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Hagen Fritzsche, Anne Weidlich, Klaus-Dieter Schaser, Elisabeth Mehnert, Doreen Winkler, and Stefan Rammelt

  • Musculoskeletal tumours of foot or ankle make up about 4–5% of all musculoskeletal tumours. Fortunately, about 80% of them are benign. However, due to the rarity and low prevalence of each single tumour entity, diagnosis is often difficult and delayed.

  • Ultrasonography is an important diagnostic tool to safely recognize ganglion cysts as a frequently encountered ‘bump’ in the foot.

  • In suspicious lesions, malignancy must be excluded histologically in a tumour center by biopsy after imaging procedures using x-ray, computed tomography (CT) and magnetic resonance imaging (MRI).

  • Most of the benign tumours do not require any further surgical therapy. Resection should be performed in the case of locally aggressive tumour growth or local symptoms of discomfort. In contrast to malignant tumours, the primary purpose in the resection is the least possible loss of function.

Michael J Raschke, Sabine Ochman, and Alexander Milstrey

  • The relevance of geriatric ankle fractures is continuously increasing.

  • Treatment of these patients remains challenging and requires adapted diagnostic and therapeutic strategies, as compliance to partial weight bearing is difficult to maintain compared to younger patients.

  • In addition, in the elderly even low impact injuries may lead to severe soft tissue trauma, influencing timing and operative strategies.

  • Recently, the direct posterolateral approach and plate fixation techniques, angular stable implants as well as intramedullary nailing of the distal fibula have been found to improve stategical concepts.

  • This article aims to provide a comprehensive overview of the diagnostic and recent aspects with respect to how this difficult entity of injuries should be approached.

Martin Riegger, Nermine Habib, Enrique Adrian Testa, Jochen Müller, Marco Guidi, and Christian Candrian


  • The biomechanical characteristics of different techniques to perform the modified Lapidus procedure are controversial, discussing the issue of stability, rigidity, and compression forces from a biomechanical point of view. The aim of this systematic review was to investigate the available options to identify whether there is a procedure providing superior biomechanical results.


  • A comprehensive literature search was performed by screening PubMed, Embase, and Cochrane databases until September 2021. There was a wide heterogeneity of the available data in the different studies. Load to failure, stiffness, and compression forces were summarized and evaluated.


  • Seventeen biomechanical studies were retrieved – ten cadaveric and seven polyurethane foam (artificial bone) studies. Fixation methods ranged from the classic crossed screw approach (n = 5) to plates (dorsomedial and plantar) with or without compression screws (n = 11). Newer implants such as intramedullary stabilization screws (n = 1) and memory alloy staples (n = 2) were investigated.


  • The two crossed screws construct is still a biomechanical option; however, according to this systematic review, there is strong evidence that a plate–screw construct provides superior stability especially in combination with a compression screw. There is also evidence about plate position and low evidence about compression screw position. Plantar plates seem to be advantageous from a biomechanical point of view, whereas compression screws could be better when positioned outside the plate. Overall, this review suggests the biomechanical advantages of using a combination of locking plates with a compression screw.

Wout Füssenich, Gesine H Seeber, Julian R Zwoferink, Matthijs P Somford, and Martin Stevens


  • A systematic review to determine the effect of different types of joint preparation, joint fixation, and postoperative weight-bearing protocols on non-union frequency in first metatarsophalangeal joint (MTPJ) arthrodesis in patients with moderate-to-severe hallux valgus.

Material and methods

  • A systematic literature search (PubMed and EMBASE), adhering to PRISMA guidelines. Data on MTPJ preparation, fixation, weight-bearing, and non-union in patients with moderate-to-severe hallux valgus were collected. Quality assessment was performed using the Coleman Methodology Score.


  • Sixteen studies (934 feet) were included, generally of medium quality. Overall non-union rate was 7.7%. At 6.3%, convex/concave joint preparation had the lowest non-union rate vs 12.2% for hand instruments and 22.2% for planar cuts. Non-union of 2.8% was found for joint fixation with a plate combined with a lag screw vs 6.5% for plate fixation, 11.1% for crossed screw fixation, and 12.5% for a plate with a cross plate compression screw. A 5.1% non-union frequency was found following postoperative full weight-bearing on a flat shoe vs 9.3% for full weight-bearing on a heel weight-bearing shoe and 0% for a partial weight-bearing regimen.


