Brazilian Orthopedic Foot and Ankle Society.
Risk factors for calcaneal fracture-related infection in open reduction and internal fixation: a retrospective cohort
Objective: To identify independent risk factors for calcaneal fracture-related infection (FRI) in open reduction and internal fixation (ORIF). Methods: Retrospective and observational study using data extracted from the TriNetX international platform, including patients of both sexes with a confirmed diagnosis of calcaneal fracture submitted to surgical treatment with ORIF, with a 1-year follow up. An adjusted multiple logistic regression test was used to identify independent variables, and the Kaplan-Meier and Log-Rank tests were used to assess disease-free survival. Results: In total, 2,830 patients with a mean age of 50 years (SD ± 15) were evaluated, most of them men, 1,788 (63.8%). One hundred eighty-one patients had FRI within one year after surgical treatment. The following variables were independent risk factors for FRI: smoking [OR 1.8 (CI 0.02;0.06), p = 0.0001], alcohol abuse [OR 1.6 (CI 1.0;2.6), p = 0.045], chronic kidney disease [OR 2.23 (CI 1.13;4.39), p = 0.017], overweight [OR 2.8 (CI 1.34;5.89), p = 0.004], fall from height [OR 2.18 (CI 1.47;3.25), p = 0.0001] and open fracture [OR 2.13 (CI 1.07;4.23), p = 0.026]. Conclusion: Smoking, alcohol abuse, chronic kidney disease, overweight, fall from height, and open fracture were independent risk factors for infection. Level of evidence II, observational study
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Modified Lapidus Procedure with a Single Screw and Staple: A Comparative Analysis
Objective: The primary objective of the study is to review the fusion rate associated with a single screw and staple construct in Lapidus bunionectomy, and to compare the complication rates, fusion outcomes, and radiographic results with those of other common fixation methods. Methods: Eighty-four bunionectomies met study criteria; in 24 cases, a single screw and staple construct was used, while 28 used a screw and locking plate, and 32 used two crossing screws. Although group matching was attempted, a greater body mass index was observed in the screw and locking plate group (p = 0.006). Results: The minimum follow-up was 12 months (mean, 31.4 months), and the primary outcome was fusion rate. Union rates were achieved in 95.8% for the single screw and staple fixation (23/24), 92.8% for the screw and locking plate (26/28), and 93.8% for crossing screws (30/32) without a statistically significant difference (p = 0.474). The single screw and staple group achieved significantly (p = 0.012) earlier radiographic and clinical union, at 11.7 (+ 1.86) weeks, compared to crossing screw (13.2 + 2.39 weeks) and screw and locking plate (13.5 + 1.69 weeks) groups. There were no significant differences in final first intermetatarsal angle (p = 0.403), hallux valgus angle (p = 0.153), or complication rates (p = 0.386) among the fixation methods. Conclusion: Our study shows that a single screw and staple construct is a viable option for Lapidus bunionectomy, demonstrating faster union time and maintained deformity correction with an acceptable complication rate. However, further research is required to validate the advantages and disadvantages of specific surgical implants. Level of evidence: III, retrospective case control study
Objective: Wearing high heels is a common practice, especially among urban women, and is part of the social and professional environment for many people. Research on the subject often focuses on the harmful health effects of high heels, including discomfort and pain, musculoskeletal disorders, and foot deformities. Since few studies have assessed the subjective effects of high heels, the objective of this study was to investigate why people wear them or not. Methods: A cross-sectional, quantitative study was conducted using an online self-administered questionnaire that covered the participants' profiles and reasons they wear or do not wear high heels. The convenience sample consisted of skeletally mature cisgender and transgender women aged ≥ 18 years. Data were collected between November 2023 and March 2024. Results: A total of 1100 responses were obtained, with a final sample of 801 participants. The variables significantly associated with wearing high heels were age, education, profession, approximate family income, and nutritional status. The reasons for wearing high heels included aesthetics (~80%), feeling more beautiful (63%), better professional appearance (54%), and improved self-esteem (47%). Conclusion: Most participants wear high heels for aesthetic reasons, and more than half of those reported feeling more beautiful and feeling more professionally dressed. Although most participants who wear high heels experience pain (66%), there are still good subjective reasons to continue wearing them. Among those who reported not wearing high heels, the main reason was foot pain or discomfort. Level of evidence II; Cross-sectional, quantitative study.
