Brazilian Orthopedic Foot and Ankle Society.
Deltoid all-inside repair in SER IV bimalleolar-equivalent ankle fractures
Introduction: Ankle fractures are the second most common fractures of the lower limb. In supination-external rotation (SER) stage 4 injuries, the medial malleolus or the deltoid ligament is disrupted. The stability of the deltoid ligament is essential for functionality; however, the need for surgical repair remains debated. The aim of this study is to assess deltoid stability in 12 ankle fractures treated with an all-inside repair technique. Methods: A prospective case series of 12 patients (8 male, 4 female aged between 25 and 53 years who had a stage 4 Lauge-Hansen SER ankle fracture with unstable deltoid ligament injury between September 2023 and February 2024. No patients in this study had an associated posterior malleolus fracture. All patients underwent deltoid all-inside repair at the time of fracture fixation. Outcomes were measured using the VAS scale, radiographic and magnetic resonance imaging (MRI), and AOFAS scores, which are reported exclusively in the Supplementary Material for historical comparability. Stability was assessed using stress and weight-bearing radiographs to measure talar tilt (TT) and medial clear space (MCS). Results: Clinically, the patients had good results, with a mean VAS of 1.5 and an AOFAS score of 87 at 6-month follow-up. There were no complications observed during the study period. MCS remained stable (p = 0.125), with means of 3.03 mm (postoperative), 2.87 mm (weight-bearing), and 3.38 mm (stress). Similarly, TT remained consistent (p = 0.597), with means of 1.17º (postoperative), 0.87º (weight-bearing), and 1.14º (stress). These findings confirm the preservation of joint alignment and ligament integrity post-repair. Conclusion: To the best of our knowledge, all-inside deltoid repair has been described; however, reports specifically within SER IV bimalleolar-equivalent fractures and short-term radiographic stability remain limited. The technique demonstrated favorable shortterm functional outcomes and radiographic stability.
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Functional Evaluation of Acute Achilles Tendon Rupture Treatment Using the Dresden Technique: A Case Series
To evaluate functional outcomes, quality of life, and complications after repair of acute Achilles tendon rupture using a minimally invasive Dresden technique. Achilles rupture is common, and management remains debated; minimally invasive approaches aim to preserve functional outcomes while reducing soft-tissue complications and sural nerve injury risk. Single-center case series (2015–2024) at a tertiary orthopedic institute. Adults with noninsertional acute ruptures (≤2 weeks) underwent repair with the Dresden technique, using minor instrument modifications and a standardized rehabilitation protocol. Outcomes included Foot and Ankle Outcome Score (FAOS), Achilles Tendon Total Rupture Score (ATRS), EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L), Patient Reported Outcomes Measurement Information System (PROMIS), heel-rise test, calf circumference, maximum plantarflexion/dorsiflexion, and gravitational equinus angle. Thirty-one patients (mean age 37.0 ± 10.55 years; 64.5% male) completed follow-up. Mean scores: FAOS 99.03 ± 1.73, ATRS 98.29 ± 2.64, EQ-5D-5L 0.98 ± 0.03, PROMIS 61.0 ± 0.51 (range 60.3–61.5). Heel-rise: 24/31 (77.4%) maintained single-leg support. Complications: none for infection, wound dehiscence, rerupture, or deep vein thrombosis; two transient sural nerve-related symptoms resolved by 2 months. Plantarflexion: 25.42° (operated) vs 25.45° (nonoperated), mean difference 0.03° (SD 0.18), p > 0.05. Dorsiflexion and gravitational equinus: no significant side-to-side differences. Calf circumference difference 1.08 cm (p < 0.05), not correlated with functional scores (p > 0.05). Very strong, statistically significant intercorrelations were observed among FAOS, ATRS, EQ-5D-5L, and PROMIS. The modified minimally invasive Dresden repair yielded excellent functional outcomes, high quality-of-life scores, and very low complication rates, with no meaningful deficits in ankle range of motion. Calf atrophy was small and not functionally relevant.
Association of medial talar chondral lesions with deltoid ligament ruptures in ankle fractures: a multicenter study of 100 cases
Introduction: Deltoid ligament ruptures are common in the context of ankle fractures and may be managed either conservatively or surgically, there is currently no clear consensus regarding the optimal treatment approach. This study aimed to determine the incidence of medial talar chondral lesions (MTCL) in ankle fractures with deltoid ligament (DL) rupture and to evaluate their relationship with fracture characteristics. The authors hypothesized that a high incidence of MTCL would support the indication for open DL repair. Methods: This was a retrospective, multicenter, cross-sectional study that included 100 consecutive adult patients with ankle fractures and DL rupture who underwent surgical treatment between 2020 and 2022. All patients underwent a standardized anteromedial ankle arthrotomy with open DL repair. MTCL were identified intraoperatively, measured, classified according to Hintermann et al., and treated when necessary. Fractures were classified using the AO system, and associated injuries (posterior malleolar fracture, syndesmotic injury, tibiotalar dislocation) were recorded. Statistical analysis was performed using chi-square tests, with p < 0.05 considered significant. Results: MTCL were identified in 43% of patients. Lesions ranged from superficial cartilage damage to full-thickness defects, with 30% of MTCL involving subchondral bone exposure. Intra-articular loose bodies were found in 13% of the total cohort and in 30% of patients with MTCL. A significant association was observed between MTCL and posterior malleolar fractures (p = 0.04). No significant correlations were found between MTCL and AO fracture classification, syndesmotic injury, or tibiotalar dislocation. Severe MTCL (Hintermann type 4) showed no significant association with fracture characteristics. Conclusion: There is a high incidence of MTCL in ankle fractures associated with DL rupture. Posterior malleolar involvement appears to increase the risk of MTCL. Open DL repair via anteromedial arthrotomy allows identification and treatment of relevant intra-articular pathology and may provide additional justification for DL repair during ankle fracture fixation, particularly when posterior malleolar fractures are present.
Results of Lisfranc lesions treated with TightRope® fixation – interosseous suture button – minimum follow-up of 5 years
Introduction: Open reduction with internal fixation or primary arthrodesis are considered gold standards for the treatment of Lisfranc lesions. However, several disadvantages are associated with these procedures, including loss of joint mobility and potential cartilage damage. More recently, TightRope® has emerged as an alternative treatment for Lisfranc lesions, which can be used alone or in combination with traditional techniques, with the potential to mitigate some of these disadvantages. The primary outcome of the study was to evaluate the functional outcomes of 20 patients treated with the TightRope® technique for Lisfranc lesions. The secondary outcome was to evaluate and describe the complications associated with the procedure. Methods: Retrospective review conducted in 20 patients undergoing surgery for acute Lisfranc lesions using the TightRope® technique. Mean follow-up was 83 months. Clinical evaluation involved assessment of complications, reoperations, midfoot AOFAS scores, VAS scores, patient satisfaction, and ability to return to previous activities. Radiographic analysis was performed to evaluate the maintenance of reduction and the development of osteoarthritis. Results: Patients demonstrated excellent results with a mean AOFAS midfoot score of 95.5 and a mean VAS of 0.50. Incomplete reduction was the only factor that significantly influenced lower AOFAS and VAS scores. Most complications were minimal. Conclusion: The TightRope® technique has been shown to be a reliable alternative for the treatment of acute Lisfranc lesions, providing satisfactory clinical and functional results.
