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Surgical Management

Foot surgery: chondral defects (AMIC vs microfracture), Lisfranc injury management, and arthrodesis/reconstruction for deformity & arthritis.

Overview

Surgical management is the recommended approach for osteochondrolipoma of the foot to provide symptomatic relief and confirm diagnosis via histopathology [2]. In childhood coxa vara, surgery is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require operative intervention [3]. For osteoarthritis of the knee, the guideline comprises 38 recommendations based on current best evidence, with 14 classified as Strong, 14 as Moderate, and 10 as Limited [4].

Outcomes for surgical management of Madelung deformity are reported inconsistently, prohibiting the pooling of studies or comparison of procedures [10]. In contrast, deliberate treatment decisions for calcaneus fractures can improve outcomes and minimize complications [5], while successful management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [6]. For osteochondral lesions of the talus, patients must be carefully selected and counseled on morbidity; clinical failure occurs in 13% of cases, with a 25% need for reoperation and an 8.8% rate of revision surgery [7].

Treatment selection for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint ranges from non-operative measures to cheilectomy, arthroplasty, and arthrodesis, depending on disease stage and patient factors [27]. Surgical indications for spastic equinovarus foot deformity focus on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot [16]. Emerging technologies in orthopaedic trauma require understanding of current evidence and appropriate indications for utilization [13].

Anatomy & Pathophysiology

The primary surgical objective across all four stages of adult-acquired flatfoot deformity is to achieve proper alignment while maintaining maximal flexibility within the foot and ankle complex [1]. Early diagnosis is critical to initiate treatment for flexible deformities while they remain mild and correctable [12]. In pediatric populations, surgical intervention for symptomatic flatfoot significantly improves static segmental alignment and mediolateral foot loading, though it may concurrently worsen fore-aft loading [35]. The efficacy of specific procedures regarding radiographic and pedobarographic parameters is directly dependent on the severity of the acquired flatfoot deformity [48].

Surgical management for spastic equinovarus deformity prioritizes obtaining a balanced, braceable, functional lower extremity with a plantigrade foot [16]. In ambulatory patients with cerebral palsy and planovalgus deformity, calcaneal lengthening osteotomy demonstrates a tendency toward overcorrection, evidenced by increased pressure exerted on the lateral midfoot [55]. Correcting altered biomechanics associated with asymmetric ankle arthritis improves functional outcomes [37]. Surgical treatment for adult idiopathic cavus foot provides good correction without compromising range of motion and allows for alternating pronation and supination during gait [68].

Regarding osseous procedures, anteromedial cannulated screw fixation for Hawkins II/III talus fractures in children does not affect ankle joint stability but is conducive to the recovery of ankle function [51]. Surgical treatment for Lisfranc fracture-dislocations aims to achieve optimal anatomical reduction and stability of the first, third, and third cuneiform-metatarsal joints [65]. For distal first metatarsal osteotomy, the chevron technique confers higher stability regarding fragment displacement during axial loading compared to other percutaneous techniques, whereas both percutaneous methods increase the plantar angulation of the metatarsal head [60]. Larger wedge sizes in lateral column lengthening decrease passive hindfoot eversion but increase lateral plantar pressure [62].

Hallux valgus deformity and its severity are positively associated with the magnitude of anteroposterior postural sway [61]. Patients undergoing Scarf osteotomy for hallux valgus exhibit a gait pattern similar to their non-operated foot, whereas those undergoing first metatarsophalangeal joint arthrodesis do not fully recover forefoot propulsive forces [69]. For Morton's neuroma excision, the plantar approach is recommended when superior cosmetic appearance is required, as it has less influence on quality of life regarding foot appearance compared to the dorsal approach [73].

Non-surgical intervention for hallux rigidus begins with shoe modifications and orthotics [23]. Early operative treatment has the potential to restore anatomical alignment and improve function in diabetic patients with stage-I Charcot arthropathy [71]. Both nonoperatively and surgically treated clubfeet demonstrate significant limitations in ankle plantar flexion, resulting in decreased range of motion, moment, and power compared with controls [70]. A textbook chapter provides a descriptive overview of foot and ankle biomechanics, gait analysis, and treatment principles for common nail disorders [29].

Classification

Osteochondrolipoma: Surgical excision is the recommended approach for osteochondrolipoma of the foot, providing symptomatic relief and confirmation of diagnosis through histopathological examination [2].

Knee Osteoarthritis: The guideline for surgical management of osteoarthritis of the knee contains 38 recommendations based on current best evidence [4]. Of these, 14 are classified as Strong, 14 as Moderate, and 10 as Limited [4]. Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores on numerous scoring systems devised to evaluate patients with knee symptoms [66].

Tarsometatarsal Joint Injuries: Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [6].

Madelung Deformity: Outcomes for surgical management of Madelung deformity are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes [10].

Adult Acquired Flatfoot Deformity: The operative management options for symptomatic flexible adult acquired flatfoot deformity emphasize the controversy regarding the best surgical technique [12]. Early diagnosis is required to initiate treatment for flexible adult acquired flatfoot deformity while the deformity is mild and flexible [12].

Hallux Valgus and Hallux Rigidus: Considerable differences in surgical management exist between general orthopaedic surgeons and foot and ankle specialists regarding hallux valgus and hallux rigidus [18].