Adequate and safe operative fixation of ankle fractures by residents and orthopedic trauma surgeons
Objective: Investigate surgical outcomes of patients with ankle fractures operated on by residents and orthopedic trauma surgeons. Methods: Retrospective cohort study including all adult patients surgically treated for ankle fracture from 2016 to 2020 in regional hospitals in the Netherlands. Data regarding patient demographics, fracture characteristics, and treatment characteristics were collected from patient medical records. Results: Patient demographics and fracture characteristics were similar for patients who underwent surgery by residents compared to those operated on by orthopedic trauma surgeons. There was no significant difference in postoperative complications, revision surgeries (2.8% vs. 4.7%), surgery duration (60.0 minutes vs. 54.0 minutes), or quality of life for residents compared to orthopedic trauma surgeons. Differences were seen in surgical treatment, with external fixation (2.2% vs. 5.2%), medial screw fixation (21.4% vs.28.5%), and dorsal plate fixation (21.4% vs. 28.5%) being significantly more often used in patients operated on by surgeons. Logistic regression showed that primary surgeon being a resident or orthopedic trauma surgeon was not a predictor for complications. Conclusion: Outcomes after surgical fixation of ankle fractures are comparable for residents and orthopedic trauma surgeons. Careful selection of patients combined with an appropriate level of supervision is necessary for residents to develop their skills without putting patients at risk. Level of evidence: Level II, Prognostic study, Retrospective study.
Translation, cultural adaptation, and validation of the AOFAS lesser metatarsophalangeal-interphalangeal scale into Brazilian Portuguese
Objective: Translate, culturally adapt, and evaluate the reproducibility of the American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale into Brazilian Portuguese. Methods: The AOFAS and SF-36 questionnaires were applied to 50 patients with lesser toes deformity. The methodology followed the criteria defined by Reichenheim & Moraes for translation and cultural adaptation of questionnaires. Result: The intraclass correlation coefficient (ICC) across the domains was 0.96, and Cronbach’s alpha was 0.80, both indicating excellent reliability. The scores of the first and second evaluations were 70.72 and 72.36, respectively, with high interobserver agreement and overlapping confidence intervals. Spearman’s correlation analysis also yielded a correlation coefficient of 96%, indicating strong agreement among the applications of the test. Conclusion: According to the established criteria, the translation and cultural adaptation of the questionnaire were conducted effectively, with very high interobserver agreement, and can be safely reproduced in Brazilian Portuguese. Level of evidence IV; Case series
Ottawa Ankle Rules and their association with ligamentous or chondral injuries of the ankle: a prospective observational study
Objective: Evaluate the association between the Ottawa Ankle Rules (OAR) and the presence of ligamentous and chondral injuries identified on magnetic resonance imaging (MRI). Methods: A prospective observational study was conducted in 48 patients who underwent clinical evaluation using the OAR with subsequent MRI assessment. Variables analyzed included patient age, gender, laterality, and presence of ligamentous or chondral injuries. Statistical analyses were performed using the Shapiro-Wilk test for normality, Student’s t-test for age comparisons, and Pearson’s chi-square test to assess associations between categorical variables. Results: Mean age of patients was 41.06 years, ranging from 15 years to 82 years. Groups with positive and negative OAR results were homogeneous regarding age (p = 0.29), gender (p = 0.42), and laterality (p = 0.09). No significant association was found between a positive OAR and the presence of ligamentous injuries (p = 0.42) or chondral injuries (p = 0.83) on MRI. Conclusion: The OAR were not associated with ligamentous or chondral injuries identified on MRI, suggesting their limitations in predicting these specific findings. Further studies are needed to develop a more accurate predictive model incorporating clinical and imaging parameters. Level of Evidence IV; Prospective Observational; Case Series
Clinical outcomes of proximal medial gastrocnemius release in the treatment of non-insertional Achilles tendinopathy
Objective: To evaluate the outcomes of proximal medial gastrocnemius release (PMGR), a procedure with relatively low morbidity, in the treatment of non-insertional Achilles tendinopathy. Methods: Twelve patients diagnosed with non-insertional Achilles tendinopathy, confirmed by clinical examination and nuclear magnetic resonance imaging, and refractory to conservative treatment, were treated with PMGR. Five patients had bilateral involvement, totaling 17 tendons treated. Results: After a mean follow-up of 32 months, the mean American Orthopaedic Foot and Ankle score increased from 62.1 preoperatively to 90.2 at last follow-up. The mean pain score on the visual analog scale decreased from 6.7 preoperatively to 1.9 at last follow-up. While some patients experienced residual pain, it was milder than preoperative pain in all cases, and all participants reported satisfaction after the treatment. Conclusion: Despite the small sample size and short follow-up period, the results were promising. As PMGR is a relatively simple procedure compared to tendon reconstruction techniques, it may be an attractive alternative treatment for this common and disabling disorder. Evidence Level: III; Type of Study: Retrospective study
