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 (LDTAvar = 96.5° ± 4.5°) and valgus (n = 6) deformity (LDTAvalg = 82.4° ± 2.5°) improved significantly relative to their post-operative equivalents (LDTAvar = 90.2° ± 3.2°); LDTAvalg = 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.

Patients with diabetes are at increased risk for postoperative complications after ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet few studies directly compare outcomes between these procedures in a matched diabetic cohort. This study evaluates outcomes of TAA vs AA in patients with diabetes with end-stage ankle arthritis. We performed a retrospective cohort study using the TriNetX Research Network. Adults undergoing primary TAA (Current Procedural Terminology [CPT] 27702) or ankle arthrodesis (CPT 27870 or 29899) between 2005 and 2025 were included. Diabetes was defined by hemoglobin A1c (HbA1c) ≥6.5% recorded at any point within 1 year prior to surgery. Propensity score matching (1:1) was performed using demographic and clinical covariates. Outcomes included 1-year infection and 1-, 3-, and 5-year structural complications and emergency department (ED) visits. ED visits captured all-cause encounters rather than ankle-specific presentations. The pre-specified primary endpoint was 1-year structural complication; secondary endpoints included infection at 1 year and ED visits and structural complications at 3 and 5 years, with FDR applied to secondary outcomes. Risk estimates, Kaplan-Meier analyses, and Benjamini-Hochberg false discovery rate (FDR) correction were applied. After propensity score matching, 255 patients remained in each group. At 1 year, postoperative infection occurred in 5.5% of TAA patients and 9.4% of AA patients; this difference did not meet statistical significance after false discovery rate (FDR) adjustment. ED visits were more common in the AA cohort at 1, 3, and 5 years after FDR correction. Structural complications occurred more frequently in the AA cohort at 1 year (29.8% vs 15.3%; RR 0.51), 3 years (38.8% vs 20.0%; RR 0.52), and 5 years (39.6% vs 21.2%; RR 0.54), and these differences were statistically supported after FDR adjustment. In patients with a recorded HbA1c ≥6.5% at any point within the previous year undergoing surgery for end-stage ankle arthritis, TAA demonstrated non-inferior structural complication rates across 1-, 3-, and 5-year follow-up without evidence of increased early infection risk after FDR adjustment.

Hallux valgus (HV) is a painful deformity of the first ray characterised by lateral deviation of the proximal phalanx and medial displacement of the metatarsal head. There are multiple surgical options for its management, including arthrodesis. In our institution, first metatarsophalangeal joint (MTPJ) arthrodesis is preferred over corrective osteotomy for patients with severe HV. This study aimed to investigate the outcomes of patients undergoing first MTPJ arthrodesis for HV. The primary outcome measures were Patient-Reported Outcome Measures (PROMs), the Manchester-Oxford Foot Questionnaire (MOxFQ), and the EuroQol-5 dimensions (EQ5D) score. Secondary outcome measures were complications, including non-union, recurrence, pain, reoperation, and infection. This was a single-center, case series study with retrospective case note review of prospectively collected data. Caldicott approval was granted. Inclusion criterion was all patients undergoing arthrodesis for HV between 2016 and 2021. Exclusion criterion was patients with inadequate operative information. 62 feet were included with an average preoperative HV angle (HVA) of 40.2 degrees (range, 19.6-82.0) and an average preoperative intermetatarsal angle (IMA) of 15.9 degrees (range, 2.7-26.4). All first MTPJ arthrodeses were performed between January 2016 and June 2021. The average improvement in composite MOxFQ scores was 33.0 points at 26 weeks (P < .001), sustained at 52 weeks and 2 years (P = .219 and P = .008, respectively). The average improvement in EQ5D time trade-off score was 0.217 at 26 weeks (P < .001), sustained at 52 weeks and 2 years (P = .918 and P = .975). Complications occurred in 12 of 62 (19.4%) feet, including nonunion (9.7%, n = 6), ongoing pain (11.3%, n = 7), and prominent metalwork requiring removal (4.8%, n = 3). Our results suggest that first MTPJ arthrodesis for HV has satisfactory early term patient-reported outcomes. Improvement in PROMs is apparent by 26 weeks and sustained at 2 years postoperatively. There was a high overall complication rate (19.4%), with a non-union rate of 9.7%.

