2025 Evidence-Based Medicine (EBM) Update

Bunions

Hallux valgus (HV) and its surgical correction continue to be popular topics. Several general themes of interest were noted, including the use of minimally invasive surgery (MIS) techniques, the assessment and impact of 3-dimensional HV deformity, concomitant foot and ankle deformity, risk factors, and predictors of success.

In a Level I randomized prospective study, Escudero et al ¹ compared 1-year outcomes between 20 patients undergoing MIS transverse distal metatarsal osteotomy with an Akin procedure and 20 patients undergoing open chevron-Akin (OC) osteotomies. The authors reported no significant differences between the groups in surgical time, patient-reported outcome measures (36-Item Short Form Health Survey [SF-36], Foot and Ankle Ability Measure [FAAM], visual analog scale [VAS], American Orthopaedic Foot & Ankle Society [AOFAS]), or radiologic measurements (intermetatarsal angle [IMA] and metatarsal length) at 1 year of follow-up. The MIS group demonstrated superior soft tissue healing at 6 weeks measured by a photographic wound assessment tool that evaluates edges, necrotic tissue type, amount, surrounding skin color, granulation tissue, and epithelialization. However, the overall complication rate was 15% in both groups. In the MIS group, complications included recurrence, wound-healing problems, and symptomatic hardware, whereas the open group experienced recurrence, asymptomatic osteoarthritis, and metatarsalgia.

The radiologic and clinical outcomes of 798 feet from 483 patients (456 female; mean age 57.9 years) who underwent MIS hallux valgus correction with a transverse osteotomy were reported by Lam et al ² in a Level IV prospective series. Outcomes included Manchester-Oxford Foot Questionnaire (MOXFQ), VAS pain, hallux valgus angle (HVA), IMA, and sesamoid position in patients with at least 12 months of follow-up. Significant improvements (P < .05) were reported in HVA and IMA, as well as in pain and function, with a recurrence rate of 4.5% and a complication rate of 6.1%.

In a separate Level IV case series, Lam et al ³ used weight-bearing computed tomography (WBCT) to evaluate first metatarsal rotation before and after transverse first metatarsal MIS osteotomies designed to supinate the distal segment. This study included 51 feet from 34 patients (32 female, 2 male; mean age 60.3 years) with a mean follow-up of 12.1 months. The authors reported significant improvements in HVA, IMA, metatarsal pronation, and sesamoid rotation (P < .05), as well as improvements across all clinical domains using the MOXFQ, EuroQol 5 dimensions–5 levels (EQ-5D-5L), and VAS. Regression analysis did not identify any radiologic or clinical variables predictive of clinical outcome.

Yoon et al ⁴ assessed the correlation between tibial sesamoid position following MIS bunion surgery and clinical and radiologic outcomes. In a retrospective cohort of 165 feet from 118 patients with a minimum of 24 months of follow-up, the authors evaluated sesamoid position in relation to clinical outcomes (VAS pain, FAOS, SF-36), radiographic parameters (HVA, IMA), recurrence, and complications. HV recurrence and revision surgery were significantly more common in patients with increased tibial sesamoid translation, despite similar functional outcomes compared with patients who had more anatomic sesamoid positioning. The authors suggested that metatarsal rotation may influence sesamoid position and may be adjustable during MIS bunion correction through rotation of the distal segment.

A Level II study by Bejarano-Pineda et al ⁵ investigated radiation exposure during MIS bunion surgery using a mini C-arm. Thirty-seven patients underwent MIS chevron and Akin osteotomies, whereas 31 underwent an open chevron with MIS Akin osteotomy based on surgeon preference. The MIS group had a longer exposure duration; however, radiation exposure for both techniques remained below occupational safety thresholds.

A Level III retrospective comparative study by Guevara et al ⁶ evaluated the use of allograft in MIS bunion surgery at a single center with 3 fellowship-trained surgeons. One surgeon used 2 mL of demineralized bone matrix gel in 26 patients, whereas the other 2 surgeons did not (42 patients). There was no difference in time to union, defined as the presence of 2 neocortices on radiographs. Lewis et al ⁷ conducted a Level III retrospective comparative study evaluating radiographic criteria for assessing healing after MIS bunion surgery in 726 feet treated with transverse osteotomies over an 8-year period. The authors specifically evaluated the “filament union sign,” defined as a filamentous bone bridge at the osteotomy site involving less than 25% of the metatarsal head width with minimal medial, lateral, or central remodeling. This sign was present in 24 feet (3.3%) and was associated with greater than 100% head shift. No nonunions or hardware failures were observed. Although a decrease in functional outcomes was noted, this difference was not clinically significant.

Carvalho et al ⁸ performed a cadaveric study on 20 specimens to assess the impact of an MIS chevron-type osteotomy at the metatarsal neck flare on surrounding soft tissues and the first metatarsal head blood supply. Gross dissection revealed injury to the flexor hallucis brevis in one specimen and to the dorsomedial nerve in another. Micro-CT imaging did not demonstrate arterial injury. The authors noted that the dorsal arm should be positioned 25.6 mm and the plantar arm 23.9 mm from the most distal point of the first metatarsal head, and that the burr should not penetrate more than 3.9 mm laterally to minimize vascular risk.

