Brazilian Orthopedic Foot and Ankle Society.
Five Years by the Numbers: What an Independent Bibliometric Study Tells Us About the Journal of the Foot & Ankle
In this issue, a group from Duke University School of Medicine, led by Julieta Brué and senior author Cesar de Cesar Netto, publishes the first bibliometric analysis of the Journal of the Foot & Ankle (JFA) since its 2020 reformulation.1 That an outside team chose to examine our journal's output in such detail is itself a form of recognition, and the picture it draws is one we are glad to share with our readers, authors, and reviewers. Between January 2020 and December 2025, JFA published 334 peer-reviewed research articles, averaging 56 per year and rising to 73 in 2025 alone — a trajectory of sustained, accelerating growth. Original articles accounted for nearly 70% of that output, and the share of systematic reviews and other higher-evidence document types has been increasing, a shift that reflects the growing methodological maturity of the manuscripts we receive. More than a thousand unique authors, an average of 5.2 per article, have contributed to this body of work, evidence of the collaborative culture our specialty has built around the journal. Geographically, the study confirms what our editorial board has long understood: JFA is a Brazilian-anchored but genuinely Ibero-American journal. Brazil accounts for 55.4% of articles, with meaningful contributions from Argentina, the United States, Spain, Chile, Mexico, Portugal, and Colombia. International collaboration, present in 10.5% of articles and reaching 14.3% in some years, shows this regional identity is not insular — it is a platform from which our authors engage the wider foot and ankle community. The authors note, and we find it worth underlining, that only 2.62% of editorial board seats across major international foot and ankle journals are held by researchers from Latin America and the Caribbean. Against that backdrop, a journal with fully regional editorial governance, authorship reach across a dozen countries, and a leadership ranking spanning Brazil, the United States, Argentina, and South Africa is not a peripheral outlet. It is infrastructure for our specialty. The citation analysis — 272 accumulated citations and a journal h-index of 6 — is, understandably, the most modest of these findings, and we present it as exactly what it is: the early footprint of a young, not-yet-indexed journal. Indexation status, more than study quality itself, is among the strongest predictors of citation accrual, and citation lag in medical publishing typically runs six to eight years; more than half of the articles counted here were published in 2024 or later, so the clock on most of our recent output has barely started. What the data do show is the raw material for growth: rising volume, rising rigor, and a Diamond Open Access model that removes cost as a barrier to publishing and reading alike — a model few regional journals sustain and one that has become a defining part of our identity. We are highlignting this study at this time because 2026 is the year JFA is pursuing indexation in SciELO. Bibliometric self-knowledge is a precondition for that process, not a substitute for it, and this independent analysis gives the journal, its editorial board, and the evaluating committees a transparent, reproducible account of five years of production, authorship, geographic reach, and citation behavior — exactly the evidence a journal is asked to produce when it applies. We are grateful to Brué, Micicoi, Rodrigues, Umrethiya, Rachayont, Pozzessere, and de Cesar Netto for undertaking this work rigorously and for choosing to publish it with us. None of the numbers above are the achievement of an editorial office alone — they belong to the surgeons and researchers who have trusted JFA with their work, to our unpaid reviewers, and to the ABTPé and FLAMeCIPP communities that sustain its Diamond Open Access mission. As we move toward SciELO indexation, our commitment remains the one this study describes: a journal that lowers barriers, preserves regional research leadership, and continues to raise the evidentiary bar of what it publishes.
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Reverdin-Isham modified vs MICA for moderate hallux valgus: A comparative study
Objective: To compare clinical, functional, and radiographic results of the modified minimally invasive Reverdin-Isham (RImod) and minimally invasive Chevron-Akin (MICA) techniques in the treatment of moderate hallux valgus. Methods: Retrospective comparative study of 81 feet (38 MICA, 43 RImod) with moderate hallux valgus (IMA ≤ 18°, HVA ≤ 40°). Preand postoperative evaluations (6 months) included the AOFAS score, intermetatarsal angles (IMA) and hallux valgus angle (HVA), and fibular sesamoid subluxation (FSS). Statistical analysis used Student’s t and Wilcoxon’s tests, with adjustment for bilateral testing. Results: Both groups demonstrated significant improvement (p < 0.001) in AOFAS (MICA: 37.9 ± 12.6 to 90.95 ± 8.1; RImod: 40.47 ± 13.1 to 93.4 ± 6.5), IMA (MICA: 14.9 ± 2.1° to 10.0 ± 3.0°; RImod: 14.4 ± 2.1° to 10.0 ± 2.8°), HVA (MICA: 31.3 ± 6.1° to 11.8 ± 5.7°; RImod: 29.0 ± 5.8° to 11.0 ± 4.4°) and FSS (MICA: 89% to 53%; RImod: 82% to 51%). There was no statistically significant difference between the techniques for functional gain (p = 0.98), IMA correction (p = 0.43), HVA (p = 0.30), or FSS (p = 0.41). The complication rate was 21.1% for MICA and 9.3% for RImod (p = 0.149), with different profiles: MICA presented problems with implants and recurrence, while RImod had cases of nerve injury and malunion. Conclusion: RImod and MICA are effective for the correction of moderate hallux valgus, with comparable clinical and radiographic results. Both techniques demonstrated significant clinical and radiographic improvements, with functional gains in AOFAS score and substantial angular corrections in HVA, IMA, and FSS. Level of Evidence III; Comparative Retrospective Study.