Equinovarus is a prevalent and debilitating foot deformity requiring surgical intervention when conservative management fails. We performed triple arthrodesis using a modified Lambrinudi combined with X-shaped plate internal fixation to correct deformity, improve gait, and restore walking function, with the primary goal of enhancing the patient's quality of life. This retrospective consecutive case series of 14 patients (mean age, 41.9 ± 15.7 years) aimed to describe clinical/radiographic outcomes and the feasibility of X‑shaped plate fixation within a modified Lambrinudi triple arthrodesis. The patient cohort comprised 4 males and 10 females, with underlying etiologies including poliomyelitis, cerebral palsy, post-traumatic sequelae, and Charcot-Marie-Tooth disease. All patients underwent modified Lambrinudi triple arthrodesis combined with soft tissue procedures. Outcomes were assessed through radiographic evaluation (including the talar-calcaneal angle, talus-first metatarsal angle, and calcaneal-fifth metatarsal angle, all measured on anteroposterior radiographs, along with the lateral talus-first metatarsal angle) and clinical investigations: MOS 36-Item Short-Form Health Survey (SF-36) score, visual analog scale (VAS), and International Clubfoot Study Group (ICFSG) Outcome Evaluation Score. Mean follow-up time was 46.1 ± 14.8 months (range, 24-69). Radiographic assessment demonstrated bony union in all patients at 6 months following triple arthrodesis. Postsurgical improvements in foot morphology and function occurred at varying levels across the cohort. At last follow-up, marked increases in SF-36 scores were observed in both physical and mental domains, whereas the VAS score decreased from 6.7 to 1.4 (P < .001) and ICFSG score decreased from 37.7 to 8.1 (P < .001), with an excellent-to-good rate of 93%. Patients' quality of life improved. Satisfactory fusion rates, favorable clinical outcomes, simple internal fixation requirements were all associated with the modified Lambrinudi procedure with X-shaped plate fixation for triple arthrodesis. This internal fixation is reliable.

Patients with an osteochondral lesion of the talus (OLT) often present with deep ankle pain, but the direct relationship between structural damage and the perceived pain remains unclear. The aim of this study was therefore to determine whether pain is associated with demographic and radiologic (computed tomography [CT]-only) lesion characteristics. This cross-sectional study was conducted in patients with symptomatic OLTs at a tertiary referral academic hospital. The primary outcome was the Pain subscale of the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included the Numeric Rating Scale (NRS) for pain at rest and during walking, as well as the other FAOS subscales. Associations with patient demographics, lesion size, morphology, and location were assessed using univariate linear regression, followed by multivariate linear regression with backward selection. A total of 310 patients were included. In the final multivariate model for the FAOS Pain subscale, higher age (β = -0.18, P = .04) and smoking (β = -8.70, P < .001) were significantly associated with worse pain scores. Lesion morphology characterized by the presence of an osteochondral fragment was associated with lower NRS pain scores during walking. For NRS pain at rest, worse scores were significantly associated with female sex, higher body mass index, smoking, non-primary lesion nature, and greater lesion depth. No association was found between CT-based radiologic lesion characteristics and patient-reported pain as measured by the FAOS Pain subscale. In secondary analyses, some lesion characteristics showed associations, but these were limited and directionally inconsistent. These findings suggest structural damage alone does not seem to fully explain the patient's pain. Given the CT‑only approach and other design constraints, further research is warranted.