Jones Fractures: Jones fractures are covered by classification, diagnosis, and treatment considerations including nonsurgical management, intramedullary screw, and plate fixation [20].

Calcaneal Osteomyelitis: Single-stage orthoplastic management of complex calcaneal osteomyelitis with large soft-tissue defects was associated with 77% eradication of infection [22]. Only one amputation occurred in the patient group treated with single-stage orthoplastic management for complex calcaneal osteomyelitis with large soft-tissue defects [22].

Osteochondral Lesions of the Talus: Patients with reoperation after surgical treatment of osteochondral lesions of the talus had significantly lower ICRS classification stages compared to patients without re-operation [34].

Navicular Stress Fractures: Navicular stress fractures require assessment and classification via CT [58]. Surgery is recommended for navicular stress fractures classified as type II, type III, or fractures with sclerosis, cysts, or avascular necrosis [58]. Treatment of navicular stress fractures should be individualized based on severity, previous treatment, and the athlete's sport [58]. A logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular has been proposed that gives associated injuries involving the lateral column due consideration [59].

Other Considerations: - Outcome Reporting: Inconsistent reporting of outcomes for Madelung deformity prohibits pooling of studies and comparisons of surgical procedures [10]. - Technique Controversy: Significant controversy exists regarding the best surgical technique for symptomatic flexible adult acquired flatfoot deformity [12]. - Specialist Variation: Considerable differences in surgical management exist between general orthopaedic surgeons and foot and ankle specialists regarding hallux valgus and hallux rigidus [18]. - Scoring System Validity: Demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores on numerous scoring systems devised to evaluate patients with knee symptoms [66].

Clinical Presentation

The primary surgical goal across all four stages of adult-acquired flatfoot deformity is to achieve proper alignment while maintaining maximal flexibility in the foot and ankle complex [1]. Early diagnosis is critical for flexible adult acquired flatfoot deformity, allowing intervention while the deformity remains mild and flexible [12]. Patients undergoing surgical intervention for this condition demonstrate significant improvements in symptoms and function [19]. Conversely, rigid flatfoot deformities in adolescents present a less predictable clinical course associated with various underlying causes [30].

Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [3]. For osteochondral lesions of the talus, patients must be carefully selected and counseled on procedural morbidity; the incidence of clinical failure is 13%, the need for reoperation is 25%, and the rate of revision surgery is 8.8% [7]. Surgical excision remains the recommended approach for osteochondrolipoma of the foot, providing symptomatic relief and diagnostic confirmation via histopathology [2]. Similarly, surgical excision is the best option for symptomatic fibrolipomatous hamartoma in the foot, particularly when involved nerves lack important motor function [21].

Acute vs. Chronic Management: Early diagnosis and treatment are essential for good outcomes in acute Lisfranc injury management [8]. Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [6]. For acute fractures of the process and tubercle of the hindfoot, nonsurgical management is frequently successful [9]. However, late surgical intervention can substantially improve pain and function in untreated chronic injuries of these structures [9]. Providers treating late presentation or late displacement of distal radius fractures retain the option of surgical fixation beyond the first few weeks after injury [11].

Infection and Complex Reconstruction: Deliberate and careful treatment decisions for calcaneus fractures can improve outcomes and minimize complications [5]. Single-stage orthoplastic management of complex calcaneal osteomyelitis with large soft-tissue defects is associated with 77% eradication of infection, with only one amputation occurring in a complex and comorbidity-heavy patient group [22]. Surgical details and addressing associated deformities with adjunct interventions should be considered for talectomy in paediatric patients [32].

Neuropathy and Nerve Pathology: Diabetic neuropathy affects up to 50% of patients within 25 years of diagnosis, with sensory neuropathy being the most prevalent manifestation [31]. Surgery should be considered as the initial treatment for carpal tunnel syndrome confirmed by nerve conduction studies, as this provides symptom resolution with a favorable cost analysis [36]. Considerable differences in surgical management exist between general orthopaedic surgeons and foot and ankle specialists for hallux valgus and hallux rigidus [18].

Investigations

Plain radiography: Radiological assessment is crucial to evaluate involved joints preoperatively to choose the appropriate treatment method for Mueller-Weiss disease [40]. Routine postoperative radiographs in isolation contribute to changes in management in the immediate postoperative period in select cases and during the period when advancement to full weight bearing is being considered up until clinical fracture union [45]. Obtaining one set of postoperative radiographs for AO type A distal radius fractures would significantly limit exposure to ionizing radiation and clinical costs, with subsequent radiographs obtained only for complaints or examination findings outside the normal postoperative course [46]. There were no notable differences in radiographic outcomes between orthopaedic surgeons with and without trauma fellowship training for rotational ankle fractures [54]. Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy [75].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [72].