Epidemiology and mechanisms of tennis-related ankle and foot injuries presenting to United States emergency departments: A 10-year national analysis (2015-2024)
Objective: To characterize the epidemiology, demographics, diagnoses, mechanisms of injury, and temporal trends of tennis-related ankle and foot injuries presenting to United States emergency departments between 2015 and 2024. Methods: This descriptive epidemiology study used the National Electronic Injury Surveillance System database to identify tennisrelated ankle, foot, and toe injuries presenting to United States emergency departments from January 1, 2015, through December 31, 2024. Demographic characteristics, injury diagnoses, body-part involvement, injury location, disposition, narrative mechanism, and temporal trends were analyzed. National estimates were calculated using NEISS sample weights, and approximate 95% confidence intervals were calculated for key proportions to contextualize estimate stability. Results: A total of 616 unweighted cases met inclusion criteria, corresponding to an estimated 22,497 emergency-department presentations nationally. Females accounted for 53.1% of injuries, while males accounted for 46.9%. The most affected age groups were 20-44 years (32.5%) and 14-19 years (31.0%). The ankle represented the most frequently injured body part, accounting for 73.1% of injuries. Sprains and strains were the most common diagnosis (63.2%), with ankle sprains/strains comprising the largest single diagnosis-body part combination (53.9%). Acute non-fall, non-contact injuries represented the predominant mechanism (74.2%). Most injuries occurred at sports and recreation facilities (77.6%), and 98.7% of patients were treated and released from the emergency department. No statistically significant temporal trends were observed across age groups. Conclusion: Tennis-related ankle and foot injuries presenting to United States emergency departments are predominantly ankle sprains sustained through acute non-contact mechanisms. These findings should be interpreted as a descriptive estimate of emergencydepartment burden rather than sport-wide incidence. Tennis-specific prevention programs emphasizing neuromuscular control, balance training, proprioception, and ankle stabilization may help reduce injury burden among tennis players. Level of Evidence III; Retrospective Descriptive Epidemiological Study.
Radiographic morphometric analysis of cuboid bone in asymptomatic adult feet: Reference values and anatomical parameters
Objectives: To establish radiographic parameters of normality of the cuboid bone and to assist in therapeutic decisions in several diseases. Methods: Five hundred and sixteen adult patients (516 feet) aged between 18 and 70 years were selected, distributed equally between sexes and without current or previous cuboid lesions. Foot radiographs at internal oblique incidence were performed and two parameters were evaluated. The first was the measurement of the alpha angle, formed between the distal and proximal articular surfaces of the cuboid, and the second was the ratio between the length of the lateral and medial walls. Results: Radiographic parameters were evaluated, and the results by sex and age group were divided into groups (18 to 50 and 50 to 70 years). Alpha angle values in the general population ranged from 21.6° to 49.2°, with a mean of 35.62°, and differed by sex, with male patients showing a higher angle (35.11° x 36.13°). The ratio between the walls ranged from 0.37 to 0.69, with a mean of 0.52 and no sex differences. Conclusion: The radiographic parameters studied may help define cuboid anatomy and guide the therapeutic approach to several foot injuries. Level of Evidence III; Radiographic Descriptive Cross-Sectional Study
Union rates in hallux interphalangeal joint arthrodesis: A retrospective review of a reproducible surgical technique
Objective: To assess the radiographic union rate and complications following hallux interphalangeal joint arthrodesis (HIPJA) using a single reproducible surgical technique and report on possible technique tips to improve the union rate. Methods: A retrospective review of all HIPJAs performed by four foot and ankle orthopedic surgeons was conducted. The surgical technique, patient factors, indications, reoperation rate, complications, and radiographic evidence of arthrodesis were collected. Radiographic union was defined as two cortical continuations or trabecular bridging, absence of hardware failure, and the absence of lytic gapping at the arthrodesis site. Results: Thirty-five primary HIPJA procedures were identified with radiographic follow-up until union or non-union was confirmed. Our cohort demonstrated a 97.1% radiographic union rate with a mean time to union of 20 weeks. There were three reoperations: two cases (5.7%; 95% CI, 0.7%-19.2%) for removal of painful hardware and one case (2.9%; 95% CI, 0.07%-14.9%) for revision of a symptomatic non-union. Because only one non-union occurred, the study was not powered to identify independent predictors of non union. Conclusion: This cohort showed a mean above-radiographic union rate with a consistent surgical technique, meticulous joint preparation, and a single large intramedullary differential pitch screw for fixation. Radiographic union took longer than expected, with a mean of 20 weeks. Level of Evidence IV; Retrospective Case Series
Clinical outcomes following interpositional arthroplasty for advanced hallux rigidus: A retrospective case series