Management of ankle fractures in diabetic patients: case series of seven patients
Objectives: To evaluate the effectiveness and safety of retrograde intramedullary nailing with antibiotic-impregnated cement in the management of ankle fractures in diabetic patients with peripheral neuropathy, focusing on postoperative outcomes. Methods: This study included seven diabetic patients with traumatic ankle fractures and peripheral neuropathy. Postoperative data collection was performed, focusing on evaluating fracture healing through radiographic evidence, time to achieve full weight-bearing, and any complications, including infection, wound dehiscence, or the need for additional surgical intervention. Results: Regarding postoperative complications, among seven diabetic patients with ankle fractures, only one patient developed a medial foot ulcer. Four patients achieved full weight-bearing without pain within five months, and no cases of delayed union, malunion, or nonunion were recorded. Conclusions: Orthopedic surgeons face challenges treating ankle fractures in diabetic patients due to high morbidity and mortality rates. Our case series demonstrated that the minimally invasive tibiotalocalcaneal option may reduce infection risk and require fewer operations, with only one postoperative complication and no intraoperative issues. Level of evidence: IV, Case series
A comparison of foot pain and dynamic stability among heeled and flat foot wear users in undergraduate female medical students
Objective: To compare foot pain and dynamic stability among flat and heeled footwear users in undergraduate medical students, raising awareness about the importance of appropriate footwear for improving health and stability. Methods: This analytical cross sectional study targeted 305 undergraduate female medical students to assess foot pain and dynamic stability. Participants were selected using a convenience sampling technique and pre-specified inclusion/exclusion criteria. Foot pain was measured using a 100 mm visual analog scale, with validity (0.76 to 0.84) and reliability (0.66 to 0.77). Dynamic stability was assessed using the four square step test (FSST), which showed excellent test-retest reliability (ICC = 0.92). The sample size was calculated using Yamane’s formula, resulting in 305 participants. Results: The study showed that 68.9% of participants had a normal body mass index, with 33.8% reporting no foot pain, while 56.1% experienced mild pain, and 10.2% severe pain. The ANOVA test revealed a significant increase in stability test times with higher heels (flat: 6.62s, low: 7.39s, high: 8.91s, F = 68.880, p < 0.001), and the Kruskal-Wallis test (Non normally distributed data) showed increased pain with higher heels (p = 0.001). The most common pain areas were the heels (38%) and the arch (27.9%), highlighting the negative impact of heel height on both pain and dynamic stability. Conclusion: The study indicates that elevated heel heights substantially exacerbate foot discomfort and hinder dynamic balance when compared to flat shoes among female undergraduate medical students. Level of evidence III; Analytical Cross-sectional Study.
Outcomes of plated metatarsophalangeal joint fusions without transarticular screw fixation
Objective: Evaluate the outcomes of metatarsophalangeal (MTP) arthrodesis performed with plate-only fixation. Methods: A retrospective observational study was conducted on 68 patients submitted to MTP arthrodesis with plate fixation between June 2021 and December 2023. The primary outcome measure was the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) score, evaluated preoperatively and postoperatively in patients who received a locking-compression plate or locking plate. Secondary outcomes included complication rates and the duration of follow-up. Results: The mean patient age was 64.0 years, with a body mass index of 28.5 kg/m2. The minimal clinically important difference of PROMIS-PF scores was achieved by 30.9% of patients. The complication rates were low, with no cases of malunion and only 2 (2.9%) nonunions. Patients who received a locking compression plate had higher postoperative PROMIS-PF scores compared to the locking plate group (46.4 vs. 42.3, p = 0.038), and a greater percentage of these patients experienced improvement in PROMIS-PF postoperatively (71.4% vs. 42.5%, p = 0.035). Conclusions: Both locking-compression and locking plates for MTP joint arthrodesis without transarticular screws are effective, with a low complication rate. These outcomes were comparable to those of prior studies evaluating screw-only and plate and screw fixation constructs. Longer follow-up studies are required to enable direct comparison of outcomes across the alternative arthrodesis techniques. Level of Evidence III; Retrospective, Case-control study.