Radiographic parameters of normality and their application in compression-type fractures (“nutcracker”) of the cuboid bone
Introduction: Cuboid fracture is associated with Lisfranc lesions, which may present with a lateral crushing pattern (“nutcracker”) and lead to complications such as arthrosis and abduction deformity. The study ought to establish normal radiographic parameters of the cuboid, with assistance in therapeutic decision-making for fractures and deformities. Methods: Selected 516 adult patients (516 feet) between 18 and 70 years (258 of each gender), without a cuboid lesion. Internal oblique radiographs were taken, and two parameters were evaluated: the measurement of the alpha angle formed between the distal and proximal articular surfaces of the cuboid and the ratio between the length of the lateral and medial walls. Fifteen patients with cuboid fracture-compression were evaluated, and their results were compared with those of the control group. Results: Radiographic parameters were evaluated, and the results by gender and age group were divided into groups (18 to 50 and 50 to 70 years). The angle of the control group ranged from 21.6 to 49.2 degrees, with a mean of 35.62 degrees. The cortical ratio of the cuboid ranged between 0.37 and 0.69, with a mean of 0.52, and there was no difference between genders. There was a difference between the findings, with an increase in the alpha angle in males (35.11 degrees to 36.13 degrees). Patients with fracture-compression presented changes in the angle, with values between 38 and 48.5 degrees, a mean of 42.27 (p = 0.000), and in the relationship between the cortical, with values between 0.37 and 0.48, a mean of 0.43 (p = 0.000). Conclusion: The radiographic parameters studied may be useful for the anatomical definition of the cuboid and in the treatment of several diseases.
Weight-bearing computed tomography in the identification of intercuneiform instability in Lisfranc lesion: a case report
Lisfranc lesions have a high rate of diagnostic failure (> 30%), especially in isolated ligament injuries. Diagnostic delay is associated with chronic pain and instability of the middle foot. Weight-bearing computed tomography (WBCT) emerges as a promising tool. The objective of this report is to present a case in which this modality of examination identified intercuneiform instability not detected by conventional methods. Evaluation of a female patient, a marathon runner, with a Lisfranc injury after falling down stairs. Performed: weight-bearing radiography, comparative bilateral conventional tomography and weight-bearing computed tomography. Surgical exploration with evaluation under intraoperative radioscopy. Conventional examinations identified C1-M1, C1-M2, C2-M2 instability and plantar avulsion at the base of the second metatarsal. Weight-bearing computed tomography additionally showed intercuneiform asymmetry (C1-C2, which was not detected in the stress test under intraoperative radioscopy. Surgical exploration confirmed this instability, modifying the planning. Fixation performed with cannulated screws 3.5 mm and a dorsal plate. Weight-bearing tomography represents an advance in the diagnosis of Lisfranc lesions, especially hidden instabilities. When unavailable, systematic intraoperative exploration is indispensable for complete diagnosis and appropriate treatment.
Syndesmosis Fixation with Rigid Synthesis in Weber B and C Ankle Fractures: A Retrospective Analysis of 100 Consecutive Cases Evaluating Screw Position and Reduction Outcomes
Introduction: Ankle fractures involving syndesmotic disruption represent a significant challenge in orthopedic surgery. Weber B and C fractures frequently involve the tibiofibular syndesmosis, and inadequate treatment can lead to chronic instability and post-traumatic osteoarthritis. The objective of this study is to evaluate the outcomes of rigid syndesmotic fixation in Weber B and C ankle fractures, analyze screw-related complications, and assess maintenance of syndesmotic reduction. Methods: Retrospective case series of 100 consecutive patients who underwent screw fixation for Weber B or C ankle fractures with syndesmotic instability. Parameters evaluated included screw position (suprasyndesmotic vs. transsyndesmotic), implant-related complications, hardware removal rates, and maintenance of reduction. Results: The cohort comprised 43 Weber B (43%) and 57 Weber C (57%) fractures. Suprasyndesmotic placement was used in 39 patients (39%), transsyndesmotic in 61 patients (61%). Suprasyndesmotic screws had a 30.8% breakage rate compared with 3.3% for transsyndesmotic screws (p = 0.0006). Syndesmotic reduction was maintained in 98% of cases. Both cases of lost reduction occurred after screw removal. Conclusion: Rigid screw fixation demonstrates excellent reliability for maintaining syndesmotic reduction. Transsyndesmotic placement significantly reduces implant failure rates. Hardware removal may compromise ankle stability.
Can posterior malleolus fracture classification influence treatment choice?
Introduction: To evaluate the intra- and interobserver reproducibility of three classifications of posterior malleolus fractures (PMF) and to analyze the relationship of treatment choice and surgical approach with the classifications. Methods: Computed tomography of the ankle 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 assessed how they would treat PMF—conservatively or surgically (in this case, by which access route they would use). Cronbach’s alpha was used to assess intraobserver agreement, and the Kappa test was used to assess interobserver agreement. The correlation of decision-making and access route was analyzed using the Chi-Square Test (Q2). Results: Intraobserver reproducibility 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, representing an adequate agreement for all. For the experts, the mean ratings for Haraguchi, Mason, and Bartoníček/Rammelt classifications were 0.86, 0.84, and 0.75, representing good, good, and adequate, respectively. For the group of non-specialists, the means were 0.72, 0.68, and 0.70, representing an adequate, average, and adequate classification, respectively. Interobserver reproducibility was considered reasonable for Haraguchi (0.38) and moderate for Mason (0.42) and Bartoníček/Rammelt (0.43). When analyzing decision-making and the access route, all classifications showed a large effect size (V > 0.50). Conclusion: The three classifications were adequate for intraobserver and reasonable or moderate for interobserver. All showed a great effect on the therapeutic decision, with Bartoníček/Rammelt being the highest values.
Risk factors for infection associated with calcaneal fracture in open reductions and internal fixations: A retrospective cohort
Introduction: The high rates of infections associated with open reduction and internal fixation (ORIF) of calcaneal fractures make it necessary to mitigate the risk factors for infection in this type of osteosynthesis. The objective of this study is to identify independent risk factors for fracture-associated infection (FAI) in ORIF of calcaneal fractures. Methods: Retrospective and observational study using data extracted from the TriNetX global platform, including patients of both sexes with a confirmed diagnosis of calcaneal fracture and who underwent surgical treatment with ORIF. The International Classification of Diseases (ICD), version 11, code S92.0 was used. The level of statistical significance adopted in the analysis was 5% (0.05). The primary outcome assessed was infection associated with the fracture within one year after surgical treatment of the fracture. Results: A total of 2,830 patients were selected for the study, with a mean general age of 50 years (SD ± 15), mostly men, 1,788 (63.8%). During the evaluation period, 181 patients had FAI within 1 year of surgical treatment. In the analysis of the risks of independent factors for FAI, the variables smoking [OR 1.8 (CI 0.02;0.06)], alcohol abuse [OR 1.6 (CI 1.0;2.6)], chronic kidney disease [OR 2.23 (CI 1.13;4.39)], overweight [OR 2.8 (CI 1.34;5.89)], fall from height [OR 2.18 (CI 1.47;3.25)] and open fracture [OR 2.13 (CI 1.07;4.23)] were statistically significant for the infection outcome. Conclusion: The identification of risk factors is essential to avoid unfavorable outcomes in ORIF’s of calcaneal fractures. Smoking, alcohol abuse, chronic kidney disease, being overweight, falls from height, and open fractures were independent risk factors for infection.