Objective: To evaluate clinical and functional outcomes following interpositional arthroplasty in a Brazilian cohort. Methods: This retrospective case series included 10 patients with grade III-IV hallux rigidus (HR) treated between January and September 2025. All procedures were performed by a single experienced foot and ankle surgeon. Inclusion criteria were failure of at least six months of conservative treatment. Exclusion criteria included diabetes mellitus, rheumatoid arthritis, and prior first metatarsophalangeal joint (MTPJ) surgery. Outcomes were assessed using the visual analog scale (VAS) and the American Orthopaedic Foot & Ankle Society (AOFAS) score preoperatively and at four months postoperatively. Statistical analysis included descriptive statistics, the Shapiro-Wilk test, and the Wilcoxon signed-rank test, with significance set at p < 0.05. Results: The cohort was predominantly female (90.00%, 9/10), with a mean age of 58.700 ± 11.180 years. All patients achieved greater than 30° of first MTPJ range of motion at final follow-up. Radiographs demonstrated adequate bone resection and preservation of joint space. Pain improved progressively, with median VAS decreasing from 7.000 (IQR 6.500-8.000) preoperatively to 1.500 at four months (IQR 0.000-2.000). Functional outcomes improved significantly, with median AOFAS increasing from 52.000 (IQR 42.000-66.750) preoperatively to 84.000 (IQR: 84.000-99.000) at final follow-up. Conclusion: Interpositional arthroplasty resulted in significant improvements in pain and function while preserving joint motion in patients with advanced hallux valgus. This technique represents a viable motion-preserving alternative for selected patients who wish to avoid arthrodesis. Level of evidence IV; Retrospective Study.
High prevalence of intra-articular lesions identified by arthroscopy during syndesmotic screw removal after ankle fracture fixation
Objective: To determine the prevalence of intra-articular lesions and evaluate syndesmotic stability using ankle arthroscopy performed at the time of syndesmotic screw removal in patients with surgically treated Weber B and C ankle fractures. Methods: A prospective observational study was conducted, including patients with unstable ankle fractures classified as Weber B or C who underwent open reduction and internal fixation with syndesmotic screw placement. Ankle arthroscopy was performed during routine syndesmotic screw removal 6–8 weeks after the index procedure. Arthroscopic findings, including chondral lesions of the talar dome, synovitis, intra articular fibrosis, meniscoid lesions, loose bodies, and syndesmotic instability, were recorded. Chondral lesions were classified according to the Outerbridge classification. Results: Twenty-two patients were included in the study. Arthroscopic evaluation revealed chondral lesions of the talar dome in 16 patients (72.7%), synovitis in 17 patients (77.3%), and diffused intra-articular fibrosis in 20 patients (90.9%). Residual syndesmotic instability was identified in two patients (9.1%). Most chondral lesions were classified as Outerbridge grade II or III. No statistically significant association was identified between mechanism of injury and arthroscopic findings. Conclusion: Arthroscopy evaluation during syndesmotic screw removal revealed a high prevalence of intra-articular lesions following ankle fracture fixation. Arthroscopic evaluation may therefore represent a valuable diagnostic and therapeutic adjunct for identifying intra-articular lesions that may contribute to persistent postoperative symptoms. Level of Evidence IV; Prospective Observational Study.
Five-year bibliometric analysis of the Journal of the Foot & Ankle (2020-2025)
Objective: To characterize productivity, document-type composition, authorship, geography, and citation impact of the Journal of the Foot & Ankle (JFA) over its first five years (2020-2025) following its 2020 refoundation. Methods: All peer-reviewed articles published in JFA between January 2020 and December 2025 were retrieved from OpenAlex and cross-checked against Crossref. The 22 articles of the founding issue (V14 N1) were registered under the predecessor journal’s ISSN and recovered separately. Meeting abstracts, articles outside the study period, editorials, and one tribute were excluded. Document type was classified by manual review of each issue’s Table of Contents. Author productivity was measured by leadership appearances (first or last author), country and institution by whole counting at the article level, and citation impact by cumulative counts and the journal h-index. Analysis was performed in R. Results: A total of 334 articles were included, with a mean of 56 per year. Original articles accounted for 68.9%. Unique authors totaled 1,037, with a mean of 5.2 per article. Brazil was the predominant country in 185 articles (55.4%), followed by the United States (10.2%) and Argentina (6.0%). The most productive institution was the Universidade Federal de São Paulo (23 articles). The total accumulated 272 citations with a journal h-index of 6. César de César Netto led the leadership ranking with 15 appearances (14 as senior author). International collaboration had a mean of 10.5%. Conclusion: JFA has consolidated as the principal Ibero-American outlet for foot and ankle research, with a Brazilian-anchored yet regionally inclusive authorship, sustained Diamond Open Access, and an early but rising citation footprint. Level of Evidence IV; Bibliometric, Descriptive Observational Study.
