Background: This study aimed to characterize longitudinal 3-dimensional morphologic, alignment, and radiographic changes of the ankle and hindfoot following surgical fixation of tibial plafond fractures and to identify structural features associated with post-traumatic osteoarthritis (PTOA) severity. Methods: Thirty-two patients with surgically treated pilon fractures from 3 institutions underwent weightbearing computed tomography (WBCT) at 6, 12, and 18 months post-operatively. At 18 months, patients were grouped into low-grade and high-grade PTOA groups. Statistical shape modeling was used to quantify morphologic and alignment variation across the tibia, fibula, talus, and calcaneus. Joint distances at the talocrural and subtalar joints were calculated using correspondence-based metrics. Radiographic parameters were automatically derived from 3-dimensional bone models using a MATLAB toolbox. Cross-sectional and longitudinal statistical differences were assessed. Results: Patients who developed high-grade PTOA demonstrated progressive flattening of the calcaneal pitch, posterior and inferior translation of the tibia and fibula, and narrowing of the central tibiotalar joint. In contrast, the low-grade group exhibited greater valgus hindfoot alignment, mild widening of the medial and posterior tibiotalar joint, and greater alignment variation over time. Radiographically, the high-grade group displayed a significant increase in tibiocalcaneal angle over time ( P = .03) and a trend toward a more varus hindfoot configuration. Conclusion: Distinct longitudinal alignment and morphologic trajectories differentiate low-grade and high-grade PTOA development following pilon fracture fixation. Preservation of coronal alignment and subtalar adaptability may provide a protective mechanism against rapid PTOA progression. These findings highlight the clinical potential of WBCT and shape-based 3-dimensional analysis for early detection of malalignment patterns associated with post-traumatic degeneration. Level of Evidence: Level III, prognostic study.
Background: Ankle fractures are prevalent, with 21% to 40% of cases requiring surgical intervention. Treatment decisions regarding non-complex fractures, whether in an inpatient (IP) or outpatient (OP) setting, are often influenced by local resource availability. Although IP care is generally expected to be more expensive, the magnitude of this difference and its interpretation across heterogeneous cost definitions, health care systems, and operative settings remain unclear. This systematic review and meta-analysis evaluates the cost differences between IP and OP surgical management of isolated ankle fractures, offering evidence to guide surgeons in optimizing care pathways while minimizing health care expenditures. Methods: This PROSPERO-registered systematic review and meta-analysis (CRD420251134624) of comparative studies evaluated cost differences for OP and IP management of ankle fractures. We queried PubMed, EMBASE, and CINAHL from inception through August 17, 2025. Because of the inconsistent definition “cost” across the literature, we extracted and analyzed the cost construct as defined by each included study and performed a random effects meta-analysis of the unstandardized mean differences (standardized to a common price year/currency)and reported them with 95% CIs. Results: Seven articles were included, with a final sample size of 21,955 patients with an average age of 43.50 ± 2.87 years and a 2.5-month mean follow-up. Overall, 53.8% (n = 11 813) of patients were treated in the IP setting and 46.2% (n = 10 142) were treated in the OP setting. The mean hospital length of stay (LOS) for IPs was 2.27 ± 0.25 days across the 5 studies reporting this value (n = 5718 IP patients). The average study reported direct cost for IP management was significantly higher than OP management ($11 236.37 ± $2205.05 vs $6990.18 ± $1670.72; P = .011, CI: 1654.50, 6920.19). Qualitatively, the safety and complication profiles between IP and OP were not different among 3 studies that examined this metric. Conclusion: Outpatient ORIF for isolated ankle fractures is associated with lower study-reported economic burden than inpatient management in appropriately selected patients, without clear evidence of worse short-term safety outcomes in the available comparative literature. These findings support outpatient pathways for patients with acceptable reduction and immobilization, manageable soft tissues, limited comorbidity burden, safe non-weightbearing mobility, and reliable follow-up. Because included studies used heterogeneous economic definitions and were observational, future prospective studies should use standardized economic outcomes and longer follow-up to better define the value of outpatient vs inpatient care.
