Brazilian Orthopedic Foot and Ankle Society.
Clinical outcomes of natural bone matrix grafting in foot and ankle surgery
Objective: This study evaluated outcomes following bone grafting in the foot or ankle using a natural bone matrix with porcine collagen (NBM-PC) composite. Methods: Sixty-six patients were enrolled in this prospective, single-arm, multicenter study. After signing the informed consent, all patients underwent standard-of-care treatment involving bone grafting on their foot or ankle. Patients were seen at 6 weeks, 3 months, 6 months, and 12 months after surgery. Patients also underwent a radiological examination, either radiograph, computed tomography, or magnetic resonance imaging. Results: The most common surgery was arthrodesis (n = 35), followed by skeletal deformity corrections (n = 12). At the 12-month follow-up, 53 patients were evaluated, and radiological examinations indicated a fusion rate of 85%. There was osteolysis of < 1 cm2 in 5% of patients, while six patients presented with non union or pseudoarthrosis. The most common serious adverse events were pseudoarthrosis (n = 2) and wound infection (n = 2), unrelated to the NBM. Conclusions: The radiographic fusion rate of 85% at the 12-month follow-up for this NBM is consistent with that reported for bone grafts other than void fillers. The lack of adverse events related to the use of NBM indicates it is safe and can provide an alternative to autografts in foot and ankle surgery. Level of evidence: IV; Prospective cohort study
Copyright (c) 2025 Journal of the Foot & Ankle https://creativecommons.org/licenses/by-nc/4.0
Hallux valgus treatment with the Percutaneous Bianchi System: a five-year evaluation
Objective: The objective of this study was to evaluate the Percutaneous Bianchi System (PBS) technique in the treatment of hallux valgus (HV) and its durability in a five-year postoperative follow-up. Method: Nineteen patients diagnosed with HV underwent surgical treatment using the PBS method, and 17 of them were evaluated radiographically before and after surgery, with a 60-month follow-up. The degree of deformity correction was recorded based on the hallux valgus angle (HVA) and intermetatarsal angle (IMA), to evaluate the durability of correction over time. Results: The HVA and IMA were significantly reduced in the immediate postoperative evaluation and remained so until 60 months after surgery, with little variability in the temporal relationship. Conclusion: The PBS technique proved to be a safe and durable procedure for correction of symptomatic HV, achieving improvement of the deformity, although further studies are needed for greater consistency in recommending the technique. Level of Evidence IV; Therapeutic Studies; Case Series.
Inter- and intra-observer reproducibility of posterior malleolus fracture classifications
Objectives: To analyze whether PMF classifications can influence treatment choice and surgical approach. In addition, verify the intraand interobserver reproducibility of the three main classifications, stratified by observers’ experience. Methods: Ankle computed tomography of 50 patients was evaluated by ten observers, four orthopedists specialized in foot and ankle surgery, and six non specialist orthopedists, with an interval of two weeks between evaluations. The evaluators classified PMF according to the Mason, Haraguchi, and Bartoníček/Rammelt classifications and determined whether to treat PMF conservatively or surgically (in this case, by access route). In addition, the reproducibility of the classifications was evaluated. The association between decision-making and access route was analyzed using the Chi-Square Test (χ2). Cronbach’s alpha was used to assess intraobserver agreement, and the kappa statistic was used to evaluate interobserver agreement. Results: In analyses of decision-making and the access route, all classifications showed large effect sizes (V > 0.50). Intraobserver reproducibility across the entire sample ranged from 0.53 to 0.95 (0.78 ± 0.12) for the Haraguchi classification, from 0.47 to 0.95 (0.74 ± 0.17) for Mason, and from 0.53 to 0.94 (0.72 ± 0.12) for Bartoníček/Rammelt, indicating adequate agreement across the three classifications. For the specialist orthopedists, the mean ratings for the Haraguchi, Mason, and Bartoníček/Rammelt classifications were 0.86, 0.84, and 0.75, corresponding to good, good, and adequate, respectively. For the group of non-specialists, the means were 0.72, 0.68, and 0.70, indicating adequate, average, and adequate, respectively. Interobserver reproducibility was considered reasonable for Haraguchi (0.38) and moderate for Mason (0.42) and Bartoníček/Rammelt (0.43). Conclusion: All three classifications had large effects on treatment choice and access route decisions, with the Bartoníček/Rammelt classification showing the highest effect. All three PMF classifications were considered adequately reproducible by intraobserver assessment. Interobserver reproducibility was considered reasonable for Haraguchi and moderate for the others. Level of evidence IV; Therapeutic studies; Case series.