Other Considerations: Surgical management of adult-acquired flatfoot deformity aims to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex across all four stages of deformity [1]. Surgical excision is the recommended approach for osteochondrolipoma of the foot to provide symptomatic relief and confirm diagnosis via histopathological examination [2]. Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [3]. The evidence-based guideline for surgical management of knee osteoarthritis contains 38 recommendations, with 14 classified as Strong, 14 as Moderate, and 10 as Limited [4]. Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [6]. Early diagnosis and treatment are essential to achieve good outcomes in acute Lisfranc injury management [8]. Providers treating patients with late presentation or late displacement of distal radius fractures have the option of surgical fixation beyond the first few weeks after injury [11]. Comparative studies of fourth-generation minimally invasive and open hallux valgus surgery suggest similar clinical and radiological outcomes, though recurrence remains a challenge necessitating long-term follow-up and standardized outcome measures [15]. Treatment considerations for fifth metatarsal Jones fractures include nonsurgical management, intramedullary screw fixation, and plate fixation [20]. Surgical excision is considered the best option for symptomatic patients with fibrolipomatous hamartoma in the foot, especially when involved nerves have no important motor function [21]. Surgical intervention for dorsal bunion in nonambulatory adolescents with cerebral palsy results in significant improvements in clinical and radiographic outcome measures [52]. A high level of suspicion, recognition of clinical signs, and appropriate radiographic studies are needed for correct diagnosis of Lisfranc joint injury to avoid late sequelae of posttraumatic arthritis [63]. Subtalar arthroscopy identified pathologies in the subtalar joint in patients with sinus tarsi syndrome, and treatment of these pathologies led to improved function [74].

Treatment

Non-Operative

Non-surgical management is frequently successful for acute fractures of the process and tubercle of the hindfoot, while non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures [9, 33]. For hallux rigidus, initial intervention begins with shoe modifications and orthotics [23]. A good trial of conservative means should be carried out before surgical measures are suggested or undertaken for disorders of the fore part of the foot [44]. In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury [53]. Percutaneous decompression is a useful minimally invasive surgical option in the treatment of early stage Mueller–Weiss syndrome that remains unresponsive to prolonged conservative treatment [28]. The mainstay of treatment for idiopathic congenital talipes equinovarus is manipulation and casting, usually followed by soft-tissue release, though some patients have been successfully treated with intensive physiotherapy instead of surgery [42].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, while moderate nonprogressive deformity often does not require surgery [3]. For adult-acquired flatfoot deformity, surgical intervention is appropriate for patients who have demonstrated significant improvements in symptoms and function [19]. Surgical indications for spastic equinovarus foot deformity are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot [16]. Surgical excision is the recommended approach for osteochondrolipoma of the foot to provide symptomatic relief and confirmation of diagnosis through histopathological examination [2]. Early diagnosis and treatment are essential to achieve good outcomes in acute Lisfranc injury management [8]. Late surgical intervention can substantially improve pain and function in untreated chronic hindfoot injuries [9].

Surgical Approach / Technique: The goal of surgery for all four stages of adult-acquired flatfoot deformity is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex [1]. Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [6]. Deliberate and careful treatment decisions in calcaneus fractures can improve outcomes and minimize complications [5]. The minimally invasive approach of MITA for hallux valgus facilitates rapid postoperative recovery and is associated with a low complication profile [17]. Postoperative satisfaction and functional recovery of patients are significantly improved with rotation scarf plus Akin osteotomy for severe hallux valgus [41]. Autologous osteochondral transplantation of the talus can be recommended as a safe and promising technique for the long-term therapy of osteochondral lesions of the talus given its high clinical efficacy [43]. Patients undergoing osteochondral allograft transfer for osteochondral lesions of the talus must be carefully selected and counseled on the morbidity of the procedure, the high incidence of clinical failure (13%), and the need for reoperation (25%) and revision surgery (8.8%) [7].

Alignment / Balancing Strategy: Understanding the current evidence and appropriate indications of emerging technologies in orthopaedic trauma is of critical importance for their utilization [13]. The outcome of calcaneal reconstruction for calcaneal malunion was maintained until the mid-term follow-up [14]. There is no conclusive evidence to recommend arthroscopic techniques over open techniques for subtalar arthrodesis [24]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors [27].

Other Considerations: Outcomes for surgical management of Madelung deformity are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes [10]. Surgeons should retain a flexible approach to treatment choice and master non-operative management, as well as both external and internal skeletal fixation techniques, due to the complexity of distal radial fractures [39]. The guideline for surgical management of osteoarthritis of the knee contains 38 recommendations for improving surgical treatment, with 14 classified as Strong, 14 as Moderate, and 10 as Limited [4].

Complications

Wound complications: In patients undergoing Chopart amputation for diabetic foot infection, 94% developed postoperative wound complications [76]. Radical surgical interventions for calcaneal osteomyelitis, where diabetic foot ulcer was the leading cause, were performed primarily on middle-aged males [77]. Deliberate and careful treatment decisions for calcaneus fractures can improve outcomes and minimize complications [5].

Functional outcomes and recurrence: Despite a high prevalence of postoperative complications, most patients were satisfied with the result of complex reconstruction for dorsolateral peritalar subluxation after a short duration of follow-up [38]. Recurrence remains a challenge in hallux valgus surgery, necessitating long-term follow-up and standardized outcome measures [15]. In a cohort of patients undergoing Chopart amputation for diabetic foot infection, only 44% successfully ambulated with a prosthesis, while the remainder required revision amputations [76].

