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Background: Osteoarthritis (OA) is the most common degenerative joint disease and affects millions of people worldwide, particularly the elderly population. The pathophysiology of OA is complex and involves multiple factors. Methods: Several studies have emphasized the crucial role of inflammation in this process. The receptor activator of NF-κB ligand (RANKL), the receptor activator of NF-κB (RANK), and osteoprotegerin (OPG) trigger a signaling cascade that leads to the excessive production of RANKL in the serum. Conclusions: The aim of this narrative review is (i) to assess the role of the RANK/RANKL/OPG signaling pathway in the context of OA progression, focusing especially on the physiopathology and on all the mechanisms leading to the activation of the inflammatory cascade, and (ii) to evaluate all the potential therapeutic strategies currently available that restore balance to bone formation and resorption, reducing structural abnormalities and relieving pain in patients with OA.

Introduction. Baropodometry is used to measure the load distribution on feet during rest and walking. The aim of this study was to evaluate changes in plantar foot pressures distribution due to period of working and due to stretching exercises of the posterior muscular chain. Methods. In this transversal study, all participants were submitted to baropodometric evaluation at two different times: before and after the working period and before and after stretching the muscles of the posterior chain. Results. We analyzed a total of 54 feet of 27 participants. After the working period, there was an average increase in the forefoot pressure of 0.16 Kgf/cm2 and an average decrease in the hindfoot pressure of 0.17 Kgf/cm2. After stretching the posterior muscular chain, the average increase in the forefoot pressure was 0.56 Kgf/cm2 and the hindfoot average pressure decrease was 0.56 Kgf/cm2. These changes were not statistically significant. Discussion. It was reported that the strength of the Achilles tendon generates greater forefoot load transferred from the hindfoot. In our study, no significant variation in the distribution of plantar pressure was observed. It can be inferred that baropodometry was a reliable instrument to determine the plantar pressure, regardless of the tension of the posterior chain muscles.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The traditional lateral approach with open reduction and internal fixation (ORIF) is the gold standard for treating ankle fractures since the 1960s. Although good results can be achieved with this technique, it has a considerable complication rate particularly in high-risk patients. Common complications include wound dehiscence, infection, hardware prominence, and fixation failure. Minimally invasive closed reduction and internal fixation with a fibular nail (CRIF) offers a biomechanically stronger alternative. This technique requires smaller incisions, minimizes soft tissue disruption, and utilizes low-profile hardware, potentially reducing complication rates. This study retrospectively compares the radiological and functional outcomes of these techniques in patients at increased risk of complications Methods: We conducted a retrospective review of patients who underwent surgical treatment for ankle fractures at a Level I trauma center between 2018 and 2020. A total of 61 patients met the inclusion criteria, with a minimum follow-up of one year. Of these, 30 patients underwent fixation with a fibular nail, while 31 were treated with plate and screws. Radiographic assessments were performed to evaluate fracture alignment and consolidation. Clinical outcomes included the reoperation rate for wound dehiscence or other complications, as well as amputation and mortality rates. Functional outcomes were measured using the Olerud and Molander Score. Results: The fibular nail group experienced significantly fewer complications compared to the ORIF group. Radiographic analysis showed comparable fracture alignment and consolidation between both techniques. At the one-year follow-up, no significant difference was observed in functional outcomes, with mean Olerud and Molander Scores of 78 (range: 0–100) in the fibular nail group and 88 (range: 20–100) in the ORIF group. Conclusion: Fibular nailing provides reliable fracture reduction and stable fixation while significantly reducing soft tissue complications compared to ORIF. Given its minimally invasive nature, biomechanical advantages, and lower complication rate, it represents a valuable alternative, particularly for high-risk patients. Further prospective studies are warranted to validate these findings and optimize patient selection criteria. Ankle fracture in an elderly diabetic patient minimally invasive fixed with a fibular nail