Background: Post-traumatic ankle deformity associated with tibiofibular incongruity has traditionally been managed with anatomical reconstruction of the fibula and syndesmosis to restore talar position. However, such reconstruction is often not feasible in chronic deformities with distorted anatomy. We hypothesized that realignment using supramalleolar osteotomy (SMO), without fibular or syndesmotic reconstruction, would improve tibiotalar congruity. Methods: A retrospective study included 11 patients (11 ankles) who underwent SMO for chronic post-traumatic ankle deformity with tibiofibular incongruity. Patients were included if they had persistent symptoms refractory to nonoperative treatment and underwent SMO as the primary realignment procedure. Anatomical reconstruction of the fibula or syndesmosis was not attempted. Radiographic outcomes included whole limb and distal tibial alignment, tibiotalar congruity, and hindfoot alignment. Clinical outcomes were assessed using the visual analog scale (VAS) and the Foot Function Index (FFI). Results: The mean follow-up was 33.1 months. Eight ankles underwent medial closing wedge SMO, and 3 underwent dome-type SMO. Postoperative tibiotalar congruity improved, with significant correction of mediolateral talar translation ( P < .05). Hindfoot valgus alignment improved toward neutral. VAS and FFI improved ( P < .05), whereas sagittal alignment showed no significant difference. All cases achieved union and no patient required conversion to ankle arthrodesis or total ankle arthroplasty. Conclusion: In selected patients with chronic post-traumatic ankle deformity associated with tibiofibular incongruity in whom anatomical fibular or syndesmotic reconstruction is not feasible, realignment using supramalleolar osteotomy was associated with improved tibiotalar alignment and congruity, with favorable clinical outcomes. This realignment-based strategy represents a viable joint-preserving alternative in complex chronic ankle deformities with tibiofibular incongruity. Level of Evidence: Level IV, prognostic.
Background: Tibiotalar arthrodesis remains the standard surgical treatment for end-stage ankle arthritis. Although arthroscopic techniques are increasingly used, differences in operative time, complication profiles, and union rates between arthroscopic and open techniques remain inconsistently reported. In Asian populations, degenerative ankle arthritis is frequently associated with varus coronal deformity, which may influence surgical approach selection and outcomes. This study compared perioperative outcomes, radiographic union, postoperative complications, and patient-reported outcomes between open and arthroscopic tibiotalar arthrodesis. Methods: This study included 83 adult patients who underwent isolated tibiotalar arthrodesis at a single tertiary institution between January 2004 and December 2024 using either an open (n = 30) or arthroscopic (n = 53) approach. Perioperative outcomes, radiographic time to union, postoperative complications, and 6-month patient-reported outcomes were compared. Results: With the numbers available, no significant difference could be detected in the primary outcome of time to radiographic union between the arthroscopic and open cohorts (120.0 ± 99.5 vs 113.1 ± 73.0 days, respectively; P = .734), and no significant difference could be detected in overall complication rates between groups (18.9% vs 23.3%, respectively; P = .778). Patients undergoing open arthrodesis demonstrated greater preoperative coronal deformity compared with those treated arthroscopically (15.6° ± 10.8 vs 8.2° ± 7.4; P = .002). Arthroscopic arthrodesis was associated with longer operative time (154.7 ± 44.0 vs 130.1 ± 49.5 minutes; P = .028), whereas fewer reoperations were observed during follow-up (3.8% vs 20.0%; P = .024). Conclusion: In this comparative cohort, with the numbers available, no significant differences were detected in radiographic union, early functional outcomes, or overall complication rates between arthroscopic and open tibiotalar arthrodesis. Fewer reoperations were observed in the arthroscopic cohort, which was generally composed of patients with less severe deformity. Both arthroscopic and open tibiotalar arthrodesis remain reasonable treatment options when selected according to patient characteristics, deformity severity, and surgical requirements. Level of Evidence: Level III, retrospective comparative cohort study.