Influence of proximal hip muscle strengthening on medial longitudinal arch alignment: A randomized trial comparing gluteus maximus and gluteus medius exercises
Objective: To compare the effects of gluteus maximus (GMax) strengthening versus gluteus medius (GMed) strengthening on medial longitudinal arch (MLA) alignment in individuals with asymptomatic flexible flatfoot. Methods: Fifty-three individuals with asymptomatic flexible flatfoot were randomly assigned to two groups for this randomized comparative study. GMax strengthening activities were assigned to Group A, and GMed exercises to Group B. For two weeks, both therapies were administered. The navicular drop test (NDT) and foot posture index (FPI), evaluated before and after the intervention, were among the outcome measures. SPSS version 26.0 was used for statistical analysis, and p < 0.05 was used for both within-group and between-group comparisons. Results: After the intervention period, both groups showed statistically significant reductions in FPI scores and navicular decrease (p < 0.05). When comparing the GMed and GMax strengthening groups, the between-group analysis showed a considerably greater improvement in MLA alignment (p < 0.05). In individuals with asymptomatic flexible flatfoot, proximal hip muscle strengthening improves MLA alignment. The significance of focused hip abductor strengthening in the treatment of flexible flatfoot is evident, as GMed strengthening appears more successful than GMax strengthening in improving foot posture and reducing navicular drop. Conclusion: Gluteus maximus and gluteus medius strengthening improved the medial longitudinal arch and foot posture in asymptomatic flexible flatfoot; however, gluteus medius strengthening was more effective, emphasizing the importance of hip abductor-focused protocols in physiotherapy. Level of Evidence II; Randomized trial, Comparative study
Orthopedic management of foot deformities due to poliomyelitis sequelae
Objective: To evaluate the clinical and functional outcomes of surgical approaches to foot deformities due to poliomyelitis sequelae. Methods: This observational, retrospective, descriptive study included adult patients with poliomyelitis sequelae who underwent surgical correction of foot deformities. Functional assessment was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale, applied descriptively during postoperative follow-up. Demographic and clinical variables, type of deformity, surgical procedures, and postoperative functional scores were analyzed without formal comparisons among techniques. Postoperative followup ranged from 12 to 48 months (mean, 27 months), and preoperative AOFAS scores were unavailable. Results: Ten patients were included, with a mean age of 55.3 years; most were men. Procedures included panarthrodesis, ankle arthrodesis, midtarsal arthrodesis with soft-tissue procedures, talectomy, and arthrodesis using the Ilizarov method. AOFAS scores ranged from 56 to 83 points, with a mean of 72.5. Overall postoperative functional status was satisfactory, with good results in pain, stability, and alignment, although sagittal and hindfoot mobility remained restricted, particularly after arthrodesis. The highest AOFAS score was observed after panarthrodesis, whereas the lowest scores were observed after talectomy. Three cases of superficial skin necrosis and one case of delayed union of the tibiotarsal arthrodesis were recorded; none required reoperation. Conclusion: Surgical treatment resulted in overall satisfactory postoperative functional status in this case series. Findings should be interpreted descriptively due to the absence of preoperative AOFAS scores, small sample size, and heterogeneity of deformities and techniques. Surgical individualization was relevant, but further comparative studies with larger sample sizes are required. Level of evidence III; Therapeutic, Retrospective Study
Plate-mediated versus lag screw-driven compression in first metatarsophalangeal joint arthrodesis for end-stage hallux rigidus: A retrospective comparative cohort study
Objective: To compare two technical sequences using the same fixation construct but differing in the mechanism responsible for primary compression across the arthrodesis site. Methods: A retrospective cohort study was performed including consecutive patients who underwent first metatarsophalangeal joint (MTPJ) arthrodesis for advanced hallux rigidus (Coughlin and Shurnas grades 3 and 4) between January 2015 and December 2024. All procedures were performed using cup-and-cone joint preparation, a low-profile dorsal plate, and an oblique cannulated screw. In technique 1 (T1), compression was generated primarily through the dynamic compression mechanism of the dorsal plate, whereas in technique 2 (T2), compression was generated primarily by the oblique lag screw. Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analog scale (VAS) for pain. Radiographic union, time to union, and complications were recorded. Results: Fifty-five patients (68 feet) were included, comprising 39 feet treated with T1 and 29 feet treated with T2. Both techniques resulted in significant improvements in AOFAS and VAS scores (p < 0.001 for all comparisons). Nonunion occurred in 3 of 39 feet (7.7%) in T1 and 1 of 29 feet (3.4%) in T2 (p = 0.631). No statistically significant differences were observed between groups regarding final AOFAS scores, final VAS scores, or overall complication rates. Mean time to union was significantly shorter in T2 than in T1 (6.89 ± 0.79 vs 7.94 ± 1.17 weeks; p < 0.001). After adjustment for age and baseline clinical differences, T2 remained independently associated with faster union (adjusted coefficient -0.80 weeks; 95% confidence interval, -1.46 to -0.15; p = 0.015). Conclusions: First MTPJ arthrodesis using a dorsal plate combined with an oblique cannulated screw provided reliable union, substantial pain relief, and significant functional improvement regardless of the sequence of implant application. Although both compression strategies yielded comparable union rates and clinical outcomes, lag screw-driven compression was associated with a significantly shorter time to fusion. These findings suggest that direct interfragmentary compression generated by the oblique lag screw may modestly accelerate arthrodesis consolidation without increasing complications. Level of Evidence III; Retrospective Comparative Cohort Study.