A finite element analysis model derived from CT imaging of a female patient with moderate HV deformity was used to assess 5 screw configurations for MIS bunion fixation. ⁹ The analysis demonstrated that 2 screws—1 bicortical and 1 intramedullary—provided superior stability and stress distribution.

Several publications investigated the 3-dimensional nature of HV deformity and its association with other foot and ankle conformational changes. In a retrospective cohort study of 131 female feet, Togei et al ¹⁰ evaluated the relationship between relative second metatarsal length and metatarsalgia in patients with hallux valgus. Radiographic measurements included HVA, IMA, and 4 methods of assessing second metatarsal length. Patients were divided into those with metatarsalgia (n = 55) and those without symptoms (n = 76). The authors reported that the Kumano method of measuring second metatarsal length, along with HVA and 1-2 and 1-5 IMAs, were predictors of metatarsalgia. HVAs ≥37° and a second metatarsal length exceeding 13.1 mm or a ratio of 18.8% were independent predictors of metatarsalgia.

Tanaka et al ¹¹ evaluated the association between concomitant second hammertoe deformity and postural stability in 45 patients with HV. Static stability was not associated with hammertoe presence; however, dynamic stability measures (Berg Balance Scale, Timed Up and Go test, and Falls Efficacy Scale–International) were impaired in patients with hammertoe deformity and moderate to severe bilateral HV. In a Level III comparative study, Togei et al ¹⁰ evaluated medial column coronal plane alignment using WBCT in four groups: patients with HV and symptomatic flatfoot, isolated HV, isolated symptomatic flatfoot, and controls (33 patients per group). Intrinsic pronation of the first metatarsal was increased in all pathologic groups compared with controls. Isolated HV and combined HV-flatfoot were associated with greater TMT pronation, naviculocuneiform supination, and sesamoid rotation/subluxation. The authors hypothesized that flatfoot compensation for first metatarsal pronation may occur primarily at the talonavicular joint. Choi et al ¹² used a deep learning model to analyze 212 radiographic parameters, including HVA, IMA, Meary’s angle, and calcaneal pitch. They identified significant correlations between parameters, including those linking pes planus and hallux valgus severity, supporting the concept of global foot deformity interdependence. A Level IV case series evaluated multiplanar deformity in 68 feet with hallux valgus (HVA > 15°) using WBCT. ¹³ First metatarsophalangeal joint rotation correlated with HVA, whereas hallucal pronation correlated most strongly with IMA. Several axial plane parameters correlated with both HVA and IMA, supporting the concept that axial plane deformity severity is associated with soft tissue dysfunction.

Several studies focused on patient expectations and factors influencing outcomes following HV surgery. In a Level III retrospective cohort study, de Buys et al ¹⁴ evaluated patient-reported motivations for seeking HV surgery. The cohort included 101 patients (5 males, 96 females; mean age 50.6 years), divided between those scheduled for surgery and those who had already undergone surgery. Both groups prioritized pain-free movement, relief of bunion pain, and the ability to walk long distances. Appearance ranked higher preoperatively, whereas shoe wear was more important postoperatively, underscoring the importance of managing patient expectations. Patel et al ¹⁵ evaluated the impact of tobacco and non-tobacco nicotine use on HV surgical outcomes using the TriNetX Global Health Research Network. All forms of nicotine use were associated with higher rates of infection, wound complications, stroke, pneumonia, renal failure, increased health care utilization, emergency department visits, and opioid-related disorders. Ferreira et al ¹⁶ compared Mayo and ankle blocks for postoperative pain control following MIS bunion surgery in 39 patients (57 feet). Pain scores at 12 and 24 hours postoperatively did not differ significantly between groups. The authors noted that a Mayo block required a smaller anesthetic volume while preserving plantar sensation. A cadaveric study evaluated the biomechanical effects of a biplanar distal chevron osteotomy with lateral (2-6 mm) and plantar (0-4 mm) translation of the first metatarsal head. ¹⁷ Twelve HV specimens were compared with 4 controls. A 4-mm lateral shift, combined with 2-4 mm of plantar displacement, restored contact pressures similar to those in normal feet.

Outcomes related to non-MIS procedures were also reported in 2025. Attia et al ¹⁸ published a Level III retrospective comparative study evaluating suspensory suture button fixation between the first and second metatarsal vs screw fixation between the first metatarsal and middle cuneiform in addition to an open modified Lapidus procedure using a plate-and-screw construct across the first tarsometatarsal joint. Forty patients were included in each group with a mean follow-up of 2.35 years. Suspensory fixation in conjunction with Lapidus procedures were associated with superior postoperative IMA despite similar initial deformity, magnitude of correction, and maintenance of correction.

A Level IV retrospective case series of 89 female feet undergoing chevron osteotomy with 5-8 years of follow-up identified predictors of successful outcomes. ¹⁹ Greater correction of HVA was associated with pain improvement. Higher preoperative HVAs correlated with lower postoperative pain, whereas higher postoperative HVAs were associated with worse pain.