Procedure-specific failure and reoperation rates: Patients undergoing osteochondral allograft transfer for osteochondral lesions of the talus must be counseled on the high incidence of clinical failure (13%) [7], the need for reoperation (25%) [7], and the need for revision surgery (8.8%) [7]. Long-term follow-up of forearm shortening and volar radiocarpal capsulotomy for wrist flexion deformity in children with amyoplasia shows that the initial improvement in wrist position is not maintained [26].

Other Considerations: Surgical management of adult-acquired flatfoot deformity aims to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex across all four stages of deformity [1]. Surgical management for coxa vara in childhood is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive coxa vara deformity in childhood often does not require surgery [3]. Nonsurgical management is frequently successful for acute process and tubercle fractures of the hindfoot, while late surgical intervention can substantially improve pain and function in untreated chronic process and tubercle fractures of the hindfoot [9]. Outcomes for surgical management of Madelung deformity are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes [10]. Outcomes of calcaneal reconstruction for calcaneal malunion were maintained until mid-term follow-up [14]. Comparative studies of fourth-generation minimally invasive and open hallux valgus surgery suggest similar clinical and radiological outcomes [15]. The minimally invasive approach for distal transverse metatarsal osteotomy–Akin osteotomy (MITA) facilitates rapid postoperative recovery, is associated with a low complication profile, and supports its role as a viable alternative to conventional open procedures and previous generation MIS techniques [17]. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis for focal cartilage defects in the knee will maintain structural and functional integrity over time [25]. The plateau for complications in minimally invasive Chevron Akin (MICA) osteotomy is achieved later than the plateau for surgeon comfort, imposing a lag between feeling comfortable with the procedure and a decrease in complications [57]. Outpatient or short-stay total ankle arthroplasty should be considered for patients with low risk of short-term complications [49].

Recovery

Light activity (weeks): Early return to desk work and light activities of daily living is contingent on the specific procedure and injury timing. For acute Lisfranc injuries, early diagnosis and treatment are essential to achieve good outcomes, implying a window for early mobilization [8]. In calcaneus fractures, deliberate treatment decisions can improve outcomes and minimize complications, though specific timelines for light activity vary by fixation method [5]. Percutaneous decompression offers a minimally invasive option for early-stage Mueller–Weiss syndrome unresponsive to conservative care, potentially facilitating earlier functional engagement [28]. For distal radius fractures, surgical fixation remains an option beyond the first few weeks, allowing for delayed but effective intervention [11].

Full activity (months): Return to manual work and sport depends on achieving union and functional stability. Union following modification of Mitchell's lateral displacement angulation osteotomy occurred promptly within eight weeks in all patients, with no loss of position [78]. Calcaneal interlocking nail fixation serves as an alternative for minimally invasive calcaneal fracture fixation, showing good function in follow-up [64]. Comparative studies of fourth-generation minimally invasive and open hallux valgus surgery suggest similar clinical and radiological outcomes, supporting a return to activity based on individual healing [15]. However, long-term results for hallux valgus surgery are often worse than expected compared to short- and mid-term outcomes, with 25.9% of patients reporting dissatisfaction at a mean follow-up of 5.2 years [56].

Complete recovery / outcome plateau (months): Final functional outcomes and symptom remission stabilize over extended periods. The outcome of calcaneal reconstruction for calcaneal malunion was maintained until mid-term follow-up [14]. While the dorsal closing wedge calcaneal osteotomy group demonstrated poorer short-term clinical outcomes for Haglund syndrome compared to posterosuperior prominence resection, it provided better long-term function and symptom remission [47]. Endoscopic dorsal soft tissue procedures (EDSTP) for hallux valgus provide good early results maintained for more than 10 years, with lasting pain relief and great foot function using only 5 incisions [50]. Conversely, long-term follow-up of forearm shortening and volar radiocarpal capsulotomy in children with amyoplasia shows that initial improvement in wrist position is not maintained [26].

Rehabilitation protocol: Rehabilitation strategies must be tailored to the specific pathology and surgical technique. Patients undergoing osteochondral allograft transfer for osteochondral lesions of the talus require careful selection and counseling regarding procedure morbidity, with a clinical failure incidence of 13% and a reoperation need of 25% [7]. The rate of revision surgery for this procedure is 8.8% [7]. For acute fractures of the process and tubercle of the hindfoot, nonsurgical management is frequently successful, whereas late surgical intervention can substantially improve pain and function in untreated chronic cases [9]. Direct exchange for infection after total hip replacement can yield success rates comparable to delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are utilized [79].

Functional milestones: Validated outcome measures reveal specific trajectories for recovery. The goal of surgery for all four stages of adult-acquired flatfoot deformity is to achieve proper alignment while maintaining as much flexibility as possible in the foot and ankle complex [1]. Satisfactory long-term patient-reported and radiographic outcomes can be achieved with joint-preserving surgery for forefoot deformities associated with rheumatoid arthritis [67]. Mobile and fixed-bearing all-polyethylene tibial component total knee arthroplasty designs functioned equivalently in low-to-moderate-demand patients at early follow-up [80]. However, recurrence remains a challenge in hallux valgus surgery, necessitating long-term follow-up and standardized outcome measures [15].

Other Considerations: Long-term structural integrity and patient satisfaction require ongoing monitoring. Further studies with long-term follow-up are needed to determine whether the grafted area in autologous matrix-induced chondrogenesis for focal cartilage defects in the knee will maintain structural and functional integrity over time [25]. Recurrence in hallux valgus surgery necessitates long-term follow-up and standardized outcome measures [15]. The EDSTP for hallux valgus correction provides good long-term radiological correction [50].

