End-stage ankle osteoarthritis is a debilitating condition that significantly impacts patient function and quality of life. Total ankle arthroplasty (TAA) has emerged as an alternative to arthrodesis, offering pain relief while preserving joint mobility. However, its outcomes in younger patients remain controversial due to concerns regarding implant survival and revision rates. This study evaluates the functional outcomes of TAA in patients ≤50 years compared with those >50 years. A retrospective cohort of 32 patients was analyzed, with functional assessment based on the Visual Analog Scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Foot Function Index (FFI). The median follow-up period was 4.1 years in the younger cohort and 4.4 years in the older cohort. Both groups demonstrated statistically significant postoperative improvements in pain and function ( P <0.05). Prosthesis revision was more frequent in patients ≤50 years, whereas all forms of reoperations were more common in those >50 years. Despite differences in complication profiles, overall functional outcomes were comparable. These findings support TAA as a viable surgical option across age groups, with younger patients demonstrating satisfactory functional results despite a higher revision rate. Adequate patient selection and long-term surveillance remain critical for optimizing outcomes. Level of Evidence: Level III.
Fat pad atrophy is an underdiagnosed cause of chronic heel pain, often mistaken for plantar fasciitis. The heel fat pad plays a crucial role in shock absorption, and its degeneration increases mechanical stress on the calcaneus, leading to pain and functional limitations. This short report on fat pad syndrome was conducted, focusing on clinical presentation, imaging techniques (ultrasound, MRI), and treatment strategies, including footwear and regenerative therapies. Fat pad syndrome is frequently misdiagnosed, resulting in delayed appropriate treatment. Imaging helps distinguish it from plantar fasciitis. Conservative management includes shock-absorbing footwear and orthotics, while regenerative therapies, such as fat grafting and PRP, show promise. Running shoes with thick cushioning and a low heel-to-toe drop (≤4 mm) may help redistribute plantar pressure effectively. A low-drop shoe encourages a midfoot or forefoot strike, reducing strain on hip and knee joints and promoting a more natural running technique. For example, Altra pioneered the “zero-drop” design, while brands such as Saucony (Guide series, 4–8 mm), New Balance (X Kaiha Road, 4 mm), and Hoka (Bondi, ~5 mm) all provide commercially available models. Recognizing fat pad syndrome is essential for accurate diagnosis and treatment. Advanced imaging and a multidisciplinary approach, including biomechanical interventions, can improve patient outcomes.
Abstract: Ankle fractures are common orthopedic injuries, with management ranging from conservative to surgical intervention. Minimally invasive techniques for medial malleolus fixation have emerged as a promising alternative to traditional open surgery, offering several advantages, including reduced surgical trauma, shorter recovery times, and fewer complications. We present a case series of 4 patients with displaced medial malleolus fractures who underwent percutaneous reduction and fixation with the presented technique. The following technique is simple and reproducible, assisted by fluoroscopic guidance to ensure proper reduction and clearance of intervening soft tissue followed by fixation, avoiding conventional incision and hence respecting soft tissue and preventing soft tissue complication and nonunion, aiming to enhance functional outcomes with the added benefit of reduced postoperative pain and faster rehabilitation. Care is taken to respect the anterior and posterior colliculi of the medial malleolus during reduction to avoid articular incongruity. Level of Evidence: Diagnostic Level IV—case series. See Instructions for Authors for a complete description of levels of evidence.
Hammertoes are a common orthopedic concern characterized by flexion of the proximal interphalangeal joint (PIPJ), often with co-occurring extension of the metatarsophalangeal joint (MTPJ). Rigid deformity at the PIP joint is frequently treated with PIPJ resection arthroplasty or PIPJ arthrodesis, while the standard treatment for persistent MTPJ deformity usually involves soft tissue release, such as tendon transfers or tenotomies. Indeed, soft tissue release techniques are associated with undesirable outcomes such as incomplete correction and motor dysfunction, and lower patient satisfaction. Here we describe a novel technique for the correction of rigid hammertoe deformities that combines a PIPJ arthrodesis with a subsequent minimally invasive proximal base osteotomy of the proximal phalanx. This technique capitalizes on the stability and corrective capacity of PIPJ arthrodesis while simultaneously addressing MTPJ deformity in a fashion that preserves extensor motor function and MTPJ range of motion, while reducing soft tissue trauma. Level of Evidence : Level IV.