Finally, Piclet-Legre et al ²⁰ conducted a Level IV retrospective case series evaluating coronal plane alignment in 58 patients undergoing open distal chevron osteotomy with rotational correction. Clinical outcomes (EFAS, EQ-5D-5L, EQ-VAS) and radiologic parameters (HVA, IMA, MPA, alpha angles) assessed using WBCT demonstrated improvements in function and alignment, approaching established normative values.

Ankle Fractures

Ankle fractures in general, and their association with syndesmotic and deltoid ligament injuries in particular were topics of interest in 2025.

Acknowledging the expanding use of advanced imaging in assessing syndesmotic injuries and the need for normative values for comparison, Bejarano-Pineda et al ²¹ evaluated anatomic parameters of the syndesmosis in a retrospective analysis of 88 individuals who underwent weightbearing CT (WBCT) for non–ankle-related indications. The authors noted no significant differences between laterality in the measurements used, including 2-dimensional area at 1, 3, and 5 cm proximal to the plafond and volumetric analysis from 0.5 cm proximal to the plafond up to 3 and 5 cm. The mean difference between ankles never exceeded 9%, with the greatest difference in area found at 3 cm above the tibial plafond and in volume from 0.5 to 3 cm above the plafond. The authors concluded that, if abnormality was defined as at least 2 SDs from the mean, then using measurements obtained 3 cm above the tibial plafond, any side-to-side volume difference greater than 19% and area difference greater than 24% indicates some degree of syndesmotic instability. Statistically significant differences were also noted between genders for all area and volume measurements.

Milstrey et al ²² investigated the impact of syndesmotic ligament disruption after repair of posterior malleolus fractures in a cadaveric study. Each specimen was evaluated using a 6–degrees-of-freedom robotic arm model with a posterior malleolus osteotomy, transection of the anteroinferior tibiofibular ligament (AITFL) and interosseous ligament (IOL), followed by ORIF of the posterior malleolus. Additional procedures included placement of a syndesmotic screw, isolated AITFL augmentation, and a combination of syndesmotic screw and AITFL augmentation. Simulated injury resulted in translational instability (6.9 mm posterior and 1.8 mm medial displacement) and rotational instability (5.5° of external rotation) of the distal fibula. ORIF of the posterior malleolus eliminated instability in the neutral ankle position; however, sagittal and rotational instability persisted in dorsiflexion and plantarflexion. This residual instability was eliminated with additional syndesmotic procedures, without notable differences between syndesmotic screw fixation and AITFL augmentation. The authors noted that syndesmotic instability could be detected by posterior fibular shift on stress testing after posterior malleolus fixation, with biomechanical equivalence between anatomic AITFL augmentation and syndesmotic screw fixation.

Karanja et al ²³ investigated injury to concomitant structures in supination-external rotation type 2 (SER-2) ankle fractures, which are traditionally managed without surgery. The authors acknowledged that SER-3 injuries (posteroinferior tibiofibular ligament injury or posterior malleolus fracture) and SER-4 injuries (deltoid ligament injury or medial malleolus fracture) traditionally mandate surgery because of concerns regarding syndesmotic instability. MRI was performed in 56 patients with radiographically stable SER-2 injuries, revealing that 25% had ruptures of the PITFL and 4% had ruptures of both the PITFL and deltoid ligament. The authors concluded that more anatomic structures may be affected in radiographic SER-2 patterns that can still be successfully treated nonoperatively, raising the question of whether select SER-3 and SER-4 injuries may also be amenable to nonoperative management despite syndesmotic injury.

The differentiation of SER-4 ankle fractures has become more widely accepted. Fibular fractures with abnormal medial clear space on stress radiographs that normalize on weightbearing radiographs correspond to SER-4A injuries and represent partial involvement of the medial deltoid ligament with an intact deep posterior tibiotalar ligament (dPTTL). In a Level II prospective comparative study, 10 SER-4A ankle fractures were compared with contralateral uninjured ankles using WBCT to assess joint contact area, tibiotalar rotation, and translation. No difference in joint contact area was observed; however, injured ankles demonstrated increased external rotation (6.6°) and lateral talar translation (1 mm). The authors noted the need for further follow-up studies to understand the clinical implications of these changes. ²⁴

Dalen et al ²⁵ evaluated SER-4B injuries, characterized by complete deltoid disruption, and the role of the dPTTL in a cadaveric model. Using 6–degrees-of-freedom robotic testing on 15 ankle specimens, 5 conditions were assessed: native joint, SER-4B injury, SER-4B injury with fibular plate fixation, SER-4B injury with dPTTL repair, and SER-4B injury with combined plate fixation and dPTTL repair. Fibular plate fixation alone did not restore ankle stability, as defined by talar shift or mortise radiographs. In contrast, ankle stability was substantially improved when fibular fixation was combined with dPTTL repair.