Epidemiological and secondary ankle stabilizer analysis of professional and amateur field soccer players
Introduction: Football has a high incidence of injuries. The most common injuries are bruises, sprains, and strains, especially to the ankles. Imbalances in muscle strength, motor control, and proprioception, along with prior injuries, increase the risk of new injuries and sprains. The objective of this study is to evaluate and compare epidemiological and performance data from functional tests of professional and amateur soccer athletes at different levels of practice, to identify possible risk and prevention factors for ankle injuries. Methods: Twenty-nine athletes aged 18 to 26 years were divided into two groups (professional and amateur). An epidemiological questionnaire was administered, collecting data on injury history, duration of modality practice, and frequency of physical and technical training in the field, followed by functional tests of single-leg long jump, Side Hop Test, Y Balance test, and objective evaluation of ankle strength using a manual dynamometer. Data were analyzed with descriptive and inferential statistics. Results: A total of 53.3% of amateurs reported previous ankle injury, against only 14.3% of professionals. The professionals, with longer practice time and greater training frequency, also achieved better performance on the unipodal jump, lateral jump, and Y Balance test, especially in the diagonal planes. The strength studied showed a significantly smaller difference in eversion among amateurs. Conclusion: Amateur athletes had a higher history of injuries and muscle imbalances, and lower functional performance, indicating a higher risk of ankle sprain.
Treatment of type Weber B lateral malleolus fractures: Comparison between MIPO technique and conventional approach
Introduction: Displaced fractures (>2 mm) of the lateral malleolus, without associated lesions, still generate debate as to the ideal management. Historically treated with cast immobilization, they began to have an expanded surgical indication, searching for faster functional recovery and reduction of the risk of secondary osteoarthritis. The minimally invasive technique (MIPO) appears as an alternative to the traditional open approach, with potential reduction of tissue aggression. This study aims to evaluate the MIPO technique for the treatment of type Weber B lateral malleolus fractures, comparing it with the conventional open approach in terms of functional recovery, operative time, and complications. Methods: Prospective, randomized study involving 40 patients undergoing osteosynthesis with a 1/3 tubular plate. Participants were divided into two groups: open lateral access (n = 19) and MIPO technique (n = 21). Surgical time, complications, and function were assessed using the AOFAS score at weeks 2, 6, and 12 postoperatively. Results: Surgical time was significantly shorter in the MIPO group (median 22 minutes) compared to the conventional group (46 minutes; p < 0.001). At the 2-week evaluation, the AOFAS score was higher in the MIPO group (median 76 vs. 65; p = 0.046), with better gait performance, range of motion, and distance traveled. At weeks 6 and 12, both groups showed satisfactory functional recovery, with no statistically significant difference in final scores (98.56 vs. 95.25; p = 0.136) or in the postoperative complication rates. Conclusion: The MIPO technique proved safe and effective for treating Weber B lateral malleolus fractures, with shorter surgical time and earlier functional recovery compared with the open approach, without increasing complications or impairing final results.
Reproducibility of T All-Inside Arthroscopic ATFL Repair With Internal Brace Augmentation: Multicenter Midterm Outcomes in Chronic Lateral Ankle Instability
Introduction: Chronic lateral ankle instability (CLAI) may require surgery after failed nonoperative care. We evaluated functional outcomes of a true all-inside arthroscopic anterior talofibular ligament (ATFL) repair augmented with suture tape internal brace, and whether concomitant intra-articular lesions or postoperative stiffness influenced results. Methods: Multicenter retrospective cohort of 51 consecutive CLAI patients treated from March 2021 to September 2023. FAAM, LEFS, MOXFQ and EQ-5D VAS were collected preoperatively and at final follow-up. Paired comparisons used Wilcoxon signed-rank or paired t tests. Subgroup analyses compared patients with/without associated lesions and with/without mild postoperative stiffness. Results: Mean follow-up was 24 months. All scores improved significantly (p<0.001) with large effect sizes: FAAM 32.97±20.98 to 95.57±6.13 (d=2.83); LEFS 44.75±17.21 to 95.95±6.83 (d=2.83); MOXFQ 57.11±20.50 to 96.81±6.04 (d=1.77); EQ-5D VAS 65.39±15.09 to 92.59±9.92 (d=1.45). Patients with concomitant lesions or mild stiffness had slightly lower absolute postoperative scores, but functional gain (Δ) did not differ between subgroups (all p>0.05). No recurrence of instability was observed. Conclusions: True all-inside arthroscopic ATFL repair with internal brace augmentation provides substantial functional improvement, high stability and low complications in CLAI, without clinically relevant compromise from concomitant lesions or mild postoperative stiffness.
Clinical results of proximal release of the medial gastrocnemius in the treatment of non-insertional Achilles tendon tendinopathy
Introduction: Noninsertional tendinopathy of the Achilles tendon is a common and disabling condition, particularly in athletes. Current interventional treatments include medications, infiltrations, and surgical procedures such as tendon transfers. This study aimed to evaluate the results of proximal release of the medial gastrocnemius (PMGR), a relatively low-morbidity procedure, in the treatment of noninsertional Achilles tendon tendinopathy. Methods: Twelve patients diagnosed with non-insertional Achilles tendon tendinopathy, as determined by clinical examination and confirmed by nuclear magnetic resonance, who were refractory to conservative treatment underwent PMGR. Five patients had bilateral involvement, resulting in 17 treated tendons. Results: After a mean follow-up of 32 months, the mean AOFAS score increased from 62.0 preoperatively to 90.2 at the last follow-up. The mean pain score on an analog scale decreased from 6.7 preoperatively to 1.9 at the last follow-up. Although some patients had residual pain, in all cases it was milder than preoperative pain, and all participants reported satisfaction with the treatment performed. Conclusion: Despite the small sample size and short follow-up period, the results indicate that PMGR is a less invasive alternative for treating noninsertional Achilles tendinopathy.