Comminuted calcaneal fractures are associated with severe debilitation, a high degree of morbidity, and disability. Typical surgical approaches for comminuted calcaneal fractures include the open lateral extensile and sinus tarsi incision. Both incisions can cause varying degrees of soft tissue damage that can be further magnified in high-risk patients. Recent studies have shown that it is beneficial to perform minimally invasive treatment of comminuted calcaneal fractures. The aim of this study was to introduce a stepwise surgical algorithm for the treatment of comminuted calcaneal fractures using a minimally invasive approach with staged open reduction and internal fixation. We presented the outcomes of 3 patients who have undergone this technique. Our study exhibited satisfactory anatomic reduction of calcaneal fracture with the use of external fixation, with patients progressing to weight-bearing without major complications. Level of Evidence: Level 4
The digital block of the first toe is a fundamental procedure in podiatric and forefoot surgery, and its success depends on precise anatomic knowledge and adequate anesthetic distribution. The inverted V digital block was developed as an alternative to traditional H and ring techniques in order to optimize anesthetic diffusion, reduce the number of punctures, and improve patient comfort. This article provides a detailed technical description of the inverted V approach and its anatomic rationale, supported by previously published prospective multicenter data demonstrating higher anesthetic efficacy and greater patient tolerance compared with the H block. The inverted V digital block represents a reproducible and efficient alternative for anesthesia of the first toe in surgical practice. Level of Evidence: Level V.
Maisonneuve fractures involve the disruption of the syndesmosis and necessitate surgical intervention. The aim of surgery is to restore fibula length and stabilize the syndesmosis. Classic manual reduction may not achieve fibular lengthening and is strenuous to maintain during syndesmosis fixation. Hence, we report our method of reduction with a distraction technique that provides mechanical advantages. We present a case series of 3 patients with Maisonneuve fractures in which indirect fibular reduction was achieved using a novel distraction technique with instruments. Cases 1 and 2 suffered an isolated high fibular fracture, whereas Case 3 had concomitant ankle fractures. Syndesmosis disruption was confirmed intraoperatively with the Cotton and external rotation tests. All 3 cases underwent dual-suture button fixation of the syndesmosis. To achieve the reduction, a 3-hole plate was applied on the distal fibula fragment with a cortical screw applied over the most proximal hole. Subsequently, a 5 mm Steinmann pin was drilled into the lateral tibia. The entry point of the tibial pin is immediately anterior to the fibula and 2 cm proximal to the applied fibular plate. An edged lamina spreader was used to apply distraction between the plate and the Steinmann pin. Temporary reduction is held with a quadcortical K-wire, followed by suture button fixation through the middle and inferior holes of the fibular plate. Postoperative imaging showed a normal talocrural angle and the fibula dime sign. This technique provides mechanical advantages in strength and stability, maintaining the reduction while freeing the surgeon’s hands to perform syndesmosis fixation. Level of Evidence: Level lV.
Syndesmosis injuries can lead to chronic instability if not properly addressed. Current reconstruction techniques demand multiple tunnels and most do not address all the injured ligaments. The authors present a novel technique for the reconstruction of all the syndesmotic ligament complex using a tendon graft, designed to simplify the surgical approach while ensuring reproducibility and adequate tensioning of the construct. In this technique, a tendon graft is prepared to replicate the native anatomy of the syndesmotic ligaments. The graft is passed through precisely located bone tunnels in the distal tibia and fibula, mimicking the course of the AITFL, PITFL, and IOL. The graft is secured using interference screws in the posterolateral and anterolateral tibia, and an additional fixation with a suture button to replicate the interosseous ligament. The key innovations in this procedure are the simplicity of the technique and the ability to tension the repair as desired. These features can reduce operative time and increase the accuracy of ligament reconstruction. Level of Evidence: Level 5.