Background:Hypothyroidism has been associated with altered bone metabolism, impaired mineralization, and increased fracture risk, but its relationship with postoperative complications after operative ankle fracture fixation remains poorly defined. This study evaluated whether preexisting hypothyroidism is associated with increased complications following surgical treatment of ankle fractures. Methods:Adults undergoing operative ankle fracture fixation or related ankle fracture surgery in TriNetX were stratified by hypothyroidism diagnosed within 6 months before or on surgery vs no recorded hypothyroidism history. Propensity score matching was performed 1:1 using demographic factors, diagnosis-coded obesity/overweight, hemoglobin A1c, tobacco-related variables, diabetes, chronic kidney disease, cardiovascular disease, chronic obstructive pulmonary disease, peripheral vascular disease, and osteoporosis. No single primary outcome was designated; all 6 outcomes were assessed on an equal, exploratory basis at 3 months, 6 months, and 1 year. Results:After matching, 10 406 patients per cohort were included in the 3- and 6-month analyses, and 10 407 per cohort were included at 1 year. With the numbers available, no significant difference could be detected for any 3-month outcome. At 6 months, nonunion/malunion (RR, 1.305; 95% CI, 1.065-1.600; RD P = .010) and hardware failure (RR, 1.302; 95% CI, 1.058-1.602; RD P = .013) were higher in hypothyroid patients. At 1 year, nonunion/malunion (RR, 1.407; 95% CI, 1.166-1.698; RD P < .001) and hardware failure (RR, 1.264; 95% CI, 1.065-1.500; RD P = .007) remained higher. Infection, hardware removal, wound dehiscence, and broad procedure-related complications were not significant at any time point. Conclusion:In this propensity-matched retrospective cohort study, preexisting hypothyroidism was associated with modest but statistically significant increases in delayed osseous and hardware-related complications after operative ankle fracture surgery (P < .05 for both outcomes at 6 months and 1 year). These findings should be interpreted as associative and warrant prospective validation. Level of Evidence:Level III, retrospective cohort study.
Background: Accurate implant positioning is essential for long-term success in total ankle arthroplasty (TAA). Although patient-specific instrumentation (PSI) and advanced imaging have improved technical precision, intraoperative alignment assessment still relies heavily on visual interpretation of fluoroscopy. The reliability of visual assessment remains poorly understood. This study evaluated the accuracy and reliability of visual assessment of tibial component alignment in TAA. Methods: Seventeen raters assessed 21 TAA cases (15 unique, 6 duplicated) using standardized anteroposterior (AP) and lateral fluoroscopic or radiographic images. True implant alignment was defined by postoperative computed tomography (CT) measurements from a previously published PSI cohort. Raters classified angular alignment as neutral (0° to 2°), 2° to 4°, or greater than or equal to 5° of deviation in varus/valgus or dorsiflexion/plantarflexion. Interobserver agreement was assessed using Fleiss κ; and intraobserver reliability was evaluated using Cohen κ and intraclass correlation coefficients (ICCs). Accuracy, mean absolute error, and perceptual thresholds were analyzed using mixed-effects models and segmented logistic regression. Results: Overall classification accuracy was modest (48.3% AP; 52.5% lateral), with low interobserver agreement (κ = 0.14-0.21). Mean absolute error ranged from 2.0° to 2.2°. Intraobserver repeatability demonstrated moderate agreement (ICC(2,1) 0.43-0.48). Observer performance was most variable near neutral alignment and improved with larger deviations. Years of experience did not improve accuracy and demonstrated a small inverse association with correct classification. Conclusion: Visual assessment of tibial component alignment in TAA demonstrated substantial variability, particularly when evaluating small angular deviations. Imaging characteristics, including view orientation and modality, were associated with measurement error, whereas surgeon experience had minimal impact on overall accuracy. These findings highlight the limitations of visual assessment under standard fluoroscopic and radiographic imaging conditions and support continued investigation of other strategies, such as computer-assisted navigation, 3-dimensional imaging, and robotic-assisted technologies, to improve intraoperative alignment assessment. Level of Evidence: Level III, diagnostic reliability study.
