What’s New in Foot and Ankle Surgery

This article summarizes select orthopaedic foot and ankle research from September 2023 to September 2024. The included studies were published in The Journal of Bone & Joint Surgery, Foot & Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, The American Journal of Sports Medicine, JAMA Network Open, The Lancet, Skeletal Radiology (the Journal of the International Skeletal Society, and the Official Journal of the Society of Skeletal Radiology and the Australasian Musculoskeletal Imaging Group), Foot & Ankle Specialist, The Bone & Joint Journal, and the Journal of Orthopaedic Trauma. Forefoot Lesser Toes Osteotomy of the proximal phalanx continues to gain popularity as a joint-sparing procedure for the treatment of lesser toe deformities. Bastías et al.1 reported a case series of 31 patients (45 toes) who underwent a proximal phalangeal shortening osteotomy. The mean visual analog scale (VAS) pain scores improved from 4.9 to 1.62 (p < 0.01). Union occurred in all patients at a mean of 11.2 weeks. Complications were observed in 4 toes (8.8%), with no recurrences. Kang et al.2 reported the outcomes of lesser toe valgus correction following proximal chevron metatarsal osteotomy and Akin osteotomy in patients with moderate to severe hallux valgus. Simply by correcting the hallux alignment, the valgus angulation improved by 37.1% in the second toe, 27% in the third toe, and 44.5% in the fourth toe. The correction was less in patients with metatarsal adductus or recurrent hallux valgus. Hallux Valgus Machine learning has been applied to foot and ankle surgery. Using deep learning model-assisted radiographic angle measurements, Choi et al.3 demonstrated a significant correlation between hallux valgus and pes planus. Additionally, Zhao et al.4 demonstrated that machine learning could predict the recurrence of hallux valgus at a 1-year follow-up and identified risk factors for recurrence. These included the preoperative hallux valgus angle, sesamoid station, and postoperative intermetatarsal angle. Hallux valgus is often associated with a flatfoot deformity. To this end, hindfoot arthrodesis for pes planus correction has been shown to improve hallux valgus deformity5. However, Mizher et al.6 demonstrated that, although combined chevron and Akin procedures led to improved clinical and radiographic hallux valgus outcomes, these procedures did not affect radiographic flatfoot parameters. Minimally invasive surgery (MIS) continues to be utilized to correct hallux valgus. Recent studies have investigated the biomechanics of MIS bunion correction. Lopez et al.7 found that MIS hallux valgus correction did not increase lateral forefoot pressure loading when controlling for sagittal plane displacements. With regard to fixation, Lewis et al.8 demonstrated that the optimal construct for securing a minimally invasive first metatarsal osteotomy includes 1 bicortical screw and 1 intramedullary screw. Hallux Rigidus Cheilectomy remains a reasonable approach to treating hallux rigidus. Gauthier et al.9 found that MIS cheilectomy combined with first metatarsophalangeal arthroscopy improved patient-reported outcomes at 1 year, with low complication and revision rates for early-stage disease. Meanwhile, Kim et al.10 examined the effect of a concomitant Moberg osteotomy in patients undergoing cheilectomy for hallux rigidus. Although 1-year pain intensity scores favored the combined group, other Patient-Reported Outcomes Measurement Information System (PROMIS) subscores had equivocal results. Ankle and Hindfoot Plantar Fasciitis Further evidence supports the use of gastrocnemius recession to treat plantar fasciitis. Slullitel et al.11 retrospectively studied 167 patients with recalcitrant disease who underwent proximal medial gastrocnemius recession. Significant improvements were noted in the mean scores for the Foot and Ankle Ability Measure-Activities of Daily Living scale and VAS pain at 1 year after the surgical procedure. In addition, Riiser et al.12 reported a long-term follow-up of 33 patients treated either with proximal medial gastrocnemius recession and stretching or with stretching alone. At 6 years, the mean VAS pain and American Orthopaedic Foot & Ankle Society (AOFAS) scores were still significantly higher in the proximal medial gastrocnemius recession group. Interestingly, no differences were observed in ankle dorsiflexion between groups. There has been further interest in the use of platelet-rich plasma (PRP) to treat plantar fasciitis. Herber et al. performed a systematic review and meta-analysis of PRP compared with other modalities for the treatment of plantar fasciitis13. They found that PRP was more effective than corticosteroid injections, extracorporeal shockwave therapy, and placebo in reducing VAS pain scores. However, PRP was not consistently advantageous across all outcome measures. Another group randomized 59 patients to PRP or