA and infection cases, without increasing hospital stay or costs.

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

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

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

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