Background: The Zadek osteotomy (ZO) is a well-established surgical option for insertional Achilles tendinopathy. By modifying the position of the posterior calcaneal tuberosity, ZO may reduce posterosuperior calcaneal prominence, mechanical conflict at the Achilles insertion, and tensile stress on the tendon. Nevertheless, the biomechanical impact of wedge orientation and hinge position—and their relationship with underlying foot morphology—has not been clearly defined. Methods: A weightbearing computed tomography (WBCT)–based virtual simulation was performed on 60 asymptomatic feet, categorized as cavus (n = 20), neutral (n = 20), or planus (n = 20) based on the calcaneal inclination angle. Nine ZO configurations were modeled by combining 3 hinge positions (posterior, A; mid-tuberosity, B; anterior, C) with 3 wedge inclinations. Pre- and post-simulation measurements were compared for calcaneal inclination angle (CIA), talocalcaneal angles, hindfoot moment arm (HMA), hindfoot alignment angle (HAA), Fowler-Philip (FP) angle, X/Y ratio, and plantar fascia (PF) length. Results: Wedge inclination showed no significant influence on any variable ( P ≈ .99). Hinge position, however, markedly affected sagittal alignment. Hinges B and C significantly reduced CIA (hinge B −0.5° [95% CI −0.66° to −0.4°]; hinge C −2.1° [95% CI −2.26° to −1.96°], both P < .001). Hinge B showed the largest reduction in FP angle (−7.6° [95% CI −8.63° to −6.59°], P = .16) and produced the greatest increase in X/Y ratio (+0.57 [95% CI +0.46 to +0.68], P = .007). In the pre- to post-simulation analysis, HMA increased slightly with hinge B ( P = .03), and PF length increased only with hinge C ( P < .001). Subgroup analysis revealed that cavus feet exhibited the greatest sagittal correction, particularly with hinge C. Conclusion: ZO significantly affected the Fowler-Philip angle, the primary radiographic outcome, with its overall foot alignment corrective power depending principally on hinge position rather than wedge inclination. These changes occurred predominantly in the sagittal plane while sparing coronal and axial alignment. Clinical Relevance: WBCT-based virtual simulation may help surgeons tailor Zadek osteotomy hinge position to baseline foot morphology and anticipate morphology-specific alignment changes before surgery. Level of Evidence: Level IV, pre-clinical simulation case series.
Background: Lateral ankle sprains are common injuries that may progress to chronic ankle instability (CAI). Although stress radiographs are widely used to assess mechanical instability, magnetic resonance imaging (MRI)-based parameters for evaluating calcaneofibular ligament (CFL) instability remain limited. The purpose of this study was to evaluate the diagnostic value of the CFL tortuosity angle (C angle) measured on oblique coronal MRI in patients with CAI and to examine its relationship with clinical and radiographic measures. Methods: A retrospective analysis of 120 patients (82 CAI, 38 controls) was performed. The C angle was measured on oblique coronal T2-weighted MRI. Talar tilt angle was assessed using stress radiography in the CAI group. Functional outcomes and ankle eversion strength were also evaluated. Results: A total of 120 patients were included, comprising 82 patients with CAI and 38 controls without a history of ankle sprain. The C angle was significantly greater in the CAI group compared with controls (76.5° ± 18.3° vs 31.9° ± 5.4°, P < .001). Receiver operating characteristic analysis demonstrated excellent diagnostic performance (area under the curve, 0.97), with an optimal cutoff of 40.9° (sensitivity, 97.6%; specificity, 100%). The C angle showed a moderate correlation with talar tilt angle ( r = 0.327, P = .003) but limited association with functional scores and muscle strength. Conclusion: The CFL tortuosity angle on oblique coronal T2-weighted MRI demonstrated high diagnostic accuracy for CAI and may serve as a useful adjunctive parameter in evaluating ligament instability. Level of Evidence: Level IV, retrospective comparative study.