  • Based on medium-quality papers, joint preparation with convex/concave reamers and joint fixation with a plate using a lag screw show the lowest non-union rate. Full postoperative weight-bearing in a stiff-soled postoperative shoe is safe and not associated with non-union vs a more protective load-bearing regimen. Further research should focus on larger sample sizes, longer follow-ups, and stronger study designs.

Patrick Ziegler, Christian Bahrs, Christian Konrads, Philipp Hemmann, and Marc-Daniel Ahrend

  • The present narrative review provides a summary of current concepts for the treatment of ankle fractures in elderly patients.

  • Despite a high complication rate, open reduction and internal fixation is the gold standard for operative care. However, individual patient-based treatment decision considering the soft-tissue status, the fracture pattern, as well as the patient’s mobility and comorbidities is mandatory to achieve sufficient patient outcomes.

  • Due to high complication rates after surgery in the past, techniques such as fibular nails or minimal invasive techniques should be considered.

Bart A Swierstra and W Annefloor van Enst

  • The aim of this study was to update the scientific evidence for ankle fracture prognosis by addressing radiographic osteoarthritis, time course and prognostic factors.

  • A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized controlled trials, controlled trials or observational studies, including case series and case-control studies investigating radiologically confirmed osteoarthritis in adults with a classified ankle fracture, treated with or without surgery, with a minimum follow-up of 1 year. Also included were studies examining prognostic factors predicting radiologically confirmed osteoarthritis. Tibial plafond and talus fractures were excluded.

  • Thirty-four studies were included examining 3447 patients. Extracted data included study type, inclusion and exclusion criteria, age, number of patients, number of fractures according to the author-reported classification method, radiological osteoarthritis, follow-up period, prognostic factors, and treatment.

  • Severe heterogeneity was visible in the analyses (I2 > 90%), reflecting clinical heterogeneity possibly arising from the presence of osteoarthritis at baseline, the classifications used for the fractures and for osteoarthritis.

  • The incidence of osteoarthritis was 25% (95% CI: 18–32) and 34% (95% CI: 23–45) for more severe fractures with involvement of the posterior malleolus.

  • The severity of the trauma, as reflected by the fracture classification, was the most important prognostic factor for the development of radiographic osteoarthritis, but there is also a risk with simpler injuries.

  • The period within which osteoarthritis develops or becomes symptomatic with an indication for treatment could not be specified.

Felix Kurt Massen, Seth Shoap, J Turner Vosseller, Weija Fan, John Usseglio, Wolfgang Boecker, Sebastian Felix Baumbach, and Hans Polzer


  • The aim of this systematic review and meta-analysis was to compare re-rupture rates, complication rates, functional outcomes, as well as return to work (RTW)/sport (RTS) among different rehabilitation protocols following operative treatment of acute Achilles tendon ruptures.


  • Systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five databases were searched for randomized controlled trials (RCTs) comparing at least two rehabilitation protocols following surgical repair of acute Achilles tendon ruptures. Rehabilitation protocols were classified as a variation of either non-weightbearing (NWB) or weightbearing (WB) and immobilization (IM) or mobilization (M). The data collection consisted of re-ruptures, complications, and RTW/RTS.


  • Out of 2760 studies screened, 20 RCTs with 1007 patients were eligible. Fourteen studies included a group consisting of WB + M (Group 1), 11 of WB + IM (Group 2), 3 of NWB + M (Group 3), and 13 of NWB + IM (Group 4). Outcome parameters available for a meta-analysis were re-ruptures, complications, RTW, and RTS. Re-ruptures overall occurred in 2.7%, with prevalences ranging between 0.04 and 0.08. Major complications occurred in 2.6%, with prevalences ranging between 0.02 and 0.03. Minor complications occurred in 11.8% with prevalances ranging between 0.04 to 0.17. Comparing the odds-ratios between the four different groups revealed no significant differences with overall favourable results for group 1 (WB+M).