Copyright (c) 2026 Journal of the Foot & Ankle https://creativecommons.org/licenses/by-nc/4.0
Development of a novel radiographic angle to assess the calcaneal tuberosity enlargement in insertional Achilles tendinopathy
Objective: This study investigated morphologic features of the calcaneal tuberosity in a group of normal controls and developed a radiographic angular metric, the Pathologic Achilles Insertion Angle (PAIA), with the goal of assisting in the insertional Achilles tendinopathy (IAT) evaluation. Methods: On lateral weight-bearing radiographs, calcaneal tuberosities of 33 control feet were analyzed to develop a mathematical algorithm-based Standard Circle to describe the ideal contour of each tuberosity. Results: Offsets of the circle center and the circle radius were scaled according to their dimensions and the weight-bearing features of the calcaneus (Algorithm 1). Then, enlarged calcaneal tuberosities of 58 feet with different severities of IAT were plotted, and their respective ideal Standard Circles were generated. An angular measurement algorithm (Algorithm 2) was developed to describe how to rotate each enlarged tuberosity to align with its ideal contour using the weight-bearing point as the apex. Thus, the PAIA angular metric provided the amount of the enlargement. Conclusion: Pathologic Achilles Insertion Angle is a novel radiographic metric that considers morphological and biomechanical features of the calcaneal tuberosity and is able to quantitatively evaluate the enlargement of the calcaneal tuberosity in IAT. Level of evidence IV; Case series; Therapeutic studies - investigating the results of treatment.
Lateral column lengthening: A cadaveric biomechanical study
Objective: This cadaveric biomechanical study aimed to investigate the potential cause of the subtalar joint impingement after lateral column lengthening (LCL). Methods: Eight fresh-frozen cadaveric feet underwent sequential LCL osteotomy with grafts of 6 mm, 8 mm, 10 mm, and 12 mm. Uniplanar motion analysis tracked anterior and posterior fragment movements. Mixed linear regression was used to assess correlations between graft size and fragment displacement. Results: During LCL, the anterior fragment shifted anteriorly while the posterior fragment shifted posteriorly, with the anterior shift being greater than the posterior shift. From 6 mm to 12 mm of lengthening, the amount of posterior shift per millimeter peaked at 8 mm of lengthening and then decreased. A linear regression relationship was detected between the amount of lengthening and the anterior shift, with 1 mm lengthening inducing 1.07 mm anterior shift (p < 0.001). Conclusion: In non-deformed cadaveric feet, LCL not only produced an anterior shift as expected but also induced a posterior shift of the tuberosity. Linear correlation was detected between the size of the lengthening and the anterior shift of the anterior fragment. The posterior shift eventually decreased after the insertion of a large graft (10 mm and 12 mm). The clinical application of these findings to flatfoot deformities remains uncertain and should be validated in future studies. Level of Evidence III.
Evaluation of an anatomical syndesmosis classification
Objective: To analyze geometric variations of the tibiofibular syndesmosis incisura fibularis to enhance understanding of its anatomical structure and propose a novel anatomical classification system. Methods: Retrospective analysis of 53 patients who underwent computerized tomography imaging of the ankle. Measurements were taken for various parameters of the incisura fibularis, including length, depth, angle, and fibular engagement. Injury status was taken into consideration. Results: Based on the incisura angle, a classification was established categorizing the incisura into three types: curved (IC, angle < 130°), normal (I0, angle 130°–160°), and shallow (IS, angle > 160°). Correlations between various parameters were identified. Additionally, significant differences in fibular engagement measurements were observed between uninjured (0.96 mm) and injured patients (0.28 mm; p = 0.017). Conclusion: Understanding anatomical variations of the incisura fibularis is crucial for optimizing surgical interventions in syndesmotic injuries. The St. Georg Classification provides a structured approach to guide orthopedic surgeons in creating individualized treatment protocols, reducing the risk of malreduction and improving patient outcomes. Further research is needed to explore the classification’s impact on injury patterns and long-term results. Level of Evidence III; Retrospective comparative study.