Background: Recurrence after minimally invasive hallux valgus correction remains a concern, particularly following combined minimally invasive transverse–Akin (META) and distal minimally invasive metatarsal osteotomies (DMMOs). The influence of deformity severity on recurrence remains unclear. Methods: This retrospective multicentre cohort study included 120 patients treated with combined META and DMMO between 2019 and 2024. Patients were stratified into mild, moderate, and severe deformity groups (n = 40 each). Radiographic outcomes and PROMIS scores were assessed preoperatively and at 3 and 12 months. Recurrence was defined as hallux valgus angle (HVA) > 20°. Multivariable logistic regression identified predictors of recurrence. Results: All groups demonstrated significant radiographic correction and clinically meaningful PROMIS improvement. Recurrence rates at 12 months were 0% in mild, 30% in moderate, and 42.5% in severe deformities ( P < .0001). Baseline HVA independently predicted recurrence (OR: 1.13 per degree; 95% CI: 1.07-1.21; P < .001). Conclusion: Combined META+DMMO was associated with substantial functional outcomes; however, recurrence increases substantially with deformity severity. Level of Evidence: Level III, retrospective cohort study.
Background: Ankle arthrodesis (AA) remains a reliable surgical treatment option for end-stage ankle arthritis in appropriately selected patients. Although traditionally performed in an inpatient (IP) setting, interest in these surgeries being done as an outpatient (OP) and ambulatory surgery center (ASC) settings has increased. We compared costs and post-operative complication rates for AA performed across these settings. Methods: Using Medicare fee-for-service claims (2016-2021), we retrospectively identified patients ≥65 years of age who underwent AA. Using subsequent inpatient and Part B (provider) claims, we evaluated postoperative complications within 1 year, defined by International Classification of Diseases, Tenth Revision ( ICD-10 ) codes, including infection, thromboembolic events, and device-related issues. We also evaluated total episode and post-acute care costs within 90 days. We tested for differences in perioperative safety indicators and costs through multivariate regressions, controlling for age, sex, race, and Charlson Comorbidity Index (CCI), dementia, and the involvement of a surgical assistant. A propensity-matched analysis was performed to minimize selection by indication bias. Results: We included 7104 initial AA cases across surgical settings: 262 (3.7%) in ASC, 3047 (42.9%) in OP, and 3795 (53.4%) in IP. Compared with IP cases, OP and ASC surgeries were performed in younger, healthier (as assessed by CCI) patients and more frequently in male patients ( P < .001). In multivariate analyses, IP cases had the highest infection rates (+7.2 percentage points compared with ASC, P = .001; +4.2 percentage points compared to OP, P = .016) and the highest 90-day total episode costs of $19 817 (95% CI: $18 137 to $21 497). Propensity-matched analyses were consistent with multivariable results, confirming the same directional associations but with modestly larger effect sizes. Conclusion: AA performed in ASC settings was associated with lower complication rates and substantially lower episode-of-care costs compared with IP and OP settings in this Medicare fee-for-service population, particularly among appropriately selected patients. Level of Evidence: Level III, retrospective comparative study.
Background: Operative fixation of distal fibula fractures is a common surgical procedure within orthopaedics. Understanding the variables that influence cost for surgical management of such injuries is increasingly important. In this study, we aimed to evaluate the cost differences in isolated distal fibula fixation. Methods: In total, 394 patients were identified who underwent isolated distal fibula fracture fixation between 2018 and 2025 based on Current Procedural Terminology ( CPT ) coding (27792). Patient demographics, fixation strategy, implant type, and surgical setting were analyzed. Multivariable generalized linear models with inverse Gaussian distribution were used to estimate adjusted cost ratios. Cost data were obtained using the Value-Drive Outcomes (VDO) tool, an instrument at our institution that aggregates itemized costs for each surgical encounter. Costs are reported as relative cost ratios rather than raw dollar amounts. Results: Of the 394 surgeries, 244 were performed at a specialty surgery center (SSC) and 150 were completed at an academic medical center (AMC). Total direct costs were higher for fibula fracture surgery performed at an AMC vs an SSC, resulting in a 42% increase in total direct costs for AMC procedures (cost ratio 1.42, 95% CI 1.32-1.52). Further, AMC facility costs were 84% higher than SSC (cost ratio 1.84; 95% CI 1.75-1.94), with the difference driven primarily by non-OR facility costs whereas OR facility costs were comparable between sites. Implant choice for fibula fixation did not appear to meaningfully influence cost. Surgeon specialty type did not differ in facility cost after controlling for surgery setting (facility cost ratio 1.00, 95% CI 0.95-1.06; P = .97). Conclusion: Distal fibular fracture fixation is significantly more costly when performed at an academic medical center than at a specialty surgery center, largely due to differences in non-OR facility costs. When medically appropriate, operative management of fibula fractures in an outpatient setting may lead to significant cost reductions. Level of Evidence: Level III, retrospective comparative study.
