What’s New in Foot and Ankle Surgery

This article provides a summary of orthopaedic foot and ankle research from September 2021 to September 2022. 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 Journal of Orthopaedic Trauma, The American Journal of Sports Medicine, JAMA (Journal of the American Medical Association), The New England Journal of Medicine, The Bone & Joint Journal, and the Journal of the AAOS (American Academy of Orthopaedic Surgeons). Forefoot Minimally invasive techniques involving the lesser metatarsals continue to grow in popularity. Neunteufel et al.1 reported a case series of 30 patients (31 feet) who underwent minimally invasive distal metatarsal metaphyseal osteotomy for metatarsalgia of ≥1 lesser metarsals2–5. All clinical scores (American Orthopaedic Foot & Ankle Society [AOFAS] Forefoot Score, Foot Function Index, Foot and Ankle Outcome Score [FAOS], and visual analog scale [VAS] pain score) improved significantly at a mean follow-up of 15.5 months. Plantar peak pressure at the relevant area was also reduced significantly. The mean metatarsal shortening across all osteotomies was 6.6 mm. Del Vecchio et al.2 reported the results of a sliding distal metatarsal minimally invasive osteotomy for the correction of a bunionette deformity in 57 patients (74 feet). At a minimum follow-up of 30 months, all radiographic and clinical outcome measures improved, with 89.1% of patients rating the procedure as excellent. The overall complication rate was 6.75%. Syndactyly release remains surprisingly problematic. Langlais et al.3 retrospectively reviewed 38 pediatric patients with 68 syndactylies who underwent syndactyly release with a dorsal commissural flap and cutaneous resurfacing. The recurrence rate was 28.1% and the complication rate was 11.7% at a mean follow-up of 6.9 years. Age of >2 years at the time of the surgical procedure was a risk factor for recurrence. Of the patients with simple syndactylies, only one-half were satisfied. Hallux Valgus Further data continue to demonstrate short-term equivalency but not superiority for minimally invasive hallux valgus surgery compared with open techniques. Hernández-Castillejo et al.4 performed a longitudinal, prospective study on 72 patients (72 feet) who underwent open chevron, open scarf, or percutaneous Reverdin-Isham osteotomy for the correction of hallux valgus deformity. At a mean follow-up of 17.7 months, all patient-reported outcome measures, including the VAS pain score and Manchester Oxford Foot Questionnaire (MOXFQ), demonstrated significant improvement independent of the preoperative radiographic parameters and type of surgical procedure. Lewis et al.5 prospectively reported on 106 consecutive feet (78 patients) that underwent third-generation minimally invasive chevron and Akin (MICA) osteotomies for severe hallux valgus. In the 86 feet (81.1%) with a minimum 2-year follow-up, there was significant improvement in all MOXFQ domains. The mean intermetatarsal angle and hallux valgus angle also improved significantly. The authors reported an 18.8% overall complication rate. Mikhail et al.6 retrospectively reviewed 248 patients (274 feet) who underwent MICA osteotomies for hallux valgus correction. At a mean follow-up of 12.9 months, the intermetatarsal angle, hallux valgus angle, and Foot Function Index improved significantly. The overall satisfaction rate was 91.6%, the mean number of 5-mg oxycodone tablets consumed postoperatively was 2.2 tablets, and the complication rate was 8.4%. The Lapidus procedure continues to grow in popularity. A retrospective review comparing Lapidus bunionectomy (73 patients) with scarf bunionectomy (63 patients) found no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function scores between groups, although patients in the scarf group had a 25% lower chance of achieving a normal intermetatarsal angle, at a mean follow-up of 17.8 months7. Veracruz-Galvez et al.8 prospectively followed 82 patients who underwent scarf osteotomy for moderate to severe hallux valgus. Normal postoperative sesamoid position (48 patients) was associated with significantly less pain (VAS), higher Self-Reported Foot and Ankle Score, and higher patient satisfaction (Likert scale) than the group with outlier sesamoid positions (34 patients). In a retrospective study comparing patients with hallux valgus (34 feet) with normal controls (20 feet), Lalevée et al.9 found that the distal metatarsal articular angle was overestimated on conventional radiographs compared with weight-bearing computed tomographic (CT) scans by a mean of 14°. However, even