botulinum toxin, followed them for 1 year, and found both modalities to be effective14. The PRP group had superior results in the long term, with significant pain reduction, functional improvement, and reduction in plantar fascia thickness, compared with the botulinum toxin group. Sasaki et al.15 retrospectively reviewed 66 patients with recalcitrant plantar fasciitis who underwent a novel technique with embolization of abnormal peripheral “neovessels.” This was performed by interventional radiologists using needles percutaneously inserted into the posterior tibial artery under ultrasound guidance. The mean Numeric Rating Scale for pain significantly improved from 7.9 to 0.7. Meanwhile, the AOFAS hindfoot score significantly improved from 65.8 to 92.8 at the 1-year follow-up. Ankle Arthroplasty Complications following total ankle arthroplasty remain a concern. Several studies have investigated strategies to minimize complications or to risk-stratify patients undergoing total ankle arthroplasty. Le et al.16 performed a meta-analysis of 12 retrospective cohort studies that included 17,331 patients, 2,580 of whom were smokers. Patients who were smoking at the time of surgery had an odds ratio (OR) of 3.30 for developing a wound complication. There was no elevated risk of developing prosthesis-related or systemic complications. With regard to diabetes, Helbing et al.17 conducted a database study of 8,317 patients who underwent total ankle arthroplasty. The 5-year cumulative incidence of being coded as having a periprosthetic joint infection was 7.3% in patients with diabetes compared with 3.9% in patients without diabetes. However, there was no difference in the cumulative incidence of all-cause revision of the total ankle arthroplasty. Meanwhile, in a similar National Surgical Quality Improvement Program (NSQIP) study, Qureshi et al.18 found that insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days. Additionally, hospital length of stay was increased in both patients with insulin-dependent and non-insulin-dependent diabetes compared with patients without diabetes. There is continued interest in patient-specific instrumentation (PSI) for ankle arthroplasty. April et al.19 reported on the accuracy of using PSI. They found that the mean accuracy, compared with normal alignment, was 2.7° in the sagittal plane and 1.3° in the coronal plane. At a mean of 45 months, the overall survival rate was 95.7%. Yau et al.20 studied the effect of PSI compared with standard instrumentation. PSI provided significant improvement in the Manchester-Oxford Foot Questionnaire (MOXFQ) walking/standing domain, but overall, there was no significant difference in patient-reported outcome measure scores at 12 months between PSI and standard instrumentation. The use of PSI did lead to a significant reduction in operative and fluoroscopic time as well as improved alignment. Tendon and Ligament Pathology Achilles Tendon Rupture Over the past decade, equivalent outcomes have been reported when comparing functional rehabilitation with operative repair for the treatment of acute Achilles tendon ruptures. Bragg et al.21 performed a systematic review of randomized controlled trials (RCTs) comparing functional rehabilitation and surgery. These authors utilized the reverse fragility index (RFI) to assess the strength of neutrality with regard to rerupture rates between groups. The median rerupture rate was 4.0% in the operatively treated group and 10.0% in the nonoperatively treated group. The median RFI was only 3, meaning that an outcome reversal would be necessary in only 3 patients to change the results from nonsignificant to significant. The authors further noted that, in 7 of the 9 included studies, the number of patients lost to follow-up was equal to or greater than the RFI of the individual original study. Early loading and motion are typically initiated after Achilles repair. A recent RCT compared patients for whom rehabilitation included early loading with patients for whom loading was delayed by 6 weeks22. The heel-rise height difference was reduced in both groups, although without a significant between-group difference. Similarly, the gastrocnemius tendon elongated in both groups over time, again without a significant between-group difference. However, the delayed loading group had better Achilles Tendon Total Rupture Scores at 1 year postoperatively. This study highlighted the need for further investigation into the optimal postoperative rehabilitation for patients undergoing Achilles tendon repair. Achilles Tendinopathy There is continued interest in the use of a dorsal closing-wedge (Zadek) osteotomy of the calcaneal tuberosity for the treatment of insertional Achilles tendinopathy. This is typically performed in a minimally invasive fashion. In a recent meta-analysis, patients who underwent a Zadek procedure had equivalent outcomes compared with those who underwent open