Results of wound complications in Achilles tendon repair at a public service
Objective: To evaluate wound healing outcomes and postoperative complications in patients undergoing surgical treatment of Achilles tendon rupture at a Brazilian university hospital operating exclusively through the public healthcare system and to identify factors associated with worse clinical outcomes. Methods: This retrospective observational study analyzed 64 adult patients with complete Achilles tendon ruptures who underwent surgical treatment between 2019 and 2024. All procedures were performed by orthopedic residents under supervision. Data collected included demographics, comorbidities (smoking, obesity, diabetes), surgical techniques, time to surgery, and wound-related complications. The primary outcome was postoperative complications. Secondary outcomes included time to complete wound healing, rerupture rates, and need for reoperation. Descriptive statistics and inferential analyses were performed with 5% significance (p < 0.05). Results: Mean patient age was 45 years, with 73% aged 40-60 years. Overall complication rate was 20.3%, primarily infection (15.6%) and wound dehiscence (12.5%). Nerve injury occurred in 7.8% and deep infection in 4.7%. No reruptures or tendon exposures were observed. Comorbidities significantly increased the risk of complications (OR ≈3.7, p < 0.05) and delayed healing. No significant associations were found between outcomes and patient age, time to surgery, or surgical technique. Conclusion: Surgical Achilles tendon repair by supervised residents yielded satisfactory outcomes with complication rates comparable to international literature. Comorbidities were the primary risk factors for adverse events, underscoring the need for preoperative optimization. This study validates the safety and effectiveness of the university hospital model when structured supervision and standardized protocols are implemented. Level of evidence III; Retrospective cohort study.
A new method for measuring hindfoot alignment: Reliability and temporal stability
Objective: To evaluate the interobserver reliability and temporal stability of an adapted Van Dijk-Asaumi method for measuring coronal hindfoot alignment. Methods: A cross-sectional, analytical, and prospective study including 42 adults without clinically apparent foot deformities. Weightbearing radiographs were obtained in the anteroposterior, profile, and long axial views of the calcaneus. Hindfoot alignment was measured using a novel adapted method by Van Dijk-Asaumi and assessed by four evaluators with different levels of experience. Interobserver reliability and test-retest reliability were assessed using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the minimal detectable change (MDC) were also calculated. Additionally, Bland-Altman analysis was performed, and Lin’s concordance correlation coefficient was determined. Results: Interobserver reliability was moderate, with ICC values ranging from 0.54 to 0.61. Test-retest reliability demonstrated adequate temporal stability, with ICC values between 0.57 and 0.61. The SEM was low (0.12°-0.14°), with an MDC below 0.4°. Bland-Altman analysis revealed negligible systematic bias and narrow limits of agreement. Lin’s concordance correlation coefficient indicated nearperfect agreement (0.996-0.997). The adapted method demonstrated low measurement error and adequate temporal stability, though only moderate interobserver reliability (ICC 0.54-0.61). Conclusions: The novel method demonstrated low measurement error, adequate temporal stability, and moderate overall interobserver agreement, establishing itself as a practical, objective, and reliable alternative for the quantitative assessment of hindfoot alignment in clinical practice. Level of evidence III; Methodological, Cross-sectional, Analytical, and Prospective Study
Postoperative evaluation of patients undergoing minimally invasive treatment for acute Aquilles tendon rupture
Objective: To evaluate the clinical and functional outcomes of patients undergoing percutaneous repair of acute Achilles tendon rupture with the Tenolig® device, associated with a structured rehabilitation protocol with eccentric exercises adapted from Alfredson’s principles. Methods: Observational, retrospective, and descriptive study with 20 patients treated with rupture less than five days. Cases with clinical and ultrasound diagnosis and distal stump suitable for the device were included. Insertional injuries, re-rupture, previous surgeries in the affected limb, and comorbidities with potential functional or scarring impairment were excluded. The postoperative protocol included initial immobilization in plantar flexion, weight-bearing progression, protected physiotherapy, and eccentric exercises after week 12. The functional evaluation used the Achilles Tendon Total Rupture Score (ATRS) and timed monopodal exercise. The median follow-up was 24 ± 4.6 months. Results: The sample included 20 patients, with a mean age of 39.7 ± 13.2 years. The mean ATRS was 98.1 ± 3.4 points, with a median of 100 and a range of 86-100. The mean monopodal exercise time was 31.8 seconds. There was a re-rupture (5%) without infection, scarring complications, or sural nerve paresthesia. Conclusion: Minimally invasive repair with Tenolig®, combined with structured rehabilitation, showed favorable outcomes and a low complication rate in this case series. The interpretation is limited due to the small sample size, retrospective design, and absence of a comparison group. Level of Evidence IV; Descriptive Observational Study
Angioleiomyoma of the Ankle with adjacent Superficial Peroneal Neuritis: A Case Report
Angioleiomyoma is a rare, benign soft tissue neoplasm accounting for approximately 0.2% of all tumors of the foot and ankle. It occurs most frequently in women, with a mean age at presentation of approximately 47 years. Angioleiomyoma arises from smooth muscle proliferation within the tunica media of vessels, possibly originating from arteriovenous anastomoses, and forms a well-circumscribed vascular smooth muscle tumor. Complete surgical excision is considered curative in most cases and is associated with a low reported recurrence rate. Approximately 1% of cases transform into malignant variants, including leiomyosarcoma. Early identification and appropriate management are therefore essential to optimize outcomes and mitigate the potential risk of malignant progression. We present a rare case of angioleiomyoma arising over the superficial peroneal nerve at the ankle, highlighting its clinical presentation, imaging characteristics, surgical management, and histopathologic findings. Level of Evidence IV, Case Report
