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BACKGROUND Painful degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP I), or hallux rigidus, mainly occurs in later stages of life. For end-stage hallux rigidus, MTP I arthrodesis is considered the gold standard. As young and active patients are affected considerably less frequently, it currently remains unclear, whether they benefit to the same extent. We hypothesized that MTP I arthrodesis in younger patients would lead to an inferior outcome with decreased rates of overall with lower rates of patient postoperative pain and function compared to an older cohort. METHODS All patients aged <50 y ears who underwent MTP I arthrodesis at our institution between 1995 and 2012 were included in this study. This group was then matched and compared with a group of patients aged >60 years. Minimum follow-up was 10 years. Outcome measures were Tegner activity score (TAS), a "Virtual Tegner activity score" (VTAS), the visual analog scale (VAS), and the Foot Function index (FFI). RESULTS Sixty-one MTP I fusions (n = 28 young, n = 33 old) in 46 patients were included in our study at an average of 14 years after surgery. Younger patients experienced significantly more pain relief as reflected by changes in VAS and FFI Pain subscale scores. No difference in functional outcomes was found with change in the FFI function subscale or in the ability to have desired functional outcomes using the ratio of TAS to VTAS. Revision rate did not differ between the two groups apart from hardware removal, which was significantly more likely in the younger group. CONCLUSION In patients below the age of 50 years with end-stage DJD of the first metatarsal joint, MTP I arthrodesis not only yielded highly satisfactory postoperative results at least equal outcome compared to an older cohort of patients aged >60 years at an average 14 years' follow-up. Based on these findings, we consider first metatarsal joint fusion even for young patients is a valid option to treat end-stage

BACKGROUND In progressive collapsing foot deformity (PCFD), an internal and plantar rotation of the talus relative to the calcaneus may result in painful peritalar subluxation. Medial soft tissue procedures (eg, spring ligament repair) aim to correct the talar position via the navicular bone if bony correction alone is not sufficient. The effect of the medial soft tissue reconstruction on the talar reposition remains unclear. We hypothesized that a subtalar talocalcaneal ligament reconstruction might be favorable in PCFD to correct talar internal malposition directly. This pilot study aims to evaluate the anatomical feasibility and kinematic behavior of a subtalar ligament reconstruction in PCFD. METHODS Three-dimensional surface model from 10 healthy ankles were produced. A total of 1089 different potential ligament courses were evaluated in a standardized manner. A motion of inversion/eversion and talar internal/external in relation to the calcaneus were simulated and the ligament strain, expressed as a positive length variation, for each ligament was analyzed. The optimal combination for the ligament reconstruction with increased length in internal rotation of the talus, isometric kinematic behavior in inversion/eversion, and extraarticular insertion on talus and calcaneus was selected. RESULTS A laterodistal orientation of the talar insertion point in respect to the subtalar joint axis and laterodistal deviation of the calcaneal insertion point presents the highest ligament lengthening in internal talar rotation (+0.56 mm [3.8% of total length]) and presented a near-isometric performance in inversion/eversion (+0.01 to -0.01 mm [0.1% of total length]). CONCLUSION This kinematic model shows that a ligament reconstruction in the subtalar space presents a pattern of length variation that may stabilize the internal talar rotation without impeding the physiological subtalar motion. CLINICAL RELEVANCE This study investigates the optimal location, feasibility, and kine

BACKGROUND In patients with osteochondral lesion, defects of the medial talus, or failed cartilage surgery, a periarticular osteotomy can unload the medial compartment. PURPOSE To compare the effects of supramalleolar osteotomy (SMOT) versus sliding calcaneal osteotomy (SCO) for pressure redistribution and unloading of the medial ankle joint in normal, varus-aligned, and valgus-aligned distal tibiae. STUDY DESIGN Controlled laboratory study. METHODS Included were 8 cadaveric lower legs with verified neutral ankle alignment (lateral distal tibial angle [LDTA] = 0°) and hindfoot valgus within normal range (0°-10°). SMOT was performed to modify LDTA between 5° valgus, neutral, and 5° varus. In addition, a 10-mm lateral SCO was performed and tested in each position in random order. Axial loading (700 N) of the tibia was applied with the foot in neutral alignment in a customized testing frame. Pressure distribution in the ankle joint and subtalar joint, center of force, and contact area were recorded using high-resolution Tekscan pressure sensors. RESULTS At neutral tibial alignment, SCO unloaded the medial joint by a mean of 10% ± 10% or 66 ± 51 N (P = .04) compared with 6% ± 12% or 55 ± 72 N with SMOT to 5° valgus (P = .12). The achieved deload was not significantly different (ns) between techniques. In ankles with 5° varus alignment at baseline, SMOT to correct LDTA to neutral insufficiently addressed pressure redistribution and increased medial load by 6% ± 9% or 34 ± 33 N (ns). LDTA correction to 5° valgus (10° SMOT) unloaded the medial joint by 0.4% ± 14% or 20 ± 75 N (ns) compared with 9% ± 11% or 36 ± 45 N with SCO (ns). SCO was significantly superior to 5° SMOT (P = .017) but not 10° SMOT. The subtalar joint was affected by both SCO and SMOT, where SCO unloaded but SMOT loaded the medial side. CONCLUSION SCO reliably unloaded the medial compartment of the ankle joint for a neutral tibial axis. Changes in the LDTA by SMOT did not positively affect load distributi