Endoscopic flexor hallucis longus transfer for acute Achilles tendon ruptures is associated with a high re-rupture rate: A prospective case series
Introduction: Achilles tendon rupture (ATR) is a frequent injury with significant functional impact. Endoscopic transfer of the flexor hallucis longus (FHL) has been proposed as a minimally invasive alternative, but its role in acute cases remains controversial. This study aimed to evaluate patient-reported outcomes, functional capacity, and re-rupture rates after endoscopic FHL transfer for acute ATR. Methods: Prospective case series including 26 patients (15 men, 11 women; mean age 47.7 years) with acute ATR treated with isolated endoscopic FHL transfer between March 2022 and December 2023. Minimum follow-up was 12 months. Assessments included pain (VAS), VISA-A, ATRS, AOFAS, plantar and hallux flexion strength, ankle mobility, heel rise, lunge test, and Achilles tendon resting angle. Results: Five patients (19.2%) sustained re-rupture between the second and fourth postoperative week. At 12 months, mean VAS was 0.5, VISA-A 94.4 (95% CI: 90.8–100), and ATRS 5.1. Plantar flexion strength and ankle mobility were significantly lower on the operated side versus contralateral (p = 0.015 and p < 0.001). No wound healing or neurovascular complications were observed. Conclusion: Despite satisfactory functional scores, the isolated endoscopic FHL transfer showed an unacceptably high re-rupture rate in acute ATR. This technique should not be routinely indicated for very active patients seeking a rapid return to activity
Neglected Achilles tendon ruptures: literature review
Introduction: Achilles tendon rupture is the most common lower limb tendon injury, with rising incidence in active adults. Up to 25% are initially neglected, becoming chronic after four weeks and leading to functional impairment. This study reviews current treatments, outcomes, and complications of neglected Achilles tendon ruptures. The objective is to review the literature on current treatments for neglected Achilles tendon ruptures, their outcomes, and potential complications. Methods: A bibliographic review of the state of the art was conducted in national and international databases. Articles published in indexed journals between 1991 and 2022 that addressed the treatment of Achilles tendon ruptures with more than four weeks of evolution were selected; however, only articles with less than 22 years of publication (2000-2022) were analyzed. Results: Surgical treatment is well established for patients with significant functional demands. The various surgical techniques described in the literature and currently used have similar success rates and complication profiles, particularly regarding patient satisfaction, functional outcomes, anthropometric measurements, and return to work and sports activities. Conclusion: Several techniques can be used to treat neglected Achilles tendon ruptures. When choosing the most appropriate technique, gap size, patient characteristics, and surgeon experience should be considered.
Long-Term Follow-Up After Calcaneoplasty: Does It Really Work?
Introduction: Posterior heel pain due to Haglund deformity is a common cause of functional limitation in active patients. While most cases respond to conservative treatment, some require surgery. Evidence on long-term outcomes after endoscopic calcaneoplasty remains limited. The objective os this study is to evaluate long-term clinical outcomes, complications, and return to activity after endoscopic calcaneoplasty, with a minimum five-year follow-up. Methods: A retrospective analysis of consecutive patients undergoing endoscopic calcaneoplasty between 2016 and 2020 after failure of ≥ 6 months of nonoperative treatment was performed. VAS, AOFAS, and VISA-A scores were collected preoperatively, at one year, and at five years. Return to activity and complications were recorded. Results: Twelve patients (14 feet) were included, with a mean follow-up of 60 months. Significant improvement was observed in all scores (p < 0.001). Mean VAS improved from 9.07 to 1.8; AOFAS from 38.7 to 94.6; and VISA-A from 37 to 85. Satisfaction rate was 91%. Most patients returned to their previous activity level. Complications were infrequent and mainly minor, with one reoperation. Conclusion: Endoscopic calcaneoplasty provided significant and sustained pain relief and functional improvement at five years, with high satisfaction and low complication rate. Outcomes continued to improve beyond the first postoperative year, supporting the procedure as a reliable option for refractory Haglund deformity.
Posterior Tibial Tendon Dislocation Associated with Achilles Tendon Rupture: A Case Report
Introduction: Posterior tibial tendon dislocation is an uncommon injury. This pathology is believed to develop from an involuntary, forceful contraction of the posterior tibial muscle triggered by forced ankle inversion combined with sudden dorsiflexion. It is often accompanied by other ankle traumas that obscure its diagnosis. This report describes a rare case of concurrent posterior tibial tendon dislocation and Achilles tendon rupture in a 37-year-old male, injured during a soccer match. Methods: Initial examination confirmed a complete Achilles tendon rupture but overlooked medial ankle pain and edema. Magnetic resonance imaging revealed posterior tibial tendon dislocation with flexor retinaculum detachment and an Achilles tendon rupture located 5.5 cm proximal to its calcaneal insertion. Surgical intervention was performed in a single session, addressing both injuries. The posterior tibial tendon dislocation was corrected through a medial approach, with tendon reduction into its retromalleolar groove and flexor retinaculum reattachment to the medial tibia using transosseous sutures. Results: Achilles tendon repair was achieved using a minimally invasive Dresden technique. Postoperative rehabilitation included progressive weight-bearing, mobility exercises, and strengthening protocols, tailored to manage both injuries concurrently. By the seventh postoperative month, the patient demonstrated full recovery, with restored tendon stability, no pain or edema, and a return to pre-injury sports activities. Conclusion: This is the second reported case of concurrent Achilles tendon rupture and posterior tibial tendon dislocation and the first to propose a comprehensive surgical strategy addressing both conditions simultaneously. Early recognition and tailored surgical planning are critical to prevent chronic complications and restore functional outcomes in these rare cases.
Mid-term outcomes of all-arthroscopic autologous matrix-induced chondrogenesis for osteochondral lesions of the talus
Introduction: Open approaches for autologous matrix-induced chondrogenesis (AMIC) in osteochondral lesions of the talus (OLT) may be associated with relevant morbidity. This study aimed to evaluate the effectiveness of the all-arthroscopic technique (AT-AMIC), with a focus on mid-term functional outcomes and complication rates. Methods: This retrospective multicenter case series included 64 patients (39 men, 25 women; 18-71 years) with symptomatic OLTs confirmed by magnetic resonance imaging, treated with AT-AMIC. The procedure included lesion debridement, subchondral bone microfracture, autologous cancellous bone grafting when needed, and implantation of a porcine bilayer collagen matrix (Chondro- Gide). Functional outcomes were assessed using the AOFAS score, with a mean follow-up of 44 months (31–62). The Wilcoxon test was used, with significance set at 5% (p < 0.05). Results: Mean lesion size was 112 mm2, with predominance in Raikin zone 4 (54.68%). Mean AOFAS score improved from 51.58 preoperatively to 89.64 at final follow-up (p < 0.0001). Seven patients (11%) had treatment failure due to complications, including membrane detachment, membrane hypertrophy, or lesion recurrence. No significant correlation was found between lesion size or symptom duration and clinical outcome. Conclusions: AT-AMIC is a reproducible method for treating OLTs, with statistically significant mid-term clinical improvement. Further comparative studies are needed to confirm long-term efficacy.