Sogard et al ²⁶ performed a systematic review and meta-analysis of 5 Level III studies investigating unstable ankle fractures with medial clear space widening. The authors compared outcomes between trans-syndesmotic fixation and anatomic deltoid ligament repair. Despite heterogeneity in fracture patterns and surgical techniques, deltoid repair was associated with lower rates of syndesmotic malreduction and hardware removal. No significant differences were observed in complication rates, reoperation rates, or clinical outcome scores. The authors acknowledged heterogeneity among the studies may limit the validity of these conclusions.

In a Level III propensity-matched database study, Florentino et al ²⁷ evaluated the impact of non-tobacco nicotine dependence (NTND) in patients undergoing surgical stabilization of bimalleolar and trimalleolar ankle fractures over a 20-year period. Compared with nonnicotine controls, NTND patients demonstrated higher short-term (90-day) risks of stroke, pneumonia, surgical site infection, wound dehiscence, and hospitalization. At 2-year follow-up, NTND patients also exhibited higher risks of nonunion or malunion compared with both controls (OR 3.04) and tobacco users (OR 2.46).

A multicenter Level I randomized controlled trial by Khojaly et al ²⁸ in Ireland investigated weightbearing protocols following operative treatment of unstable ankle fractures (excluding plafond fractures). Eighty patients (mean age 45.5 years, range 15-94) were randomized to either a period of non-weightbearing (NWB) for 6 weeks or immediate weightbearing (IWB) in a CAM boot as tolerated from postoperative day 1 under physiotherapist guidance. Outcome measures included the Olerud-Molander Ankle Score, RAND-36, complication rates, time to return to work, hospital stay, and cost-effectiveness. Cost-effectiveness was calculated as the difference in total cost divided by the difference in quality-adjusted life years (QALYs). Over 1 year, IWB cost €1027.68 with a health benefit of 0.741 QALYs, compared with €1825.70 and 0.704 QALYs for NWB. NWB was €798.02 more expensive and resulted in 0.04 fewer QALYs. Immediate weightbearing demonstrated superior early functional outcomes, earlier return to work, greater cost savings, and similar complication rates compared with NWB in a cast at 1 year.

Nitinol

The use of nitinol fixation in foot and ankle surgery is an expanding topic of interest attributed to nitinol’s shape-memory and continuous compression properties, which may enhance fusion rates while minimizing implant prominence and surgical time. In the last year, 3 retrospective studies evaluating outcomes of nitinol-based fixation for various foot and ankle arthrodesis procedures were published.

In a Level IV study, Labmayr et al ²⁹ reviewed 60 cases of Lapidus arthrodeses for hallux valgus deformity using 2 orthogonally placed nitinol staples with a median follow-up of 37 months (range, 15-64 months). The authors reported fusion, defined by radiographs, in 96.7%, with 2 symptomatic nonunions (3.3%), both occurring in smokers. The IMA improved from 15.8° to 8.9° and HVA from 37.5° to 17.3° (P < .001). The overall reoperation rate was 16.7%, most commonly for hardware irritation (8.3%) or deformity recurrence (5%). Patient-reported outcomes (PROs) were favorable, with a mean FAAM-ADL score of 81.7/84, and 90% of patients reporting satisfaction. Notably, isolated staple breakage did not universally result in nonunion, suggesting that remaining implants may provide sufficient stability and possibly ongoing compression. Operative time for isolated Lapidus procedures was relatively short (median 41 minutes), highlighting a potential efficiency advantage of staple-based fixation. In summary, nitinol fixation for Lapidus procedures yielded acceptable results comparable to alternative fixation constructs.

In a Level III study, Balu et al ³⁰ performed a retrospective comparative cohort study evaluating isolated nitinol staple fixation (N = 59) vs combined nitinol staple-plus-screw fixation (n = 54) for midfoot and hindfoot arthrodesis over 10 years, with a mean follow-up of 2.2 years and minimum of 6 weeks. Although the shorter follow-up of some patients merits consideration, the authors found that overall fusion rates (CT-confirmed) were high in both groups, with no statistically significant difference between the staple-only group and the staple-plus-screw group (89.1% vs 89.5%, P > .99), even when stratified by anatomic region. The staple-plus-screw group had a significantly higher overall reoperation rate than the staple-only group (17.1% vs 4.0%, P = .02). This difference was not significant in the midfoot (17.9% vs 7.3%, P = .26) but reached statistical significance in the hindfoot (16.7% vs 0%, P = .02). Reasons for revision included nonunion, infection, and symptomatic hardware. The authors concluded that nitinol staple fixation may achieve fusion rates and complication profiles comparable to staple-plus-screw constructs in midfoot and hindfoot arthrodesis. Although supplemental screw fixation may offer theoretical biomechanical advantages in select scenarios, routine augmentation of nitinol staples with screws did not appear to provide a clear early clinical advantage in this cohort.