Fibrodysplasia ossificans progressiva (FOP) is an exceptionally rare and disabling genetic disorder clinically characterized by malformed great toes and progressive heterotopic ossification of soft tissues. Diagnosis of FOP requires generic confirmation by the presence of ACVR1 mutation. We describe the case of a 12-year-old girl who presented without malformed great toes but developed restricted hip movement after minor trauma, followed by soft tissue swelling and impaired mobility of the lumbar spine, cervical spine, and shoulders several months later. Radiographic imaging revealed heterotopic ossification adjacent to the left greater trochanter, without underlying skeletal abnormalities. Genetic analysis confirmed a heterozygous pathogenic mutation in the ACVR1 gene (c.617G>A, p.Arg206His). The diagnosis of FOP prompted reconsideration of the previously planned surgery for hip stiffness relief, given the known risk that surgical procedures may trigger disease flare-ups and additional heterotopic ossification. During follow-up, the patient experienced recurrent flare-ups characterized by localized swelling, which responded well to high-dose corticosteroid therapy and supportive anti-inflammatory management. Management focused on minimizing trauma, maintaining functional mobility, and avoiding invasive procedures known to exacerbate disease progression. Preventive strategies and timely intervention during flare-ups are essential to preserving the quality of life in affected individuals. This case highlights the importance of early clinical suspicion in atypical presentations of FOP, which may help clinicians avoid unnecessary surgical procedures that could potentially exacerbate heterotopic ossification. Early recognition and a multidisciplinary approach are essential for optimizing patient outcomes and preserving functional mobility. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Osteochondral lesions of the tibial plafond (OLTPs) are rare and pose significant treatment challenges, especially in cases of failed prior interventions such as subchondroplasty. Conventional surgical techniques may be limited by access constraints, lack of precision, and the risk of damaging the articular cartilage. We describe the case of a 44-year-old male police officer with a symptomatic posteromedial OLTP that persisted after posterior ankle arthroscopy and subchondroplasty. Preoperative imaging revealed a residual subchondral cyst despite prior cement augmentation. The patient underwent computer-assisted navigated retrograde drilling of the cystic lesion with allograft bone chips and bone marrow aspirate concentrate (BMAC) grafting, using intraoperative CT-based navigation. The procedure was completed successfully without violating the overlying cartilage. At 6 months postoperatively, the patient achieved complete resolution of pain, returned to unrestricted activity, and resumed running and occupational duties. The AOFAS Ankle-Hindfoot Score improved from 68 preoperatively to 100, while the Visual Analogue Scale (VAS) for pain reduced from 5 to 0. RAND-36 health survey results showed improvements in bodily pain, mental health, and general health perception. Postoperative MRI confirmed graft incorporation with adjacent marrow healing and a preserved joint surface. This case highlights that CT-navigated retrograde drilling with biological augmentation is a safe and effective technique for recurrent OLTPs, offering precise targeting and cartilage preservation with excellent radiologic and clinical outcomes.
Chronic ankle instability often results from lateral ankle sprains, primarily affecting the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). When conservative treatments fail, surgical options include anatomic repair and reconstruction. The Brostr & ouml;m-Gould and Karlsson techniques aim to restore native ligament structures, while reconstruction is necessary for irreparable cases. Both arthroscopic and percutaneous approaches have been explored. We present a promising minimally invasive nonanatomic reconstruction technique for the ATFL and CFL, offering a viable alternative for managing chronic ankle instability. Only one graft rupture was reported, similar to 10 months postoperatively, following a traumatic event. No other intraoperative or postoperative complications were observed. This nonanatomic minimally invasive technique represents a reliable and promising approach for the reconstruction of chronic lateral ankle instability.
Calcaneonavicular coalition is a congenital coalition caused by failure of embryonic segmentation, leading to an abnormal connection between the calcaneus and the navicular bones. If symptomatic with no evidence of arthritis, surgical excision is thought to be the best operative option. Extensor digitorum brevis interposition is a well-described technique to reduce the risk of recurrence. Previous retrospective reviews cite a high rate of wound complications and a symptomatic bony prominence over the lateral border of the foot after extensor digitorum brevis interposition. This manuscript modifies the previously described technique for extensor digitorum brevis interposition to only transpose the dorsal/medial half of the muscle. This allows for anatomic repair of the fascia and a more normal anatomy of the lateral border of the foot.