An unusual presentation of multiple metatarsophalangeal joint irreducible dislocation: A case report
Dislocations of multiple metatarsophalangeal joints are a rare injury, as the compact arrangements of tissues around the joint make it a stable condyloid joint. There are a few cases in the literature showing four or all metatarsophalangeal dislocations. We present a case of a male patient who sustained a fall from height resulting in dorsiflexion injury of the metatarsophalangeal joint. Closed reduction techniques failed; therefore, we had to perform an open reduction of the dislocation. Two dorsal incisions are used to address the injury. It was found that the plantar plate and buttonholing of the capsule prevented its reduction. A dorsal approach prevents further injury to the plantar plate, but the capsule had to be incised to achieve reduction. Level of Evidence V; Case Report.
Medial naviculocuneiform fracture-dislocations: A report of two cases
Medial naviculocuneiform fracture-dislocation – classified as a type B1 Lisfranc injury according to the Hardcastle classification modified by Myerson, or perhaps more accurately termed a ‘Lisfranc-like medial column injury extending to the naviculocuneiform joint’ – is an uncommon pathology. Available evidence is limited, with only a few cases reported in the literature. We present two cases of medial naviculocuneiform fracture-dislocation treated with different surgical techniques. The first case presented acutely and was managed with rigid fixation using cannulated screws. In contrast, the second case underwent primary arthrodesis due to a prolonged time since the injury and articular damage. Both patients were followed clinically and radiographically for 12 months. At the final follow-up, the acute case demonstrated an American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score of 70/100 and a visual analog scale (VAS) score of 4/10, but with early osteoarthritic changes. In contrast, the delayed presentation case achieved an AOFAS midfoot score of 85/100 and a VAS score of 2/10. Level of Evidence IV; Case Report
Simultaneous Shepherd, Cedell, and lateral process talar fractures: A case report
Synchronous fractures of the lateral tubercle (Shepherd), the medial tubercle (Cedell), and the lateral process of the talus, associated with a hallux fracture-dislocation, represent a rare and complex injury pattern. Few cases have been reported in the literature. We present the case of a 40-year-old male patient involved in a motorcycle accident who sustained blunt trauma to his left ankle. Initial plain radiographs and subsequent computed tomography (CT) confirmed displaced fractures involving both tubercles of the posterior process of the talus as well as the lateral process, along with a fracture-dislocation extending into the tibial condyle of the proximal phalanx at the hallux interphalangeal joint. Surgical fixation was performed, including anatomical reduction and internal fixation. Clinical and radiological follow-up over 18 months demonstrated satisfactory functional recovery and bone union, with the patient scoring 70/100 on the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, 42% on the Foot Function Index (FFI), and 4/10 on the Visual Analog Scale (VAS) for pain. For the hallux, the AOFAS hallux score was 69 points. This case underscores the clinical importance of recognizing peripheral talar fractures, which are frequently overlooked on radiographs and require CT imaging for accurate diagnosis and appropriate management. Level of Evidence IV; Case report
Perception and Clinical Outcomes of Arthrodesis and Contralateral Total Ankle Replacement for Ankle Osteoarthritis: A Narrative Review
Objective: To evaluate the current evidence on perception, satisfaction, and functional outcomes in patients with bilateral ankle osteoarthritis treated with a total ankle replacement on one limb and contralateral arthrodesis. Methods: This narrative review, conducted as a qualitative, descriptive thematic synthesis in accordance with the Scale for the Assessment of Narrative Review Articles, searched four electronic databases between March and April 2026 with no restriction on publication year. The intra-individual design was intended to reduce demographic and lifestyle heterogeneity, although it does not eliminate biomechanical interdependence between limbs. Results: Three studies met the inclusion criteria, with mean follow-up ranging from 2 to 6.2 years across cohorts. Both procedures achieved comparable pain relief. Total ankle replacement preserved sagittal-plane motion, producing higher functional scores and a more intuitive, physiologic gait, whereas arthrodesis offered a stable weight-bearing base but restricted dorsiflexion, induced compensatory midfoot kinematics, and increased the cognitive burden of monitoring the environment to prevent falls. Patientreported and general health measures showed comparable satisfaction between sides; replacement complications were predominantly mechanical, whereas arthrodesis complications were predominantly biological. The hybrid strategy was reported as more cost-effective than bilateral arthroplasty. Conclusion: In bilateral end-stage ankle osteoarthritis, combining a replacement on one limb with a contralateral arthrodesis allows patients to alternate limb use according to task; standardized, long term prospective studies are required to confirm these observations. Level of Evidence V; Narrative review
Hallux rigidus is a common disorder of multifactorial etiology and highly disabling in many cases. Factors associated with the development of the condition include trauma, particularly in cases of unilateral involvement, the shape of the metatarsophalangeal joint and shortening of the soft-tissue structures of the posterior chain. Excessive length and elevation of the first metatarsal are factors that have also been associated with the disorder in some studies. Conservative treatment may provide temporary symptom relief, especially in the early stages, but cannot eliminate or reduce established degenerative changes. Surgical treatment is guided by the patient's characteristics and expectations, as well as the clinical and radiographic stage of the disorder. Joint-preserving procedures, such as metatarsal and proximal phalanx osteotomies, are the preferred approach for less severe grades of the disorder, whereas interposition arthroplasty and arthrodesis are indicated for more advanced disease. Provided that technical indications are followed, good to excellent results are expected in the majority of the cases.