Nitinol has been incorporated into intramedullary devices used for tibiotalocalcaneal arthrodesis. ³¹ In a Level IV retrospective case series, Anastasio et al evaluated the early clinical and radiographic outcomes of the Phantom ActivCore nail (Paragon 28), an intramedullary nail designed with active-compression nitinol material for tibiotalocalcaneal arthrodesis. Twenty-one patients were included. The overall union rate at a mean follow-up of 9.4 months (range, 4.3-19 months) was 90.4% (95% CI: 69.6%, 98.8%). Seven patients (33.3%) experienced at least one device-related adverse event; however, the authors reported a complication rate requiring secondary device-related procedures of 9.5% (n = 2). Radiographically, the majority of cases demonstrated preservation of compression across the arthrodesis site, as indicated by stable displacement values of the nail’s inner core at 3 and 6 months, postoperatively. This supports the notion that the implant maintains continuous compression during the early phase of bone healing. Clinically, complications were comparable to those historically reported for traditional fixation constructs, with no clear evidence of increased risk attributable to the nitinol implant. The findings align with biomechanical data suggesting that continuous compression may be advantageous for fusion biology. However, whether these theoretical benefits translate into superior union rates, faster healing, or improved functional outcomes compared with established fixation strategies remains unknown.

Collectively, these 3 studies provide emerging retrospective evidence that nitinol-based fixation can achieve high fusion rates with acceptable complication and reoperation profiles for select foot and ankle arthrodesis procedures. Continuous compression, low-profile design, and ease of implantation are potential advantages; however, current evidence remains limited by retrospective designs, lack of control groups, short-term follow-up, and heterogeneity in procedures. Higher-level comparative studies with longer-term data are needed to define optimal indications and fixation strategies for nitinol implants in foot and ankle surgery. Until then, these devices may be viewed as fixation options rather than as proven replacements for traditional constructs, with implant selection guided by the surgeon’s experience, patient-specific risk factors, and procedural demands.

Insertional Achilles Pathology

Management of insertional Achilles tendinopathy was a topic of particular interest in 2025. Consistent with the observed trend of increasing popularity of minimally invasive surgical (MIS) techniques for insertional Achilles tendinopathy, several studies investigated the outcomes of MIS techniques, while others evaluated the complications associated with open techniques.

In a Level III, retrospective cohort study, Kiriluk et al ³² compared the results of open Haglund resection and Achilles insertional reconstruction (n = 43) to those of the MIS Zadek osteotomy (n = 34) at a single institution. Patient selection between open and MIS procedures was agnostic to the presence of a Haglund deformity and the degree of tendinopathy. The open approach was performed with the patient positioned prone and included a midline tendon split, Haglund excision, partial Achilles detachment/debridement, and suture anchor repair. The MIS Zadek procedure was performed by removing a 10-mm dorsal closing wedge from the calcaneus using a 3 × 30 burr from the lateral side, and fixation using two 7.0-mm headless compression screws. The authors reported significant improvement in Patient-Reported Outcomes Measurement Information System (PROMIS) function (P < .001), pain (P < .001), and mobility (P < .001) scores in both cohorts at a minimum of 1 year postoperatively. No statistically significant differences in the magnitude of clinical improvement were detected between cohorts, and both groups improved more than the predicted minimum clinically important difference for all outcome instruments. A significant increase in wound complications (11/43, 25.6%) was reported in the open group compared to the percutaneous MIS group (1/34, 2.9%; P = .007). Two MIS patients (5.7%) required removal of hardware, and 1 patient (2.9%) experienced sural nerve pain. The MIS group had a shorter mean follow-up (21.6 ± 7.3 months) compared with the open group (32.1 ± 12.3 months; P < .001).

Cattolico et al ³³ explored an alternative MIS approach to insertional Achilles tendinopathy using a percutaneous Haglund resection combined with a proximal medial gastrocnemius recession technique in a Level III, retrospective comparative cohort study. The authors prospectively analyzed a group of 224 patients. One subgroup (n = 106; 47.2%) had an “Achilles–plantar complex contracture,” and another group without contracture (n = 118; 52.7%) was identified based on passive dorsiflexion. All patients underwent a percutaneous Haglund resection and Barouk proximal medial gastrocnemius release (PMGR). This group was compared to a historical cohort of 259 patients treated with percutaneous Haglund resection alone. In the prospective group, there was significant clinical improvement measured by Foot Function Index (FFI) and Victorian Institute of Sport Assessment–Achilles (VISA-A) questionnaire scores. The cohort receiving both percutaneous Haglund resection and Barouk proximal medial gastrocnemius release had significantly greater clinical improvement at all postoperative time points compared with the historical comparison group treated with percutaneous Haglund removal only. The authors acknowledged the challenges of comparing a prospective cohort to a historical one. They opined that these results may suggest that decreasing tension on the Achilles, in addition to decompression of Haglund impingement, regardless of the presence of a contracture, may be clinically meaningful.