Background:Navicular stress fractures are rare with increased prevalence in athletes. Repetitive motion in sports can overload the navicular creating microfractures resulting in structural insufficiency. In athletes, the literature suggests surgical fixation for type II and type III fractures demonstrates a quicker and more predictable return to sport and lower rate of nonunion compared with nonoperative treatment. The present paper outlines a detailed surgical technique and postoperative protocol for treatment of navicular stress fractures. Vitamin D and calcium supplementation and use of a bone stimulator are used in concert with a period of 6 weeks of non-weight bearing. The present protocol allows for release to high-impact sports as early as 4.5 months after surgery.Level of Evidence:Level 5.
The Brostr & ouml;m-Gould procedure is a widely accepted surgical technique for the treatment of chronic ankle instability. For patients at a higher risk of failure, ligament augmentation with suture tape has been shown to decrease failure rates and shorten recovery time. However, this technique may compromise talar integrity, leading to the development of sinus tarsi pain. Suture tape may also decrease the range of motion. This paper proposes an alternative modification to the traditional Brostr & ouml;m-Gould technique, enhancing lateral ankle stability through the addition of a third anchor placed proximally and laterally on the fibula in a dual-row fashion. This augmentation method presents a novel technique that could potentially improve tension potential of patients with poor ligament quality without the need for talar screw placement. However, further biomechanical and clinical studies are needed to confirm higher tensile strength and long-term patient-reported outcome measures.Level of Evidence:Level V
Base of the 5th metatarsal (MT) fracture is a common occurrence that needs to be identified and treated appropriately to minimize risk of poor clinical outcomes. An uncommon occurrence is the base of 5th MT fractures associated with progressive retraction of the peroneal brevis (PB) tendon resulting in foot eversion weakness. We report a case of 5th MT base avulsion fracture with sequential proximal retraction of the displaced fragment with its attached PB tendon. A middle-aged gentleman was referred to our clinic after sustaining a foot inversion injury with localized tenderness at the base of 5th MT associated with swelling on ambulation and weakness on eversion. Radiographs exhibited an avulsion fracture at the base of 5th MT with proximal retraction. He was counselled and underwent surgical reconstruction of the avulsed PB tendon with a posterior tibial tendon (PTT) allograft. At 3-month follow-up, there was progressive return of foot eversion strength. By 6 months, the patient returned to functional ambulation and light jogging. Our case utilizing a PTT allograft for reconstruction of a contracted peroneus brevis and displaced 5th metatarsal avulsion fracture suggests a viable treatment option showing good clinical and functional outcomes.Level of Evidence:Level V.
The authors describe a case involving a young male patient with an uncommon osteochondral lesion of the proximal phalanx of the hallux within the metatarsophalangeal joint, associated with a gouty tophus. The surgical approach included curettage of the subchondral cyst, filling the defect with autologous bone graft, and repairing the cartilage using autologous matrix-induced chondrogenesis (AMIC). The postoperative care protocol is detailed, and the results are discussed.Level of EvidenceLevel of evidence 4 - Case Report.
Introduction: In the osteochondral autograft transfer system (OATS) procedure, a wide accessible area is required to introduce the femoral plug at varying angles. This may not always be achievable through standard anteromedial or anterolateral arthrotomy approaches. The aim of this case report was to describe the use of an anterior chevron-type tibial osteotomy as a technical approach for treating a centrolateral osteochondral lesion of the talus (OLT) with the OATS technique. Methods: A 48-year-old female patient with chronic ankle pain following an ankle sprain 32 years ago. The anterior osteotomy was performed with dimensions of 3 cm in width, 2 cm in depth, and 4 cm in height. After removing the anterior tibial bone block, we identified and debrided the OLT. The lesion site was prepared, and a bone plug obtained from the lateral femoral trochlea was inserted, congruent with the surrounding articular cartilage. The temporarily removed anterior tibial bone block was reattached and secured with three cannulated screws. Results: By 44 months postoperatively, the patient demonstrated significant clinical improvement and had returned to full activity. Preoperatively, she reported a VAS score of 7 for pain, which improved to 1 postoperatively. Her American Orthopaedic Foot and Ankle Society ankle-hindfoot score increased from 41 to 90. Ankle range of motion improved, from a preoperative total of 90 degrees to 100 degrees postoperatively. No complications were observed following the tibial osteotomy or the OATS procedure. Conclusion: The anterior chevron-type tibial osteotomy provided an adequate exposure of a centrolateral OLT, enabling precise graft positioning during the OATS procedure. It allowed safe insertion of the plug at the desired angle while preserving joint congruity. This technique may represent a surgical option for treating centrally and laterally located OLT when conventional approaches do not provide sufficient access.