OBJECTIVE: Three-dimensional (3D) analysis and implementation with patient-specific cutting and repositioning blocks enables correction of complex tibial malunions. Correction can be planned using the contralateral side or a statistical model. Patient-specific 3D-printed cutting guide blocks enable a precise osteotomy and reduction guide blocks help to achieve anatomical reduction. Depending on the type and extent of correction, fibula osteotomy may need to be considered to achieve the desired reduction. CONTRAINDICATIONS: a) Poor soft tissue (flap surgery, adherent skin in field of operation); b) infection; c) peripheral artery disease (stage III and IV classified according to Fontaine, critical transcutaneous oxygen partial pressure, TcPO$_{2}$); d) general contraindication to surgery. SURGICAL TECHNIQUE: Before surgery, a 3D model of both lower legs is created based on computed tomography (CT) scans. Analysis of the deformity based on the contralateral side in a 3D computer model (CASPA) and planning of the osteotomy. If the contralateral side also has a deformity, a statistical model can be used. Printing of patient-specific guides made of nylon (PA2200) for the osteotomy and reduction. Surgery is performed in supine position, antibiotic prophylaxis, thigh tourniquet, which is used as needed. Ventrolateral approach to the tibia. Attachment of the patient-specific osteotomy guide, performance of the osteotomy. Reduction using the guide. Fibula osteotomy through a lateral approach is performed if the reduction of the tibia is hindered by the fibula. This can be performed freehand or with patient-specific guides. Wound closure. POSTOPERATIVE MANAGEMENT: Compartment monitoring. Passive mobilization of the ankle in the cast as soon as the wound healing has progressed. Partial weightbearing in a lower leg cast for at least 6-12 weeks, depending on the routinely performed radiographic assessment 6 weeks postoperatively. Thromboprophylaxis with low molecular weight hepa

BACKGROUND Amputation of the second toe is associated with destabilization of the first toe. Possible consequences are hallux valgus deformity and subsequent pressure ulcers on the lateral side of the first or on the medial side of the third toe. The aim of this study was to investigate the incidence and possible influencing factors of interdigital ulcer development and hallux valgus deformity after second toe amputation. METHODS Twenty-four cases of amputation of the second toe between 2004 and 2020 (mean age 68 ± 12 years; 79% males) were included with a mean follow-up of 36 ± 15 months. Ulcer development on the first, third, or fourth toe after amputation, the body mass index (BMI) and the amputation level (toe exarticulation versus transmetatarsal amputation) were recorded. Pre- and postoperative foot radiographs were evaluated for the shape of the first metatarsal head (round, flat, chevron-type), the hallux valgus angle, the first-second intermetatarsal angle, the distal metatarsal articular angle and the hallux valgus interphalangeal angle by two orthopedic surgeons for interobserver reliability. RESULTS After amputation of the second toe, the interdigital ulcer rate on the adjacent toes was 50% and the postoperative hallux valgus rate was 71%. Neither the presence of hallux valgus deformity itself (r = .19, p = .37), nor the BMI (r = .09, p = .68), the shape of the first metatarsal head (r = - .09, p = .67), or the amputation level (r = .09, p = .69) was significantly correlated with ulcer development. The interobserver reliability of radiographic measurements was high, oscillating between 0.978 (p = .01) and 0.999 (p = .01). CONCLUSIONS The interdigital ulcer rate on the first or third toe after second toe amputation was 50% and hallux valgus development was high. To date, evidence on influencing factors is lacking and this study could not identify parameters such as the BMI, the shape of the first metatarsal head or the amputation level as risk factors for

