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• Orthobiologics are biological substances that are used therapeutically for their positive effects on healing skeletal and soft-tissue injuries. The array of orthobiological products currently available to the foot and ankle surgeon is wide, and includes bone allografts, bone substitutes, growth factors, and chondral scaffolds. Nonetheless, despite the surge in interest and usage of orthobiologics, there remains a relative paucity of research addressing their specific applications in foot and ankle surgery. In this review, we attempt to provide an overview of the literature on commonly available allogenic bone grafts and bone substitutes.

• There is Level II, III and IV evidence addressing allogenic bone grafts in primary arthrodesis and osteotomy procedures in foot and ankle surgery, which compares favourably with autogenic bone grafts in terms of fusion rates and clinical outcomes (often with fewer complications), and supports a Grade B recommendation for its use.

• Pertaining to bone substitutes, the multiplicity of products, coupled with a lack of large prospective clinical trials, makes firm recommendations difficult. Level II and IV studies of calcium phosphate and calcium sulphate products in displaced intra-articular calcaneal fractures have found favourable results in addressing bone voids, maintaining reduction and promoting union, meriting a Grade B recommendation. Evidence for TCP is limited to level IV studies reporting similarly good outcomes in intra-articular calcaneal fractures, warranting a Grade C recommendation. The use of demineralised bone matrix products in hindfoot and ankle fusions has been described in Level II and III studies, with favourable results in achieving fusion and good clinical outcomes, supporting a Grade B recommendation for these indications.

• Overall, despite the general lack of high-level evidence in foot and ankle surgery, allogenic bone grafts and bone substitutes continue to hold front-line roles in treating the bone defects encountered in trauma, tumour, and deformity correction surgery. However, more investigation is required before firm recommendations can be made.

Cite this article: EFORT Open Rev 2017;2:272–280. DOI: 10.1302/2058-5241.2.160044

• Cavovarus deformity can be classified by the severity of malalignment ranging from a subtle and flexible to a severe and fixed cavovarus deformity of the foot.

• In the mild cavovarus foot, careful clinical assessment is required to identify the deformity.

• Weight-bearing radiographs are necessary to indicate the apex of the deformity and quantify the correction required.

• Surgery is performed when conservative measures fail and various surgical procedures have been described, including a combination of soft-tissue releases, tendon transfers and osteotomies, all with the aim of achieving a plantigrade and balanced foot.

• Joint-sparing surgery is the best option in flexible cavovarus foot even in Charcot-Marie-Tooth (CMT) disease (peroneal muscular atrophy).

• Arthrodesis is indicated in severe rigid cavus foot or in degenerative cases.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160077. Originally published online at www.efortopenreviews.org

• Most of tumours of the foot are tumour-like (synovial cyst, foreign body reactions and epidermal inclusion cyst) or benign conditions (tenosynovial giant cells tumours, planta fibromatosis). Malignant tumours of the soft-tissue and skeleton are very rare in the foot and their diagnosis is often delayed with referral to specialised teams after initial inappropriate procedures or unplanned excisions. The adverse effect of these misdiagnosed tumours is the increasing rate of amputation or local recurrences in the involved patients. In every lump, imaging should be discussed before any local treatment. Every lesion which is not an obvious synovial cyst or plantar fibromatosis should have a biopsy performed.

• After the age of 40 years, chondrosarcoma is the most usual malignant tumour of the foot. In young patients bone tumours such as osteosarcoma or Ewing’s sarcoma, are very unusually located in the foot. Synovial sarcoma is the most frequent histological diagnosis in soft tissues. Epithelioid sarcoma or clear cell sarcoma, involve more frequently the foot and ankle than other sites. The classic local treatment of malignant conditions of the foot and ankle was below-knee amputation at different levels. Nowadays, with the development of adjuvant therapies, some patients may benefit from conservative surgery or partial amputation after multidisciplinary team discussions.

• The prognosis of foot malignancy is not different from that at other locations, except perhaps in chondrosarcoma, which seems to be less aggressive in the foot. The anatomy of the foot is very complex with many bony and soft tissue structures in a relatively small space making large resections and conservative treatments difficult to achieve.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160078. Originally published online at www.efortopenreviews.org

• Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component.

• High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density.

  • Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient.

• Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects.

• A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments.

• Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org

• The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness.

• An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it.

• Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together.

• Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org

• An estimated 40% of the US population have foot problems.

• Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed ‘hallux rigidus’. First MTP osteoarthritis is the most common arthritic condition in the foot.

• Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.

• In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.

• In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.

• A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal head

• Multiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results.

Cite this article: EFORT Open Rev 2017;2:13–20. DOI: 10.1302/2058-5241.2.160031

• Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders.

• The most common foot and ankle tendoscopies are: Achilles; peroneal; and posterior tibial tendon.

• Tendoscopy may be used as an adjacent procedure to other techniques.

• Caution is recommended to avoid neurovascular injuries.

• Predominantly level IV and V studies are found in the literature, with no level I studies still available.

• There are many promising and evolving endoscopic techniques for tendinopathies around the foot and ankle, but studies of higher levels of evidence are needed to strongly recommend these procedures.

Cite this article: EFORT Open Rev 2016;1:440-447. DOI: 10.1302/2058-5241.160028

• Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature.

• The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities.

• There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions.

• We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed.

Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.

• Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity.

• Eccentric stretching is the most effective treatment.

• Surgical treatment is reserved for recalcitrant cases.

• Minimally-invasive and tendinoscopic treatments are showing promising results.

Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024.

• Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone.

• Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus.

• Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms.

• There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial.

• Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically.

• Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved.

Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.