Perception of quality of life in patients with diabetic foot
Objective: Investigate the factors that influence the perception of quality of life in patients with diabetic feet, with and without ulcers in the lower limbs. Methods: An observational cross-sectional study in 50 adult patients with type 1 and 2 diabetes mellitus, where sociodemographic, clinical, and treatment data were collected, and the Neuropathy Specific Quality Of Life (NEUROQOL) questionnaire was applied, which consists of 35 items that evaluate six domains related to quality of life. Comparisons were performed using appropriate statistical tests, considering the significance of p < 0.05. Results: The mean age was 70 years, with 13 patients having a history of amputations, and 18 had foot ulcers. The domains significantly affected were sensorimotor symptoms, limitations in daily activities, interpersonal problems, and emotional distress. Patients with amputations or ulcers had higher scores, indicating poorer quality of life. Physical activity was associated with significantly better scores in several domains. Conclusion: Patients with diabetic foot complications, such as amputations or ulcers, had a poorer quality of life, especially in the domains related to functionality and emotional well-being. Physical activity proved to be a relevant protective factor. Preventive and therapeutic strategies that promote mobility, health education, and adequate clinical management can contribute to improving the quality of life in individuals with diabetic feet. Level of Evidence IV; Therapeutic studies - investigating the results of treatment; Case series.
Decellularized human dermis vs. standard care in two diabetic foot ulcers: A comparative case report
Objective: To describe healing trajectories in two neuropathic diabetic foot ulcer cases—one treated with decellularized human dermis (DHD) and one with moist wound management (MWM). Methods: After a two-week optimization period, two adults with long standing diabetes and plantar ulcers were managed weekly for 12 weeks. Case 1 received a single 4 × 4 cm DHD graft combined with non-adherent dressings, and case 2 received gauze-based MWM alone. Wound area was quantified using digital planimetry. Results: Case 1 achieved an 80% area reduction by week 4 and achieved full epithelialization at week 8. Case 2 showed a 7.8% area reduction by week 2, a transient 21.6% area increase between weeks 3 and 5, and reached 68.6% reduction by week 12 without closure. No adverse events occurred. Conclusion: The results of our study suggest that DHD may accelerate closure compared with standard care. Due to the small sample size, randomized controlled studies with longer follow-up are essential. Level of Evidence V; Case report.
Adipose mesenchymal stem cells in ankle osteoarthritis: a case report
Ankle osteoarthritis, mostly of traumatic origin, compromises the mobility and quality of life of patients. Conventional treatment includes physical therapy and infiltrations, while advanced cases require arthrodesis or arthroplasty. In this context, mesenchymal cells from adipose tissue emerge as a promising alternative. We report the case of a 43-year-old patient with advanced ankle osteoarthritis treated with micro-fragmented adipose tissue (MFAT) infiltration using Lipogems® technology. The procedure resulted in significant improvement in pain and joint function in the first three months, followed by partial regression at six months. The findings corroborate previous studies, suggesting transient efficacy and indicating that more advanced cases may have a limited response. Further research with larger samples and longer follow-up is needed to elucidate the therapeutic potential of this approach. Level of evidence V; Case report.
Association of bilateral trans-syndesmotic lesion with logsplitter and syndesmosis instability with high ankle sprain in a young patient: a case report
Dislocated fractures of the ankle are frequently associated with ligament injuries; between 20% and 45% of injuries of the distal tibiofibular syndesmosis occur in 6% to 16% of patients without associated fracture. These lesions can occur by different mechanisms: abduction, external rotation and dorsiflexion (Danis-Webber C), pronation and external rotation Lauge-Hansen and by vertical shearing, the latter being little described in the literature. Clinical presentation includes pain, edema, instability, restricted dorsiflexion, and functional limitation support and gait. The most characteristic symptom is pain over the tibiofibular ligaments. On physical examination, diagnostic suspicion is based on the presence of pain, edema, ecchymosis, and deformity at the ankle level. Diagnostic tests include different clinical signs, conventional and stress radiography, computed tomography, magnetic resonance imaging and fluoroscopy under anesthesia, in some cases), arthroscopy, and intraoperative clinical tests. We present the clinical case of a 21-year old female patient with right ankle dislocated fracture and bilateral injury of the distal tibiofibular syndesmosis following axial trauma to the lower limbs after a fall from a height of six meters. Level of evidence V; Case report.