debridement23. However, there was a significantly lower rate of wound complications in the Zadek group. Ankle Instability Several investigations examined the ligaments and stability of the distal lower-extremity syndesmosis. A computed tomographic (CT) scan remains valuable for assessing syndesmotic instability. Shamrock et al.24 utilized a weight-bearing CT scan to determine the mean pooled area of the distal lower-extremity syndesmosis in healthy ankles (103.8 ± 20.8 mm2). This value did not significantly change with stress. Beeler et al.25 investigated bilateral external torque CT in a cadaveric model of syndesmotic instability. These authors reported greater sensitivity and similar specificity when comparing this imaging technique with the arthroscopic lateral hook test. With regard to flexible fixation for distal lower-extremity syndesmosis stabilization in the setting of ankle fractures, Kim et al.26 assessed the accuracy of reduction and clinical outcomes in 59 patients: 35 had accurate reduction and 24 had malreduction. After 1 year, there were no differences in AOFAS and VAS pain scores and Foot and Ankle Outcome Scores (FAOS) between the 2 groups. Fifty-six patients had arthroscopic evidence of syndesmotic stability when the implant was removed. Meanwhile, Jlidi et al.27 compared screw fixation with modified suture button fixation of the distal lower-extremity syndesmosis in operatively treated ankle fractures. The quality of the reduction on CT was satisfactory in both groups. The dynamic fixation group had better motion and better AOFAS scores and returned to work earlier. However, this group had a greater incidence of early skin complications. Obey et al.28 performed a multicenter study comparing syndesmosis suture button and screw fixation. Patients with suture button fixation had significantly higher Tegner activity scores, although there was no significant difference in Foot and Ankle Ability Measure scores. The rate of implant removal was 3.2% for suture button fixation and 9% for screws. One patient, fixed with screws, required a revision surgical procedure for malreduction. Arthroscopic stabilization remains a useful tool for treating chronic instability of the lateral ligament complex, with equivalent outcomes when compared with open repair. Mortada-Mahmoud et al.29 examined the results of 100 patients who underwent arthroscopic repair of the anterior talofibular ligament through 2 portals. Follow-up ranged from 24 to 48 months. The anterior drawer and talar tests were normal in all patients. The mean VAS pain scores improved to 0.39 ± 0.63, and clinical outcomes scores also improved significantly. Peroneal Tendons Peroneal tendon instability is known to be associated with calcaneal fractures. However, the optimal method for diagnosing peroneal tendon instability is less clear. Vosoughi et al.30 performed a retrospective cross-sectional study using the CT scans of 400 consecutive operatively treated calcaneal fractures. In one-sixth of cases, peroneal tendon instability was confirmed intraoperatively by the superior peroneal retinacular stress test, and the authors suggested that this test be routinely performed when repairing calcaneal fractures. The most specific CT finding to predict peroneal tendon instability was a fracture-dislocation of the calcaneus. There was also a significant association between peroneal tendon instability and the presence of fracture fragments in the lateral gutter as well as Sanders type-IV injuries. Although the specificity and accuracy of these parameters for diagnosing peroneal tendon instability were relatively high, sensitivity was low. The authors commented that peroneal stabilization could be performed if the proximal portion of an L-shaped or sinus tarsi incision was extended. That said, they noted that this should be performed with great caution and acknowledged that there have been few reports of peroneal tendon instability following the operative repair of calcaneal fractures. Trauma Ankle When performing open reduction and internal fixation (ORIF) of unstable bimalleolar ankle fractures, the medial malleolus often reduces after fibular fixation. Is medial malleolar fixation necessary in these patients? Carter et al.31 investigated this question in an RCT that included 154 patients randomized to either fixation or closed management of the medial malleolar fragment. Although the outcomes were similar between the groups at 1 year, there was a higher rate of nonunion (20% compared with 0%; p < 0.001) in the group that did not undergo fixation. Most patients were asymptomatic, but 1 patient did require a revision surgical procedure. There is continued interest in early weight-bearing following the operative treatment of ankle fractures. In a multicenter RCT in the United Kingdom, investigators randomized 561 patients to early (2-week) or standard (6-week) weight-bearing following fracture fixation32. Ankle function