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Background: Monitored anesthesia care (MAC) combined with regional anesthetic techniques is commonly used for open reduction and internal fixation (ORIF) of unstable ankle fractures. When compared to general anesthesia (GA), MAC with regional anesthesia has been associated with reduced systemic adverse effects and shorter recovery times, although regional anesthesia carries additional costs and potential complications of its own. A new technique involving the infiltration of high-volume, low-concentration (VL) local anesthetic was therefore developed. When used in conjunction with MAC, we refer to this technique as MAC-VL. This study evaluates outcomes and recovery metrics following outpatient ankle ORIF performed under GA vs MAC-VL without regional anesthesia. Methods: An IRB-approved retrospective cohort study was conducted including 159 adults who underwent outpatient ankle ORIF between February 1, 2023, and January 31, 2026. Patients were identified using standardized diagnostic and procedural codes and grouped according to anesthesia type. All patients received a standardized injection of local anesthetic around the proposed operative sites before the procedure; anesthesia type was MAC (n = 48) or GA (n = 111). The primary outcome was time to discharge, defined as the interval from incision closed to hospital discharge. Secondary outcomes were considered exploratory and included tourniquet, operative, anesthesia time, time in room, Post Anesthesia Care Unit length of stay, conversion from MAC to GA, reported postoperative nausea and vomiting, admissions, and postoperative emergency department visits. Results: Among 160 procedures for which no significant difference in case mix could be detected with the numbers available, MAC-VL was associated with a significantly shorter time to discharge—reducing discharge time by 55.2 minutes ( P < .001) following adjustment for demographic, clinical, and operative covariates—and shortened total anesthesia and operating room time compared with GA. With the numbers available, no significant difference was detected for the remaining secondary outcomes. Conclusion: The MAC-VL protocol was associated with shorter operating room and recovery times and may improve health care resource use. Level of Evidence: Level III, retrospective cohort study.

Background: Midfoot arthritis can cause debilitating dorsal midfoot pain and functional limitation. Deep peroneal nerve (DPN) neurectomy is a minimally invasive surgical option that addresses pain through selective denervation. Although favorable midterm outcomes have been reported, long-term durability remains unclear. The purpose of this study was to evaluate changes in patient-reported physical function and pain interference between midterm and long-term follow-up after DPN neurectomy using validated Patient-Reported Outcomes Measurement Information System (PROMIS) instruments. Methods: A retrospective review identified patients who underwent isolated DPN neurectomy for midfoot arthritis between 2017 and 2021 and completed PROMIS Physical Function (PF) and Pain Interference (PI) questionnaires at midterm and long-term follow-up. Mean follow-up was 2.9 years (midterm) and 6.1 years (long-term). PROMIS scores were compared using paired t tests. Clinically meaningful improvement was defined using established minimal clinically important difference (MCID) thresholds (+5.88 for PF, −5.49 for PI). Results: The final cohort included 32 patients (81.2% female, mean age 68.4 ± 7.3 year). PF improved from 37.7 ± 6.2 to 39.0 ± 7.5 (Δ = +1.3, 95% CI [−0.7 to +3.4], P = .188), whereas PI decreased from 62.6 ± 8.8 to 59.2 ± 9.0 (Δ = −3.4, 95% CI [−6.3 to −0.5], P = .020). Clinically meaningful improvement was achieved by 7 of 32 (21.9%) for PF and 15 of 32 (46.9%) for PI. Five patients experienced clinically meaningful worsening, including patients with stroke, chronic pain syndrome, or contralateral foot and ankle pathology or surgery. Conclusion: DPN neurectomy was associated with stable longitudinal PROMIS outcomes through extended follow-up, with a nonsignificant mean PF change of +1.3 points and a statistically significant but sub-MCID mean PI decrease of −3.4 points over approximately 6 years. Outcomes were heterogeneous; fewer than half of patients achieved clinically meaningful improvement in pain interference, and a subset experienced worsening. These findings suggest that DPN neurectomy may provide durable symptom stability in appropriately selected patients with refractory dorsal midfoot pain, although clinically meaningful benefit at the individual level is not universal. Level of Evidence: Level III, comparative series.