Key Evidence

  • [L5] In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. (10.5435/00124635-200807000-00005)
  • [Case_report] Surgical excision is the recommended approach, providing symptomatic relief and confirmation of diagnosis through histopathological examination. (10.1186/s12891-024-07308-1)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L1] The guideline contains 38 recommendations for improving the surgical treatment of patients with osteoarthritis of the knee based on current best evidence, with 14 classified as Strong, 14 as Moderate, and 10 as Limited. (10.5435/jaaos-d-16-00159)
  • [L5] Nevertheless, deliberate and careful treatment decisions can improve outcomes and minimize complications. (10.5435/jaaos-d-24-00567)
  • [L5] Successful surgical management is predicated on anatomic reduction and stable fixation. (10.5435/jaaos-d-15-00556)
  • [L1] However, patients must be carefully selected and counseled on the morbidity of the procedure as well as the high incidence of clinical failure (13%) and need for reoperation (25%) and revision surgery (8.8%). (10.1016/j.arthro.2016.06.011)
  • [L4] Early diagnosis and treatment are essential to achieve good outcomes. (10.1302/0301-620x.106b12.bjj-2024-0581.r1)
  • [L5] Nonsurgical management is frequently successful for acute fractures, while late surgical intervention can substantially improve pain and function in untreated chronic injuries. (10.5435/00124635-200512000-00002)
  • [L1] However, outcomes are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes. (10.1177/1558944718793179)
  • [L3] Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury. (10.1177/1558944720930301)
  • [L5] The article discusses the pathophysiology, classification, and treatment options for flexible adult acquired flatfoot deformity, emphasizing the controversy regarding the best surgical technique and the need for early diagnosis to initiate treatment while the deformity is mild and flexible. (10.1007/s00167-009-1015-6)
  • [L4] This outcome was maintained until the mid-term follow-up. (10.1186/s12891-019-2419-1)
  • [L4] Comparative studies suggest similar clinical and radiological outcomes, but recurrence remains a challenge necessitating long-term follow-up and standardized outcome measures. (10.1302/0301-620x.107b1.bjj-2024-0597.r2)
  • [L5] Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot. (10.5435/jaaos-d-23-01007)
  • [L4] Its minimally invasive approach facilitates rapid postoperative recovery and is associated with a low complication profile, supporting its role as a viable alternative to conventional open procedures and previous generation MIS techniques. (10.1186/s13018-025-06361-3)
  • [L4] Considerable differences in the surgical management were found in the practice of the general orthopaedic surgeons and the foot and ankle specialists. (10.1186/s12891-015-0751-7)
  • [L1] Furthermore, patients who received surgical interventions had significant improvements in symptoms and function. (10.1186/s13018-019-1094-0)
  • [L5] This article reviews the classification, diagnosis, and treatment considerations for Jones fractures, covering nonsurgical management, intramedullary screw, and plate fixation, with a focus on the authors' preferred technique using intramedullary screw fixation. (10.5435/jaaos-d-21-00542)
  • [L4] Especially when the involved nerves have no important motor function, surgical excision seems to be the best option for symptomatic patients. (10.2106/00004623-200203000-00015)
  • [L4] Single-stage orthoplastic management was associated with 77% eradication of infection and only one amputation in this complex and comorbid patient group. (10.1302/0301-620x.106b12.bjj-2024-0219.r1)
  • [Paper] Non-surgical intervention begins with shoe modifications and orthotics. (10.1302/2058-5241.2.160031)
  • [L3] However, there is no conclusive evidence to recommend one technique over another. (10.1016/j.jisako.2022.10.006)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] Long-term follow-up of the procedure shows that the initial improvement in wrist position is not maintained. (10.1016/j.jhsa.2011.10.013)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L4] Percutaneous decompression is a useful minimally invasive surgical option in the treatment of early stage Mueller–Weiss syndrome, which remains unresponsive to prolonged conservative treatment. (10.1007/s00167-010-1305-z)
  • [L5] Rigid flatfoot deformities in adolescents have a less predictable clinical course and are associated with various underlying causes, making it critical to investigate the etiology to recommend proper management. (10.5435/jaaos-d-21-00448)
  • [L4] Surgical details and addressing associated deformities with adjunct surgical interventions should be considered. (10.1186/s12891-021-04309-2)
  • [L1] Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. (10.1177/0363546509355408)
  • [L4] Patients with reoperation had significantly lower ICRS classification stages compared to patients without re-operation. (10.1186/s13018-021-02282-z)
  • [L4] Surgical treatment resulted in significantly improved static segmental alignment and mediolateral foot loading, but worsened fore-aft loading. (10.1302/0301-620x.95b5.30594)
  • [L3] Surgery should be considered as the initial form of treatment when patients are diagnosed with carpal tunnel syndrome confirmed by nerve conduction studies, as this provides symptom resolution with a favorable cost analysis. (10.1016/j.jhsa.2009.04.034)
  • [L5] Clinical studies demonstrate that correcting the altered biomechanics associated with asymmetric arthritis improves functional outcomes. (10.5435/jaaos-d-12-00124)
  • [L4] Despite the high prevalence of postoperative complications, most patients were satisfied with the result of the procedure after the short duration of follow-up. (10.2106/00004623-199911000-00006)
  • [L5] Surgeons should retain a flexible approach to treatment choice and master non-operative management, as well as both external and internal skeletal fixation techniques, due to the complexity of distal radial fractures. (10.1054/jhsb.2000.0516)
  • [L3] It is crucial to use radiological assessment to evaluate the involved joints preoperatively and then chose the appropriate method to treat different patients. (10.1186/s13018-017-0513-3)
  • [L4] Postoperative satisfaction and functional recovery of patients are significantly improved. (10.1186/s12891-022-05356-z)
  • [L5] The mainstay of treatment is manipulation and casting, usually followed by soft-tissue release, though some patients have been successfully treated with intensive physiotherapy instead of surgery. (10.5435/00124635-200207000-00002)
  • [L4] Given the high clinical efficacy of AOT, this procedure can be recommended as a safe and promising technique for the long-term therapy of OLT. (10.1007/s00167-022-07237-3)