Outcome parity in low and high-energy Lisfranc injuries: Evaluation of minimally invasive percutaneous plate osteosynthesis
Objective: This study aims to present the clinical and radiographic results of a prospective cohort followed for three years, treated with indirect reduction and percutaneous fixation in Lisfranc injuries. Methods: A prospective study of 27 consecutive patients with Lisfranc injury was conducted. Patients underwent percutaneous plate and extraarticular screw fixation. Quality of reduction was classified as anatomical, almost anatomical, and non-anatomical. The AOFAS score was used for clinical evaluation. A statistical analysis was performed. Results: Twenty-seven patients with a mean follow-up of 35.5 months were analyzed. Seventeen sustained high-energy injuries, while ten presented low-energy injuries. The postoperative AOFAS at the final follow-up was 81 points. Patients with a greater number of affected columns, evident instability, or staged procedures had lower AOFAS scores. Global quality of reduction positively correlates with the AOFAS score, although no significant association between the number of affected columns and the quality of reduction was observed. Conclusion: Patients with high-energy injuries achieved good results, with a high percentage of anatomical reductions, without differences compared with low-energy injuries. Level of Evidence; IV Case series
Intraoperative comparative tests for syndesmosis: Cotton, external rotation stress, valgus, and tap-tests
Objective: To compare the tap-test and other intraoperative tests, such as the Cotton, external rotation stress, and valgus tests, for the evaluation and diagnosis of distal tibiofibular syndesmosis injuries. This analysis is important for improving diagnostic accuracy and, consequently, optimizing the diagnosis of these injuries, which are often underdiagnosed. Methods: This retrospective cross-sectional study included 111 medical records of patients undergoing surgical treatment for ankle fractures at a referral hospital for orthopedic trauma between March 2023 and June 2024. During data collection, descriptive data were recorded, including trauma mechanism, age, sex, and Weber classification. Intraoperative data were also collected, including the syndesmosis test performed and the injury identification, which determined the need for surgical intervention, such as placement of an inter-tibiofibular screw. Results: The analysis revealed that older patients had a lower prevalence of syndesmosis injuries. The trauma mechanism did not demonstrate significant statistical relevance regarding this type of injury. The tap-test showed a higher rate of intraoperative positivity and a greater proportion of intraoperative detections than Cotton’s, external rotation, and valgus tests. However, no statistically significant difference was found between the tap test and other diagnostic tests. Conclusion: The tap-test demonstrated a high intraoperative positivity rate and detection ratio, indicating its potential as a promising test for detecting syndesmosis instability. Level of evidence IV; Retrospective study.
Epidemiological study and clinical-functional evaluation of patients undergoing surgical treatment of tibial pilon fractures
Objective: To describe the epidemiological profile of patients undergoing osteosynthesis for tibial pilon fractures and to perform a functional-clinical evaluation using the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society questionnaires. Method: Retrospective and descriptive study based on the analysis of 35 patients diagnosed with tibial pilon fracture undergoing surgical treatment between January 1, 2019, and December 31, 2021. The parameters analyzed included: age, sex, profession, side affected, trauma mechanism, interval between surgeries, comorbidities, and postoperative complications. Results: The sample consisted of 23 males (66%) and 12 females (34%), with a mean age of 47.6 years, with falls from height and automobile accidents being the main trauma mechanisms. The distribution of the affected side was balanced: 18 cases in the left ankle (51%) and 17 in the right (49%). According to the AO/OTA classification, fractures classified as AO 43C1 (28.6%) and 43C3 (25.7%) were the most frequent. It was observed that 88.8% of patients classified as 43C3 fractures experienced complications. Conclusion: The development of complications in tibial pilon fractures is significantly associated with AO/OTA classification, which directly reflects poorer clinical functional outcomes. Level of Evidence III; Retrospective.