Surgical site infection (SSI) after elective orthopedic foot and ankle surgery is uncommon and may be higher in selected patient groups. Our main aim was to investigate the risk factors for SSI in elective orthopedic foot surgery and the microbiological results of SSI in diabetic and non-diabetic patients, in a tertiary foot center between 2014 and 2022. Overall, 6138 elective surgeries were performed with an SSI risk of 1.88%. The main independent associations with SSI in a multivariate logistic regression analysis were an ASA score of 3-4 points, odds ratio (OR) 1.87 (95% confidence interval (CI) 1.20-2.90), internal, OR 2.33 (95% CI 1.56-3.49), and external material, OR 3.08 (95% CI 1.56-6.07), and more than two previous surgeries, OR 2.86 (95% CI 1.93-4.22). Diabetes mellitus showed an increased risk in the univariate analysis, OR 3.94 (95% CI 2.59-5.99), and in the group comparisons (three-fold risk). In the subgroup of diabetic foot patients, a pre-existing diabetic foot ulcer increased the risk for SSI, OR 2.99 (95% CI 1.21-7.41), compared to non-ulcered diabetic patients. In general, gram-positive cocci were the predominant pathogens in SSI. In contrast, polymicrobial infections with gram-negative bacilli were more common in contaminated foot surgeries. In the latter group, the perioperative antibiotic prophylaxis by second-generation cephalosporins did not cover 31% of future SSI pathogens. Additionally, selected groups of patients revealed differences in the microbiology of the SSI. Prospective studies are required to determine the importance of these findings for optimal perioperative antibiotic prophylactic measures.

Purpose: The use of total ankle arthroplasty (TAA) is increasing over time, as so will the need for revision TAAs in the future. Restoration of the ankle joint line (JL) in revision TAA is often difficult due to severe bone loss. This study analyzed the accuracy of a three-dimensional (3D) registration of the contralateral tibia and fibula to restore the ankle joint line (JL) and reported side-to-side differences of anatomical landmarks. Methods: 3D triangular surface models of 96 paired lower legs underwent a surface registration algorithm for superimposition of the mirrored contralateral lower leg onto the original lower leg to approximate the original ankle JL using a proximal, middle and distal segment. Distances of the distal fibular tip, anterior and posterior medial colliculus to the JL were measured and absolute side-to-side differences reported. Anterior lateral distal tibial angle (ADTA) and lateral distal tibial angle (LDTA) were measured. Results: Mean JL approximation was most accurate for the distal segment (0.1 ± 1.4 mm (range: -3.4 to 2.8 mm)) and middle segment (0.1 ± 1.2 mm (range: -2.8 to 2.5 mm)) compared to the proximal segment (-0.2 ± 1.6 mm (range: -3.0 to 4.9 mm)) (p = 0.007). Distance of the distal fibular tip, the anterior, and posterior medial colliculus to the JL, ADTA and LDTA yielded no significant side-to-side differences (n.s.). Conclusion: 3D registration of the contralateral tibia and fibula reliably approximated the original ankle JL. The contralateral distal fibular tip, anterior and posterior medial colliculi, ADTA and LDTA can be used reliably for the planning of revision TAA with small side-to-side differences reported.

Post-traumatic tibial deformity is a common pathology, which can lead to overload and pain in the ankle joint. Once conservative treatment has failed the operative correction of a tibial deformity has proven to be an established procedure with satisfactory clinical results. Historically, all kind of corrections have been based on deformities in the coronal and sagittal plane, which could accurately be assessed on plain radiographs. Whenever possible, correction of the deformity should be performed at the CORA while following the rules for osteotomies as formerly described by Paley (Principles of deformity correction. Springer Berlin Heidelberg, Berlin, Heidelberg, 2002). Three-dimensional imaging allows proper spatial visualisation and better understanding of biplanar deformities. In complex cases, computer-based simulations can help to plan the osteotomy. Nowadays, patient-specific instrumentation and intraoperative navigation allow a more accurate correction of deformities.

