BACKGROUND:Ankle contracture/arthrofibrosis is addressed with physical therapy or low-intensity stretch assist splints, requiring prolonged treatment and if clinician-set goals remain unmet, surgical intervention is considered. Mechanical therapy using a hydraulic stretch assist device with a high-intensity stretch protocol offers a potential non-operative alternative. This study evaluated the effectiveness of a hydraulic stretch-assist device in improving ankle dorsiflexion range of motion (ROM). METHODS:This retrospective study reviewed patients from an internal database prescribed the Ermi Ankle Flexionater + device between October 2021 and May 2023 after plateauing in dorsiflexion recovery despite at least four weeks of standard treatment Dorsiflexion ROM was measured using the ErmiMotion application in straight- and bent-leg positions at baseline and follow-up. Changes between initial and final measurements were assessed using paired t-tests, with significance set at α< 0.05. RESULTS:Seventy-four patients had complete data available. Treatment began 214 days after injury/surgery. The final dorsiflexion ROM significantly improved in straight (from 4.0°±10.8° to 12.5°±10.2°; p < 0.001) and bent leg positions (from 8.1°±11.7° to 15.0°±10.8°; p < 0.001). Effect sizes were large (Cohen's d=0.86 and 0.80, respectively). Patients with severe motion loss showed marked improvement (straight: -7.7°±6.5° to 7.3°±11.4°; p < 0.001; bent: -9.1°±10.7° to 9.6°±10.3°; p = 0.001), with very large effect sizes (Cohen's d=1.52 and 3.06, respectively). CONCLUSIONS:Treatment with a hydraulic stretch assist device was associated with improved dorsiflexion ROM in patients with ankle contracture, including those with severe limitations. These findings support consideration of using a hydraulic stretch assist device for individuals who do not respond adequately to standard treatments. LEVEL OF EVIDENCE:Level III.
INTRODUCTION:Sagittal- and axial-plane lesser-toe deformities may be associated with plantar-plate attenuation, scarring, or rupture - limiting the feasibility of direct repair. Conventional options include osseous decompression, plantar-plate repair and flexor-to-extensor transfer. This technical tip describes a suture-based flexor digitorum longus (FDL) tenodesis to the proximal phalanx as an alternative for selected deformities. TECHNIQUE:Two operative approaches are presented. For deformity centred at the metatarsophalangeal (MTP) joint with preserved interphalangeal joints, the FDL is accessed through a dorsal approach following a Weil osteotomy and sutured to the proximal phalanx via a tunnel drilled through the base of the phalanx. Tendon position and suture tension are adjusted to provide dorsiflexion restraint and axial correction. Where concomitant proximal interphalangeal (PIP) joint fusion is required in a primarily sagittal plane deformity, the FDL may be accessed through the PIP joint, and sutures passed along either side of the proximal phalanx and tensioned after fusion. RESULTS:We have used this technique to provide dynamic stabilisation of the MTPJ. Asymmetric tendon positioning or tensioning can also generate an axial corrective moment. Established procedures remain appropriate, but this technique may have a role in selected patients. CONCLUSION:FDL tenodesis offers a suture-based option for multiplanar lesser-toe deformities as an alternative to plantar-plate repair. Its role may be considered within an individualised reconstructive strategy, with further clinical studies warranted to clarify its long-term comparative performance.