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Surgical site infections (SSIs) account for 31% of all hospital-acquired infections, significantly impacting postoperative recovery and healthcare costs. Foot and ankle surgeries present infection rates between 0.5% and 6.5%, with trauma cases and comorbidities being key risk factors. Despite previous studies, long-term data on infection incidence and predictive factors remain limited. This 7-year cohort study aimed to determine the incidence of SSIs in foot and ankle surgeries and identify independent predictors of infection, particularly differentiating superficial and deep infections. Understanding these risk factors is essential for optimizing infection control protocols and refining perioperative management strategies to improve surgical outcomes. Methods: This retrospective cohort study included 2,180 patients undergoing foot and ankle surgery between 2014 and 2020 in a private hospital. Elective and trauma-related procedures were included, excluding cases of pre-existing infections, open fractures, and septic arthritis. SSIs were classified as superficial (requiring local wound care or oral antibiotics) or deep (requiring surgical debridement or implant removal). Data on age, sex, diabetes mellitus (DM), systemic arterial hypertension (SAH), smoking, ASA score, and BMI were collected. Multivariate logistic regression was used to assess independent predictors of SSIs, with statistical significance set at p < 0.05. The primary outcome was infection incidence, while secondary outcomes included risk factor analysis and infection severity stratification. Results: The overall SSI incidence was 4% (83/2,180 cases), with 2.8% superficial and 1.2% deep infections. Smoking (OR 2.9, 95% CI 1.4–5.3, p = 0.001) and ASA score >2 (OR 3.4, 95% CI 1.2–8.4, p = 0.013) were independent predictors of infection. The deep infection group had significantly higher rates of smoking (p = 0.002), systemic hypertension (p = 0.018), and trauma-related procedures (p = 0.049). No significant associations were found between infection and diabetes mellitus (p = 0.404) or obesity (p = 0.816). Trauma surgeries, particularly ankle fractures, had the highest infection rates, reinforcing the need for enhanced infection control measures in high-risk patients. Conclusion: This 7-year cohort study confirmed a 4% SSI incidence in foot and ankle surgeries, with smoking and ASA score >2 emerging as significant risk factors. Trauma-related procedures, particularly ankle fractures, had higher infection rates, emphasizing the importance of preoperative risk stratification and perioperative infection control. Surprisingly, diabetes and BMI were not significant predictors, possibly due to effective preoperative optimization. These findings support the implementation of targeted preventive strategies, particularly in high-risk patients, to reduce infection rates and improve surgical outcomes. Characterization of the sample according to the presence of infection This table presents the demographic and clinical characteristics of patients undergoing foot and ankle surgery, stratified by infection status (no infection, superficial infection, and deep infection). Trauma cases (p = 0.049), arterial hypertension (p = 0.018), ASA score ≥ II (p < 0.001), smoking (p = 0.002), and overweight status (p = 0.002) were significantly associated with infection. Diabetes mellitus (p = 0.687) and BMI (p = 0.321) were not statistically significant predictors. The findings suggest that preoperative risk factors such as smoking, ASA score, and hypertension should be considered in infection prevention strategies for foot and ankle surgery patients.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Ankle arthroscopy is a widely performed procedure for diagnosing and treating ankle pathologies. While generally safe, surgical site infections (SSIs) remain a concern, with reported incidences ranging from 0.13% to 3.08%. Although relatively uncommon, SSIs can delay rehabilitation, increase healthcare costs, and lead to severe complications like septic arthritis. Identifying predictors of infection is crucial to improving surgical outcomes. Previous studies suggest that diabetes mellitus (DM) and high body mass index (BMI) may be associated with increased infection risk, but data remain limited. This 8-year retrospective study aimed to determine the incidence of postoperative infections in ankle arthroscopy and identify significant predictors of SSI, using a multivariate analysis of demographic and clinical risk factors. Methods: This retrospective cohort study included 321 patients who underwent ankle arthroscopy