Risk factors for metatarsal fracture in minimally invasive hallux valgus surgery: A case-control study
Introduction: Minimally invasive hallux valgus (HV) correction techniques, including percutaneous Chevron-Akin (PECA) and metaphyseal extra-articular transverse and Akin (META) osteotomies, offer favorable outcomes but are associated with unpredictable metatarsal fractures. This study identifies predictive factors for first metatarsal fractures following minimally invasive HV surgery. Methods: This retrospective case-control study analyzed 370 patients (499 feet) who underwent minimally invasive HV correction between November 2017 and August 2024 at a tertiary orthopedic center. Cases from the learning curve, revision procedures, and patients lost to follow-up were excluded. Patients were classified by the presence or absence of a first metatarsal fracture, and logistic regression was conducted to identify associated risk factors. Results: First metatarsal fractures occurred in 5.4% (27/499 feet), with Type II fractures being most common (40.7%). On multivariable logistic regression, both older age and simultaneous bilateral surgery were independently associated with fracture. The odds of fracture increased by 8.6% per year of age (OR 1.086, 95% CI 1.032-1.150, p = 0.003) and were higher in patients undergoing bilateral vs unilateral surgery (OR 4.02, 95% CI 1.75-9.80, p = 0.001). Bone mineral density (BMD) of the femur and lumbar spine was not associated with fracture risk. Conclusion: Advanced age and bilateral surgery are key predictive factors for metatarsal fractures following minimally invasive hallux valgus correction. Tailoring surgical and postoperative strategies, especially in elderly patients, may help mitigate fracture risk. Further research should explore metatarsal-specific bone density, surgical biomechanics, and younger patient cohorts.
Postoperative evaluation of patients undergoing minimally invasive treatment for acute calcaneal tendon rupture
Introduction: Achilles tendon rupture (ATR) is a frequent musculoskeletal injury, representing the most affected tendon of the lower limb, with an incidence of approximately 40 cases per 100,000 inhabitants. With the advancement of surgical techniques, minimally invasive procedures have gained prominence for promoting less tissue aggression, reduced complications, and potentially faster rehabilitation. Among these techniques, the use of the Tenolig® device stands out, which is designed to promote adequate approximation of the tendon stumps during the healing process. Thus, the present study aims to evaluate the degree of patient satisfaction and clinical-functional results, such as pain, range of motion, muscle strength, time to return to activities, and occurrence of complications, undergoing the minimally invasive technique in the treatment of Achilles tendon rupture, using a percutaneous repairer (Tenolig®) followed by Alfredson eccentric protocol. Methods: Retrospective and descriptive observational study, including 20 patients with acute Achilles tendon rupture (<5 days), treated by percutaneous technique with Tenolig® Results: The sample consisted predominantly of men (75%), with a mean age of 39.7 years. The ATRs score showed that 75% of patients had a score of 0, indicating no functional limitation. The mean Alfredson test execution time was 31.8 seconds, with no significant pain. There was one case of re-rupture (5%). Lower adherence to the rehabilitation protocol was observed among patients with lower education and social support. Conclusion: Minimally invasive treatment with Tenolig® proved effective and safe in the management of acute Achilles tendon rupture, with low complication rates and excellent functional results.
Excellent Functional Outcomes and Low Complication Rates After Arthroscopic Broström Repair With Internal Brace Augmentation for Chronic Lateral Ankle Instability
Introduction: Chronic lateral ankle instability (CLAI) may persist after recurrent sprains, causing pain, giving-way, and functional limitation. Arthroscopic Broström repair with minimally invasive internal brace augmentation (IBA) may improve stability and support earlier rehabilitation. This study evaluated functional outcomes, complications, and recovery after minimally invasive IBA for CLAI. Methods: Retrospective multicenter cohort of consecutive adults (> = 18 years) with CLAI treated with minimally invasive Arthroscopic Broström plus IBA (2018-2022) at three tertiary centers in Brazil. Primary outcome: change in AOFAS Hindfoot score. Secondary outcomes: pain, complications, residual stiffness/range of motion loss, and return to activity/sport. Mean follow-up: 2.4 ± 1.3 years. Results: Seventy-six patients were included (35.1 ± 10.2 years; 51.3% male). Mean AOFAS improved from 54.6 ± 15.9 to 95.9 ± 5.5 (p < 0.001), with a median gain of 41 points (95% CI 37.0-44.5; Cohen d = 3.18). Return to preinjury activity level occurred in 93.4%. Longer instability duration correlated with lower AOFAS gain (r = -0.23; p = 0.043). Complications occurred in 7.8% of cases, mostly minor/ transient, with no recurrent mechanical instability or reoperation. Conclusions: Minimally invasive IBA is a safe and effective option for CLAI with excellent mid-term functional recovery. Prospective comparative studies are needed to confirm long-term durability and cost-effectiveness.
Anterior chevron-type tibial osteotomy for treatment of osteochondral lesion of the talus using osteochondral autograft transfer system: A case report and technical description
Introduction: In the osteochondral autograft transfer system (OATS) procedure, a wide accessible area is required to introduce the femoral plug at varying angles. This may not always be achievable through standard anteromedial or anterolateral arthrotomy approaches. The aim of this case report was to describe the use of an anterior chevron-type tibial osteotomy as a technical approach for treating a centrolateral osteochondral lesion of the talus (OLT) with the OATS technique. Methods: A 48-year-old female patient with chronic ankle pain following an ankle sprain 32 years ago. The anterior osteotomy was performed with dimensions of 3 cm in width, 2 cm in depth, and 4 cm in height. After removing the anterior tibial bone block, we identified and debrided the OLT. The lesion site was prepared, and a bone plug obtained from the lateral femoral trochlea was inserted, congruent with the surrounding articular cartilage. The temporarily removed anterior tibial bone block was reattached and secured with three cannulated screws. Results: By 44 months postoperatively, the patient demonstrated significant clinical improvement and had returned to full activity. Preoperatively, she reported a VAS score of 7 for pain, which improved to 1 postoperatively. Her American Orthopaedic Foot and Ankle Society ankle-hindfoot score increased from 41 to 90. Ankle range of motion improved, from a preoperative total of 90 degrees to 100 degrees postoperatively. No complications were observed following the tibial osteotomy or the OATS procedure. Conclusion: The anterior chevron-type tibial osteotomy provided an adequate exposure of a centrolateral OLT, enabling precise graft positioning during the OATS procedure. It allowed safe insertion of the plug at the desired angle while preserving joint congruity. This technique may represent a surgical option for treating centrally and laterally located OLT when conventional approaches do not provide sufficient access.
Clinical and functional results of surgical treatment of osteochondral lesions of the talus by matrix-induced autologous chondrogenesis technique (AMIC)
Introduction: There is still no consensus on the ideal method for treating osteochondral lesions of the talus (OCL). Matrix-induced autologous chondrogenesis (AMIC), with the application of a collagen membrane, aims to enhance cartilage regeneration and promote restoration of the articular surface. This technique has been used as a promising alternative in the management of talar OCLs. The objective of this study was to evaluate the clinical and functional results of the AMIC technique in the treatment of talar OCL and to analyze the association between outcomes and lesion characteristics, procedures performed, and imaging findings at follow-up. Methods: A retrospective multicenter study that included 36 patients undergoing the AMIC technique. The outcomes evaluated were the AOFAS, VAS scores, and the rate and time of return to physical activities. Area, depth, quadrant, presence of subchondral cyst, and lesion containment were analyzed. Associated procedures, use of bone graft, and surgical approach (open/arthroscopic) were also evaluated. The presence of bone edema or cysts on postoperative magnetic resonance imaging (MRI) was also correlated with clinical outcomes. Results: The mean age of the patients was 40.69 years, with a mean follow-up of 39.11 months. Significant improvement in AOFAS and VAS scores was observed (p < 0.001). The rate of return to physical activity was 83%, with a mean time of 8.6 months. The only significant correlation found was between bone edema on postoperative MRI and lower AOFAS score (p = 0.033). The other variables analyzed did not show a significant correlation with the outcomes. Conclusion: The AMIC technique led to significant clinical and functional improvements, with a high rate of return to physical activities. The characteristics of the lesion and the associated procedures did not influence the results in this patient sample, whereas the persistence of bone edema on MRI was associated with a lower functional score.