Biologic augmentation, using substances like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP), shows promise for improving outcomes in foot and ankle surgery, particularly in high-risk patients. Historically, autologous bone graft is the benchmark due to its trifecta of osteogenic, osteoinductive, and osteoconductive properties, despite its associated donor site morbidity. Current evidence supporting orthobiologics remains fragmented and inconclusive, with a lack of high-level randomized controlled trials (RCTs). BMAC shows fusion rates comparable to autograft in some foot and ankle applications, but PRP evidence is often conflicting due to a lack of preparation standardization. The regulatory environment is complex. The Food and Drug Administration (FDA) oversees human cells and tissues (HCT/Ps) through a tiered system: high-risk §351 products (eg, cultured stem cells) require rigorous premarket approval, whereas §361 products (eg, allograft bone) have minimal oversight. BMAC and PRP often bypass this through the Same Surgical Procedure Exemption or are regulated through their processing devices, meaning the biologics themselves are not FDA-approved therapeutics. This regulatory gap and direct-to-consumer marketing necessitate meticulous informed consent, transparently discussing the lack of specific FDA approval, limited evidence, and high out-of-pocket costs. Future success depends on standardized, prospective RCTs and a collaborative “middle-ground pathway” for regulatory approval.

Background Supination-external rotation (SER) variant ankle fractures can have unstable injury patterns indicating surgical treatment. Medial clear space (MCS) on 2-dimensional radiographs is often variable, and validity of this measurement is argued. Recently, lateral talar subluxation (LTS) has been posed to be a more specific measurement than MCS likely because the pattern of injury is an external rotation pivoting displacement mechanism. However, there have been no studies using computed tomography (CT) scans to investigate the 3-dimensional talar displacement with this novel measurement. This axial rotation measurement of the talus may be a better measure than current standards, as the rotational component of these ankle fractures is underestimated. Methods This study is a retrospective review that initially identified 158 patients with unstable (SER IV) bi- or trimalleolar ankle fracture variants with injury radiographs and CT scans over a consecutive 10-year period from 2013 to 2023. Standardized measurements of radiographic MCS and LTS were acquired as well as CT scan measurements of the axial MCS, axial LTS, and a novel measurement of axial rotation angle, which is the amount of talar rotatory fracture deformity relative to the tibia. Coronal MCS and coronal LTS were also measured (Figure 1). Ultimately, 20 patients fit our inclusion criteria. The primary outcome measure investigated was the degree of external rotation of the talus in SER IV patterns. Secondary outcomes were other measurement surrogates and their correlations. Regression analysis was performed to predict the amount of rotational displacement by MCS or LTS abnormalities. Post hoc power analysis was subsequently performed. Results The mean axial rotation angle was noted to be 6.20 ± 3.79 degrees in external rotation. Axial MCS and axial LTS were 3.64 mm ± 1.10 mm and 2.20 mm ± 1.41 mm, respectively. Coronal MCS and coronal LTS were 3.15 mm ± 1.28 mm and 1.08 mm ± 1.61 mm, respectively. There were significant correlations between both MCS and LTS with respect to talar external rotation on axial CT (r = 0.85 and 0.78, respectively). Regression analysis predicted that for each 1 mm of MCS increase, there are 1.5 degrees of increased talar external rotational displacement. Similarly, for every 1 mm LTS increase, there are 2 degrees of talar external rotational displacement. Conclusion Lateral talar subluxation has previously been described as a useful measurement tool in identifying ankle instability and the potential need for surgical intervention. However, plain radiographs have limitations as the talus undergoes displacement in 3-dimensional positional planes. Using CT imaging, we found that both increased MCS and increased LTS positively correlated with increased talar external rotational as well as other displacement surrogates. There may be unrecognized rotational displacement that persists after SER ankle fracture injury, and careful consideration should be given by the surgeon for this phenomenon. Level of Evidence: Level III, retrospective cohort study