BACKGROUND:Hallux valgus is the most prevalent forefoot condition and is associated with substantial pain, functional impairment and reduced health-related quality of life. Despite established clinical effectiveness, since 2021 an increasing number of Integrated Care Boards in the UK have classified surgical correction as a procedure of limited clinical benefit, citing a perceived absence of population-level cost-effectiveness data. National-scale evidence is required to inform commissioning decisions and ensure equitable access to care. METHODS:A cost-utility analysis was performed from the perspective of the UK National Health Service (NHS) using British Orthopaedic Foot and Ankle Society (BOFAS) Registry data for adults undergoing primary hallux valgus correction by osteotomy (open or minimally invasive surgery, MIS). Fusion procedures were excluded. EuroQol-5 Dimension five-level (EQ-5D-5L) utility scores at baseline and 12 months were used to estimate quality-adjusted life year (QALY) gains. A six-state Markov model simulated lifetime costs and outcomes over 40 annual cycles from the UK NHS perspective, with costs and benefits discounted at 3.5% per annum. Incremental cost-effectiveness ratios (ICERs) were calculated against conservative management and deterministic sensitivity analysis was performed across procedural cost, utility gain and benefit duration. A pre-specified subgroup analysis compared open and MIS techniques. RESULTS:From 1111 registry pathways, 306 patients had complete EQ-5D-5L datasets for cost-utility modelling, comprising 129 open and 177 MIS procedures. EQ-5D-5L utility improved from 0.69 (95% CI 0.65-0.72) at baseline to 0.84 (95% CI 0.81-0.88) at 12 months in the open group, and from 0.69 (95% CI 0.66-0.72) to 0.82 (95% CI 0.79-0.84) in the MIS group (both p < 0.001). The base-case lifetime Markov model produced an ICER of £ 8737 per QALY for open correction and £ 11,969 per QALY for MIS correction, both well below the NICE willingness-to-pay threshold. In sensitivity analysis using incremental costs against conservative management, the ICER ranged from cost-saving (-£374 per QALY) to £ 3219 per QALY across all tested scenarios. Open correction was the dominant strategy in the pre-specified subgroup analysis, primarily driven by lower implant costs and higher removal rates in current literature. CONCLUSION:Hallux valgus correction surgery is highly cost-effective from the UK NHS perspective, with cost per QALY values substantially below those reported for total hip and total knee arthroplasty. The current restriction of access in some UK regions is not supported by national health-economic evidence. LEVEL OF EVIDENCE:III (economic and decision analysis based on prospective registry data).
Background Restricted ankle dorsiflexion from gastrocnemius tightness contributes to multiple foot and ankle disorders. Proximal medial gastrocnemius release (PMGR), originally developed for spasticity, is increasingly used for adult pathologies, yet its indications and outcomes remain debated. Methods We performed a contemporary review of PubMed, EMBASE, and CENTRAL up to January 2025, including clinical and biomechanical studies on PMGR in adults. Non-English, pediatric, distal gastrocnemius releases, and non-original articles were excluded. Results The Silfverskiöld and lunge tests remain the main diagnostic tools, though no standardized protocol exists. PMGR appears safe, with rare minor complications, and generally preserves calf strength. Evidence supports its role in plantar fasciitis with durable pain and function improvements. For Achilles tendinopathy, metatarsalgia, and progressive collapsing foot deformity, only small case series exist. Data for neuropathic ulcers and hallux deformities are sparse and inconclusive. Conclusions PMGR is effective for plantar fasciitis, but current evidence is limited and heterogeneous for other conditions. High-quality trials are required to define its broader role. Level of evidence Level IV, therapeutic review.
INTRODUCTION:Displaced intra-articular calcaneal fractures (DIACFs) managed with open reduction internal fixation through extensile lateral or sinus tarsi approaches are associated with a high rate of soft tissue complications. We present the technique of minimally invasive percutaneous fixation of DIACFs and the early outcomes from a major trauma centre. METHODS:This was a retrospective case series from a single major trauma centre between 2021 and 2024. Seventeen DIACFs in 13 patients were followed up for a mean of 14 months (range, 12-16 months). The mean age was 41 years (range, 18-60 years). Two out of 17 fractures were open injuries. There were seven Sanders type 2 and ten Sanders type 3 fractures. Simple tongue-type fractures were excluded. Fracture reduction was performed using a Schanz pin, combined with the 'Essex-Lopresti manoeuvre' and manual correction of varus and shortening. Fixation was with at least three 6.5 mm partially-threaded cancellous screws. Patients were immobilised in a below knee backslab for 6-weeks post-operatively. Radiological parameters (Böhler's angle, calcaneal height and width), the Kerr-Atkins score, VAS pain score, and any re-operations or complications were recorded. RESULTS:At final follow-up, the mean Kerr-Atkins score was 67 and the mean VAS pain score was 3.4. The average time from injury to surgery was 6.9 days (range, 3-21). All patients were mobilising unaided, and only 2 patients required orthotic footwear. One patient had a re-operation due to a late-declaring necrotic eschar. Mean Böhler's angle increased from 14.9° to 26.8° (p < 0.0001). The mean calcaneal height increased from 38.7 mm to 45.4 mm (p < 0.0001). No patients had developed clinical or radiological subtalar arthritis during the study period. CONCLUSION:In our case series, we have demonstrated that minimally invasive percutaneous fixation of DIACFs is a safe procedure, with a very low complication rate. Early functional and radiological outcomes are excellent, with all patients mobilising unaided, and most were able to wear normal footwear with a plantigrade, shoeable foot.