Clinical and functional results in the surgical treatment of osteochondral lesions of the talus: A comparative study between the matrix-induced autologous chondrogenesis (AMIC) technique isolated and associated with bone marrow aspiration (BMA)
Introduction: Osteochondral lesions of the talus (OCL) remain a therapeutic challenge, with no consensus on the ideal surgical strategy. Matrix-induced autologous chondrogenesis (AMIC), which uses a collagen membrane, aims to stimulate cartilage regeneration and has shown promise. Bone marrow aspiration (BMA) has been used as an adjuvant to enhance osteochondral repair by offering progenitor cells and growth factors. However, comparative evidence on the clinical impact of this association is still limited. The aim of this study was to compare the clinical and functional outcomes of AMIC alone versus AMIC + BMA. Methods: A retrospective multicenter study comparing two groups: AMIC alone (n = 39) and AMIC + BMA (n = 39). The outcomes evaluated included AOFAS, VAS, rate and time of return to activities, and the presence of residual limitations in physical activities and daily living. Lesion characteristics (area, depth, quadrant, and presence of subchondral cyst) were analyzed, as well as associated procedures, use of bone graft, and surgical approach (open or arthroscopic). Results: Improvement in AOFAS and VAS scores was significantly greater in the AMIC + BMA group (p < 0.001). However, the rate and time of return to activities were similar between groups (p = 0.076 and p = 0.301). A higher frequency of postoperative residual limitations for physical activities and daily living was observed in the AMIC + BMA group (p = 0.006). Conclusion: Both techniques promoted significant clinical improvement in the treatment of talar OCL. The AMIC + BMA association was related to greater functional gain and greater pain reduction when analyzed by score variation. However, there was no difference in return to activities, and the AMIC + BMA group had a higher frequency of residual functional limitations, suggesting that any potential biological benefit should be interpreted with caution.
Postoperative evaluation of the treatment of chronic ankle ligament instability: Broström Gould vs Arthroscopic Brostöm – 10 years of follow-up
Introduction: Ankle sprain is one of the most frequent ligament injuries in the lower limbs, with a high prevalence in athletes. Although conservative treatment is effective for most patients, about 20% develop chronic instability and may require surgical intervention. The modified Broström-Gould technique is considered the gold standard, while the arthroscopic Arthro-Brostrom technique appears as a minimally invasive alternative. This study aims to functionally compare the outcomes of both techniques with a 10-year follow-up, using the AOFAS scale. Methods: This is a retrospective longitudinal study comparing two treatment groups that evaluated 113 patients with chronic lateral ankle ligament instability, operated between January 2011 and December 2014, divided into two groups: modified Broström-Gould (n = 46) and Arthro-Broström (n = 67). All had previously undergone conservative treatment for at least six months. The AOFAS score was applied pre- and postoperatively. Results: There was no statistically significant difference between the groups regarding clinical characteristics. Both groups showed a significant increase in the postoperative AOFAS score (p < 0.001), with a mean improvement of 38.6 points for Broström-Gould and 39 points for Arthro-Broström. The final mean score was slightly higher in the Arthro-Broström group (92.1 vs. 91.4), but there was no statistically significant difference between the methods (p = 0.847). Conclusion: Both the modified Broström-Gould and Arthro-Broström techniques proved to be effective for the treatment of chronic ankle instability, providing significant functional improvement and a low rate of complications. The arthroscopic approach showed advantages, including lower morbidity and improved visualization of associated lesions, making it a safe and effective option.
Antônio Alício Moreira de Oliveira Júnior
Combined multi-ligament instability in patients with chronic symptoms following rotational ankle injuries. A prospective cohort study
Introduction: To prospectively quantify isolated versus combined ligamentous instability in symptomatic patients after rotational ankle injuries (RAI) and assess changes in patient-reported outcomes (PROs) after targeted surgical stabilization. Methods: Adults with pain and/or subjective instability > 6 months after RAI who failed ≥ 3 months of nonoperative care were enrolled in a prospective cohort. All underwent diagnostic ankle arthroscopy and open stabilization based on standardized intraoperative criteria for lateral, syndesmotic, and deep deltoid instability; combined patterns were classified. PROs (VAS pain, EFAS, PCS, PROMISPF, and PROMIS-PI) were obtained preoperatively and at follow-up. Results: Twenty-nine patients (30 ankles; age 36.1 years, BMI 31.2 kg/m2) were included; 90% followed a sprain and 10% fractures. The interval from injury to surgery was 58.4 months; the mean follow-up was 45.2 months. Instability prevalences were lateral 97%, syndesmotic 77%, and deep deltoid 83% (72% anterior, 28% combined anterior/posterior). Instability patterns were multidirectional (lateral/deltoid/syndesmotic) in 60%, rotational (lateral/deltoid) in 20%, anterolateral (lateral/syndesmotic) in 13%, and anteromedial (deltoid/syndesmotic) in 3.5%; isolated lateral instability occurred in 3.5%. Significant improvement (p < 0.04) in VAS (4.7 to 2.3), EFAS (6.2 to 9.5), PROMIS-PF (38.2 to 44), PROMIS-PI (62.1 to 54.8), and PCS (17.8 to 9.4) were noted. Three complications occurred (two minors, one major), all resolved after treatment. Conclusion: In symptomatic patients after RAI, multi-ligament ankle instability predominated, most commonly multidirectional or rotational patterns. Arthroscopy-guided comprehensive stabilization yielded significant improvements in PROs with a low complication rate. Systematic assessment for combined instability is warranted, and larger comparative studies should validate these findings.
Medial and lateral osteochondral lesions of the talus treated with double AT-AMIC using a biological scaffold
Introduction: Osteochondral lesions of the talus (OLT) are challenging due to poor cartilage healing and the talus’s role in ankle biomechanics. Biological augmentation may improve outcomes. Simultaneous bilateral treatment is rarely reported. This report describes the feasibility and early outcomes of one-stage bilateral arthroscopic OLT treatment. Methods: A 47-year-old man with bilateral OLT and no comorbidities underwent simultaneous bilateral ankle arthroscopy with debridement, microfracture, and implantation of a type I/III collagen scaffold fixed with fibrin glue. Both ankles were immobilized for six weeks, followed by rehabilitation. Results: At three months, the patient showed marked pain reduction, improved range of motion, and functional recovery, with no perioperative or postoperative complications. Conclusions: Simultaneous bilateral arthroscopic treatment of OLT with microfracture and collagen scaffold appears feasible and safe in selected patients, with potential clinical and logistical advantages.
Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis of randomized controlled trials
Introduction: Acute Achilles tendon rupture is a frequent and disabling injury. When early functional rehabilitation protocols are standardized, the independent effect of surgical versus nonoperative management on rerupture and complications remains unclear, as does the influence of surgical technique. Methods: A systematic review and meta-analysis of parallel-group randomized controlled trials was performed, including adults with acute (≤ 14 days), unilateral, closed Achilles tendon rupture. Nonoperative management with functional bracing and early rehabilitation was compared with open or minimally invasive surgical repair, with both groups following equivalent rehabilitation protocols. Searches of PubMed, Embase, and Cochrane were conducted following PRISMA guidelines. Primary outcomes at 12 months were rerupture and complications, including deep infection, superficial infection, and sural nerve injury. Risk ratios were pooled using a random-effects model, with prespecified subgroup analyses by surgical technique. Results: Seven randomized controlled trials, including 1,003 patients, were analyzed; 410 underwent nonoperative treatment and 593 surgical repair (410 open, 183 MIS). Nonoperative management was associated with a significantly higher 12-month rerupture rate than surgery (RR 3.35; 95% CI 1.35–8.30). No significant differences were observed in deep or superficial infection rates. Sural nerve injury was significantly less frequent in the nonoperative group (RR 0.20; 95% CI 0.05-0.85). Subgroup analysis showed persistently higher rerupture rates with nonoperative treatment than with open surgery, while superficial infection rates were lower in the nonoperative group. Conclusion: When early functional rehabilitation is standardized, surgical repair reduces the risk of rerupture at 12 months, whereas nonoperative management is associated with fewer sural nerve injuries. Treatment selection should be individualized based on patientspecific risks and priorities.
Epidemiological analysis of stress fractures in runners
Introduction: Stress fractures represent an important cause of sports absence in runners and result from the interaction between repetitive mechanical overload and biological capacity for bone remodeling. In Brazil, there is a shortage of epidemiological data that integrates intrinsic and extrinsic factors in risk analysis. Thus, this study aimed to investigate the incidence and multifactorial determinants of stress fractures among Brazilian runners, analyzing interactions between intrinsic (biological, metabolic, and biomechanical) and extrinsic factors (training load, equipment, and training location). Methods: Cross-sectional observational study approved by the Research Ethics Committee, including 230 runners linked to sports advisory services, with a minimum training frequency of twice a week. The collection took place electronically, via email, and was disseminated to groups of amateur runners. Demographic, anthropometric, clinical, training-related, and metabolic health variables were evaluated. Results: The overall self-reported incidence was 26.5%, with a higher prevalence among females (37.2%) than males (16.2%). The tibia was the most affected site (42.6%), followed by metatarsals (21.3%) and femur (11.5%). Running experience of more than three years and persistent pain during training were independent predictors. Regular practice of strength training proved to be a protective factor. In women, low BMI, high weekly volume, and amenorrhea were associated with a significantly higher risk. Conclusion: Stress fractures in Brazilian runners have a multifactorial character. The interaction between female gender, low BMI and metabolic impairment showed greater relevance than mechanical load alone. The findings reinforce the need for integrated preventive strategies, including load control and metabolic, hormonal and nutritional screening.
Effects of calcaneo-stop arthroereisis on joint kinematics during simulated walking: a cadaver study
Introduction: The calcaneo-stop procedure is a form of arthroereisis designed to limit valgus motion at the subtalar joint in progressive collapsing foot deformity. Although more frequently used in pediatric patients, it has also been performed in adults despite limited biomechanical evidence. This study evaluated the effect of the calcaneo-stop procedure on hindfoot kinematics during simulated level walking in a cadaveric deformity model. We hypothesized that the procedure would restore subtalar and talonavicular motion toward intact patterns. Methods: Eight cadaveric distal tibia and foot specimens were mounted in a six-degree-of-freedom robotic system that simulated the stance phase of gait. Four conditions were tested: intact, simulated deformity, calcaneo-stop with the screw head at the subtalar joint line, and calcaneo-stop with the screw head positioned above the joint line. Reflective markers placed in the talus, calcaneus, and navicular were tracked by infrared cameras to calculate subtalar and talonavicular rotational kinematics. Bias-corrected bootstrapped 95% confidence intervals were used for comparisons. Results: The simulated deformity increased subtalar eversion and talonavicular abduction. With the screw at the joint line, subtalar eversion decreased by 3.8° in early stance, resulting in a 1.5° undercorrection relative to intact. Talonavicular abduction decreased by 4.9°, with a 1.4° undercorrection. When the screw was positioned above the joint line, eversion decreased by 6.2°, producing a 2.4° vercorrection, and talonavicular abduction decreased by 6.9°, with a 2.5° overcorrection. Conclusion: The procedure shifted kinematics toward intact values, but superior screw placement led to overcorrection. Accurate intraoperative positioning appears essential, and further clinical studies are necessary to confirm these findings and evaluate complications.
Middle facet uncoverage changes after flexible progressive collapsing foot deformity reconstruction
Introduction: Recent studies have associated the percentage of subtalar middle facet uncoverage with progressive collapsing foot deformity (PCFD). However, its postoperative behavior, relationship with conventional radiographic parameters, and impact on outcomes remain unclear. This study evaluated postoperative correction of middle facet uncoverage, its correlation with standard twodimensional measures, and its association with minimum two-year patient-reported outcomes. Methods: We performed a retrospective review of prospectively collected data from patients undergoing reconstruction for flexible deformity with pre- and postoperative weight-bearing computed tomography (WBCT) scans and baseline and minimum two-year PROMIS scores. Hindfoot fusions were excluded. Thirty-six patients met the criteria. Middle facet uncoverage and foot and ankle offset were measured on WBCT. Hindfoot moment arm and talar lateral incongruency angle were obtained from standard weight-bearing radiographs. PROMIS Physical Function, Pain Intensity, and Pain Interference were recorded at two years. Pre- and postoperative uncoverage were compared using t-tests. Spearman correlation with bootstrapped confidence intervals assessed associations among imaging parameters and outcomes. Results: Mean uncoverage improved from 31.1 percent preoperatively to 22.5 percent postoperatively, demonstrating significant correction. Preoperative values moderately correlated with postoperative uncoverage, and higher baseline uncoverage was associated with greater improvement. No meaningful correlations were found between uncoverage and foot and ankle offset, hindfoot moment arm, or talar lateral incongruency angle. Postoperative uncoverage did not correlate with two-year PROMIS scores, and patients with corrections below 17.9% did not demonstrate superior outcomes. Conclusion: Surgery improves middle facet uncoverage, but this parameter was not associated with radiographic alignment measures or patient-reported outcomes at two years.