Is sports practice a relevant risk factor for hallux valgus? A literature review
Objective: To investigate the relationship between Hallux valgus (HV) and the practice of different sports modalities, considering the etiological and etiopathogenic mechanisms and the functional impacts described in the literature. Methods: This is an integrative literature review, which followed the systematic steps of search, selection, and analysis of studies. Controlled keywords and Boolean operators were used to search the PubMed database for publications from January 2005 to January 2025. After applying the inclusion and exclusion criteria, eight articles were included in the final sample. Results: The analysis revealed that sports practice is a relevant risk factor for HV, whose etiopathogenesis may be associated with both repetitive microtraumas—common in sports such as ballet, sports dance, and climbing—and unique traumas—characteristic of modalities such as American football and baseball. In 62.5% of the studies analyzed, there was a relationship with chronic overload in the metatarsophalangeal joint, while 37.5% related HV to acute trauma. Conclusion: Although multiple factors influence the development of HV, sports practice, when associated with joint overload or direct trauma, is a significant contributor to the pathogenesis of the deformity. Level of Evidence V; Review.
Modified Broström technique for repair of the lateral ankle ligament complex: Narrative review
Objective: To evaluate the effectiveness of anatomic repair of the lateral ankle ligament complex, with emphasis on the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), using the modified Broström technique, specifically the Gould modification and contemporary variants (e.g., capsular reinforcement, inferior extensor retinaculum, and suture‑tape augmentation). Methods: Narrative review conducted in PubMed/MEDLINE, SciELO, LILACS, Web of Science, and Scopus databases, using search terms related to ankle instability, Broström technique, and ligament reconstruction. Studies published in Portuguese, English, and Spanish were included, without date restrictions, presenting data on clinical and functional outcomes. Results: Included studies showed significant improvement in functional scores, especially in the AOFAS score, after anatomic repair. The findings indicate high success rates for the technique, with reduced recurrence of instability, improved strength and joint mobility, and high patient satisfaction. Comparison with other surgical techniques suggests that the modified Broström technique has equivalent or superior clinical outcomes with lower morbidity. Conclusion: The modified Broström technique is effective for anatomic repair of the lateral ankle ligament complex, promoting functional recovery and joint stability in patients with chronic lateral instability. Despite the methodological limitations of the available studies, the findings support the clinical relevance of the procedure and its role as the first line surgical option in appropriately selected cases. Level of evidence V; Expert opinion.
Analysis of clinical and functional outcomes of ankle fracture treatment
Objective: Analyze the clinical and functional outcomes of conservative and surgical treatment of ankle fractures in adults, considering postoperative complications, recovery time, need for reinterventions, quality of reduction, and patient satisfaction. Methods: This study conducted an integrative literature review, searching PubMed, Scopus, Web of Science, Embase, and SciELO databases for publications between 2014 and 2024. Fifty-two articles were initially identified, and after applying the inclusion criteria, six were selected for analysis. The main outcomes evaluated were complication rates, recovery time, quality of reduction, and patient satisfaction. Results: The results indicated that surgical treatment, especially in unstable fractures, favors anatomical reduction and faster recovery, but presents a higher risk of postoperative complications, such as infection and fixation failure. Conservative treatment, although associated with slower recovery and risk of addictive consolidation, showed a lower incidence of serious adverse events. Conclusion: The results presented herein should be interpreted as a preliminary synthesis, useful for guiding clinical practice, but insufficient for generalization. The therapeutic decision for ankle fractures should remain individualized, based on the type of fracture, the patient’s clinical profile, and the team’s experience, with active patient involvement in the decision-making process. Level of Evidence II; Review.