Osteochondral lesions of the talus: diagnostic and therapeutic approaches in orthopedics
Objective: Evaluate the diagnostic and therapeutic approaches currently employed in the management of osteochondral lesions of the talus, with an emphasis on technological advances and regenerative therapies. Methods: This review was conducted based on the PRISMA guidelines and included 16 studies published between 2010 and 2024, selected from the PubMed, Scopus, Web of Science, and Embase databases. Results: Advanced imaging techniques, such as magnetic resonance imaging with T2 mapping and three dimensional computed tomography, are fundamental for early diagnosis and surgical planning. Conservative approaches, such as immobilization and physiotherapy rehabilitation, have demonstrated efficacy in providing symptomatic relief for minor lesions; however, they present limitations in tissue regeneration and the long-term maintenance of joint function. Conventional surgical procedures, including microfractures and subchondral perforation, were associated with initial functional improvements but with a risk of progressive degeneration of the reparative fibrocartilage. Regenerative therapies, such as autologous and allogeneic osteochondral transplantation, as well as the use of mesenchymal stem cells and bioactive scaffolds, have shown potential in restoring hyaline cartilage and preserving the joint, particularly in complex and refractory lesions. Despite technological and therapeutic advances, challenges persist, including the standardization of protocols, high costs, and limited accessibility to emerging therapies. Additionally, a meta-analysis was not possible to perform due to the heterogeneity of the included studies, which encompassed both randomized clinical trials and observational studies. Conclusion: Integrated and individualized therapeutic strategies are crucial for optimizing clinical outcomes, preserving joint functionality, and enhancing the quality of life for patients with osteochondral lesions of the talus. Level of evidence I; Systematic Review.
Impact of immobilization time on the recovery of ankle function after Achilles tendon rupture
Objective: To analyze the impact of immobilization time on the recovery of ankle function after Achilles tendon fracture. Methods: Studies published between 2013 and 2023, extracted from databases including PubMed, Scopus, Web of Science, Embase, and Cochrane Library, were included. Results: The analysis revealed that protocols with immobilization of 0-2 weeks resulted in better recovery of range of motion, muscle strength, and greater patient satisfaction, without a significant increase in complication rates or re-ruptures. In contrast, immobilization of 4-6 weeks was associated with greater joint stiffness and delayed return to sports activities. Conclusion: The findings reinforce the benefits of early mobilization after Achilles tendon rupture and reinforce the need for a more individualized approach. Level of Evidence I; Systematic Review
Comparison of Chevron and Scarf osteotomies in hallux valgus correction: Functional and radiographic outcomes
Objective: To compare the functional and radiographic outcomes between Chevron and Scarf osteotomies in hallux valgus correction. Method: A systematic review was conducted in the PubMed/MEDLINE, SciELO, Lilacs, and Embase databases from 2004 to 2024. Inclusion criteria included clinical trials and observational studies that directly compared both techniques. Results: Both osteotomies showed similar effectiveness in improving functional scores (AOFAS) and correcting hallux valgus and intermetatarsal valgus angles. Chevron osteotomy was more indicated in mild to moderate deformities, while Scarf osteotomy showed greater stability and versatility in severe deformities. Conclusion: Both osteotomies are effective, with specific advantages. The surgical choice must be individualized. Level of Evidence Level I; Systematic Review
Return to sport after hallux valgus surgery in athletes: Current Evidence
Abstract Introduction: Hallux valgus affects approximately one-third of the population and is characterized by a three-dimensional deformity. This condition can impact performance in sport-related activities. The most suitable surgical option for athletes with hallux valgus remains unclear. The current lack of evidence and studies covering various registration systems and sports makes them non comparable. Objective: This study aims to present evidence regarding the different surgical techniques for hallux valgus and their impact on return to sports. Methods: Two authors conducted a search using PubMed, Embase, MEDLINE, Google Scholar. The inclusion criteria were articles involving case series published in the English language from 1995 through January 2025. Exclusion criteria were hallux rigidus, traumatic deformity, sesamoid pathology, and review articles. Studies that did not describe the athlete's level of play and the type of sport were also excluded. Results: This review identified eight studies on the surgical correction of hallux valgus in “athletes” published to date. Currently, the evidence supports Chevron osteotomy for mild to moderate deformities and Scarf osteotomy for moderate to severe deformities, both resulting in low recovery time. At best, metatarsophalangeal arthrodesis provides 96% satisfaction in sport-related activities. Conclusion: Chevron and scarf osteotomies are effective surgeries for athletes with minor deformities. For severe hallux valgus, there is no clear consensus, but metatarsophalangeal arthrodesis appears to demonstrate a good result. Future studies need to document activity levels and return to sport to help guide treatment. Level of evidence I; Systematic Review.