  • Early functional rehabilitation protocols with early ankle M and WB following surgical repair of acute Achilles tendon ruptures are safe and they apparently allow for a quicker RTW and RTS and seem to lead to favourable results.

F T Spindler, V Herterich, B M Holzapfel, W Böcker, H Polzer, and S F Baumbach


  • The aim was to conduct a systematic literature review and meta-anaylsis to analyze the diagnostic accuracy of the external rotation stress test (ERST) for syndesmotic injuries.


  • The systematic review was conducted according to the PRISMA-P guidelines (Prospero ID: CRD42021282457). Four common databases were searched from inception to September 29, 2021. Eligible were any studies facilitating the ERST under fluoroscopy in a defined state of syndesmotic instability. Syndesmotic ligament-specific rupture must have been proven by MRI, arthroscopy, or controlled dissection (cadaver study). Two reviewers independently conducted each step of the systematic literature review. The risk of bias was assessed by the Quality Appraisal for Cadaveric Studies Score scale. The data analysis was performed qualitatively and quantitatively.


  • Eight studies were eligible for a qualitative analysis, and six studies were eligible for a quantitative analysis. All studies included were cadaver studies. The qualitative analysis comprised 94 specimens and revealed considerable heterogeneity. Six studies allowed for a quantitative analysis of the tibiofibular clear space (TFCS) and five studies for the medial clear space (MCS) during the ERST. The quantitative analysis of the TFCS revealed no significant differences between intact and any stage of syndesmotic injury. The MCS was able to differentiate between intact and 2-ligament- (Z = 2.04, P = 0.02), 3-ligament- (Z = 3.2, P = 0.001), and 3-ligament + deltoid ruptures (Z = 3.35, P < 0.001).


  • The ERST is the only noninvasive test to assess syndesmotic instability and can be conducted bilaterally. The uninjured contralateral side can serve as a baseline reference. Based on the conducted quantitative analysis, the MCS seems to be able to differentiate between stable (intact/1-ligament) and unstable (2-ligament/3-ligament) lesions.

Xue Ling Chong, Lisca Drittenbass, Victor Dubois-Ferriere, and Mathieu Assal

  • Current literature has described many of the complications following hallux valgus surgery and their treatment options.

  • Iatrogenic transfer metatarsalgia is a distinctive and challenging complication that has not been addressed in a comprehensive fashion yet.

  • Iatrogenic transfer metatarsalgia may result from poor preoperative assessment, planning and/or surgical technique.

  • We have classified the causes of iatrogenic transfer metatarsalgia based on a multiplanar assessment of the malalignment(s) and are recommending a comprehensive treatment algorithm to guide surgeons in addressing this complication.

  • With this knowledge, surgeons may avoid potential pitfalls in the primary surgery that can result in iatrogenic transfer metatarsalgia and find the appropriate treatment option to correct them.

Victor Lu, Maria Tennyson, Andrew Zhou, Ravi Patel, Mary D Fortune, Azeem Thahir, and Matija Krkovic


  • Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation. Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of TTC nailing for fragility ankle fractures.


  • A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, and Web of Science, identifying 14 studies for inclusion. Studies including patients with a fragility ankle fracture, defined according to NICE guidelines as a low-energy fracture obtained following a fall from standing height or less, that were treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. This review was registered in PROSPERO (ID: CRD42021258893).


  • A total of 312 ankle fractures were included. The mean age was 77.3 years old. In this study, 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection was 10% (95% CI: 0.06–0.16), deep infection 8% (95% CI: 0.06–0.11), implant failure 11% (95% CI: 0.07–0.15), malunion 11% (95% CI: 0.06–0.18), and all-cause mortality 27% (95% CI: 0.20–0.34). The pooled mean post-operative Olerud–Molander ankle score was 54.07 (95% CI: 48.98–59.16). Egger’s test (P = 0.56) showed no significant publication bias.


  • TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent post-operative rehabilitation protocols. Prospective randomised control trials with long follow-up times and large cohort sizes are needed to guide the use of TTC nailing for ankle fractures.