Recognizing the multiple potential pain generators relevant to insertional Achilles tendinopathy and the variety of described surgical techniques, Hall et al ³⁴ evaluated outcomes in 17 patients treated with MIS Zadek osteotomy and compared them to preoperative assessments of Achilles tendinopathy severity based on MRI using a previously described scoring system.^34,35 They reported an overall revision rate of 5.9% and a satisfaction rate of 94.1%, with all 3 groups demonstrating significant postoperative improvement in pain in this Level IV case series. Hall Kiriluk et al ³⁶ assessed outcomes following MIS Zadek osteotomy based on the preoperative X/Y ratio, where X represents the length from the posterior-most aspect of the calcaneus to the anterior-most aspect of the anterior process, and Y represents the distance from the posterosuperior prominence to the posterior-most aspect of the posterior subtalar joint facet. This ratio has been hypothesized to be relevant in predicting the success of Zadek osteotomies, as excessively long calcanei—defined by an X/Y ratio less than 2.5—have previously been suggested as a predictor of clinical success of the Zadek procedure. ³⁷ In the current study, all patients demonstrated significant improvement in function, pain, and mobility at 1 year following surgery regardless of X/Y ratio. Hall Kiriluk et al found that patients with an X/Y ratio ≥2.5 had significantly greater improvement in PROMIS pain scores following MIS Zadek osteotomy, suggesting that a specific X/Y ratio may not correlate with successful outcomes after the procedure.

Two biomechanical studies investigated relevant considerations surrounding the Zadek osteotomy. Karaismailoglu et al ³⁸ used weightbearing ankle CT scans from patients with symptomatic insertional Achilles tendinopathy and simulated Zadek osteotomies with plantar starting points either 1 or 2 cm distal to the plantar calcaneal tubercle and dorsal resection wedges of 6, 10, or 14 mm. All osteotomy types demonstrated significant decreases in lateral talocalcaneal angle and calcaneal pitch, with anterior-based osteotomies having a larger impact on these measurements. Additionally, anterior-based osteotomies resulted in greater changes in subtalar joint orientation and Böhler angle compared to posterior-based osteotomies. The change in distance between the Haglund prominence and the Achilles tendon was similar between anterior- and posterior-based osteotomies, although the posterior-based 6-mm and 10-mm osteotomies demonstrated significantly greater decompression distances than their corresponding anterior-based osteotomies. The decompression distance was approximately 50% of the size of the resection wedge for all groups. The authors suggested that a posterior-based osteotomy with a wedge resection of at least 10 mm may be advantageous by providing greater decompression of the Achilles insertion with less impact on subtalar biomechanics; however, an anterior-based osteotomy may be advantageous in cases of cavus deformity because of its greater effect on calcaneal pitch.

Meanwhile, in a cadaveric study by Bhimani et al, ³⁹ a 10-mm Zadek osteotomy was performed on 12 specimens, and medial calcaneal tuberosity pressure and plantar fascia strain were measured before and after the osteotomy. The apex of the osteotomy was positioned just anterior to the medial calcaneal tuberosity. Following the osteotomy, there was a statistically significant mean 43% increase in medial calcaneal tuberosity pressure. Lateral and medial band plantar fascia strain increased by an average of 11% and 24%, respectively, although neither reached statistical significance. The authors concluded that these changes may place greater stress on plantar structures, potentially contributing to symptoms mimicking plantar fasciitis.

Two studies specifically investigated complications surrounding surgical treatment of Haglund syndrome. The impact of postoperative protocols and complications was evaluated in a Level III comparative study by Hinton et al. ⁴⁰ The authors retrospectively reviewed 387 patients who underwent open surgical management of Haglund syndrome by fellowship-trained surgeons at a single institution over an 8-year period. The most common postoperative regimen was nonweightbearing (n = 268; 69.3%), followed by touchdown weightbearing (n = 56; 14.5%), weightbearing as tolerated (n = 54; 14.0%), and partial weightbearing (n = 9; 2.3%). The most common surgery-related complications were persistent pain (n = 40; 10.3%), weakness (n = 6; 1.6%), wound breakdown or infection (n = 33; 8.5%), rupture (n = 1; 0.3%), and revision surgery (n = 7; 1.8%). The authors reported no association between postoperative weightbearing protocols and complication rates.

Morrissette et al ⁴¹ evaluated the impact of body mass index (BMI) on surgical complications surrounding open treatment of Haglund syndrome in 370 patients at a single academic center over an 8-year period in a Level IV retrospective study. Wound breakdown occurred in 11% of the obese group (n = 273; 73.8%), compared with 2.6% of the overweight group (n = 77; 20.8%), and none of the normal-weight patients (n = 20; 5.4%) (P = .02). The authors noted a greater prevalence of diabetes mellitus, higher ASA scores, female sex, and Black/African American patients in the obese cohort compared with the normal-weight and overweight cohorts. Surgical techniques and postoperative protocols did not differ across groups, and there were no statistically significant differences in rates of rerupture or infection, despite these complications occurring only in the obese cohort.

Calcaneus Fractures and Hindfoot Injuries

Several notable studies were published surrounding the management of calcaneus fractures and hindfoot injuries.

Recent epidemiologic data offered further insights into injury patterns and treatment trends for calcaneal fractures and hindfoot trauma. A Level IV nationwide analysis of the Swedish Fracture Register demonstrated that calcaneus fractures most commonly affect middle-aged adults with a mean age of 48 years (SD ± 18), and 60% occurring in men. ⁴² The most frequent mechanism of injury was a fall from a height. AO/OTA type A (avulsion) and type C (intra-articular) fractures were equally common. Intra-articular type C fractures were more common among males, and more frequently required operative intervention, whereas type A and B fractures were largely managed nonsurgically. Bilateral fractures, although less common, were associated with younger age and high-energy trauma, underscoring the heterogeneity of injury features and severity within this population.