Background: Insertional Achilles tendinopathy (IAT) is a common yet challenging condition that often resists conservative treatment. Traditional open surgical repair carries risk of complications including delayed wound healing and infection. This study compares the outcomes of a minimally invasive surgical (MIS) technique using arthroscopic-assisted double-row repair vs open repair. Methods: Fifty-six patients with IAT underwent surgical intervention between June 2021 and September 2024 (32 MIS, 24 open). Patient-reported outcomes (PROs) were assessed pre- and post-operatively with a minimum 1-year follow-up. Six patients were excluded from analysis for comparability between groups. Statistical analysis used 2-tailed t tests with a Bonferroni adjustment (α = 0.05/3 = 0.0167). The proportion of each cohort reaching the minimal clinically important difference (MCID) was compared via χ 2 analysis, and complications were correlated to body mass index (BMI) and age using logistic regression analyses. Sensitivity analyses using multiple linear regressions, adjusted for follow-up time, were performed on the full cohort (α = 0.05). Results: The MIS group had significantly worse preoperative scores compared with the open group. But at a mean follow-up of 2.2 years for the MIS group and 2.0 years for the open group, the MIS group demonstrated significantly greater improvements in Patient-Reported Outcomes Measurement Information System physical function and visual analog scale scores ( P < .001 for both) and a significantly greater proportion of patients at MCID ( P < .05 for both). Foot and Ankle Ability Measure activities of daily living subscale showed similar findings without significance detected. All PROs retained significance on sensitivity analysis. Complication rates were 0% in the MIS group and 5.0% in the open group with no correlation to BMI or age. Conclusion: Despite limitations necessitating further studies, our results begin to suggest superior functional outcomes following MIS repair for IAT compared to traditional open repair, supporting MIS as a potentially safer and more effective alternative for appropriate patients. Level of Evidence: Level III, retrospective comparative study.
Background: Minimally invasive surgery (MIS) for insertional Achilles tendinopathy (IAT) has been adopted to reduce soft tissue trauma, accelerate recovery, and minimize complications associated with open procedures. Both percutaneous and arthroscopic repairs have demonstrated favorable outcomes, but direct comparison is limited. This study compares complication rates and patient-reported outcomes (PROs) between the two techniques. We hypothesized that both approaches would achieve postoperative scores comparable to population means. Methods: This retrospective nonrandomized cohort study included patients undergoing percutaneous or arthroscopic IAT repair with minimum 1-year follow-up. PROs including Foot and Ankle Ability Measure Activities of Daily Living subscale (FAAM ADL), Patient-Reported Outcomes Measurement Information System for Physical Function (PROMIS PF), and visual analog scale (VAS) scores were analyzed using Bonferroni adjusted significance thresholds (α = 0.05/3 = 0.0167). Minimal clinically important difference (MCID) achievement was compared using χ 2 tests and sensitivity analyses were performed to account for baseline differences (α = 0.05). Results: Fifty patients (25 arthroscopic, 25 percutaneous) were included. The arthroscopic group had significantly longer follow-up ( P < .001), and a significantly higher prevalence of diabetes ( P < .01). There were no complications. All PROs improved significantly from baseline ( P < .001 or P < .01). Postoperative VAS scores were significantly lower in the percutaneous group (0.3 ± 0.5 vs 1.6 ± 1.7, P < .01), averaging 2.2 points lower after adjustment (β = −2.22, 95% CI −3.33 to −1.12; P < .001). Postoperative FAAM ADL scores were higher in the percutaneous group (92.4 ± 15.5 vs 82.5 ± 15.5), although this did not meet the pre-specified significance threshold ( P = .03; α = 0.0167); after adjustment, scores averaged 13 points higher in the percutaneous group (β = 12.99, 95% CI 1.29-24.69, P < .05). Conclusion: Both percutaneous and arthroscopic MIS approaches were associated with significant improvements in pain and function postoperatively. The percutaneous approach was associated with significantly lower postoperative pain scores after adjustment, and may also be associated with higher FAAM ADL scores, although this finding did not meet the pre-specified significance threshold and requires confirmation in larger prospective studies. Level of Evidence: Level III, retrospective comparative study.