  • [L5] A good trial of conservative means should be carried out before surgical measures are suggested or undertaken. (10.2106/00004623-196446050-00015)
  • [L3] Routine radiographs in isolation contribute to changes in management in the immediate postoperative period in select cases and during the period when advancement to full weight bearing is being considered up until clinical fracture union. (10.5435/jaaos-d-17-00114)
  • [L3] The authors suggest that obtaining one set of radiographs post-operatively would significantly limit exposure to ionizing radiation and clinical costs, with subsequent radiographs obtained only for complaints or examination findings outside the normal postoperative course. (10.1177/1753193414562354)
  • [L3] Compared to the PPR group, the DCWCO group had poorer short-term clinical outcomes but provide better long-term function and symptom remission. (10.1186/s13018-020-01687-6)
  • [L5] In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity. (10.2106/jbjs.e.00045)
  • [L3] Outpatient or short-stay TAA should be considered for patients with low risk of short-term complications. (10.1186/s13018-020-01793-5)
  • [L4] The EDSTP has good early postoperative results that are maintained for >10 years, providing good long-term radiological correction, lasting pain relief, and great foot function using only 5 incisions. (10.1016/j.arthro.2017.12.017)
  • [L4] It does not affect the stability of the ankle joint and is conducive to the recovery of ankle function. (10.1186/s13018-023-04253-y)
  • [L4] The study reports significant improvements in clinical and radiographic outcome measures following the surgical intervention. (10.2106/jbjs.24.00092)
  • [L3] In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. (10.1186/s13018-020-01856-7)
  • [L3] There were no notable differences in radiographic outcomes between surgeons with and without trauma fellowship training. (10.5435/jaaos-d-16-00687)
  • [L3] Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot. (10.2106/jbjs.24.00394)
  • [L3] When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. (10.1302/0301-620x.97b2.34891)
  • [L4] The plateau is achieved later for complications, imposing a lag between surgeon feeling comfortable with the procedure and a decrease in complications. (10.1186/s12891-023-06706-1)
  • [Letter] Navicular stress fractures are difficult injuries requiring assessment and classification via CT; treatment should be individualized based on severity, previous treatment, and the athlete's sport, with surgery recommended for type II, III, or fractures with sclerosis, cysts, or avascular necrosis. (10.1177/0363546510379341)
  • [L4] We propose a logical, all-inclusive, and mutually exclusive classification system for fractures of the navicular that gives associated injuries involving the lateral column due consideration. (10.1302/0301-620x.100b2.bjj-2017-0879.r1)
  • [L5] Although the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head. (10.1186/s13018-023-03702-y)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L5] Larger wedge sizes decreased passive hindfoot eversion and increased lateral plantar pressure, suggesting optimal lengthening may be smaller than current practices suggest. (10.2106/jbjs.23.00866)
  • [L5] A high level of suspicion, recognition of clinical signs, and appropriate radiographic studies are needed for correct diagnosis to avoid late sequelae of posttraumatic arthritis. (10.5435/00124635-201012000-00002)
  • [L4] The outcomes of follow-up showed good function, and the system could be an alternative method for minimally invasive calcaneous fracture fixation. (10.1186/s12891-022-05871-z)
  • [L5] Surgical treatment aims to achieve optimal anatomical reduction and stability of the first, second, and third cuneiform-metatarsal joints. (10.1302/2058-5241.4.180076)
  • [L4] Numerous scoring systems have been devised to evaluate patients who have symptoms related to the knee, but demographic variables such as advanced age, low family income, and multiple medical conditions significantly affect scores. (10.2106/00004623-199706000-00009)
  • [L4] Satisfactory long-term patient-reported and radiographic outcomes after joint-preserving surgery for forefoot deformities associated with RA can be achieved. (10.2106/jbjs.20.01144)
  • [L4] This surgical procedure provides good correction of adult idiopathic cavus foot without compromising the range of motion of the foot, allowing alternating pronation and supination during gait. (10.2106/00004623-200200002-00008)
  • [L3] Patients who underwent Scarf osteotomy had a gait pattern similar to that of their non-operated foot, whereas those who underwent arthrodesis of the first metatarsophalangeal joint did not totally recover the propulsive forces of the forefoot. (10.1302/0301-620x.98b5.36406)
  • [L3] Compared with controls, both nonoperatively and surgically treated clubfeet had significant limitations in ankle plantar flexion resulting in decreased range of motion, moment, and power. (10.2106/jbjs.18.00317)
  • [L4] To our knowledge, the present study is the first to demonstrate the potential for early operative treatment to restore anatomical alignment and improve function of diabetic patients with stage-I Charcot arthropathy. (10.2106/00004623-200007000-00005)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L3] The plantar approach is recommended if the patient needs a better appearance, as it had less influence on quality of life regarding foot appearance compared to the dorsal approach. (10.1186/s12891-022-05858-w)
  • [L4] Subtalar arthroscopy identified pathologies in the subtalar joint in patients with STS and showed that treatment of these pathologies led to improved function. (10.1016/j.arthro.2008.05.007)
  • [L3] Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy. (10.1186/s13018-019-1241-7)
  • [L4] In this patient cohort, 94% of patients developed postoperative wound complications, and only 44% successfully ambulated with a prosthesis, while the remainder required revision amputations. (10.5435/jaaos-d-19-00757)
  • [L4] In this cohort of patients that received radical surgical interventions, the majority were middle-aged males, and the diabetic foot ulcer was the leading cause. (10.1186/s13018-025-06197-x)
  • [L4] Union took place promptly within eight weeks in all patients with no loss of position. (10.2106/00004623-196951070-00024)
  • [L4] The experience suggests that direct exchange can yield a rate of success comparable with that of delayed exchange if antibiotic-loaded cement and appropriate postoperative antibiotics are used. (10.2106/00004623-199807000-00004)
  • [L1] The two designs functioned equivalently at the time of early follow-up in this low-to-moderate-demand patient group. (10.2106/jbjs.j.00157)