3D printing in the manufacture of orthoses to correct children’s flatfoot
Objective: To analyze, through an integrative literature review, the available evidence on the technical aspects, clinical impacts, economic viability, and challenges of adopting three-dimensional (3D) technology in the pediatric context. Methods: The search was conducted on PubMed, Scopus, SciELO, and Web of Science databases, using specific keywords and previously defined inclusion and exclusion criteria. The data were synthesized descriptively and compared with the existing literature. Results: 3D printing allows the production of customized orthoses with high anatomical precision and shorter manufacturing time, presenting clinical benefits such as improved function, reduced pain, and increased adherence to treatment. The economic analysis suggests potential cost reduction in the medium term, although strategies are needed to expand access to technology. Conclusion: 3D printing in the manufacture of orthoses to correct children’s flatfoot is a promising technological alternative, capable of favoring higher anatomical precision, comfort, and potential cost reduction compared to traditional methods. Level of Evidence I; Systematic Review.
Plate versus intramedullary nail fixation in the treatment of distal tibial fractures: Clinical and functional impacts on the ankle
Objective: To compare the effectiveness of plate and intramedullary nail fixation in the treatment of distal tibial fractures and evaluate the impact of each technique on ankle function. Methods: An integrative literature review was conducted, including articles published between 2010 and 2025 in the PubMed, Scopus, Web of Science, LILACS, and SciELO databases, which compared the two surgical methods and presented relevant clinical and functional data. Initially, 512 studies were identified through a systematic search. After applying the inclusion and exclusion criteria, 20 articles were included in the final sample for analysis. Results: The analysis revealed that both techniques have high consolidation rates, ranging from 92% to 97%, with plate fixation associated with greater anatomical precision in complex intra-articular fractures and intramedullary nail fixation associated with shorter surgical time, less soft-tissue trauma, and earlier rehabilitation. Postoperative complications differ by method: plate fixation is most often associated with surgical site infection and delayed soft-tissue healing, while intramedullary nail fixation is at higher risk of mechanical misalignment and anterior knee pain. Regarding ankle function, evaluated mainly by standardized clinical scores such as the American Orthopaedic Foot and Ankle Society, quality of life indexes (SF-36), and range of motion measurements, the results showed equivalence between the techniques in extra-articular fractures. However, a slight functional superiority of plate fixation in complex joint fractures was observed, attributed to its greater capacity to anatomically restore the distal tibial articular surface. Conclusion: The research demonstrates that there is no absolute superiority of one method over the other, and the choice depends on the fracture pattern and the patient’s clinical profile. The findings reinforce the importance of individualizing treatment, preventing complications, and optimizing joint function, and highlight the need for prospective studies with prolonged follow-up and standardized assessment instruments. Level of Evidence I; Systematic Review.
Exactly 50 years ago, on December 12, 1975, ninety-eight Brazilian orthopedic surgeons gathered, at the invitation of Professor Manlio Mario Marco Napoli, to take part in the founding of the Brazilian Society of Podiatry—today known as the Brazilian Association of Foot and Ankle Medicine and Surgery (ABTPé). The founding ceremony was held at the headquarters of the São Paulo Medical Association and was honored by the presence of two world-renowned icons of Foot and Ankle Medicine and Surgery of that era, Dr. Antonio Viladot Pericé (Spain) and Dr. Hampar Kelikian (USA), who encouraged and strongly supported this Brazilian initiative. At that same meeting, the principal objectives of the new society were established: To bring together physicians interested in the clinical practice and surgery of the foot and ankle. To encourage, improve, and disseminate studies, knowledge, and practice in foot and ankle medicine and surgery. To maintain close cultural and scientific relationships with the Brazilian Society of Orthopedics and Traumatology (SBOT), the Brazilian Medical Association (AMB) and their regional branches, as well as with other official national entities and corresponding international organizations. To promote congresses, scientific meetings, symposia, and other academic activities. To publish and disseminate scientific and technical advances related to this field of medical knowledge. These objectives, defined half a century ago, remain alive and actively pursued in the daily work of ABTPé. Celebrating fifty years of history is an achievement that reflects the commitment, dedication, and scientific excellence that ABTPé has consistently upheld over the years. Its contribution to the development of the specialty—both in Brazil and throughout the region—represents a fundamental pillar for the advancement of knowledge, the training of highly qualified professionals for society, and the continuous improvement of patient care. It is deeply gratifying to recognize that, over the decades and through the dedication of successive boards and generations of members, we have preserved our focus and built a strong, cohesive, and effective society. United, we have continuously fulfilled and refined the goals inherited from our founders: We have disseminated scientific knowledge through 21 national congresses, numerous scientific meetings and thematic courses, national and international Foot Clubs, webinars, and the publication of textbooks dedicated to the specialty. We actively participate in the Latin American Federation (FLAMECiPP) and the International Federation of Foot and Ankle Societies (IFFAS), while maintaining close collaboration with federations in Europe, North America, Latin America, and the Asia-Pacific region. The Journal of the Foot and Ankle, the official scientific journal of the Latin American societies and Portugal, represents yet another original dream that has become a reality. In this year marking our fiftieth anniversary, we extend our sincere gratitude to each and every member of this Association who, in their own way, contributed to the many achievements we celebrate today.