Background: It is unknown how the increased range of motion and improved gait mechanics provided by total ankle arthroplasty (TAA) affects the progression of subtalar arthritis compared with ankle arthrodesis (AA). We hypothesized that patients treated with TAA would have a lower incidence of postoperative subtalar arthrodesis (SA) compared to AA. Methods: We retrospectively reviewed a matched cohort of 2105 AA and 2105 TAA surgeries performed between January 1, 2016, and December 31, 2022, using a commercial claims database. Patients with a history of preoperative ipsilateral SA were excluded. Patients were matched 1:1 for gender, age, indication for ankle surgery, and obesity at time of ankle surgery. The primary endpoint was the cumulative incidence of subtalar arthrodesis following the index ankle procedure. Univariate and multivariate regression analyses were performed. Significance was set at P <.05. Results: Demographics were similar between cohorts, including age, gender, presence of obesity, and length of follow-up. At the 5-year time point, the cumulative incidence of subtalar arthrodesis was 42 SAs for every 1000 AAs (4.2%, absolute risk [AR] = 1.425%), compared with 14 SAs for every 1000 TAAs (1.4%, P = .018; AR = 0.713%, absolute risk reduction [ARR] = 0.71%, CI = 0.09%-1.33%). A univariate analysis demonstrated that AA was associated with increased risk of SA (OR = 2.01, CI = 1.08-3.76), whereas factors such as age, gender, laterality, obesity, and diagnosis did not significantly affect SA risk (all P > .05). In a multivariate analysis, AA remained associated with increased risk of requiring SA (OR = 1.90, CI = 1.01-3.56). Conclusion: In this study, we found a significantly higher incidence of subtalar arthrodesis following AA compared with TAA. Surgeons may consider the risk of progression to SA when deciding between TAA and AA for patients with advanced ankle arthritis, particularly in preoperative counseling for patients without existing subtalar arthritis, as TAA may offer an opportunity to mitigate this risk. Level of Evidence: Level III, retrospective comparative study.
Background: The Broström procedure and its modifications remain the gold standard for surgical treatment of chronic lateral ankle instability (CLAI). Internal brace augmentation has gained popularity because of its enhanced mechanical stability and potential to facilitate earlier rehabilitation. However, the effectiveness of internal brace augmentation without formal ligament repair remains unclear. This study compared 1-year postoperative outcomes between standalone internal brace augmentation and modified Broström repair with internal brace augmentation. Methods: We retrospectively reviewed all lateral ankle stabilization procedures performed at a single academic center between January 2017 and December 2020. Patients were grouped by surgical technique: (1) Internal Brace Alone, defined as suture-tape augmentation without formal ligament repair (ST), and (2) Broström + Internal Brace. Outcomes assessed at a minimum follow-up of 1 year included satisfaction, persistent pain, recurrent instability, and revision surgery. Results: A total of 80 patients met inclusion criteria, including 58 (72.5%) in the ST cohort and 22 (27.5%) in the combined cohort. Baseline demographic and comorbidity profiles were similar between groups (all P > .05). At a minimum follow-up of 12 months, both cohorts demonstrated high satisfaction rates, with no significant difference between the ST and combined groups (87.5% vs 90.9%, P = .67). Persistent ankle pain was reported in 32.7% of ST patients vs 22.7% of combined-group patients ( P = .38). Recurrent instability occurred in 6.9% and 4.5% of patients, respectively ( P = .70). Revision surgery was required in 12.1% of ST patients compared with 4.5% of combined-group patients ( P = .32). Conclusion: With the sample size available, no statistically significant differences in measured 1-year outcomes could be detected between standalone internal brace augmentation and modified Broström repair with internal brace augmentation. These findings should be considered preliminary and require confirmation in adequately powered prospective studies. Level of Evidence: Level III, retrospective comparative study.