between 2014 and 2022. Patients were excluded if they had pre-existing infections, open fractures, or incomplete medical records. Demographic and clinical data, including age, sex, BMI, smoking status, diabetes mellitus (DM), hypertension (SAH), and ASA score, were collected. The primary outcome was SSI incidence, with infections classified as superficial (managed conservatively) or deep (requiring surgical debridement or implant removal). Multivariate logistic regression was performed to identify independent predictors of infection, controlling for potential confounders. Statistical significance was set at p < 0.05. This study provides one of the largest long-term analyses on infection risk factors in ankle arthroscopy, offering critical insights into patient selection and perioperative management strategies. Results: The overall SSI incidence was 2.5% (8/321 patients), with 6 superficial and 2 deep infections requiring further surgery. Diabetes mellitus (DM) and high BMI emerged as independent predictors of infection. Patients with BMI ≥40 kg/m² had a 50% infection rate (p = 0.008), while DM patients had an 11.8% infection rate (p = 0.013). No significant associations were found with hypertension (p = 0.862), smoking (p = 0.254), ASA score (p = 0.616), or sex (p = 0.075). The most common indications for arthroscopy were synovectomy, impingement, and loose body removal (48.3%), followed by osteochondral defect treatment (16.8%) and ligament repair (12.8%). These findings suggest that BMI and DM should be considered in preoperative risk stratification. Conclusion: This 8-year study confirms that BMI and diabetes mellitus are independent predictors of postoperative infection in ankle arthroscopy, while other demographic factors, including hypertension, smoking, and ASA score, showed no significant correlation. Although the overall infection rate was low (2.5%), deep infections requiring surgical intervention reinforce the importance of early recognition and risk-based perioperative management. These findings support the implementation of targeted infection prevention strategies, particularly in patients with high BMI and diabetes, to optimize surgical outcomes and minimize complications. Preoperative screening and tailored postoperative care are essential to reducing infection risk in this patient population. Fisher’s Exact Test Results for Risk Factors Associated with Infection in Ankle Arthroscopy This table presents the association between clinical and demographic risk factors and surgical site infections (SSIs) following ankle arthroscopy. Diabetes mellitus (p = 0.013) and BMI (p = 0.008) were significantly associated with infection, indicating their role as independent risk factors. Other variables, including hypertension, smoking, gender, ASA score, and type of surgical procedure, did not show statistically significant associations (p > 0.05).

Introduction: Peroneal disorders are a common cause of ankle pain and lateral instability and have been described in as much as 77% of patients with lateral ankle instability. Clicking, swelling, pain, and tenderness in the peroneal tendons track are frequent symptoms, but they can be confused with other causes of lateral ankle pain. The management of peroneal disorders can be conservative or surgical. When the conservative treatment fails, surgery is indicated, and open or tendoscopic synovectomy, tubularization, tenodesis or tendon transfers can be performed. The authors present a surgical technique of tendoscopy associated to minimally invasive tenodesis for the treatment of peroneal tendon tears, as well as the preliminary results of patients submitted to this procedure. Methods: Four patients with chronic lateral ankle pain who were diagnosed with peroneal brevis pathology were treated between 2020 and 2022 with tendoscopic-assisted minimally invasive synovectomy and tenodesis. Using a 2.7 mm 30° arthroscope and a 3.0 mm shaver blade, the entire length of the peroneus brevis tendon and most parts of the peroneus longus tendon can be assessed within Sammarco’s zones 1 and 2. After the inspection and synovectomy, a minimally invasive tenodesis is performed. Results: All patients were evaluated at least six months after surgery. All of them reported improvement in daily activities and in the Foot Function Index (FFI) questionnaire (pre-surgery mean FFI = 23.86%; post-surgery mean FFI = 6.15%), with no soft tissue complications or sural nerve complaints. Conclusion: The tendoscopy of the peroneal tendons allows the surgeon to assess their integrity, confirm the extent of the lesion, perform synovectomy, prepare the tendon for tenodesis, and perform it in a safe and minimally invasive way, reducing the risks inherent to the open procedure.