after computerized correction of the first metatarsal rotation and plantar flexion, the valgus alignment of the first metatarsal distal articular surface was 8.6° higher in patients with hallux valgus than in the control patients on weight-bearing CT scans. Hallux Rigidus Cichero et al.10 retrospectively reviewed 280 first metatarsophalangeal arthrodeses. The overall nonunion rate was 7.9% (22 feet). The risk of nonunion was >3 times higher in patients who had a single-construct locking plate with an interfragmentary compression screw inserted through the plate compared with patients who had a locking plate and a lag screw inserted outside of the plate. Hindfoot Tarsal Tunnel Syndrome The results of tarsal tunnel release remain inconsistent. Bouysset et al.11 retrospectively reviewed 73 patients (84 feet) who underwent tarsal tunnel release with follow-up of at least 1 year. The effectiveness of the release, based on patient willingness to repeat the procedure under similar preoperative circumstances, was significantly lower in patients with marked hindfoot varus or valgus and in patients with plantar fasciitis. Patients in only 51% of cases (43 feet) said that they would undergo the procedure again. Plantar Fasciitis Bildik and Kaya12 performed a double-blinded, randomized controlled trial that compared platelet-rich plasma (30 patients) with autologous blood (30 patients) for the treatment of plantar fasciitis. At 6 months after the injection, both groups demonstrated significant and similar improvements in the VAS pain scores and the Foot and Ankle Disability Index health-related quality-of-life scores compared with baseline. Kaiser et al.13 performed a prospective randomized controlled trial comparing a 6-week formal physical therapy program (27 patients) with a 6-week home stretching program (30 patients) for the treatment of plantar fasciitis. At 6 months, both groups significantly and identically improved from baseline in terms of VAS pain scores, Foot and Ankle Ability Measure scores, and Short Form-36 (SF-36) scores, and results were maintained through the 1-year follow-up. Insertional Achilles Tendinitis Arunakul et al.14 compared conventional rehabilitation (18 patients) with accelerated rehabilitation (31 patients) after debridement and reattachment of the Achilles tendon. At 3 months, the mean scores for VAS pain, Foot and Ankle Ability Measure, and SF-36 were significantly better in the accelerated rehabilitation group, but by 6 and 12 months there were no differences. There also were no complications. In a retrospective series of 50 open Zadek osteotomies fixed with a 6-hole lateral plate for treatment of Haglund syndrome, Tourne et al.15 reported significant improvement in the AOFAS Hindfoot scores and the Victorian Institute of Sport Assessment–Achilles scores at a mean follow-up of 7 years. Of 50 patients, 46 (92%) returned to the same or higher level of sports activity. The authors recommended using the Zadek osteotomy for the treatment of Haglund syndrome in the setting of a long calcaneus or when the novel X/Y ratio proposed in the study is <2.5, where X is the length of the calcaneus and Y is the length of the tuberosity on a lateral weight-bearing radiograph. Pes Planus In an attempt to establish the diagnostic reliability of a new classification for progressive collapsing foot deformity, Li et al.16 distributed a survey to current trainees, graduates, and faculty of 13 foot and ankle fellowship programs. For the entire cohort, the diagnostic accuracy rates were 71.0% overall, 78.3% for class, and 81.7% for stage. The misdiagnosis rates for the entire cohort for were 3.3% for class A, 17.5% for class B, 11.1% for class C, 26.0% for class D, and 3.7% for class E. Importantly, this survey used example patients for whom the physical examination findings were provided to the raters. The reliability of the scheme would likely be even lower in a real-world practice situation. The classification scheme for progressive collapsing foot deformity was evaluated with actual patients by Lee et al.17. Three independent observers assessed 92 feet (84 patients). The authors reported very good intraobserver reliability (Cohen kappa, 0.851; p < 0.001) and much worse interobserver reliability (Fleiss kappa, 0.561; p < 0.001). The classification scheme should not be considered reliable until changes result in improved interobserver reliability. The Cotton osteotomy is a dorsally based opening-wedge osteotomy of the medial cuneiform that is utilized to correct the forefoot varus component of adult-acquired flatfoot