Pain and functional disability related to foot and ankle among high heel users: Analytical cross-sectional study
Objective: To assess the intensity of pain and functional disability related to the foot and ankle among high-heel users. Methods: A total of 208 female participants aged 18 years or older were included in this analytical cross-sectional study. Participants who met the inclusion criteria and provided informed consent were included in the study. Pain and functional disability were assessed using the Numeric Pain Rating Scale (NPRS) and Foot and Ankle Disability Index (FADI), respectively, and data regarding heel use, including duration and frequency per day and per week, were collected through a structured questionnaire. The data were not normally distributed; therefore, non-parametric tests were applied. Spearman correlation was used for correlation analysis, while multivariate multiple regression was applied to identify independent predictors of pain and functional disability. Results: A total of 208 female participants were included, with a mean age of 24.25 ± 6.39 years and a mean BMI of 22.03 ± 3.25 kg/m2. The mean NPRS score was 4.90 ± 2.21, and the mean FADI score was 83.35 ± 18.27. Pain distribution showed 13.9% with no pain, 29.3% with mild pain, 39.9% with moderate pain, and 16.8% with severe pain. NPRS and FADI scores showed significant variation (p = 0.001 and p = 0.002), while BMI was not significantly associated with either outcome. Multivariate multiple regression analysis demonstrated that age was the only significant independent predictor, with higher pain intensity (β = 0.152, p < 0.001) and lower functional ability (β = -1.106, p < 0.001), whereas BMI and heel-use characteristics showed no significant associations with either outcome. Conclusion: Most participants experienced mild to moderate foot pain, with moderate pain being the most common category. Increasing age was significantly associated with higher pain intensity and greater functional disability, as reflected by higher NPRS scores and lower FADI scores. In contrast, BMI, heel height, and the frequency of daily and weekly heel use were not significantly associated with either outcome. Age was identified as a significant predictor of higher pain intensity and reduced functional ability, whereas heel-use characteristics did not predict either outcome. Level of Evidence III; Analytical Cross-sectional Study
Anatomical structures at risk in third- and fourth-generation minimally invasive hallux valgus surgery: A comprehensive review
A critical limitation common to all minimally invasive surgery (MIS) approaches is the lack of direct visualization during osteotomy execution, which exposes arteries, nerves, and tendon insertions to iatrogenic injury within a confined anatomical space. This review synthesizes applied anatomical knowledge relevant to third- and fourth-generation MIS for hallux valgus (HV), incorporating findings from cadaveric dissection and micro-computed tomography (CT) vascular mapping to characterize the tendinous, neural, vascular, and sesamoid architecture of the first metatarsal head complex and to define quantitative safety zones for intraoperative reference. Micro- CT perfusion studies have established that the apex of the Chevron osteotomy should be positioned at a minimum distance of 25.6 mm (dorsal arm) and 23.9 mm (plantar arm) from the most distal point of the first metatarsal articular surface, with the excursion of the Shannon burr limited to 3.9 mm and 4.0 mm beyond the exit point on the lateral cortex. The Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META) technique introduces a geometrically distinct risk profile by simultaneously addressing the dorsal and plantar metatarsal arteries in a single transverse plane; for this technique, a unified safety distance of approximately 26 mm is proposed for the osteotomy, pending specific anatomical application and micro-CT validation. Neurological risk for both osteotomy generations centers on the dorsomedial nerve of the first toe. Biomechanical and radiographic equivalence between third- and fourth generation constructs indicates that the choice of technique should be guided by surgical training rather than perceived mechanical superiority, and that safe execution depends on mastering the anatomical boundaries described in this review. Level of Evidence V; Expert Opinion, Basic Science Study
Total ankle arthroplasty in younger patients: Current concepts, contemporary evidence, and decision-making considerations
This article reviews the current evidence on total ankle arthroplasty (TAA) in patients younger than 55 years, including recent clinical outcomes and technical considerations, through a comparative analysis that underscores the areas of greatest controversy in its application. It is highlighted that, although in this group of patients there are higher rates of revision and re-operation, compared to older patients, the current evidence of TAA with state-of-the-art implants shows an acceptable survival in the medium term even in cohorts with young patients, indicating that, although age may be a risk modifier, it is not in itself an absolute contraindication. Rigorous patient selection and precise alignment are determinants, while prosthetic design and proper deformity correction significantly influence outcomes. Level of Evidence V; Narrative Review, Expert Opinion
Association between fluoroquinolones and Achilles tendon injuries: A systematic review