Background: Total ankle arthroplasty (TAA) using patient-specific instrumentation (PSI) has increased in popularity with evidence for decreased operative duration, fluoroscopy usage, and increased implant placement accuracy. To date, no comparisons have verified the accuracy of PSI in vivo using preoperative and postoperative weightbearing computed tomography (WBCT). Our study aims to supplement the literature by quantifying the accuracy and precision of PSI-guided implant positioning using WBCT. The primary study outcome is to identify positioning deviations in degrees or millimeters in any plane for talus and tibial PSI-guided resections and subsequent implant placement. Secondary outcomes were correlation and regression analyses performed to identify variables that correlate to resection or implant placement deviation, as well as comparison to existing radiography-based PSI techniques. Methods: This was a single-surgeon, single-implant consecutive patient retrospective study where preoperative and postoperative WBCTs were obtained. TAA was performed by the senior author with the same low-profile implant for all cases. Talus and tibial resection analysis was performed in computer-automated fashion on postoperative segmented WBCTs and is described as 3 possible deviations from plan (cut height in millimeters, sagittal slope, varus/valgus deviation). Overall deformity in this group was not severe. Implant placement factors independent of PSI guides are described as center-of-mass translations (mm) and axial rotation (degrees). Desired accuracy for the PSI system was within ±2 mm or ±2 degrees of the preoperative plan. Statistical analysis of data collected included Student t test and linear regression analyses. Results: Thirty patients were included. Four talus implants were excluded per intraoperative surgeon discretion (deviation from PSI plan, use of conventional instruments). All postoperative tibial measurements were within the desired limits, except for mediolateral center of mass positioning ( P = .003) and slope ( P = .013). Two of six talar parameters also diverged from preoperative measurements: axial rotation ( P = .015) and anteroposterior positioning ( P = .002). In addition, no correlations exceeding r = 0.5 were noted between preoperative deformity measurements and postoperative positioning. Conclusion: For the 26 ankles that did not require an intraoperative deviation from PSI plan and/or use of conventional instruments, total ankle replacement performed with PSI using WBCT results in component placement with relatively little deviation from the preoperative plan. In addition, the lack of correlation between preoperative deformity and implant placement suggests that the magnitude of preoperative deformity in this group was not associated with the accuracy of PSI-guided component positioning. Level of Evidence: Level III, retrospective cohort study.

Background: End-stage ankle arthritis is successfully treated with surgery with either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Much is described comparing the 2 treatments in tightly selected patient groups. Limited evidence attempts to examine specific elements of technical complexity that increase perioperative risk for the surgical treatment of ankle arthritis. There is suspicion that AA may be preferable in the setting of elevated patient complexity, or that procedures may require staging to diminish complication risk when there is also foot deformity present. The aim of this study is to evaluate the effect of adjunctive procedures on overall postoperative complication (POC) risk, for both TAA and AA. Primary outcome measures were to compare overall complication and reoperation risk for TAA and AA. Secondary outcome measures were to identify patient factors, intraoperative factors, and factors of procedural complexity via number of associated surgeries and the incidence of complications and reoperation. Methods: A retrospective chart review of AAs and TAAs performed at a single academic institution from the years 2008-2024 was performed using Current Procedural Terminology ( CPT ) codes identifying AA and TAA. Patient demographics, operative details, and postoperative data were abstracted to collect relevant information. Statistical analyses, including odds ratios and analysis of variance, were then performed to reveal specific risk factors and correlations. Results: Four hundred ninety-one patients were identified in the initial database query. After exclusions, 246 remained, of which 110 underwent AA and 136 underwent TAA. The mean length of follow-up was 36.4 months for TAA patients and 46.1 months for AA patients in this study. Overall, patients who underwent TAA were older and had an increased number of preoperative comorbidities (5.74 ± 3.07) compared to AA (4.74 ± 2.76) ( P = .008). Additionally, TAA patients experienced a lower overall rate of POCs (20/136, 14.71%) and reoperation (14/136, 10.29%) compared with patients who underwent AA (21/110, 19.09%; 21/110, 19.09%) ( P = .36 and P = .05, respectively). As the number of adjunctive procedures increased, so did the rate of POCs, but not reoperation, in patients who underwent TAA. The number of adjunctive procedures was not significantly associated with complication or reoperation risk in AA patients. There were no specific adjunctive procedures that demonstrated a significant correlation with increased risk of complications or reoperation in both groups. Osteoporosis and coagulopathies were identified as predisposing TAA patients to postoperative complications. Conclusion: In our retrospective cohort study with relatively low statistical power, we found that patients who undergo TAA or AA plus adjunctive procedures did not experience an increased risk of major complications or reoperation compared to patients who did not undergo adjunctive procedures. Several preexisting comorbidities in TAA patients were associated with higher rates of POCs or reoperation, including osteoporosis and coagulopathies; no comorbidities were linked to increased reoperation or POC risk in the AA group. These findings suggest a need to evaluate comorbidities, and lifestyle factors when recommending an ankle reconstruction procedure to minimize the odds of postoperative complications and improve likelihood of patient satisfaction. Level of Evidence: Level III, retrospective cohort study.