deformity, but it may not provide lasting results. Abousayed et al.18 reported a mean 8.6-year follow-up for the Cotton osteotomy performed with either allograft wedges (17 feet) or metal wedges (2 feet). Although a significant improvement was noted in the lateral talus-first metatarsal angle from preoperatively to the first postoperative follow-up (p < 0.0001), approximately one-half of the patients lost >50% of that correction at the final follow-up. The lengthened angular shape of the medial cuneiform was maintained, indicating that collapse occurred through surrounding medial column joints. Sports Osteochondral Lesions of the Talus The management of large osteochondral lesions of the talus is challenging. Shi et al.19 retrospectively compared autologous osteoperiosteal transplantation from the iliac crest (23 patients) with autologous osteochondral transplantation from the ipsilateral knee (23 patients) for the treatment of large, cystic, medial osteochondral lesions of the talus. At a mean follow-up of 48 months, there was no difference between the groups in terms of VAS pain scores, AOFAS scores, or Tegner scores. There was significantly less donor site morbidity in the autologous osteoperiosteal transplantation group. Magnetic resonance observation of cartilage repair tissue (MOCART) scores and International Cartilage Regeneration & Joint Preservation Society (ICRS) scores from second-look arthroscopy showed no differences between groups. Fletcher et al.20 reported on a prospective series of 31 patients who underwent fresh structural allograft transplantation for osteochondral lesions of the talar shoulder. At a mean 56.2-month follow-up, significant improvement was found in VAS scores, SF-36 scores, and the Short Musculoskeletal Functional Assessment Bother Index and Function Index compared with the preoperative status. The overall graft survival was 96.8%. Fifteen patients (48.4%) underwent an additional surgical procedure, typically implant removal or arthroscopic debridement. Microfracture for osteochondral lesions of the talus that have previously undergone a surgical procedure (secondary lesions) may not be as beneficial as previously reported. Arshad et al.21 performed a systematic review of 12 studies to assess patient-reported outcomes and pain scores after arthroscopic bone marrow stimulation for secondary talar lesions. No perioperative complications were noted, but, in studies that reported a revision surgical procedure as an end point, 26 (34%) of 77 patients underwent a revision procedure. Overall, patient-reported outcomes such as AOFAS score and VAS pain score showed inconsistent improvements, and many positive changes were less than the minimal clinically important difference (MCID) for these scales. Enthusiasm for subchondroplasty in the talus has waned. Hanselman et al.22 retrospectively reviewed 7 cases of talar osteonecrosis after subchondroplasty for bone marrow lesions. The mean time to radiographic confirmation of osteonecrosis was 23 months. Three of 7 patients had osteonecrosis risk factors (alcoholism and/or chronic corticosteroid use). The authors urged caution with this procedure, especially in patients with osteonecrosis risk factors. Achilles Rupture and Tendinosis Research continues on the optimal management of acute Achilles tendon ruptures. Seow et al.23 performed a meta-analysis to determine complication rates after the treatment of acute Achilles tendon ruptures and included a best-case and worst-case scenario analysis for rerupture rates. The best-case scenario assumed a 0% rerupture rate in those lost to follow-up, and the worst-case scenario assumed a 100% rerupture rate. Surgical treatment significantly reduced the risk of rerupture compared with nonoperative management. The pooled rerupture rate was 3.6% (3.4% best-case scenario, 8.3% worst-case scenario) in the surgical treatment arm and 12.1% (11.7% best-case scenario, 15.0% worst-case scenario) in the nonoperative treatment arm. The rate of complications, excluding reruptures, was significantly lower with nonoperative treatment (pooled complication rate, 7.1%) compared with surgical treatment (pooled complication rate, 18.5%). Percutaneous Achilles repair may be better paired with less aggressive rehabilitation to avoid stretching the repair. Maffulli et al.24 compared a traditional rehabilitation protocol (31 patients) with a slowed-down rehabilitation protocol (29 patients) for patients undergoing percutaneous repair of an acute Achilles tendon rupture. At a 12-month follow-up, the Achilles tendon resting angle and Achilles Tendon