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results Introduction/Purpose: Ankle fractures are among the most common orthopedic injuries and are frequent associated to deltoid ligament. Despite the high prevalence of this injury, there is still no consensus on the need for repair of the deltoid ligament. However, it is increasingly believed that, due to its role in rotational instability, repair should be performed in all cases. The use of arthroscopy associated with the treatment of ankle fractures allows the identification of associated injuries allows removing debris and proteases that can accelerate the process of joint degeneration. Arthroscopic deltoid ligament repair has been demonstrating results like open repair, with less local morbidity. This study aims to functionally evaluate patients undergoing surgical deltoid ligament repair and compare the currently available methods. Methods: A prospective observational study was conducted to monitor outcomes. Inclusion criteria included all patients over 18 years of age undergoing surgical treatment for ankle fractures, provided they had no prior surgeries on the affected ankle. Exclusion criteria included patients with chronic joint diseases, previous surgeries on the affected ankle, those unwilling to participate in the study, or those without the cognitive capacity to consent. All patients with surgical ankle fractures were approached arthroscopically, and the pattern of their ligament injuries was documented. The OMAS scale was applied to all participants after a minimum follow-up of two years, with data collected via telephone survey. Results: A study of 121 patients included 53 women (43.8%) and 68 men (56.2%). Regarding deltoid ligament injuries, 77 patients had no injury (63.6%), while 44 patients (36.4%) presented with deltoid ligament injury. Among the patients with deltoid injury, 33 cases (75.0%) were repaired; of these, 10 underwent open repair and 23 underwent arthroscopic repair. Tourniquet time was longer in cases where the deltoid ligament was repaired (p = 0.0068; 95% CI −35.34,−6.52). Functional outcomes measured by the OMAS scale showed an average score of 88 in patients without deltoid injury, 80 in patients with deltoid injury not requiring repair, 75 in those who underwent open deltoid repair, and 78 in those who underwent arthroscopic repair, indicating similar functional results between the two repair methods. Conclusion: This study helps surgeons in the decision-making process when treating ankle fractures with deltoid ligament injuries. By identifying clear injury patterns, it allows a more specific and individualized approach to treatment. The results also confirm that arthroscopic repair of the deltoid ligament is a safe and reliable method, providing functional outcomes similar to open repair, with the advantage of less local morbidity. These findings encourage the use of arthroscopy as an effective option for managing these injuries.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The use of intramedullary fibular nailing for ankle fracture fixation has gained popularity, particularly in patients at elevated risk of wound complications. Despite its advantages, concerns remain regarding the safety of this technique and the quality of fracture reduction achieved through its minimally invasive approach. This anatomical study aimed to evaluate the potential risks to adjacent anatomical structures during the implantation of a percutaneous retrograde locked intramedullary fibular nail and to analyze the quality of fracture reduction using radiographic assessment. Methods: Ten human cadaveric lower extremities were subjected to a simulated fracture and then fixed with a nail. Reduction quality was evaluated fluoroscopically and graded accordingly. Specimens were dissected to assess damage to nearby anatomical structures, and the shortest distances between surgical sites and adjacent structures were measured. Results: Reduction quality was deemed adequate in all specimens. No damage to the peroneal tendons was observed. The mean distance between the sural nerve and the distal portal was 14.95 mm (SD 3.99) therefore this was considered a safe zone. The superficial peroneal nerve (SPN) was identified as the structure at the highest risk of injury, with a mean distance of 4.52 mm (SD 3.27) from the anterior portal and 14.17 mm (SD 5.25) from the lateral portal. The SPN was found in contact with the anterior portal in three specimens, however no structures were injured during instrumentation. Conclusion: Adequate fracture reduction can be achieved with the nail. The SPN was identified as the structure at the highest risk of damage; however, no tendons or nerves were injured during the procedure. Clinical relevance: The current findings supports intramedullary nailing as an efficient method for achieving proper fracture reduction while minimizing soft tissue complications. Nevertheless, strict adherence to the percutaneous technique is essential to minimize iatrogenic injury to neighboring structures. This includes using skin-only incisions, performing blunt dissection down to the bone, and maintaing close approximation of protection sleeves and bone at all times.