See Also

References

[1] Adult-acquired Flatfoot Deformity. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200807000-00005

[2] Osteochondrolipoma of the foot treated by surgical excision: a case report and literature review. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07308-1

[3] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[4] Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-16-00159

[5] Calcaneus Fractures: A Review of Management, Treatment, and Recent Advances. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00567

[6] Management of Tarsometatarsal Joint Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00556

[7] Osteochondral Allograft Transfer for Treatment of Osteochondral Lesions of the Talus: A Systematic Review. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.06.011

[8] Acute Lisfranc injury management. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b12.bjj-2024-0581.r1

[9] Process and Tubercle Fractures of the Hindfoot. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200512000-00002

[10] Surgical Management of Madelung Deformity: A Systematic Review. HAND. 2018. DOI: 10.1177/1558944718793179

[11] Radiographic Outcomes and Complications of Delayed Fixation of Distal Radius Fractures. HAND. 2020. DOI: 10.1177/1558944720930301

[12] Operative management options for symptomatic flexible adult acquired flatfoot deformity: a review. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-009-1015-6

[13] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[14] Mid-term follow-up results of calcaneal reconstruction for calcaneal malunion. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2419-1

[15] Current concepts of fourth-generation minimally invasive and open hallux valgus surgery. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b1.bjj-2024-0597.r2

[16] Spastic Equinovarus Foot Deformity. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01007

[17] Outcomes and Complications for Minimally Invasive Distal Transverse Metatarsal Osteotomy–Akin Osteotomy (MITA) for Hallux Valgus: 493 Cases. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06361-3

[18] Surgical management of hallux valgus and hallux rigidus: an email survey among Swiss orthopaedic surgeons regarding their current practice. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0751-7

[19] Surgical procedures for treatment of adult acquired flatfoot deformity: a network meta-analysis. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1094-0

[20] Fifth Metatarsal Jones Fractures: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-21-00542

[21] FIBROLIPOMATOUS HAMARTOMA IN THE FOOT: MAGNETIC RESONANCE IMAGING AND SURGICAL TREATMENT. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200203000-00015

[22] Single-stage orthoplastic treatment of complex calcaneal osteomyelitis with large soft-tissue defects. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b12.bjj-2024-0219.r1

[23] Hallux rigidus. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160031

[24] Inconclusive evidence that arthroscopic techniques yield better outcomes than open techniques for subtalar arthrodesis—A systematic review. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2022.10.006

[25] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[26] Long-Term Results of Forearm Shortening and Volar Radiocarpal Capsulotomy for Wrist Flexion Deformity in Children With Amyoplasia. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.10.013

[27] Current Concepts Review - Hallux Rigidus and Osteoarthrosis of the First Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00015

[28] Percutaneous decompression for the treatment of Mueller–Weiss syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1305-z

[29] 8. Foot and Ankle Surgery. 2013.

[30] Evaluation and Management of Adolescents With a Stiff Flatfoot. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00448

[31] Chapter 118 The Diabetic Foot and Ankle. 2019.