Background Lisfranc injuries are frequently overlooked or underestimated. Treatment of neglected injuries is challenging, and the optimal surgical strategy in delayed presentations remains unclear. Methods A PRISMA-compliant systematic review and meta-analysis were performed. Observational studies reporting surgical outcomes of corrective surgery for neglected Lisfranc injuries were included. Random-effects meta-analyses were conducted for AOFAS scores, complication rates, and return-to-work proportions. Meta-regression evaluated the influence of injury energy, surgical procedure, and treatment delay. Results Ten studies with 262 cases were included. Surgery was associated with a significant improvement in AOFAS scores. Patients with high-energy injuries demonstrated lower preoperative scores but greater absolute postoperative improvement, while postoperative scores remained comparable. The choice of surgical procedure and delay were not associated with functional improvement. The pooled complication rate was 34%, with higher rates observed in high-energy injuries and with longer delays. Conclusions In neglected Lisfranc injuries, functional recovery reflects baseline severity rather than timing alone. Surgical decision-making should prioritize joint viability and reducibility over delay.
BACKGROUND:The literature for a first metatarsocuneiform joint (MCJ) arthrodesis procedure and an early weight bearing post-operative regime (<2 weeks) has been systematically reviewed [1,2]. The concern regarding an increased risk of non-union with early weight bearing has largely been anecdotal. This is a single surgeon retrospective review assessing the union rates achieved following a Lapidus (1st tarsometatarsal joint) arthrodesis in the treatment of Hallux valgus using an anatomically contoured plantar plate and applying an early weight-bearing regime. METHODS:A retrospective study of consecutive patients who underwent this surgical technique between June 2019 and January 2025 were reviewed. Patients were evaluated at 8 weeks post operation for weight bearing x rays and returned for final clinical review at 6 months post operation. Clinical outcomes were validated through the Manchester-Oxford Foot Questionnaire (MOXFQ) and patient satisfaction (PSQ10) survey. Union of the arthrodesis and complications were reported. RESULTS:A total of 72 patients (60 female and 12 male) with a mean age of 60.60 (range 29 - 75) were analysed. The mean MOXFQ score improved across all domains. All three domains demonstrated highly significant post-operative improvement (p < 0.001 for all). Mean reductions were 26.2 points for Walking Standing (95% CI: 18.6-35.0; Cohen's d = 0.93), 25.6 points for Pain (95% CI: 18.7-32.9; Cohen's d = 1.03), and 37.5 points for Social Interaction (Cohen's d = 1.66). Effect sizes ranged from large to very large, indicating clinically meaningful improvements. There were no reported non-unions or plate failures. Fixation removal was required in 1 patient (1.5%). Ninety percent of patients were back to normal supportive footwear by 8 weeks. CONCLUSION:This study has demonstrated the low complication rates and acceptable safety profile of an immediate weight bearing post-operative regime following a first MCJ arthrodesis procedure with a single locking plantar plate fixation modality. It provides a larger cohort of patients to support the benefits of plantar plate fixation highlighted in other supporting systematic reviews for a first tarsometatarsal joint arthrodesis. [2] LEVEL OF EVIDENCE: IV.
Isolated cuboid dislocation is rare, with only 7 cases described in the literature. We describe three cases, two in professional rugby league players. The mechanism of injury was the same in the rugby league players with an external rotation injury to the midfoot during a tackle. The dislocation is easily missed on X-rays and CT would appear to be the investigation of choice. None of the dislocations could be reduced closed and all underwent open reduction and wire stabilisation. The wires were removed at 6 weeks. The short and long term functional results were good. Both rugby league players returned to play. One player was reviewed 6 years and 8 months post dislocation. He was still playing professional rugby league. His AOFAS midfoot score was 100. His X-rays however showed marked post traumatic arthritis in his 4th and 5th tarsometatarsal joints. Clinically this was asymptomatic. The second player was reviewed 4 years and 2 months after the injury, achieving an AOFAS Midfoot Score of 88/100. He reported some clicking and discomfort in the affected foot, particularly in the mornings. However, he did not require analgesia and had no limitations to activity.