Extensive lesser toes plantar plate tears reconstruction: A novel surgical technique with short-term clinical observations
Extensive lesser toes plantar plate tears still challenge surgeons, as primary repair is not feasible. Reconstructive procedures used in these cases are often associated with stiffness, persistence of discomfort, floating toe, vascular compromise, and amputation. We describe a new technique, based on the concept of synthetic neoligamentplasty, in which synthetic tape and absorbable screws are used to achieve metatarsophalangeal joint stabilization in extensive tears (grade IV). Level of evidence IV.
When rare conditions collide: plantar vein thrombosis in hereditary spherocytosis
Plantar heel pain is a common orthopedic complaint, but less frequent etiologies like plantar vein thrombosis (PVT) are often overlooked. We present the case of a 27-year-old female with a history of hereditary spherocytosis who developed left plantar foot pain shortly after starting combined oral contraceptives. Initially suspected to be plantar fasciitis, conservative treatment provided no relief. Imaging studies, including Doppler ultrasonography and MRI, revealed a thrombus in the medial plantar vein. The patient was successfully treated with a 30-day course of anticoagulation therapy using enoxaparin, followed by acetylsalicylic acid. Her symptoms resolved completely, and she remained asymptomatic at a one-year follow-up. This unique case highlights the importance of considering PVT in the differential diagnosis of atypical foot pain, particularly in patients with a history of thrombotic risk factors, to ensure early and effective treatment. Level evidence IV.
Arthroscopic excision of osteoid osteoma of the talus: A case report
Osteoid osteomas are among the common benign bone tumors. They typically found in the cortex of long tubular bones, causing characteristic night pain and significant disability. They are commonly found in younger males characterized by lesions with vascularized nidus surrounded by sclerotic bone. They rarely affect talus. Due to their subtle presentation, they are often missed during clinical examination and on plain radiographs. Computed tomography (CT) is essential for accurate diagnosis. Recently, CT guided radiofrequency ablation has become the preferred treatment. In this article, we present a case of large osteoid osteoma of the talar neck with associated impingement. We utilized arthroscopy to identify the subarticular lesion by its characteristic wine-red colour and performed curettage of both the lesion and the osteophyte in a single procedure. At six months follow-up, patient reported complete pain relief with improved ankle range of motion. Level of evidence IV; Therapeutic study; Case report.
The hidden threat of retained rubber and radiolucent foreign bodies in extremity trauma: Diagnostic and surgical challenges
Penetrating extremity injuries are common among individuals involved in farming and ground-level occupations, often caused by materials such as thorns, wood, ceramics, plastic, and metal. While foreign body retention is well-documented, retained rubber fragments are rarely reported. Such foreign bodies can trigger a granulomatous inflammatory response, leading to symptoms ranging from acute pain and swelling to chronic complications, such as abscesses and discharging sinuses, if untreated. Radiological imaging is key to diagnosis. While plain radiographs detect radiopaque objects, they often miss radiolucent materials such as rubber, wood, and plastic. Ultrasound and magnetic resonance imaging are more effective in these cases, with the latter offering superior sensitivity and aiding in surgical planning. Surgical removal is the definitive treatment, but radiolucent materials pose intraoperative challenges, as C-arm imaging is ineffective. Ultrasound-guided extraction enhances precision, particularly for deeply embedded foreign bodies. In our case, despite initial challenges, intraoperative ultrasound guidance and meticulous dissection ensured successful removal, highlighting the importance of advanced imaging and surgical expertise in managing complex foreign body injuries. Level of evidence V; Case report.