Lymphedema and edema of the lower limbs: what do foot and ankle orthopedists need to know? A narrative review
Objective: To review in the literature updates on lymphedema and differential diagnoses of lower limb edema for foot and ankle orthopedists. Methods: This is a narrative review, and the search was conducted on the PubMed and SciELO databases, using established keywords. Articles published in the last 15 years were included. The research question was “What do foot and ankle orthopedists need to know about lymphedema and lower limb edema?” Results: Lymphedema is one of the causes of chronic lower limb edema, characterized by excessive lymphatic fluid in the interstitial medium due to impaired lymphatic drainage. It can be classified as primary or secondary lymphedema, with trauma being one of the most important etiologies of the latter. The diagnosis of this condition is primarily clinical, typically established through a thorough medical history and physical examination. Complementary examinations can evaluate indirect signs of lymphedema or direct signs of lymphatic dysfunction through lymphoscintigraphy. The differential diagnosis of chronic lower limb edema is challenging, and venous, cardiac, and traumatic etiologies, as well as lipedema, should be considered. Conclusion: A thorough clinical examination, combined with appropriately indicated diagnostic tests such as lymphoscintigraphy, is essential for the differential diagnosis of chronic lower limb edema—a common finding in orthopedic clinical practice. Level of Evidence V; Narrative review
Glomus tumor of the hallux: A technical tip and narrative review
Tumores glômicos são neoplasias benignas e raras, com poucas descrições de 5 acometimento das extremidades inferiores. Este artigo descreve um caso de tumor 6 glômico no hálux, com localização atípica e a técnica cirúrgica de ressecção utilizada, 7 com excelente resultado clínico; e apresenta revisão narrativa relacionada a 8 incidência, características clínicas e opções terapêuticas para esse tumor benigno. 9 Nível de evidência V, Estudo terapêutico, Opinião do especialista
Modified posterolateral approach for fixation of posterior malleolar fractures associated with distal tibiofibular syndesmosis injury: A surgical technique
Posterior malleolar fractures are challenging to treat in ankle injuries and, when not treated properly, can lead to unfavorable results, especially if associated with syndesmosis injury. Posterior access approaches (posterolateral and posteromedial) are recommended for reduction and adequate fixation of the posterior malleolus; however, they usually do not allow direct visualization of the syndesmosis, one of the main prognostic factors in the treatment of these injuries. We present a modified posterolateral approach that enables direct visualization of the syndesmosis, in addition to the use of syndesmosis fixation implants integrated with lateral implants when associated with a lateral malleolar fracture. Level of evidence IV; Case series
Much more rapidly than anticipated, we have observed the submission of manuscripts to the Journal of the Foot and Ankle that have been predominantly produced with the assistance of Artificial Intelligence (AI). This observation stems primarily from the diligent work of our editorial board, which is committed to providing constructive and collaborative reviews rather than merely selective evaluations. This editorial philosophy obliges each reviewer to engage deeply with the manuscripts, working alongside the authors to improve not only the structural formalities of a scientific paper but also the clarity and precision of the language. In doing so, reviewers decisively influence the quality of the final product, thereby enhancing the dissemination of ideas and results, and facilitating the incorporation of new knowledge into daily practice. However, this task has increasingly become exhausting — and at times nearly unmanageable — when confronted with lengthy, complex texts that are clearly inflated by the use of AI. Such manuscripts are often riddled with thematic confusion, inconsistent insertions attempting to establish non-existent correlations, and a troubling duplication — or even multiplication — of papers on similar topics that overlap in an abnormal and unacceptable manner. The same phenomenon has been identified in high-volume preprint platforms, where the participation of so-called “paper mills” and AI-based tools has significantly increased the proportion of LLM-generated manuscripts, reaching figures as high as 10% in the biological sciences and 22% in computer science. The “symptoms” of AI-driven manuscripts may be summarized as follows: Overreliance on technology – texts produced without the rigor of conventional scientific methodology; Stereotyped writing – instead of advancing knowledge, such texts contribute to increased “noise” within scientific fields; Authorship opacity – lack of transparency regarding the role of AI in manuscript production; Fabricated claims – due to AI “hallucinations” that introduce false data and references; Rapid dissemination of misinformation – amplified by modern preprint publication systems; An “arms race” between AI authors and AI detectors – which may generate false positives and unfairly penalize legitimate authors. The central concern, therefore, lies in the undeniable risk of disseminating low-quality articles that circulate misleading or false information, thereby severely undermining the trustworthiness of scientific output. In our ongoing efforts toward the indexation of the Journal of the Foot and Ankle, we must now contend with this additional challenge. Stricter differentiation between authentic manuscripts and those generated by AI will be indispensable, as it represents the only viable means of safeguarding the integrity — and the very survival — of this journal.