Posterior tibial tendon dislocation is an uncommon injury. This pathology is believed to develop due to an involuntary and violent contraction of the posterior tibial muscle triggered by forced ankle inversion combined with sudden dorsiflexion. And is often accompanied by other ankle traumas that obscure its diagnosis. This report describes a rare case of concurrent posterior tibial tendon dislocation and Achilles tendon rupture in a 37-year-old male, injured during a soccer match. Initial examination confirmed a complete Achilles tendon rupture but overlooked medial ankle pain and edema. Magnetic resonance imaging revealed posterior tibial tendon dislocation with flexor retinaculum detachment and an Achilles tendon rupture located 5.5 cm proximal to its calcaneal insertion. Surgical intervention was performed in a single session, addressing both injuries. The posterior tibial tendon dislocation was corrected through a medial approach, with tendon reduction into its retromalleolar groove and flexor retinaculum reattachment to the medial tibia using transosseous sutures. Achilles tendon repair was achieved using a minimally invasive Dresden technique. Postoperative rehabil-itation included progressive weight-bearing, mobility exercises, and strengthening protocols, tailored to manage both injuries concurrently. By the seventh postoperative month, the patient demonstrated full recovery, with restored tendon stability, absence of pain or edema, and return to preinjury sports activities. This is the second reported case of concurrent Achilles tendon rupture and posterior tibial tendon dis-location and the first to propose a comprehensive surgical strategy addressing both conditions simultaneously. Early recognition and tail-ored surgical planning are critical to prevent chronic complications and restore functional outcomes in these rare cases. Level of Evidence: Level 5
Midfoot arthritis can be a painful condition that can limit shoe options and affect quality of life. Traditional methods for treating midfoot arthritis have included steroid injections to the affected joints or arthrodesis for surgical management. The medial midfoot joints are innervated by the deep peroneal nerve and can also commonly be affected by midfoot arthritis with shooting pain in the foot and ankle. Deep peroneal neurectomy is a viable surgical option that has a quick recovery and predictable outcomes. Nerve pain or neuroma following neurectomy procedures is a potential complication. A hyaluronic acid alginate hydrogel can be used to the neurectomy site to help avoid postoperative neuroma complications. Level of Clinical Evidence: Technique/Case Study 5.
Flatfoot is one of the most common clinical presentations in orthopedic practice. When symptomatic flexible flatfoot fails to respond to nonoperative measures, surgical intervention may be necessary. Surgical options include soft tissue and bony procedures. However, deformity correction often requires bony procedures, as soft tissue interventions alone are rarely successful. Evans and Hintermann calcaneal osteotomies are the most commonly used techniques for lateral column lengthening. Despite being performed under fluoroscopic guidance, these osteotomies carry the risk of calcaneal articular surface invasion. Therefore, a more precise and accurate method is needed. This study describes the use of 3D printed patient specific guide for lateral column lengthening osteotomy (LCLO). A CT scan of the affected foot was used for image segmentation via DICOM files to produce a 3D visualization of the calcaneus using 3D Slicer software. A patient specific osteotomy guide designed with anatomic curves to fit the lateral calcaneal surface at the level of the sinus tarsi is 3D printed. The guide directs the osteotomy precisely to the desired direction based on patient calcaneal facet anatomy to avoid articular surface violation. Both Evans and Hintermann osteotomies can be accurately performed using these 3D-printed guides. Postoperative CT scans revealed that the osteotomy was performed as planned, without violation of the articular facets. Patient specific 3D printed guide for lateral column lengthening osteotomy may be a safer and more accurate method to avoid articular surface violation during this demanding osteotomy. Level of Evidence: Diagnostic Level 5.