Lisfranc injuries are complex midfoot injuries that, if inadequately managed, produce lasting pain, deformity and functional loss. Operative management has historically centred on open reduction and internal fixation (ORIF) and primary arthrodesis (PA), and more recently on flexible fixation (FF) constructs such as suture button devices, the InternalBrace and nitinol staples. This narrative review consolidates contemporary evidence on these three strategies to support surgical decision-making. Across direct comparisons, ORIF and PA yield broadly comparable functional outcomes and complication rates, with outcome governed chiefly by the achievement and maintenance of anatomic reduction; PA tends to reduce reoperation and loss of reduction, particularly in purely ligamentous injuries and complete fracture-dislocations, whereas ORIF preserves midfoot motion but commonly requires planned hardware removal. Flexible fixation produces excellent functional scores and minimal planned hardware removal in isolated ligamentous injuries, with early-recovery advantages over rigid fixation that largely attenuate by one year. The evidence base remains limited by short follow-up, small sample sizes and heterogeneity. No single construct is universally superior; anatomic reduction and patient selection by injury pattern are the principal determinants of outcome.
Arthrodesis of the hindfoot can be performed using either open or arthroscopic techniques. A retrospective comparative study was conducted including 38 patients, 41 feet, who underwent tibiotalocalcaneal (TTC) and pantalararthrodesis between 1/2012 and 12/2024. Feet were divided into two groups: 21 treated arthroscopically (15 TTC and 6 pantalar fusions) and 20 treated with open techniques (14 TTC and 6 pantalar fusions) All patients had minimum follow up of 12 months. TTC arthrodesis: Two feet (2/15; 13%) in the arthroscopic group, vs. seven (7/14; 50%) in the open group had significant deformity. Clinical union of all joints was achieved in 14 out of 15 (93.3%) arthroscopic and 13 out of 14 open procedures (92.8%) (p = 1.0, Fischer’s exact test), whilst mean time to union was similar (p = 0.42, T-test). Two asymptomatic (radiographic) nonunions were observed in the arthroscopic group, and one in the open group, not requiring additional surgery. Thus, total radiographic union rates were 80% (12 out of 15) in the arthroscopic and 85.7% (12 out of 14) in the open groups (p = 1.0, Fischer’s exact test). Pantalar arthrodesis: 11 out of 12 feet had significant deformity. Union was achieved in all six cases in the open, and in five out of six in the arthroscopic group, whilst, time to union was shorter in the arthroscopic group (13.7 vs. 21.7 weeks), but not significantly (p = 0.13, T-test). Three patients (3/6; 50%) in the arthroscopic group experienced complications, two (2/6; 33%) requiring revision arthrodesis due to nonunion and malunion. Whilst arthroscopic arthrodesis has a trend towards shorter union time and fewer wound complications, in our study there was an increased rate of nonunion and malunion, though these differences were not significant. However, one malunion requiring revision surgery, was observed in the arthroscopic group. Minimally invasive approaches may be preferable for selected patients, but should be used with caution if deformity is present, though larger prospective studies are required to confirm these findings.
BACKGROUND:The conservative management of Achilles tendon rupture (ATR) commonly utilises various orthotic devices to facilitate healing alongside functional rehabilitation protocols. However, comparative evidence regarding functional outcomes, complication rates, re-rupture rates and return to pre-injury status between individual orthoses remains limited. The aim of this systematic review was to assess which orthotic device yielded the best results for these categories. METHODS:We performed a systematic review of 14 studies including 2011 patients treated non-operatively for ATR with five orthotic device categories: VACOped®, Ossur Boot/Fixed Angle Walking Wedge (FAWW), Mixed, Foam Walker/Aircast, and Other. Outcomes included demographic data and patient reported outcome measures. Specifically, Achilles Tendon Total Rupture Score (ATRS) at < 6 and > 12 months, complication and re-rupture rates, and time to return to pre-injury function. RESULTS:Mean patient age ranged from 40.7 to 49.8 years. ATRS was the only patient-reported functional outcome reported with sufficient consistency for grouped comparison. Complications, re-rupture, and return to pre-injury status were analysed on an outcome-specific descriptive basis. ATRS scores showed no statistically significant differences between boot types at both < 6 and > 12 months follow-up. Complication rates varied significantly (p < 0.0001), with Mixed (31.2%) and Ossur/FAWW (19.5%) groups exhibiting the highest rates, while VACOped® (5.75%) and Foam Walker (4.4%) had the lowest. Re-rupture rates ranged from 3.05% (VACOped®) to 12.5% (Other) without significant intergroup differences. Return to pre-injury function times varied widely (13.8-40 weeks), with no statistically significant differences. CONCLUSION:Orthotic device selection influences complication risk but not long-term functional outcomes in non-operative ATR treatment. VACOped® and Foam Walker/Aircast were associated with more favourable descriptive outcome profiles; however, findings should be interpreted cautiously given the heterogeneity of included studies and the absence of formal meta-analytic effect estimation. Further prospective, standardised research is required to confirm these findings and inform evidence-based orthotic selection in Achilles tendon rehabilitation.