Rupture Score were significantly better in the slowed-down rehabilitation protocol group. Additionally, calf circumference and isometric strength were more similar to those in the contralateral, uninjured leg in the slowed-down rehabilitation protocol group. Trauma The Major Extremity Trauma Research Consortium (METRC)25 published a randomized controlled trial comparing a high perioperative FiO2 (fraction of inspired oxygen) of 80% with a standard perioperative FiO2 of 30% and its effect on surgical site infections in patients undergoing a surgical procedure for tibial plateau, tibial pilon, or calcaneal fractures. At 6 months postoperatively, they found a significant difference in overall surgical site infections (superficial and deep) between the groups: 7.0% for the experimental group compared with 10.7% for the control group (relative risk [RR], 0.65; p = 0.03). The difference was driven by fewer superficial infections in the experimental group (1.7%) compared with the control group (4.3%), for which the RR was 0.41 (p = 0.02); there was no difference in the risk of deep infections (5.6% in the experimental group compared with 6.6% in the control group [RR, 0.86; p = 0.5]). Anterior impaction of the tibial plafond has been shown to portend a particularly poor prognosis. Jo et al.26 retrospectively reviewed 50 patients (52 fractures) who underwent open reduction and internal fixation (ORIF) of OTA/AO 43B and C pilon fractures. At a mean follow-up of 25 months, the group with anterior impaction (28 fractures) had significantly higher rates of implant removal for pain, significantly greater anterior subluxation, and significantly worse posttraumatic arthritis than the group without anterior impaction. Noori et al.27 found that the Lawrence and Botte classification of proximal fifth metatarsal fractures has a low level of interrater reliability (an observed agreement of 77% compared with a chance agreement of 33%). Classification at the interface between Zones 2 and 3 was much less reliable than that between Zones 1 and 2. The authors suggested that a new classification system for these fractures is required for both clinical and research purposes. Ankle Fractures Allen et al.28 studied the effect of acute, intermediate, and late-phase synovial fluid fracture hematoma on cartilage discs from fresh allograft human tali. Compared with controls, the cartilage discs cultured in synovial fluid fracture hematoma demonstrated a significantly greater production of inflammatory cytokines, metalloproteinases, and cartilage matrix fragments, suggesting that cartilage-damaging pathways had been activated. The addition of compounds that inhibit inflammation (interleukin 1 receptor antagonist or doxycycline) decreased the pro-inflammatory effect of synovial fluid fracture hematoma on the cartilage tissue. Clinical tests for fracture stability continue to be debated. In a retrospective Level-III study of supination-external rotation 2 (SER-2) ankle fractures, Ali et al.29 reported no difference (p = 0.595) between manual stress views and gravity stress views for determining fracture stability and the need for a surgical procedure. Despite their ability to limit complications in older patients, fibular nails appear to have drawbacks when used in younger patients. Kho et al.30 retrospectively compared young patients (mean age, 41.4 years) who underwent closed reduction and intramedullary fixation (CRIF) with a fibular nail (n = 94) compared with ORIF with a locking plate (n = 110). At a minimum follow-up of 3 years, complications were lower in the CRIF group (9.5% compared with 39%; p < 0.001). However, the CRIF group demonstrated significantly higher rates of posttraumatic arthritis (21.3% compared with 9.1%; p = 0.024) and fair or poor reduction (p < 0.001) on 3-D CT scans. The authors recommended that surgeons consider ORIF in active young patients, especially for more complex fracture patterns. Stupay et al.31 performed a retrospective cohort study to identify risk factors for aseptic revision of operatively treated ankle fractures. Using multivariable logistic regression modeling, the authors reported that falls in the early postoperative period, movement-altering disorders, a nonanatomic mortise (medial clear space was greater than superior clear space) on initial postoperative imaging, more severe initial fracture displacement, substance abuse, and polytrauma are independent risk factors for aseptic revision after ankle ORIF. Identifying these risk factors may help surgeons to counsel patients and improve safety and outcomes after