Custom megaprosthesis for the management of a failed total ankle replacement with massive cortical osteolysis
Ankle arthritis is a common, debilitating condition. Total ankle replacement (TAR) has become a popular management option for end stage ankle arthritis. Aseptic loosening is the most common mechanism for implant failure. Third body-mediated inflammatory bone resorption, such as metallosis, is a described mechanism of aseptic loosening. Metallosis can result in massive cortical lysis. Standard revision TAR is not a viable option in the setting of massive cortical osteolysis. The authors present a case of a 67-year-old female,15 years post-primary TAR, presenting with a failed TAR secondary to periprosthetic osteolysis due to metallosis. She was managed with staged revision. The first stage included implant removal, biopsy, debridement, and cement spacer insertion. Histology diagnosed aseptic loosening due to metallosis. Due to massive cortical osteolysis and poor bone stock, the second stage procedure was a custom total ankle megaprosthesis. At the 2-year follow-up, the patient had regained pain-free function, and the AOFAS score improved from 18 to 97. Cortical osteolysis in the setting of a failed TAR makes revision TAR surgery impossible using off-the-shelf revision implants. We describe the successful management of this pathology using a custom-made total ankle megaprosthesis, with good clinical outcomes at two years. Routine clinical and radiographic follow-up is critical following TAR. Level of evidence V, Case Study
Isolated posterior malleolus fractures: A systematic review
Objective: To clarify the mechanism, evaluation, surgical indications, and outcomes of isolated posterior malleolus fractures without additional osseous injury. Methods: A systematic review was conducted using PubMed, Cochrane, and EMBASE databases from their inception to March 31, 2023, focusing on isolated posterior malleolus fractures. Inclusion criteria included adult patients (≥ 18 years old), full-text articles, and studies on isolated posterior malleolus fractures. Results: Of 1,193 screened articles, 25 met the inclusion criteria, comprising 117 patients. Among them, 28 (23.9%) underwent surgery, while 89 (76.1%) received non-operative treatment. Common surgical indications included fragment size, displacement, and syndesmotic instability. Two studies (n = 41) of non-operative management reported three cases of osteoarthritis at long-term follow-up. Conclusion: Current literature on isolated posterior malleolus fractures is limited to case reports and small series. Diagnosis can be challenging, but accurate identification is crucial, as some patients benefit from surgical intervention. Non-operative management remains the standard approach, with excellent long term functional outcomes; however, larger cohort studies with longer follow-up are needed to strengthen current knowledge. Level of Evidence: Level IV; Therapeutic Studies- investigating the results of treatment; Systematic Review of Level III & IV Studies
Foot and ankle minimally invasive surgery what’s up?
Minimally invasive surgery has become much more prevalent in foot and ankle surgery. The rate of publication has increased dramatically, and there is considerable interest in minimally invasive surgery. There are both proponents and critics, as well as benefits and potential complications. In this article, a review of the current literature on the evidence for and against minimally invasive surgery was conducted to present a balanced argument. I will also summarize my personal experience so that, upon reading this article, surgeons have a better understanding of why I have made this change and continue to evaluate outcomes, risks, and benefits. Level of evidence I; Therapeutic studies - investigating the results of treatment.