Background Minimally invasive surgery for hallux valgus (MIS-HV) has become a prominent topic in orthopaedic research, with a rapidly growing body of literature. Purpose This study provides a bibliometric analysis of the scientific literature on MIS-HV to identify publication trends, influential contributors, collaboration networks, and major research themes. Methods A systematic search was conducted in the Web of Science Core Collection database for articles published between 2005 and 2025. The bibliometrix was used to extract and analyse data, including annual scientific production, author and country productivity, journal distribution, and bibliometric laws (Lotka's and Bradford's). Results A total of 142 articles from 38 journals were analysed, involving 563 authors from multiple countries. Annual scientific production demonstrated a significant increasing trend with an annual growth rate of 16.7%. The authors with the highest number of publications were Lewis T.L. (n = 12). Foot & Ankle International was the journal with the highest number of publications with 31 publications (21.8%). Keyword co-occurrence analysis revealed major research clusters centred on surgical techniques (MICA, chevron osteotomy), patient-reported outcomes (MOXFQ), and the underlying pathophysiology and anatomical characteristics of the deformity. Retrospective case series were the most common study design (n = 94), followed by prospective case series (n = 19), with only nine randomised controlled trials identified. Conclusions Research on MIS-HV has grown exponentially over the last decade, mirroring the global adoption of third and fourth-generation techniques. This analysis maps the field's intellectual structure and highlights key contributors, collaborative networks, and evolving research trends, while underscoring the critical scarcity of multicentre randomised controlled trials. Study design Bibliometric analysis. Level of evidence V
BACKGROUND:Midfoot osteoarthritis affects approximately 12% of adults over 50 years and is a common cause of chronic foot pain and disability. When conservative management fails, midfoot arthrodesis remains the standard surgical treatment but carries significant morbidity, including nonunion rates of 3-10% and prolonged non-weightbearing. Deep peroneal nerve (DPN) neurectomy has emerged as a motion-preserving alternative; however, clinical evidence has not been systematically evaluated. METHODS:A systematic review following PRISMA 2020 guidelines was conducted (PROSPERO: CRD420251266344). MEDLINE, Cochrane CENTRAL, and Web of Science were searched from inception to October 2025. Quality was assessed using the ROBINS-I tool. Data were synthesised narratively due to heterogeneity in outcome reporting. RESULTS:Four retrospective case series (Level IV evidence) comprising 88 patients (106 feet) met inclusion criteria. Mean age was 66.3 years; 80% were female. Follow-up ranged from 4 weeks to 51 months. Patient satisfaction was approximately 75% across studies, though variably defined and best regarded as an illustrative estimate.The pooled surgical complication rate was 5.7% (6/106 feet), comprising predominantly minor wound complications. Reoperations, including revision neurectomy, exostosis excision, and conversion to arthrodesis, were required in 7.5% of feet (8/106). Conversion to midfoot arthrodesis occurred in 4.7% of feet (5/106). All four studies were assessed as having serious risk of bias using ROBINS-I. CONCLUSION:DPN neurectomy may provide clinically meaningful pain relief with low complication rates in selected patients with midfoot osteoarthritis, offering faster recovery than arthrodesis. Current evidence is limited to small retrospective case series; prospective comparative studies are needed.
Background Individuals with plantar heel pain (PHP) are often excluded from randomised clinical trials (RCTs) despite having care-seeking behaviour and symptoms consistent with PHP. This study aimed to describe their clinical course over 12 months after not being included in the FIX-Heel Trial. Methods We conducted a prospective cohort study of individuals with PHP who did not meet one or more of the inclusion criteria: 1) pain on palpation at the medial calcaneal tubercle, 2) plantar fascia thickness > 4.0 mm, or 3) pain > 30 mm on a 100-mm visual analogue scale. Individuals completed the Foot Health Status Questionnaire (FHSQ) and care-seeking behaviour at baseline and after 4, 12, 26, and 52 weeks. Results We included 28 individuals who were primarily not included in the trial due to their plantar fascia thickness (86%). Significant improvements were observed in FHSQ Pain and Function scores at 12 weeks compared to baseline (mean difference 9.0 (95%CI: 1.5;16.5, P = 0.019) and 7.7 (95%CI: 0.3;15.2, P = 0.043), respectively), with continued improvement at 26 and 52 weeks. Less than half received treatment at any time point. Conclusion Despite limited care, individuals not included in an RCT experienced clinically meaningful long-term improvement. These findings shed light on the clinical course of individuals excluded from trials.