[32] Complications associated with talectomy in paediatric patients: a comparative retrospective study of two surgical techniques. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04309-2

[33] Management of Tarsal Navicular Stress Fractures. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509355408

[34] Re-operation rate after surgical treatment of osteochondral lesions of the talus in paediatric and adolescent patients. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02282-z

[35] The operative correction of symptomatic flat foot deformities in children. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b5.30594

[36] The Cost-Effectiveness of Nonsurgical Versus Surgical Treatment for Carpal Tunnel Syndrome. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.04.034

[37] Supramalleolar Osteotomies for the Treatment of Ankle Arthritis. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-12-00124

[38] Complex Reconstruction for the Treatment of Dorsolateral Peritalar Subluxation of the Foot. Early Results After Distraction Arthrodesis of the Calcaneocuboid Joint in Conjunction with Stabilization of, and Transfer of the Flexor Digitorum Longus Tendon to, the Midfoot to Treat Acquired Pes Planovalgus in Adults. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199911000-00006

[39] Should Anatomic Reduction be Pursued in Distal Radial Fractures?. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0516

[40] Open triple fusion versus TNC arthrodesis in the treatment of Mueller-Weiss disease. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0513-3

[41] Rotation scarf + Akin osteotomy for severe hallux valgus with a new evaluation index: distance between the first and second metatarsals. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05356-z

[42] Idiopathic Congenital Talipes Equinovarus. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200207000-00002

[43] Favorable long‐term clinical and radiologic outcomes with high survivorship after autologous osteochondral transplantation of the talus. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07237-3

[44] Surgical Treatment of Disorders of the Fore Part of the Foot. The Journal of Bone & Joint Surgery. 1964. DOI: 10.2106/00004623-196446050-00015

[45] Utility of Routine Postoperative Radiographs After Fixation of Lower Extremity Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00114

[46] The value of post-operative radiographs in clinical management of AO type A distal radius fractures. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414562354

[47] Comparison of dorsal closing wedge calcaneal osteotomy versus posterosuperior prominence resection for the treatment of Haglund syndrome. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01687-6

[48] Correction of Moderate and Severe Acquired Flexible Flatfoot with Medializing Calcaneal Osteotomy and Flexor Digitorum Longus Transfer. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00045

[49] A propensity score-matched analysis comparing outpatient and short-stay hospitalization to standard inpatient hospitalization following total ankle arthroplasty. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01793-5

[50] Endoscopy‐Assisted Hallux Valgus Correction Provides Sustainable Long‐Term >10‐Year Outcomes. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.12.017

[51] Anteromedial cannulated screw fixation for Hawkins II/III talus fractures in children: a retrospective study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04253-y

[52] Management of Dorsal Bunion in Nonambulatory Adolescents with Cerebral Palsy. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.00092

[53] Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01856-7

[54] Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00687

[55] Outcomes of Calcaneal Lengthening Osteotomy in Ambulatory Patients with Cerebral Palsy and Planovalgus Foot Deformity. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00394

[56] Surgery for the correction of hallux valgus. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34891

[57] Learning curve in relation to radiation exposure, procedure duration and complications rate for Minimally Invasive Chevron Akin (MICA) osteotomy. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06706-1

[58] Letter to the Editor. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510379341

[59] A new and reliable classification system for fractures of the navicular and associated injuries to the midfoot. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b2.bjj-2017-0879.r1

[60] Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques—a cadaveric study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03702-y

[61] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[62] Passive Eversion Assessment for Progressive Collapsing Foot Deformity After Lateral Column Lengthening. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00866

[63] Treatment of Lisfranc Joint Injury: Current Concepts. Journal of the American Academy of Orthopaedic Surgeons. 2010. DOI: 10.5435/00124635-201012000-00002

[64] Calcaneous interlocking nail treatment for calcaneous fracture: a multiple center retrospective study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05871-z

[65] Lisfranc fracture-dislocations: current management. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180076

[66] Demographic Biases of Scoring Instruments for the Results of Total Knee Arthroplasty. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00009

[67] Patient-Reported and Radiographic Outcomes of Joint-Preserving Surgery for Rheumatoid Forefoot Deformities. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01144

[68] SURGICAL TREATMENT OF ADULT IDIOPATHIC CAVUS FOOT WITH PLANTAR FASCIOTOMY, NAVICULOCUNEIFORM ARTHRODESIS, AND CUBOID OSTEOTOMY. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200200002-00008

[69] Ground-reactive forces after hallux valgus surgery. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b5.36406

[70] Functional Outcomes Following Treatment for Clubfoot. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00317

[71] Arthrodesis as an Early Alternative to Nonoperative Management of Charcot Arthropathy of the Diabetic Foot. The Journal of Bone and Joint Surgery-American Volume*. 2000. DOI: 10.2106/00004623-200007000-00005

[72] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[73] Plantar and dorsal approaches for excision of morton’s neuroma: a comparison study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05858-w

[74] Subtalar Arthroscopy for Sinus Tarsi Syndrome: Arthroscopic Findings and Clinical Outcomes of 33 Consecutive Cases. Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.05.007

[75] Outcomes after scarf osteotomy with and without Akin osteotomy a retrospective comparative study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1241-7

[76] Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00757

[77] Radical surgical treatment of calcaneal osteomyelitis: clinical characteristics and treatment efficacy based on a synthesis analysis of 364 reported cases. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06197-x

[78] Modification of Mitchellʼs Lateral Displacement Angulation Osteotomy. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00024

[79] Direct-Exchange Arthroplasty for the Treatment of Infection after Total Hip Replacement. An Average Ten-Year Follow-up. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199807000-00004

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b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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