ankle fracture surgery. Syndesmotic Injuries Bhimani et al.32 retrospectively reviewed preoperative bilateral weight-bearing CT scans in patients with unilateral Weber B fibular fractures and a symmetric medial clear space who did (n = 23) and did not (n = 18) have intraoperatively confirmed syndesmosis instability. The authors found that weight-bearing CT was able to distinguish a stable from an unstable syndesmosis even in the presence of a Weber B fibular fracture. Syndesmotic volume measured to a height of 5 cm proximal to the tibial plafond was the best measurement for diagnosing syndesmosis instability. Wong et al.33 utilized 4-D CT scans to characterize the impact of ankle range of motion on syndesmotic position. The authors found significant medial translation and external rotation of the fibula during ankle plantar flexion but no change in sagittal translation with non-weight-bearing in vivo motion. There was no difference in side-to-side measurements between ankles in healthy controls. The authors concluded that syndesmotic reduction in the setting of an ankle fracture can be reliably templated from the uninjured ankle if the ankle position is standardized. The same investigators34 used 4-D CT scans to compare syndesmotic motion at 12 months after flexible syndesmosis fixation (n = 6) and rigid syndesmosis fixation (n = 7). Although the patient numbers were small, ankles with initial rigid fixation demonstrated significantly reduced syndesmosis range of motion in 4 of 5 measures (p < 0.01) when compared with the uninjured ankle. No differences in syndesmosis range of motion between injured and uninjured ankles were observed in the group with flexible fixation. Lee et al.35 retrospectively reviewed 166 patients with a minimum 5-year follow-up after surgical fixation of the syndesmosis in the setting of an ankle fracture. Thirty-four patients (20.5%) had chronic syndesmosis instability, defined as pain with a squeeze test and >2 mm of syndesmosis widening compared with the intact ankle on bilateral CT scans at 5 years postoperatively. Multivariate analysis identified a body mass index of ≥30 kg/m2 (p = 0.012) and the presence of a posterior malleolar fracture (p = 0.032) as risk factors for chronic syndesmosis instability. Williams et al.36 performed a cadaveric study confirming the posteromedial vertical syndesmotic line as the posterior border of the syndesmosis on a mortise view of the ankle. The authors described a safe zone extending 12 mm medially from the posteromedial vertical syndesmotic line, which ensures that posterior-to-anterior screws utilized to fix posterior malleolar fractures are not in the syndesmosis and will not injure the flexor hallucis longus tendon. Ankle Arthritis and Reconstruction Positive outcomes of custom 3-D printed implants and instrumentation for ankle and hindfoot reconstruction have been reported. In a comparison of 24 ankle arthroplasty cases with patient-specific instrumentation and 25 cases with standard instrumentation, Heisler et al.37 found no difference between the techniques for component position or duration of the surgical procedure. All cases were performed by a single, experienced surgeon. In a study of 39 cases that utilized 3-D printed, porous-coated titanium implants for critical osseous defects of the hindfoot and/or ankle, Abar et al.38 found that 33% of cases required secondary procedures and 26% of cases required removal of the implant for septic or aseptic nonunion. These outcomes are at least similar to or better than previous findings using bulk allograft for these difficult cases. As in the use of allograft, neuropathy was strongly associated with the need for a secondary procedure (odds ratio [OR], 5.76; p = 0.03). Long-term and large-scale follow-up of ankle replacement has been further reported, including some of the first available registry data. Using the French Discharge Records Database, Dagneaux et al.39 found survivorship of metal components to be 84% at 5 years and 78% at 10 years. Younger age, second-generation implants, and low institutional volume for the procedure were independent predictors of all-cause revision. The first 20-year data for ankle replacement were reported by Bedard et al.40, who reviewed the 132 cases originally performed by the developer of the Agility prosthesis. Of the 126 ankles available for the study, 107 (85%) were still functioning with the original prosthesis in place at the last follow-up or at the time of death. The authors proposed 85% survivorship as a benchmark for second-generation and third-generation arthroplasties. Few