From Industry to Academia: A Leading Orthopaedic CEO’s Journey into Research
As a child, I never dreamt of feet. I never considered their importance or complexity. I certainly never said, “One day I will grow up and improve people’s ability to walk.” And yet, I find myself in a place where I am inspired every day to seek answers, think creatively, and improve lives. Today, I can say with confidence and childlike wonder: my purpose is feet. I grew up in a Portuguese household with three amazing siblings, the youngest of whom was born with spina bifida. Our family was close-knit, and I spent much of my childhood by my sister’s side. Through her, I experienced life with a disability—the longing to blend in, the silent resilience of wanting to feel “normal.” I remember taking her trick-ortreating in a basket on a three-wheeled bike so she could share in the joy of childhood. I dreamt, even then, of finding a cure. I never imagined I would spend my career trying to create solutions that might fulfill that dream not just for her, but for countless others. I didn’t become a doctor—a minor disappointment to my loving Portuguese mother—but I did become an engineer. And I fell in love with the world of orthopedics through sales. I explored hips, knees, spine, and sports medicine, but it was foot and ankle that captured my heart. The field was young, diverse, and underdeveloped—with over 100 indications and very limited data. I remember being asked for 10-year follow-up data and thinking, “We are lucky to have any data at all.” The foot itself is a miracle of biomechanics. From the plantar fascia controlling arches and force vectors to the interplay between rigid and flexible columns—we understand so little about something so fundamental. Every day, I learn more, and every day I am more convinced that I have found the purpose I never knew I needed. This is bigger than any financial goal. I know I can help. I vividly recall a conversation with Dr. Michael Houghton about syndesmotic reduction. He described how subtle and tactile the procedure is—how you rely on a 1 mm overlap and “feel” the tilt of the talus. Years later, finite element modeling at the University of Virginia quantified what he described: a deviation of less than 1 mm alters pressure in the talar gutter enough to initiate arthritis. It confirmed what I already believed—this field needs precision, clarity, and innovation. In 2010, I co-founded Paragon 28 with Lee Rosenthal in his basement in Birmingham, Alabama. We didn’t fully grasp the scale of what we were building. Understandably, our wives were not thrilled when we announced we were quitting our jobs and investing our life savings in a dream. At the time, Foot & Ankle was growing at 9–10% annually—an anomaly in orthopaedics—and larger companies took notice. But to many of them, it was just a growth opportunity. That offended me. I walked trade show floors seeing the same recycled ideas. Changing anodization color or screw diameter by 1 mm and calling it innovation? That is not what transforms patient care. We believed our market deserved better—and that conviction built one of the most effective Foot & Ankle companies in the industry. A company built on research first, without a product in mind. Research that would drive the next generation of understanding. We cared deeply about leaving a legacy of transforming an entire segment. By 2019, we crossed $100 million in revenue—a milestone that required us to evolve. What got us there would not get us to the next $100 million. We conducted a surgeon survey that made one thing clear: innovation was not yet changing lives. We asked ourselves hard questions. Would outcomes with our “cool” solutions actually outperform k-wires? That was the moment we committed to enabling technologies.