Objective: To analyze the available scientific evidence on the association between fluoroquinolone use and the risk of Achilles tendon injuries, including tendinopathy, tendinitis, and tendon rupture, compared with unexposed individuals or those exposed to other antibiotics. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) recommendations. Searches were performed in MEDLINE via PubMed, Embase, the Cochrane Library, SciELO, and Google Scholar as a supplementary search source. Study selection, data extraction, and methodological quality assessment were performed by two independent reviewers using Joanna Briggs Institute tools according to each study design. Results: Seventeen studies were included, predominantly cohort studies, case-control studies, and case reports, with higher methodological quality among studies with a comparator group. The evidence indicated an association between fluoroquinolones and an increased risk of tendinitis, tendinopathy, and Achilles tendon rupture, particularly during the first weeks after exposure. Risk was higher among older adults, patients with renal impairment, diabetes mellitus, obesity, and corticosteroid users. Ciprofloxacin and levofloxacin were the drugs most frequently associated with tendon outcomes. Conclusion: Fluoroquinolones are associated with an increased risk of Achilles tendon injuries, particularly among individuals with predisposing factors. Early identification of at-risk groups and judicious prescribing of these antimicrobials may reduce severe tendon complications. Level of evidence V; Systematic Review
Surgical approaches to hallux rigidus: a systematic review of arthrodesis and alternative techniques
Objective: To analyze and compare the clinical outcomes of arthrodesis versus alternative surgical techniques for hallux rigidus in adults. Methods: A systematic literature review was conducted in accordance with PRISMA guidelines. Electronic searches were performed in major databases to identify studies reporting surgical outcomes of arthrodesis and alternative techniques for hallux rigidus. Study characteristics, surgical techniques, reported outcomes, and complications were qualitatively synthesized. Results: The included studies were predominantly retrospective and demonstrated substantial heterogeneity in surgical techniques, outcome measures, and follow-up durations. Reported outcomes varied widely across procedures, and direct comparative evidence was limited. Conclusions: Current evidence on the surgical management of hallux rigidus is limited by study design, heterogeneity, and risk of bias. The available literature does not allow definitive conclusions regarding the superiority or equivalence of arthrodesis and motionpreserving procedures. High-quality comparative studies are needed to better define the role of alternative techniques in the treatment of hallux rigidus. Level of Evidence III; Systematic Review.
Commentary on: “A comparison of foot pain and dynamic stability among flat and heeled footwear users in undergraduate female medical students”
We read with great interest the article “Comparing foot pain and dynamic stability among flat and heeled footwear users in undergraduate female medical students.” This study addresses an often-overlooked health issue: the long-term musculoskeletal consequences of habitual footwear choices among young professionals. The topic is clinically relevant, particularly in populations where prolonged use of heeled footwear is common. The authors should be commended for addressing an understudied population and for employing validated outcome measures such as the visual analog scale and the Four Square Step Test (FSST)(1). The study demonstrates several methodological strengths, including a clearly defined objective, an adequate sample size, appropriate differentiation of heel-height categories, and the use of suitable statistical tests after assessing data normality. Reporting test-retest reliability for the FSST and acknowledging study limitations further enhance the study’s transparency. However, certain methodological and interpretative aspects need discussion. First, the use of a convenience sampling technique from a single academic institution limits external validity. While this is acknowledged by the authors, the conclusions appear to extend beyond what the sampling frame reasonably supports. The findings may not be generalizable to non-medical students, working women, or older populations, in whom footwear habits, physical activity levels, and musculoskeletal loading differ substantially. Second, while the use of ANOVA and Kruskal-Wallis tests is appropriate, the analysis relies predominantly on p-values. Reporting effect sizes and confidence intervals would have provided a clearer understanding of the clinical relevance of the observed differences, particularly given the statistically significant findings across heel-height categories(2). Additionally, the absence of multivariable analyses limits the ability to examine variables such as body mass index, duration and frequency of heel use, habitual physical activity, and previous minor foot symptoms that did not meet the exclusion criteria. Third, the categorization of heel height also deserves consideration. Grouping a wide range of heel heights into broad categories may introduce misclassification bias and obscure dose-response relationships. Future studies might benefit from narrower heel-height intervals or from analyzing heel height as a continuous variable. In conclusion, present a timely and clinically meaningful study. Addressing the above points in future research through longitudinal designs, probabilistic sampling, and multivariable statistical approaches would further strengthen the evidence base and enhance the applicability of the findings. We congratulate the authors on their contribution and appreciate the opportunity to engage in this scholarly discussion.