Tarsometatarsal (TMT) joint arthrodesis is essential for managing surgical management of severe bunion deformities, complex midfoot trauma, and osteoarthritis. Various fixation methods and bone grafting types have been described, but the impact of the number of joints fused on union rates remains unclear. This study aimed to evaluate whether fusing multiple joints affects arthrodesis rates and to compare union outcomes among different fixation constructs and grafting techniques. We conducted a single-center retrospective cohort study of 582 TMT fusions, comparing single- vs multiple-joint fusions involving medial and central columns. The average follow-up was 15.5 months. Two fellowship-trained foot and ankle surgeons assessed radiographs and computed tomographic (CT) scans. Radiographic union was evaluated at 8 and 12 weeks as well as the specific fixation constructs and bone graft used across each joint. Single-TMT-joint surgeries had a significantly greater proportion of fusions occurring by 12 weeks than the multiple-TMT-joint surgeries, 74.9% vs 67.0%, respectively, P = .0002. Ultimate union rates were similar for single-joint fusions (80.3%) and multiple-joint fusions (82.6%. Many nonunions were asymptomatic; the combined asymptomatic nonunion and union rate was 95.4%. The revision rate for all nonunions was 25.5%. Staple fixation was associated with higher nonunion rates in the second (46.15%) and third (37.5%) TMT joints, whereas screw fixation showed the highest nonunion at the first TMT joint (54.6%). The lowest nonunion rates were observed with combined interfragmentary screw fixation and plating across all joints. Diabetic patients and current smokers experienced higher complication and nonunion rates. Although the radiographic nonunion rate (18.2%) exceeded prior reports, symptomatic nonunion was rare (4.6%). Multiple-TMT-joint surgeries required more time to confirm radiographic union than single joint surgeries. Among the modifiable factors, implant and graft choice were associated with differences in union rates.

Background:Definitive and successful treatment of end-stage ankle arthritis is either total ankle replacement (TAR) or ankle fusion (AF). The long-term implications of both treatments remain unclear. AF may predispose patients to subsequent hindfoot joint fusion, and TAR potentially risks high rates of complex revision surgery. The study investigates the risks of further surgery, adjacent joint surgery, and rare but serious complications following AF and TAR.Methods:An England population cohort study was performed using the Hospital Episode Statistics database, linked to Office of National Statistics (ONS) mortality data (1998-2023). The primary outcome was Kaplan-Meier curve analysis of revision surgery–free survival of TAR vs AF. Secondary outcome measures were the rates of adjacent joint/hindfoot fusion, any further re-intervention to the ankle, peri-operative mortality, 90-day complications, and serious adverse events.Results:A total of 10 335 TARs and 30 704 AFs were analyzed. The AF revision rate was significantly lower than TAR at all time points including 5 years (2% vs 6.1%, relative risk [RR] 0.12, 95% CI 0.10-0.16), 10 years (2.5% vs 10.2%, RR 0.12, 95% CI 0.08-0.18), and 20 years (3.1% vs 13.55%, RR 0.12, 95% CI 0.01-0.23). There was no significant difference in the 25-year risk of adjacent joint fusion following AF (8.64%, 95% CI 7.79%-9.58%) vs TAR (6.82%, 95% CI 5.36% to 8.66%). TAR was associated with higher risks of intra-operative fracture (0.42% vs 0.10%, RR=4.35) and re-intervention for wound infection (0.26% vs 0.15%, RR 1.74) but a lower observed 90-day pulmonary embolus rate than AF (0.23% vs 0.58% respectively).Conclusion:Both TAR and AF are definitive treatments of ankle arthritis with low peri-operative risk. In this England-wide registry cohort, TAR showed higher cumulative revision risk than AF over long-term follow-up. Estimates at the furthest time points have lower certainty. Furthermore, AF did not appear to pre-dispose patients to hindfoot fusion and was not associated with a higher 25-year rate of hindfoot fusion than TAR. These estimates do not capture joint degeneration managed non-operatively.