reports have compared the results of primary ankle replacement with those of revision ankle replacement, an important consideration, given the potentially viable alternative option of arthrodesis when a prosthesis fails. Jennison et al.41 performed a comparative cohort study of 33 patients with primary ankle replacement and 23 patients with revision ankle replacement. No original components were preserved during revision. There was significantly greater improvement (p = 0.024) in the overall MOXFQ scores for primary total ankle replacement (48.8 points) compared with revision (20.2 points). Coronal plane deformity for ankle replacement or arthrodesis is less worrisome than previously thought, but concerns remain. In an observational trial, Johnson et al.42 found that, at follow-up of 2 to 3 years, patients with coronal plane deformity of >10° who underwent either arthrodesis or arthroplasty benefited from the procedure. No difference between the 2 procedures could be discerned using the SF-36 and the Musculoskeletal Functional Assessment, but the results as a whole were inferior to those of a control cohort without deformity. Lateral-approach total ankle replacement is an alternative to the more common anterior procedure. Intermediate-term osteolysis rates using this procedure have begun to be reported. Maccario et al.43 reported radiographic osteolysis in 8 (9.3%) of 86 cases at a mean follow-up of 65 months. Using more sensitive CT imaging, Kormi et al.44 reported osteolytic lesions in 8 (10%) of 80 cases at a mean follow-up of 39 months. These rates of intermediate-term osteolysis are similar to those observed for anterior-approach prostheses. The advantages to the lateral approach are still difficult to define. An earlier report by the same group45 on the same cohort of patients found a 20% rate of early complications and 37 reoperations in 104 cases. Charcot Arthropathy The results of Charcot reconstruction may be slowly improving. In a retrospective review of 70 patients who underwent hindfoot Charcot reconstruction with an intramedullary nail, Najefi et al.46 reported an 83% overall hindfoot union rate at a mean follow-up of 54 months. A greater nail diameter-to-isthmus ratio (p = 0.034) and supplemental hindfoot compression screws (p = 0.038) were associated with a higher union rate. An intact medial malleolus was protective against nonunion (p = 0.018) and hindfoot metalwork failure (p = 0.021). Demographic and clinical factors including age, body mass index, hemoglobin A1c level, and prior revascularization did not affect union rates. Kavarthapu and Budair47 retrospectively reviewed 22 patients (23 feet) who underwent 2-stage reconstruction with internal fixation for infected and deformed Charcot feet. At a mean 44-month follow-up, the authors reported a 100% rate of limb salvage, with 22 of 23 patients weight-bearing independently. There were 6 reoperations. The authors advocated for a multidisciplinary approach, a robust and rigid fixation, and the use of local antibiotics in the wound. Amputations Although diabetes is often emphasized as a risk factor for amputation, vascular disease is equally important. Among a U.S. veteran population of 19,875 patients (98.8% men; median age, 66 years)48, below-the-knee amputation was associated with a 15.4% 5-year probability of conversion to above-the-knee amputation and a 47.7% 5-year probability of death. The risk was highest in patients with peripheral vascular disease (hazard ratio [HR], 2.66; p = 0.001), followed by urgent operation (HR, 1.32), cerebrovascular disease (HR, 1.19), chronic obstructive pulmonary disorder (HR, 1.15), and previous myocardial infarction (HR, 1.10) (all p < 0.02). The study stressed the need for improved early diagnosis and surveillance strategies for patients with vasculopathy. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles relevant to foot and ankle surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Johannsen F, Olesen JL, Øhlenschläger TF, Lundgaard-Nielsen M, Cullum CK, Jakobsen AS, Rathleff MS, Magnusson PS, Kjær M. Effect of ultrasonography-guided corticosteroid injection vs placebo added to exercise therapy for Achilles tendinopathy: a randomized clinical trial. JAMA Netw Open. 2022 Jul 1;5(7):e2219661. In a randomized controlled trial on the treatment of noninsertional Achilles tendinopathy, Johannsen et al. compared corticosteroid injection and physical therapy with placebo injection and physical therapy. Injections were ultrasound-guided and were placed in the peritendinous tissue anterior to the thickest part of