Research Type: Level 1 - Randomized controlled trial (RCT), Meta-analysis of randomized trials with homogeneous results Introduction/Purpose: Background: A stress fracture is an overuse injury to the bone caused by repetitive, submaximal forces that gradually exceed the bone’s natural capacity for self-repair and several biological and mechanical risk factors influence its occurrence. Given the role of vitamin D in bone health, the potential relationship between this micronutrient and stress fractures is of great importance and warrants further investigation. Hypothesis/Purpose: This study aims to establish an association between lower vitamin D status and a higher risk of stress fractures Methods: This systematic review and meta-analysis was conducted and reported according to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Systematic search was performed without date restriction until June 2024. After the selection process, 7 studies (9 trials and 797 subjects) were included. Risk of bias assessment was performed by independent reviewers using the Newcastle-Ottawa Scale (NOS) (Wells et al., 2021). Mean and standard deviation results of the variables of interest were obtained from the included studies. I2 statistic was used to evaluate the heterogeneity of the studies included in the meta-analysis. The effect size (ES) Cohen’s or Hedges’ was calculated for all studies. The weighted mean of the ES was calculated based on the differences in sample sizes. The unweighted mean ES was also calculated and associated with a 95 % CI. The Cohen classification was used to assess the magnitude of the ES. Results: 8500 articles were identified through the database and references. After removing duplicates and excluding articles that did not meet eligibility criteria according to their titles, abstracts and full texts, 7 studies were selected for inclusion in the systematic review and meta-analysis A total of 7 studies (9 trials and 797 subjects) were included in the meta-analysis. Pooling data from 9 trials that evaluated the influence of serum vitamin D on stress fracture incidence, the meta-analysis revealed that subjects diagnosed with stress fractures had lower vitamin D levels, with a small effect size (-0.23; 95% CI: [-0.32, -0.13]; p = 0.01). The fixed-effects analysis showed no heterogeneity between the studies (I2 = 0.00%, Q = 12.29, df = 8, p = 0.14) Conclusion: In summary, the results clearly show a correlation between a lower vitamin D status and a higher incidence of stress fractures. Thus, serum vitamin D should be evaluated when dealing with patients with a higher risk of presenting a stress fracture, since it may be an important measure in order to determine prevention and therapeutic approaches

Category: Bunion Introduction/Purpose: The minimally invasive Chevron Akin (MICA) osteotomy have been widely used treating hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure, and to evaluate the clinical and radiographic outcomes Methods: Sixty consecutive feet (52 patients) undergoing MICA for severe HV were included. Patients were assessed pre and postoperatively. Clinically evaluation was realized by visual analogue pain scale (VAS) and American Orthopaedic Foot & Ankle Society Score (AOFAS). Radiographic assessments included measurement of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length and plantar offset of MT head. Results: The mean age was 59.9 years and follow-up were 18.5 months. The average AOFAS increased from 41.2 to 90.9 points and the VAS decreased from 8.1 to 1.3 at the last follow up. Average HVA decreased from 41.2° to 11.6° and IMA reduced from 17.1° to 6.8°. Average shortening of the first metatarsal and the plantar offset of MT head was 3.9 mm and 2.8 mm respectively. There was significant improvement (p<0.001) in all clinical and radiographic parameters (p<0.001). The most observed complication was hardware discomfort, observed in four feet (6.6%). Conclusion: The MICA technique is a safe and reproducible method to treat severe HV.