The purpose of this study was to assess the subtalar joint's kinematics in in the frontal plane (inversion-eversion) using 3D weightbearing cone beam computed tomography by measuring both translational and angular range of motion. In this cohort study, weightbearing cone beam computed tomography images were acquired of 41 subjects under weightbearing stress in 20 degrees inversion and 10 degrees eversion tilt, achieved with hard plastic wedges. The ankle was in neutral position, and the sole of the foot was entirely on the wedge. Interobserver and intraobserver reliability were assessed using intraclass correlation coefficients. All the measured numeric range of motion values in the normal subtalar joint's bony structures were small; however, values were larger in eversion than in inversion. Translational range of motion in the middle facet (1.4 mm) is smaller than in the anterior facet (4.9 mm). Reliability was good to excellent for most parameters; however, several showed poor reliability-particularly interobserver agreement for inversion measures of the middle-facet angle/translation and select talocrural metrics (midpoint/medial joint-space width, joint angle). This study defines the subtalar joint's translational and angular range of motion in the frontal plane (inversion-eversion) under weightbearing stress in normal subtalar joint's bony structures. The applicability of the method should be investigated in different patient groups.

Is first metatarsophalangeal joint replacement a viable alternative to arthrodesis for the treatment of end-stage hallux rigidus? There are few studies evaluating the medium- to long-term outcomes of the Roto-Glide prosthesis. This study prospectively analyses the medium- to long-term outcomes of consecutive patients who underwent first metatarsophalangeal joint replacements using the Roto-Glide prosthesis from 2014 to 2020 at 2 centers in the United Kingdom. The inclusion criteria were (1) patients over the age of 18 years with stage 3 or stage 4 hallux rigidus, (2) failed conservative measures, and (3) patients who had consented for arthroplasty after shared decision making. Patients with less than 18 years of age, active infection, hallux valgus of more than 25 degrees, and those with a follow-up of less than 24 months were excluded from the study. The primary objectives were to assess for patient-reported functional outcomes and medium- to long-term implant survivorship with total prosthetic joint explantation to fusion as the end point. Functional outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ) scores preoperatively and postoperatively at multiple time points. Implant failure was assessed by weightbearing radiographs, which were taken preoperatively and at multiple time points during follow-up. Intraoperative and postoperative complications were evaluated. Forty total joint replacements using the Roto-Glide prosthesis were performed in 35 patients over a 6-year period (2014 to 2020). Two patients were lost to follow-up, and 2 died because of unrelated causes. One patient had the prosthesis removed in the first month because of infection and subsequently got lost to follow-up. Thirty-five total joint replacements in 30 patients were included in the study. The mean age was 57.9 years (range 41-80). The mean follow-up period was 95 months (range 24-122 months). There was a statistically significant improvement in MOXFQ scores from 47.0 (SD 8.1, 95% CI 43.1-48.8) preoperatively to 21.0 (SD 11.8, 95% CI 16.9-25.1) at 6 months (P < .001). At 1 year, the mean was 12.9 (SD 11.8; 95% CI 8.6-17.3; P < .001), at 2 years 6.4 (SD 7.6, 95% CI 3.6-9.3; P < .001), and at final follow-up 6.3 (SD 11.5, 95% CI 1.8-10.7; P < .001). At the average follow-up of 8 years, the implant survivorship was 89.2% (95% CI 79.2-99.2). Four patients (11.4%) had first MTP joint stiffness postoperatively requiring further procedures. Five patients (14.3%) had prosthesis explantation to fusion during the follow-up period for infection (1 patient), aseptic loosening (3 patients), or persistent subluxation (1 patient). One patient had intraoperative FHL injury. First metatarsophalangeal joint replacement using Roto-Glide prosthesis results in statistically and clinically significant improvement in patient-reported outcome measures in the medium to long term. We found overall good implant survivorship in the medium term. However, postoperative surgical complications were relatively high. With marked reduction in surgical complications, first MTP joint replacement may be considered an alternative for patients with end-stage hallux rigidus who want to retain joint motion. Further comparative studies with longer-term follow-up are required to compare the outcomes of arthroplasty to arthrodesis, which is considered the gold standard. Level IV, prospective series of one operation with no control.