OBJECTIVE Ankle joint line orientation (AJLO) is influenced by the subtalar foot and frontal leg alignment. However, the influence of axial leg alignment on AJLO remains unclear. The study aimed to analyze the influence of frontal, axial leg alignment on AJLO in healthy subjects. METHODS Thirty healthy subjects (60 legs) without prior surgery underwent standing biplanar long leg radiograph (LLR) between 2016 and 2020. AJLO was measured in standing long-leg radiographs relative to the ground. Meary's angle and calcaneal pitch were measured. Hip-knee-ankle angle (HKA), femoral antetorsion, and tibial torsion were assessed with SterEOS software (EOS Imaging, Paris, France). LLR was acquired with the feet directing straight anteriorly, which corresponds to a neutral foot progression angle (FPA). The influence of subtalar, frontal, and axial alignment on AJLO was analyzed in a multiple regression model. RESULTS An increase in knee valgus increased relative valgus AJLO by 0.5° (95% CI: 0.2° to 0.7°) per 1° (P < 0.001). A decrease in femoral antetorsion increased relative valgus AJLO by 0.2° (95% CI: 0.1° to 0.2°) per 1° (P < 0.001), whereas Meary's angle and calcaneal pitch did not influence AJLO. CONCLUSION A link between frontal, axial leg alignment, and AJLO could be demonstrated, indicating that a valgus leg alignment and relative femoral retrotorsion are associated with an increase of valgus AJLO in healthy subjects when placing their feet in a neutral position. Alteration of the frontal, or rotational profile after realignment surgery or by implant positioning might influence the AJLO, when the FPA is kept constant.

BACKGROUND Peroneus brevis tendon tears are associated with chronic ankle pain and instability following sprain injuries. The aim of this study is to elucidate the biomechanical changes induced by a peroneus brevis split and surgical treatment by tubularizing suture or partial resection. METHODS Nine human lower leg specimens were biomechanically tested. Preexisting tendon pathology was ruled out by magnetic resonance imaging and histology. Specimens were subjected to sequential testing of 4 conditions of the peroneus brevis tendon: (1) native, (2) longitudinal lesion, (3) tubularizing suture, and (4) 50% resection. The outcome parameters were the tendon stiffness (N/mm) and the length variation of the split portion at 5 N load. RESULTS The median specimen age at death was 55.8 years (range 50-64 years). The longitudinal tendon split led to an elongation by 1.21 ± 1.15 mm, which was significantly reduced by tubularizing suture to 0.24 ± 0.97 mm (P = .021). Furthermore, 50% resection of the tendon elongated it by a mean 2.45 ± 1.9 mm (P = .01) and significantly reduced its stiffness compared to the intact condition (4.7 ± 1.17 N/mm, P = .024) and sutured condition (4.76 ± 1.04 N/mm, P = .011). CONCLUSION Longitudinal split and 50% resection of the peroneus brevis tendon led to elongation and loss of tendon stiffness. These properties were improved by tubularizing suture. The significance of these changes in the clinical setting needs further investigation. CLINICAL RELEVANCE Tubularizing suture of a peroneus brevis split can restore biomechanical properties to almost native condition, potentially aiding ankle stability in symptomatic cases. A split lesion and partial resection of the tendon showed reduced stiffness and increased elongation.

BACKGROUND To optimize the biomechanical outcomes in lateral ankle ligament reconstruction, avoid stiffness or residual laxity, aiming for an isometric reconstruction of the anterior lateral talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is mandatory. However, the localization of the optimal ligament insertion remains challenging to assess intraoperatively. METHOD Three-dimensional (3D) surface models from 10 healthy ankles were generated. 30 insertion points of the CFL were defined on the lateral side of the calcaneus each 10% of its total length in the dorsal-to-ventral and proximal-to-distal plane. 6 insertion points were defined at the ventral ridge of fibula from the malleolar tip and 5 insertions were defined along the lateral talar process. The ligament length variation of ATFL and CFL was assessed after a simulation of the flexion/extension around a simulated tibiotalar axis and inversion/eversion around a simulated subtalar axis in 36 different positions. RESULTS The isometric point of CFL on the calcaneus is located at about 60% along the dorsal-to-ventral and between 60% and 70% along the proximal-to-distal plane. From maximal extension to flexion, these points present respectively a length variation of - 0.8 to - 1.1 mm (p = 0.46) and - 1.1 to - 0.8 mm (p = 0.56). A fibular insertion at 5 mm proximal to the malleolar tip present a length variation ranging from - 0.1-1 mm (p < 0.001) for ATFL and from - 0.7-0.5 mm (p < 0.001) for CFL. A talar insertion point of the ATFL located 5 mm proximal to the subtalar joint present the lowest variation, ranging from - 1.1-0.7 mm (p < 0.001), however an insertion at 20- or 25-mm present isometry (+0.1 to +0.9 mm p = 0.1, and +0.4 to +0.4 mm p = 1 respectively) if the fibular insertion is located at 5 mm proximal to the malleolar tip. CONCLUSION This study provides anatomical references which are reproducible in daily practice. These insertion points allow to achieve a stable reconstruction while m