Surgical management strategies for displaced intra-articular calcaneal fractures (DIACFs) have evolved, with growing evidence favoring minimally invasive approaches. Multiple comparative studies have shown that the sinus tarsi approach (STA) offers complication rates comparable to or lower than the traditional extensile lateral approach (ELA). ⁴³ A Level I meta-analysis by Purdie et al ⁴⁴ compared the ELA to 2 MIS techniques, STA and percutaneous approaches, in 1367 patients (mean age = 6.3 years; 25.7% female). MIS techniques were associated with significantly reduced wound complications compared to ELA (RR 6.48, 95% CI 4.03-10.41, P < .00001). Functional scores favored MIS techniques, whereas radiologic outcomes were equivalent.

In a level III propensity-matched cohort of 241 patients with DIACFs by El Barbari et al, ⁴⁵ no significant differences in revision rates, radiologic reduction, or functional outcomes between STA and ELA were reported, further supporting STA as a safe alternative even in moderate to severe fractures including Sanders 3 and 4 fracture patterns. In another large multicenter review of 782 surgically treated calcaneal fractures conducted by Seaver et al, ⁴⁶ deep infection rates were significantly lower with the STA compared to ELA (3.0% vs 6.8%), even among higher-risk patients. The ELA was associated with more wound complications, and the STA with symptomatic implants.

MIS and minimally invasive fusion-based techniques are reported to be useful for severe fracture patterns, particularly Sanders III and IV injuries. The C-PASTA procedure, which combines percutaneous reduction with posterior arthroscopic subtalar arthrodesis, achieved 100% fusion at 3 months in a small cohort Level III study by Anand et al. ⁴⁷ In addition to the high fusion rate, there were no major complications, suggesting a promising alternative to traditional open fusion for high-grade DIACFs.

Postoperative rehabilitation of surgically treated patients with unilateral DIACFs is a topic of interest. A recent systematic review and pooled analysis by Verstappen et al ⁴⁸ of early weight-bearing (EWB) protocols derived from 20 studies and 1007 subjects. Favorable functional outcomes, minimal pain, and low complication rates with implementation of early weightbearing protocols were reported. A mean decline of 0.4° in Böhler angle at the time of final follow-up suggests that EWB may not compromise radiographic alignment.

Several studies highlighted associated injuries and biomechanical considerations in the management of calcaneal and hindfoot fractures. A cadaveric Level IV study by Bhimani et al ⁴⁹ recently mapped the sural nerve’s proximity to STA incisions and demonstrated that modified STA extensions can substantially improve visualization of the lateral calcaneal wall and posterior facet, albeit with increased nerve-related risk that warrants careful intraoperative attention. Another Level IV radiographic/anatomic study by Wakker et al ⁵⁰ demonstrated that the sural nerve was consistently laying adjacent to the posterior tail of anatomic plates, and is at risk with MIS fixation techniques. The authors suggested that such risk may be mitigated with use of fluoroscopy and attention to radiographic landmarks.

Traumatic peroneal tendon dislocation (PTD) is known to occur with pilon and calcaneus fractures; however, literature describing PTD in concurrence with injury to the talus remains limited. Cho et al ⁵¹ retrospectively reviewed 128 talus fractures in a Level III study. They found that PTD occurred in 21.1% of talus fractures. PTD occurred in 16.7% of isolated talus fractures, and 39% of lateral process fractures were associated with PTD. PTD was associated with the presence of fleck sign on injury radiographs (P < .00001). Advanced imaging identified 51.9% of cases, 14.8% were identified by operative report, and 33.3% by a combination of both.

Correction of posttraumatic deformity was recently evaluated by Feng et al. ⁵² The authors performed a retrospective comparative analysis of 56 patients with calcaneal fracture malunion (CFM) in which a modified 3-plane joint-preserving osteotomy (n = 26) was compared to subtalar arthrodesis (n = 30). Radiologic parameters, visual analog scale (VAS) score for pain, and 12-Item Short Form Health Survey (SF-12) mental component summary (MCS) and physical component summary (PCS) scores were compared between the 2 groups of patients at approximately 2 years follow up. Both treatments improved pain and quality of life, and the osteotomy group had better subtalar range of motion and reduced intra-articular step-off, preserving joint motion.