was measured using the Olerud and Molander Ankle Score (OMAS) and was found to be noninferior in the early weight-bearing group at 4 months (p = 0.024). Early weight-bearing was also found to be cost-effective, and complication rates were similar between groups. Other investigators from the United Kingdom, Matthews et al., investigated whether function after ankle fracture surgery improves with early motion and directed exercise (EMADE)33. These authors randomized 157 patients to EMADE or cast immobilization at 2 weeks after the surgical procedure. At 12 weeks postoperatively, outcome scores were significantly better in the EMADE group (OMAS, 62.0 compared with 48.8; p < 0.001). In contrast to the prior U.K. investigators, the EMADE protocol required patients to remain non-weight-bearing until 6 weeks postoperatively. These large RCTs should inspire confidence for clinicians to consider early rehabilitation, whether exercise or weight-bearing, following ankle fracture fixation. Talus Osteonecrosis remains a concern following talar fractures. The historical literature has often focused on dislocation driving osteonecrosis. Recent investigations have reported on other prognostic factors. Alley et al.34 performed a prognostic Level-III chart review that included 798 fractures across 22 trauma centers. The overall rate of osteonecrosis was 42%. Significant risk factors for the development of osteonecrosis included more severe Hawkins grade, open injury, tobacco smoking, dual surgical approaches, and increased body mass index. The time to reduction for Hawkins IIB-IV neck injuries was no different for those who developed osteonecrosis and those who did not. The osteonecrosis rate for patients who had reduction within 6 hours was 48.8% and 57.5% for those who had reduction at >6 hours after the injury (p = 0.11). In a similar study, the rate of osteonecrosis in patients with isolated talar neck fractures was compared with patients who had talar neck fractures with concomitant foot and ankle fractures35. The osteonecrosis rate was higher in the latter group but the difference did not reach significance (46% compared with 30%; p = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing osteonecrosis were significantly higher in this group (OR, 2.43; p = 0.047). Jaeblon et al.36 investigated open fractures of the talar neck and body and reported an overall infection rate of 15.6%. All infections occurred in body fractures; in these cases, nearly 6 surgical procedures were required per patient. Meanwhile, Griffin et al.37 challenged the significance of the Hawkins sign. In this series of 105 talar neck fractures, a Hawkins sign was observed in 21 cases. Three patients (14%), all smokers, later developed osteonecrosis. In the remaining 84 cases without a Hawkins sign, only 32 (38%) developed osteonecrosis. Calcaneus Ahluwalia et al.38 compared 46 displaced calcaneal fractures treated surgically using either a sinus tarsi incision or percutaneous fixation and 46 propensity-matched controls treated nonoperatively. After 2 years, there was no significant difference in the MOXFQ scores. However, despite higher fracture complexity, patients treated surgically had significantly higher general health-related quality-of-life scores (p < 0.05), return-to-work rates (91% compared with 72%; p < 0.05), and physical activity rates (46% compared with 35%; p < 0.05). Despite a minimally invasive approach, 16% of patients developed wound complications, all treated nonoperatively. Six patients (13%) in the nonoperative group later underwent arthrodesis. 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In the et al. compared orthopaedic management with management of metatarsal fractures at management was more with (OR, p = orthopaedic weight-bearing compared with p < 0.001). 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A value of a value in in patients. The surgical management of remains a in the et performed a retrospective review of with that were surgically treated with reduction of the dislocation and of the correction with percutaneous and external fixation after joint for arthrodesis. The authors reported clinical outcomes in of cases. had outcomes with required clinical outcomes included (14%), and on Patient-Reported Outcomes outcome to an in foot and ankle surgery. et examined scores in patients, that physical function and significantly across and are more in chronic The between and scores were for more chronic those that are associated with relatively physical as hallux valgus. In a review of studies, et further the value of preoperative patient-reported outcome finding that postoperative patient-reported outcome and higher complication rates in patients undergoing foot and ankle surgery. et pain scores into postoperative to follow-up after foot and ankle surgery. that to of patients, by preoperative pain and improvement by postoperative but still follow-up the of the