Reliability and temporal stability of the Van Dijk-Asaumi method for measuring backfoot alignment
Introduction: Rear foot deformities are associated with pain, instability, and joint degeneration, with kinetic repercussions throughout the lower limb, making their quantitative evaluation fundamental. This study aimed to evaluate the interobserver reliability and temporal stability of a new proposed method for measuring the coronal alignment of the hindfoot. Methods: Cross-sectional, analytical, and prospective study, including 42 adults without apparent clinical deformities in the feet. Loaded radiographs were performed in the anteroposterior, lateral, and long axial views of the calcaneus. The alignment of the hindfoot was measured using the Van Dijk–Asaumi method, a new approach proposed by four evaluators with varying levels of experience. Interobserver and test-retest reliability were analyzed using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM), minimum detectable difference (MDD), Bland-Altman analysis, and Lin coefficient of agreement were also calculated. Results: Interobserver reliability was moderate, between 0.54 and 0.61. The test-retest reliability showed high temporal stability (ICC between 0.57 and 0.61). The SEM was low (0.12°-0.14°), with MDD less than 0.4°. The Bland-Altman analysis showed practically no bias and narrow limits of agreement. The Lin coefficient indicated almost perfect agreement (0.996-0.997). Conclusions: The new method exhibited low measurement error, excellent temporal stability, and high global agreement, making it a practical, objective, and reliable alternative for quantitative evaluation of hindfoot alignment in clinical practice.
Comparison of isolated and combined osteotomies on progressive collapsing foot deformity correction: A cadaveric study
Introduction: Lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and cotton osteotomy (CO) are commonly used to treat progressive collapsing foot deformity (PCFD). However, the correction achieved by isolated or combined procedures is poorly defined, and surgical planning remains largely empirical. The biomechanical effects of osteotomy magnitude are also debated, with limited data correlating the size of the correction with alignment. This study aimed to compare the three-dimensional correction produced by isolated and combined LCL, MDCO, and CO in a cadaveric model. We hypothesized that combining procedures would enhance overall alignment correction. Methods: Twelve cadaveric legs without deformity were mounted under 75 kg axial load with physiological tendon tension. Weightbearing CT (WBCT) scans were obtained preoperatively. Small, intermediate, and large corrections were performed for each osteotomy. Combinations of two procedures and all three procedures were subsequently executed. Foot and ankle offset (FAO) was measured after each WBCT acquisition. Results: All osteotomies significantly influenced FAO (p < 0.05). As isolated procedures, LCL, MDCO, and CO decreased FAO by 0.36%, 0.8%, and 0.29% per millimeter, respectively. Increasing correction magnitude produced progressive alignment improvement (p < 0.05). Two-procedure combinations decreased FAO by 3.9%-7.2% with no significant differences among them (p = 0.226). Combining all procedures resulted in FAO reductions of 5.2%-14.2%, with significant differences between groups (p = 0.002). Conclusion: MDCO produced the greatest isolated correction. Increasing osteotomy magnitude resulted in a gradual improvement in alignment. While two-procedure combinations had similar effects, maximal correction was achieved when all procedures were combined with larger displacements. These findings may help guide surgical planning in PCFD.
Minimally invasive surgery in the correction of recurrent hallux valgus: a case series with 2 year followup
Introduction: Recurrent deformity following surgical correction remains a complex and technically demanding condition. This study aimed to evaluate the clinical and radiographic outcomes of minimally invasive surgery (MIS) in patients undergoing revision procedures for recurrent hallux valgus (HV). Methods: This retrospective case series included 33 feet that underwent minimally invasive revision surgery using either the thirdgeneration minimally invasive Chevron-Akin (MICA) or the fourth-generation Metaphyseal Extra-Articular Transverse and Akin osteotomies (META), following failure of a previous HV correction performed by open or MIS. Clinical outcomes were assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ), the visual analog scale (VAS) for pain, and patient satisfaction. Radiographic parameters and complications were recorded and statistically analyzed using R software. Results: Both techniques proved effective in angular correction, with significant reductions in the hallux valgus angle (HVA) and intermetatarsal angle (IMA) (p < 0.001), as well as in bone and soft-tissue forefoot width (p < 0.05). Significant improvements were also observed in all three MOXFQ domains (p < 0.001) and in VAS scores (p < 0.001). Subgroup analysis revealed no statistically significant differences between MICA and META in either radiographic or clinical outcomes related to pain and function (p > 0.05). Conclusion: Third- and fourth-generation minimally invasive surgical techniques have proven effective in correcting radiographic parameters and improving pain and functional scores in patients undergoing revision for recurrent hallux valgus, with a low rate of complications
Surgical correction of flat foot due to posterior tibial muscle tendon injury: case report
Rupture of the posterior tibial tendon (PTT) is the main cause of acquired flatfoot in adults, commonly treated by transfer of the flexor digitorum longus (FDL) tendon. This study aims to report and describe the surgical application of a poorly documented technique: PTT reconstruction using hamstring autografts to treat stage II flatfoot deformity in a patient who suffered low-energy trauma. This is a case report of a 44-year-old female patient with a complete rupture of the retromalleolar portion of the PTT after ankle sprain. Surgical treatment involved a combined approach (open and arthroscopic) using grafts from the semitendinosus and gracilis tendons. The technique included Pulvertaft tenorrhaphy, fixation to the navicular bone with an interference screw, and retinaculum reconstruction. The surgery provided satisfactory correction of the plantar arch, as evidenced by the immediate formation of a medial cavus and confirmed by podoscopy in the postoperative period. The patient presented preservation of dorsiflexion and inversion movements, absence of pain during ambulation, and satisfactory balance. Only temporary plantar paresthesia was observed due to the neurolysis required during the procedure. Reconstruction with hamstring autograft showed favorable results in the treatment of stage II flatfoot secondary to PTT rupture. Despite the technique’s potential, the literature still lacks sufficient studies to establish a definitive consensus on its application.
Advancing Scientific Excellence: Highlights from the 22nd Brazilian Congress of Ankle and Foot Medicine and Surgery
É com grande satisfação que apresentamos este suplemento especial da nossa revista científica, dedicado aos anais dos artigos enviados como temas livres e pôsteres do 22º Congresso Brasileiro de Medicina e Cirurgia do Tornozelo e Pé, realizado em São Paulo. Como presidente do Congresso, tenho o privilégio de testemunhar o crescimento no número e na qualidade dos trabalhos científicos enviados ao nosso evento. Neste suplemento, publicamos uma seleção variada de resumos de trabalhos originais, abrangendo desde trabalhos anatômicos até estudos de artroscopia, de pé diabético e de lesões ligamentares, entre outros. Os temas livres e pôsteres selecionados refletem o rigor metodológico e a relevância clínica das contribuições enviadas, submetidas a um processo de revisão por pares que garante a excelência acadêmica. Agradecemos aos autores por compartilhar seus achados inovadores, aos revisores pela expertise indispensável e ao comitê organizador pelo empenho incansável. Que este suplemento inspire colaborações, estimule novas investigações e fortaleça nossa comunidade científica. Convido a todos a explorar estas páginas e a participar ativamente das próximas edições do Congresso. Juntos, avançamos na excelência do cuidado ao pé e ao tornozelo no Brasil.