The infrapatellar branch of the saphenous nerve (IPBSN) is implicated in nerve injury from different knee surgeries because of its intimate course relative to the knee joint capsule. Pain physicians encounter patients in their practice for the management of neuralgia of this nerve or in the context of advanced management of knee osteoarthritis. This article aims to provide a comprehensive review of the anatomy, sonoanatomy, and the intervention of the IPBSN in pain management of infrapatellar neuralgia and chronic knee pain.

Introduction Surgical site infections (SSI) continue to be a risk associated with surgery. The Centers for Disease Control (CDC) uses surgical wound class (SWC) to predict SSI postoperatively. Prior studies have shown that the current wound class definitions are unreliable for surgical subspecialties. Therefore, an alternative surgical wound classification (ASWC) was created to more accurately reflect risk of SSI following orthopedic procedures. The purpose of this study was to compare the two systems. Methods Seventy patients who developed 90-day SSI following total joint arthroplasty (TJA) were matched 1:1 to patients without postoperative SSI. The SWC was recorded from operative reports. Wounds were then retrospectively reclassified according to the ASWC based on preoperative history from the medical record. The degree of agreement and degree of association with occurrence of SSI was compared between the two systems. Results The proportion of agreement between the systems was poor (41.4%). The current SWC was associated with risk of SSI in both unadjusted (p=0.045) and multivariable analysis (p=0.050). Comparatively, the ASWC demonstrated a stronger association with SSI in both unadjusted (p=0.001) and multivariable analysis (p=0.001). Conclusion The results of this study suggest that the ASWC is more predictive for SSI following TJA than the current SWC definitions for total joint arthroplasty.

Background Minimally invasive (MIS) treatment of hallux valgus (HV) deformity is increasing in popularity. A 2-mm diameter burr is used to create a distal first metatarsal osteotomy prior to capital fragment translation and fixation. The metatarsal will shorten by the burr’s diameter (2 mm). Plantar or dorsal capital fragment displacement may also cause load transference and possibly transfer metatarsalgia. The purpose of this study is to examine the effect of MIS HV on forefoot loading mechanics with respect to metatarsal shortening and sagittal plane displacement. Methods Four lower-limb cadaveric specimens were studied. A pedobarography pressure-sensing mat was used to record forefoot plantar pressure in a controlled weight-bearing stance position. Control and postosteotomy measurements were obtained with the capital fragment fixated in 3 possible positions: 0 mm, 5 mm dorsal, and 5 mm plantar displacement. Pedobarography data yielded pressure data within measurable graphical depictions. Raw mean contact pressure measurements were taken under the first and fourth metatarsal heads to establish medial and lateral forefoot loading pressure ratios. An a priori power analysis was performed based on previous peer-reviewed pedobarographic data, and our study was adequately powered. Results Around 40 measurements were recorded, and ratios of medial-to-lateral forefoot loading were constructed. Medial forefoot pressure control versus 0 mm displacement, and control versus dorsal displacement were not found to be statistically significant ( p = 0.525, p = 0.55, respectively). Medial pressure significantly increased when comparing control versus plantar displacement ( P = .006). Lateral pressure significantly increased with dorsal displacement of the osteotomy ( P = .013). Conclusion Our study found that MIS HV correction did not cause an increase in lateral forefoot pressure loading when sagittal plane displacements were controlled. Plantar displacement increased medial loading, and dorsal displacement increased lateral loading. It may be valuable for surgeons to consider metatarsal head position postosteotomy, as a decrease in medial loading and subsequent increase in lateral loading may lead to lateral forefoot pain and transfer metatarsalgia. Levels of Evidence: IV.

Bone autografts are frequently harvested for use in foot and ankle surgery. A commonly used harvest site is the iliac crest; however, because of known morbidity with this site, the tibia and calcaneus are attractive alternatives. There remains limited understanding regarding the osteogenic potential of autografts from each of these locations. In this review, we provided an update of the known data on bone autografts from the iliac crest, tibia, and calcaneus, focusing on the total cells harvested from each site as well as the presence of osteogenic osteoprogenitor cells. Level of Evidence: Level V, expert opinion.