Background: First metatarsophalangeal joint (MTPJ) arthrodesis is the gold standard for end-stage hallux rigidus and a salvage option for failed hallux valgus correction. Although complication rates for primary and revision fusion have been reported separately, no large-scale study has directly compared outcomes between these cohorts. Methods: Primary and revision first MTPJ arthrodesis cases were identified using the PearlDiver Mariner national administrative claims database. The revision and salvage cohort was defined as first MTPJ arthrodesis performed ipsilateral to any prior hallux procedure, including hallux valgus correction, cheilectomy, arthroplasty, or prior fusion, and is not limited to revision of a failed prior first MTPJ arthrodesis specifically. Cases involving trauma, infection, malignancy, or fewer than 2 years of follow-up were excluded. After 1:1 propensity score matching on demographics and comorbidities, 2099 patients remained in each cohort. Thirty-day complications, 2-year reoperations and failure-related diagnoses, postoperative opioid use, and cumulative health care expenditures were compared between cohorts. Results: Early postoperative complication rates were low and comparable between groups (revision 3.7% vs primary 3.1%, P = .30), with no significant differences in infectious, medical, or surgical complications. At 2 years, revision arthrodesis was associated with significantly higher rates of any reoperation (12.6% vs 8.2%, P < .001), repeat fusion (7.2% vs 4.4%, P < .001), hardware removal (5.4% vs 2.1%, risk ratio 2.51, P < .001), nonunion diagnoses (9.9% vs 4.1%, P < .001), infection-related diagnoses (10.1% vs 6.6%, P < .001), and wound complications (6.7% vs 4.2%, P < .001). Postoperative opioid fill rates were higher in the revision cohort at all evaluated time points, including within 30 days (38.7% vs 34.4%, P = .003) and at 1 year (56.7% vs 51.5%, P = .001). Conclusion: Revision first MTPJ arthrodesis is associated with similar short-term perioperative risk but significantly greater long-term failure burden compared with primary fusion. These findings emphasize the importance of durable primary correction and suggest that salvage cases may warrant heightened attention to patient optimization. Although fixation strategy and biologic augmentation were not directly evaluated in this study, these represent plausible clinical considerations for mitigating reoperation risk and downstream resource use that merit prospective investigation. Level of Evidence: Level III, retrospective cohort study.
Ankle osteoarthritis (OA) is predominantly post-traumatic in origin. It differs in important ways biologically, mechanically, and clinically from hip and knee OA. Despite recognition of its long-term burden, treatment strategies for ankle OA remain largely reactive and centered on end-stage reconstruction. The Arthritis Foundation and the American Orthopaedic Foot & Ankle Society (AOFAS) co-sponsored an Ankle Arthritis Think Tank to address this deficiency in Napa, CA, on January 22, 2026. The focus was to solve patient frustration of limited treatment options and relatively poor outcomes when comparing to hip and knee osteoarthritis. The 2026 meeting brought together a multidisciplinary group of scientists and clinicians to present our current related state of knowledge and to define translational research priorities capable of advancing prevention and treatment of ankle OA within the next decade. Four structured sessions addressed topics relating to ankle OA: (1) Biologic and Biomechanical Pathogenesis, (2) Diagnostic and Management Challenges, (3) Therapeutic Strategies, and (4) Research Methodology. A moderated closing discussion focused on identifying actionable and fundable research pathways. Session presentations and discussion are synthesized here into a unified review.