Background Falls in older adults remain a major clinical concern. Although the Enhanced Paper Grip Test (EPGT), provides an objective measure of lower limb strength and has shown promise in controlled settings, its use in routine podiatric practice has not been described. Aim To audit the implementation of the EPGT in routine private podiatric practice and to explore whether EPGT measures are associated with self-reported recent falls in older adults. Methods The EPGT was introduced on a trial basis in three independent private UK podiatry clinics for six months. People (aged ≥60 y) were tested when the treating podiatrist considered the assessment clinically appropriate. Anonymised routine clinical data were extracted retrospectively at the end of the audit period, including EPGT outcomes, age, sex, and self-reported history of an unexplained fall in the previous twelve months. Results Seventy-eight participants (mean age 72 ± 7 years) were assessed; 17 reported a fall. Median EPGT force was statistically significantly lower in fallers (11.9 N) than in non-fallers (21.4 N), U= 283,z = -3.554,p < .0005. Differences remained significant after adjustment for age and sex and were robust to outlier exclusion. Hallux-related pathology was not associated with EPGT outcomes. Conclusions In this pragmatic private practice audit, the EPGT could be incorporated into routine podiatric assessment and lower EPGT values were associated with self-reported recent falls. These findings support the EPGT as a potentially useful adjunct to falls risk screening that could be offered as part of routine podiatry care. Prospective studies are needed before predictive use or clinical thresholds can be established.
Injuries at the medial gastrocnemius-soleus junction are common among athletes and physically active individuals. They typically result from sudden overstretching or repetitive microtrauma, leading to significant calf pain and functional limitations. Diagnosis is primarily clinical, with ultrasound or MRI used to assess injury severity. Most cases are managed conservatively, including rest, cryotherapy, anti-inflammatory therapy, and structured rehabilitation focusing on gradual stretching, eccentric strengthening, and proprioceptive training. Recovery generally occurs within 6-12 weeks, with return to activity guided by functional recovery rather than symptom resolution alone. A thorough understanding of the anatomy, pathophysiology, and evidence-based management strategies is essential to prevent complications, reduce recurrence, and facilitate a safe return to sport. ABSTRACT(CONCISE VERSION): Despite their prevalence in athletes, medial gastrocnemius-soleus junction injuries respond well to early conservative care, with most patients regaining full function. Diagnosis is based on clinical evaluation, supported by imaging when needed. Most cases are treated conservatively with rest, anti-inflammatory measures, and structured rehabilitation. Recovery typically occurs within 6-12 weeks, allowing safe return to activity while minimizing recurrence.
OBJECTIVE:To determine the optimal anatomical location for performing Achilles tendon tenotomy in children under 18 months of age, using MRI measurements to enhance surgical safety and efficacy during the Ponseti method for clubfoot correction. METHODS:A retrospective study was conducted of children aged 18 months or younger without clubfoot deformity who underwent MRI scans of the foot and ankle in our tertiary center from January 2012 to December 2023 for unrelated clinical indications. T1-weighted post-gadolinium images were analyzed to measure the medial distance between the Achilles tendon and the posterior tibial neurovascular bundle, as well as tendon width, at four levels: at the superior border of the calcaneus, and 10 mm, 20 mm, and 30 mm proximal. Measurements were performed independently by three orthopedic team members, and mean values were calculated. RESULTS:Eleven patients were included in the final analysis. At the superior border of the calcaneus, the mean distance to the neurovascular bundle was 11.43 ± 1.54 mm, decreasing to 10.56 ± 2.17 mm at 10 mm, 8.39 ± 2.01 mm at 20 mm, and 7.10 ± 1.80 mm at 30 mm proximally. The Achilles tendon width was widest at the calcaneal border (11.33 ± 1.23 mm) and decreased significantly at more proximal levels. CONCLUSION:Performing the tenotomy 10-20 mm proximal to the superior calcaneal border offers an optimal balance between tendon width and a safe distance from the posterior tibial neurovascular bundle. This location may reduce the risk of iatrogenic vascular injury during Ponseti treatment of clubfoot in infants.