Virtual and augmented reality in contemporary orthopedics: From simulation to the operating room
Virtual reality (VR) and augmented reality (AR) technologies are redefining the landscape of orthopedic surgery by enhancing surgical education, preoperative planning, intraoperative navigation, and postoperative rehabilitation. These immersive tools provide surgeons with spatially rich environments to rehearse procedures, interact with patient-specific anatomical models, and perform operations with enhanced precision. Intraoperative AR applications, in particular, have demonstrated potential to improve accuracy while minimizing reliance on conventional imaging. In rehabilitation settings, VR-based platforms promote patient engagement and functional recovery through interactive and gamified experiences. While extended reality (XR) is increasingly integrated into clinical workflows, barriers such as hardware limitations, cost, and lack of high-quality clinical evidence remain. Nonetheless, the growing body of early clinical experience highlights its feasibility, safety, and impact. Extended reality is no longer a theoretical promise; it is a practical tool that is actively reshaping orthopedic care. Further studies are needed to guide the safe and effective expansion into routine surgical practice. Level of evidence I; Therapeutic studies - investigating the results of treatment.
Insertional Achilles tendinopathy: Causes, diagnosis, and treatment
Insertional Achilles tendinopathy (IAT) is a multifactorial condition characterized by degeneration at the tendon-bone interface, leading to chronic heel pain, stiffness, and functional impairment. This review explores etiopathogenesis, clinical presentation, diagnostic strategies, and both conservative and surgical treatments for IAT. Risk factors include mechanical overload, aging, metabolic disorders, and biomechanical abnormalities. Diagnosis is primarily clinical, supported by imaging modalities such as ultrasound and magnetic resonance imaging, although imaging severity may not correlate with symptoms. Initial management emphasizes non-surgical options, including eccentric exercises, footwear modifications, and extracorporeal shockwave therapy, which have shown promising outcomes in symptom reduction and functional improvement. Injectable therapies—particularly hyaluronic acid and platelet-rich plasma—have emerged as potential adjuncts, though further evidence is needed to validate their efficacy and define ideal protocols. Surgical interventions are considered in refractory cases and include open debridement, calcaneoplasty, tendon reattachment with or without flexor hallucis longus transfer, and minimally invasive techniques. The choice of approach depends on the extent of tendon degeneration, anatomical considerations, and patient-specific factors such as activity level and comorbidities. Minimally invasive procedures, including percutaneous calcaneoplasty and Zadek osteotomy, offer reduced complication rates and faster recovery, especially in selected patients. Outcomes are generally favorable across techniques when all pathological components are addressed. However, complications such as wound healing issues and nerve injuries remain concerns. The review underscores the need for individualized treatment strategies and further high-quality studies to optimize IAT management and establish standardized therapeutic algorithms. Level of evidence I.
Distal tibiofibular syndesmosis and its secrets
The distal tibiofibular syndesmosis is a critical fibrous joint essential for ankle stability. Injuries to this complex, if misdiagnosed or improperly treated, can lead to chronic pain, instability, and premature osteoarthritis. This review covers the essential aspects of syndesmotic injuries, including anatomy, biomechanics, diagnosis, and current treatment strategies. The syndesmosis is stabilized by the anterior and posterior inferior tibiofibular ligaments and the interosseous ligament. These structures permit controlled motion during ankle movement. The typical injury mechanism involves excessive external rotation and dorsiflexion, leading to a sequential ligamentous rupture. Clinical diagnosis relies on the mechanism of injury and physical tests such as the squeeze and external rotation tests, although their reliability is debated. Imaging is crucial for confirmation. Weight-bearing radiographs are the first-line study, but computed tomography (CT), especially weight-bearing CT, offers greater accuracy for diagnosing instability. Magnetic resonance imaging (MRI) is excellent for assessing soft-tissue damage and associated injuries. Treatment is determined by joint stability. Stable, partial injuries are managed conservatively with immobilization and structured rehabilitation. Unstable injuries require surgical intervention to ensure anatomic reduction and restore stability. While rigid screw fixation was historically the standard, it impairs physiological motion and often necessitates a second surgery for hardware removal. Flexible fixation with suture-button devices has emerged as the modern standard of care. This technique provides dynamic stabilization, allows for natural joint micro-motion, and is associated with improved clinical outcomes and a lower rate of reoperation. Arthroscopy is a valuable tool for diagnosing and treating these injuries, enabling direct visualization and debridement to ensure accurate reduction. Proper management of syndesmotic injuries is paramount for optimizing patient recovery and preserving long-term ankle function. Level of evidence IV.