PURPOSE: Posttraumatic fibular malunion alters ankle joint biomechanics and may lead to pain, stiffness, and premature osteoarthritis. The accurate restoration is key for success of reconstructive surgeries. The aim of this study was to analyze the accuracy of a novel three-dimensional (3D) registration algorithm using different segments of the contralateral anatomy to restore the distal fibula. METHODS: Triangular 3D surface models were reconstructed from computed tomographic data of 96 paired lower legs. Four segments were defined: 25% tibia, 50% tibia, 75% fibula, and 75% fibula and tibia. A surface registration algorithm was used to superimpose the mirrored contralateral model on the original model. The accuracy of distal fibula restoration was measured. RESULTS: The median rotation error, 3D distance (Euclidean distance), and 3D angle (Euler's angle) using the distal 25% tibia segment for the registration were 0.8° (- 1.7-4.8), 2.1 mm (1.4-2.9), and 2.9° (1.9-5.4), respectively. The restoration showed the highest errors using the 75% fibula segment (rotation error 3.2° (0.1-8.3); Euclidean distance 4.2 mm (3.1-5.8); Euler's angle 5.8° (3.4-9.2)). The translation error did not differ significantly between segments. CONCLUSION: 3D registration of the contralateral tibia and fibula reliably approximated the premorbid anatomy of the distal fibula. Registration of the 25% distal tibia, including distinct anatomical landmarks of the fibular notch and malleolar colliculi, restored the anatomy with increasing accuracy, minimizing both rotational and translational errors. This new method of evaluating malreductions could reduce morbidity in patients with ankle fractures. LEVEL OF EVIDENCE: IV.

BACKGROUND Progressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction. METHODS We reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind. RESULTS Groups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively. CONCLUSION The different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome o

Background Autologous matrix-induced chondrogenesis (AMIC) has been shown to result in favorable clinical outcomes in patients with osteochondral lesions of the talus (OLTs). Though, the influence of ankle instability on cartilage repair of the ankle has yet to be determined. Purpose/Hypothesis To compare the clinical and radiographic outcomes in patients with and without concomitant lateral ligament stabilization (LLS) undergoing AMIC for the treatment of OLT. It was hypothesized that the outcomes would be comparable between these patient groups. Study Design Cohort study; Level of evidence, 3. Methods Twenty-six patients (13 with and 13 without concomitant ankle instability) who underwent AMIC with a mean follow-up of 4.2 ± 1.5 years were enrolled in this study. Patients were matched 1:1 according to age, body mass index (BMI), lesion size, and follow-up. Postoperative magnetic resonance imaging and Tegner, American Orthopaedic Foot & Ankle Society (AOFAS), and Cumberland Ankle Instability Tool (CAIT) scores were obtained at a minimum follow-up of 2 years. A musculoskeletal radiologist scored all grafts according to the MOCART (magnetic resonance observation of cartilage repair tissue) 1 and MOCART 2.0 scores. Results The patients' mean age was 33.4 ± 12.7 years, with a mean BMI of 26.2 ± 3.7. Patients with concomitant LLS showed worse clinical outcome measured by the AOFAS (85.1 ± 14.4 vs 96.3 ± 5.8; P = .034) and Tegner (3.8 ± 1.1 vs 4.4 ± 2.3; P = .012) scores. Postoperative CAIT and AOFAS scores were significantly correlated in patients with concomitant LLS (r = 0.766; P = .002). A CAIT score >24 (no functional ankle instability) resulted in AOFAS scores comparable with scores in patients with isolated AMIC (90.1 ± 11.6 vs 95.3 ± 6.6; P = .442). No difference was seen between groups regarding MOCART 1 and 2.0 scores (P = .714 and P = .371, respectively). Conclusion Concurrently performed AMIC and LLS in patients with OLT and ankle instability resulted in clini