the tendon rather than in the tendon itself. At 6 months, the corticosteroid group had significantly greater improvement in the Victorian Institute of Sport Assessment–Achilles score compared with the placebo group. There was no deterioration of improvement at the 2-year follow-up. There were no infections and no ruptures in either group. Although traditional teaching advocates against local corticosteroid injection for the treatment of Achilles tendinopathy, guided placement of corticosteroid into the anterior peritendinous tissue appears to be a safe and efficacious adjunct to physical therapy when treating noninsertional Achilles tendinosis. Myhrvold SB, Brouwer EF, Andresen TKM, Rydevik K, Amundsen M, Grün W, Butt F, Valberg M, Ulstein S, Hoelsbrekken SE. Nonoperative or surgical treatment of acute Achilles’ tendon rupture. N Engl J Med. 2022 Apr 14;386(15):1409-20. In this large (554 patients), multicenter, randomized controlled trial, Myhrvold et al. compared nonoperative, open operative, and minimally invasive surgical (MIS) treatment of acute Achilles tendon ruptures. This is by far the largest high-quality study of the topic. The authors reported no significant difference between groups in the mean change in the Achilles Tendon Rupture Score from the preinjury baseline to 3, 6, and 12 months postoperatively. Although significance was not reported by the authors, the study was adequately powered for a comparison of rerupture rates. The rate of rerupture was significantly higher in the nonoperative treatment group (11 [6.2%] of 178 patients) compared with the operative groups (1 [0.6%] of 176 patients in the open repair group and 1 [0.6%] of 172 patients in the MIS repair group). Nine nerve injuries (5.2%) were reported in the MIS group, and 5 nerve injuries (2.8%) were reported in the open repair group. Although this study suggested that there was no difference in patient-reported health status between nonoperatively and operatively treated acute Achilles tendon ruptures at 1 year, it is important to note that the results may have been affected by the decision to stop collecting Achilles Tendon Rupture Scores of patients who sustained a rerupture, as documented in the protocol available online. This disproportionately eliminated the likely worst results from the nonoperative group. A future study without data censoring that follows patient-reported outcomes through the entire course of care, regardless of complications, will be required to more fully inform the choice for a surgical procedure. Patients considering a surgical procedure to treat an Achilles rupture should be counseled that they can expect similar results for nonoperative management and operative management as long as they do not sustain a rerupture, but the risk of rerupture is clearly higher with nonoperative management. Paget LDA, Reurink G, de Vos RJ, Weir A, Moen MH, Bierma-Zeinstra SMA, Stufkens SAS, Kerkhoffs GMMJ, Tol JL; PRIMA Study Group. Effect of platelet-rich plasma injections vs placebo on ankle symptoms and function in patients with ankle osteoarthritis: a randomized clinical trial. JAMA. 2021 Oct 26;326(16):1595-605. To date, clinical improvement of ankle arthritis symptoms after platelet-rich plasma injection has been supported by anecdote and small case series. Paget et al. found no benefit to platelet-rich plasma injection at 26 weeks in a placebo-controlled, randomized trial. Although the primary outcome variable was the now-antiquated AOFAS Hindfoot Score, which has a nonstandard mathematical construction and is not an exclusively patient-reported instrument, several validated secondary outcome scales also supported their conclusion. Patients should be counseled that there is no convincing support for platelet-rich plasma injection in ankle osteoarthritis. Wheeler PC, Dudson C, Gregory KM, Singh H, Boyd KT. Autologous blood injection with dry-needling vs dry-needling alone treatment for chronic plantar fasciitis: a randomized controlled trial. Foot Ankle Int. 2022 May;43(5):646-57. This double-blinded, randomized controlled trial compared autologous blood injection plus dry needling (45 patients) and dry needling alone (45 patients) for the treatment of chronic plantar fasciitis. The mean pain scores within both groups improved by 50% at a 26-week final follow-up. There were no between-group differences in patient-reported function or numeric pain scores at any time point. When treating plantar fasciitis, physicians should educate patients that there is no clear benefit to adding autologous blood injection to dry needling procedures.