Lisfranc Injuries

The evaluation and management of Lisfranc injuries garnered significant interest in 2025. Grün et al ⁵³ performed a retrospective study evaluating a novel triplanar weightbearing CT (WBCT) method for identifying Lisfranc injuries. The authors opined that conventional measurement of the C1-M2 interval on WBCT does not account for the second metatarsal’s triplanar orientation, potentially leading to inaccuracies. In this Level III retrospective cohort study, 2 fellowship-trained foot and ankle surgeons performed measurements of the injuries using a uniplanar method and a novel triplanar technique proximally and distally in the C1-M2 interval that realigns the measurement planes with the second metatarsal and not the floor. The authors reported that the triplanar method produced higher intra- and interrater reliability, particularly for the distal measurement compared to the uniplanar method (intraobserver: 0.96-0.97; interobserver: 0.94-0.97 vs intraobserver: 0.86-0.91; interobserver: 0.84-0.90, respectively). Of interest, the uniplanar method erroneously measured the M1-M2 interval instead of the intended C1-M2 interval in 22.6% of injured feet, but no errors occurred in contralateral feet or with the triplanar method. All 6 performed C1-M2 measurements showed significant differences between the injured and contralateral feet (P < .05). The triplanar method applied distally in the coronal plane yielded the greatest absolute side-to-side difference (1.81 mm, SD 1.60). The authors concluded that this novel method yields improved precision, but they cautioned the need for further study regarding clinical significance.

Saito et al ⁵⁴ investigated stabilization of Lisfranc injuries using suture buttons in a retrospective case series of 20 patients with at least 5-year follow up. The authors evaluated VAS and AOFAS midfoot scores, patient satisfaction, ability to return to activity, and radiographic maintenance of reduction and progression of osteoarthritis. Complications included the need for reoperation in 1 patient, and loss of reduction (defined by greater than 2 mm between the first and second metatarsal) and radiographic osteoarthritis were observed in 2 patients, respectively. The average VAS score was 0.50 and a mean AOFAS midfoot score of 95.5. Incomplete reduction was associated with lower VAS and AOFAS scores.

Stern et al ⁵⁵ compared outcomes of subtle Lisfranc injuries defined as 2- to 5-mm C1-M2 diastasis, treated with primary open reduction internal fixation (ORIF) vs primary arthrodesis (PA) in a Level III retrospective comparative study of 73 patients (PA: n = 41; ORIF: n = 32). Treatment was based on surgeon preference and PROMIS scores were evaluated preoperatively and at least 2 years postoperatively. Both treatment groups showed significant improvement in PROMIS physical function, with no significant differences in patient-reported outcomes or overall complication rates between groups. The ORIF group required significantly more secondary hardware removal procedures than those treated with PA. Overall, both ORIF and PA appear to be effective options for subtle Lisfranc injuries, though treatment choice may influence the likelihood of additional surgery.

In a Level III retrospective cohort study, Sroka et al ⁵⁶ evaluated the clinical impact of hardware removal (HWR) after ORIF surgery for acute Lisfranc injuries via measurement of PROMIS physical function (PF) and pain intensity (PI) scores of at least 6 months postoperatively. Patients of 77 feet underwent ORIF followed by HWR, and 30 feet underwent ORIF without HWR. HWR occurred on average 443 months after ORIF. HWR was associated with a significant and clinically meaningful improvement in PROMIS PF scores as early as 6 weeks after removal (P < .001); approximately two-thirds met the MCID for PF. PI scores showed a smaller, initially nonsignificant improvement (P = 0.24), suggesting functional gains were not primarily driven by pain reduction and potentially improved midfoot biomechanics. Overall, planned HWR after Lisfranc ORIF appears to accelerate early functional recovery without clear long-term differences in outcomes.

Two studies investigated the outcomes of patients who underwent ORIF for Lisfranc injuries and subsequently required fusion. Wilhelmina Maria Engelmann et al ⁵⁷ performed a retrospective cohort study comparing American Orthopaedic Foot & Ankle Society midfoot score and Foot Function Index outcome scores of primary arthrodesis (PA; n = 11) to secondary arthrodesis (SA; n = 18) performed after failed initial ORIF and non-surgical treatment for Lisfranc injuries. At a median follow-up of 7.1 (PA) to 9.3 (SA) years (P = .01), PA was associated with fewer complications, including no infections, universal union, and HWR (n = 5; 45.5%). SA was associated with higher rates of infection (n = 2; 11.1%), malunion (n = 2; 11.1%), implant removal (n = 6: 33%), and revision surgery (n = 4; 22.2%). The AOFAS scores were “good” in PA (77.7, SD 17.3) compared with “fair” in SA (67.1, SD 21.3, P = .19). FFI was better in PA (26.0, SD 26.2) than SA (37.6, SD 30.8, P = .32), which exceeded the minimally important clinical difference but not statistically significant. Overall, PA demonstrated at least equivalent compared to SA.

Campbell et al ⁵⁸ performed a Level III retrospective cohort study surrounding outcomes of PA for acute Lisfranc injuries compared to SA after ORIF. Among 489 feet in 482 patients, 20% received acute treatment with PA. Thirty-four (8.7%) of patients who underwent primary ORIF received subsequent SA. SA was associated with worse clinical and patient-reported outcomes (PROMIS PI and PF scores) than those treated with PA (P < .001). Divergent injury patterns and tightrope fixation had higher odds of requiring secondary fusion (P = .6 and P = .003, respectively). Overall, clinical outcomes were worse following SA subsequent to index ORIF compared with PA. This emphasizes the importance of identifying risk factors for patients that may fail ORIF and be better treated with PA.

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