Faculty Bibliography

BackgroundBone grafting is a commonly used adjunct in foot and ankle surgery to enhance osseous healing in fracture fixation and arthrodesis. Although autologous corticocancellous bone is commonly used, donor site morbidity and limited graft availability have driven the development of allogenic alternatives such as demineralized bone matrix (DBM).FormulationsDemineralized bone matrix is produced through decalcification of donor bone, preserving a collagen-rich scaffold and biologically active proteins that support osteoconduction and osteoinduction. Commercial formulations vary in carrier systems, structural properties, and quality control processes. Products such as DBX (DePuy Synthes/MTF Biologics) and AlloSync (Arthrex) incorporate lot-specific osteoinductivity testing, whereas others including AlloMatrix (Stryker), OrthoBlast II (SeaSpine/Orthofix), and Grafton (Medtronic) use carriers to improve handling. Carrier-free and structural grafts, as well as injectable systems, further expand available options.Clinical ApplicationsThe strongest clinical evidence for DBM exists in fracture fixation, where high union rates have been consistently reported. In arthrodesis procedures, DBM demonstrates union rates comparable to autograft, though without evidence of superiority. Applications in osteochondral lesions of the talus and hallux valgus correction remain less clearly defined, with variable outcomes reported in predominantly small case series. Limited evidence also suggests a potential role in calcaneal bone cysts.ConclusionDemineralized bone matrix is a safe and versatile adjunct that avoids donor site morbidity and provides favorable handling characteristics. However, the current literature is dominated by level III-IV evidence, with no high-quality comparative studies demonstrating superiority over autograft. Demineralized bone matrix is best used in fracture fixation and selective arthrodesis, while further studies are required to define its role in cartilage-related and forefoot procedures.

Concentrated bone marrow aspirate (cBMA) is an autologous biologic increasingly used in orthopaedic surgery for its regenerative potential. It contains mesenchymal stem cells (MSCs), growth factors, and cytokines that contribute to tissue repair and immunomodulation. Mesenchymal stem cells primarily exert their effects through paracrine signaling and macrophage reprogramming, promoting a shift from a pro-inflammatory (M1) to a reparative (M2) phenotype. Emerging evidence also suggests a role for mitochondrial transfer in this process. In foot and ankle surgery, cBMA has been investigated in the management of osteochondral lesions of the talus, fracture healing, and tendon disorders. Early clinical studies suggest potential improvements in functional outcomes, healing rates, and revision rates; however, the available evidence remains heterogeneous and is largely limited to small, non-randomized studies. Variability in cBMA preparation and reporting further limits comparability across studies. As such, while cBMA represents a promising adjunct in foot and ankle surgery, its clinical role is not yet fully defined. Future research should focus on prospective, controlled studies with standardized methodologies and explore emerging cell-free approaches, including MSC-derived extracellular vesicles, to optimize regenerative strategies.

BACKGROUND:The purpose of this systematic review is to evaluate the clinical outcomes, complication rates, and failure rates following platelet-rich plasma (PRP) injections for lateral ankle ligament injuries. METHODS:During June 2025, a systematic review of the PubMed, EMBASE, and Cochrane Library databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines to identify comparative clinical studies evaluating PRP for lateral ankle ligament injuries. Data extracted included patient demographics, clinical outcomes, complications, failures, and secondary procedure rates. RESULTS:Five studies were included involving a total of 126 patients (126 ankles) who received PRP injections and 48 patients (48 ankles) who were in the control cohort, with a mean follow-up of 7.1 ± 4.3 months. Across studies, no consistent differences were found in clinical outcome scores between PRP and control cohorts at short-term follow-up. Significant heterogeneity in PRP preparation and administration protocols precluded a pooled meta-analysis from being performed. Platelet-rich plasma injections were associated with low complication (3.4%) and failure (5.1%) rates, and no secondary procedures were reported. Overall, the certainty of the available evidence was low, representing a limited and heterogeneous evidence base. CONCLUSION/CONCLUSIONS:Based on limited short-term data, the available studies do not demonstrate a clear or consistent difference in clinical outcomes between PRP-treated patients and controls. However, the evidence base is scarce, highly heterogeneous, and of low certainty. Substantial variability in PRP preparation and administration, small sample sizes, and short follow-up preclude reliable quantitative synthesis and comparative conclusions. Consequently, the current literature is insufficient to determine whether PRP provides any clinical advantage over standard care for lateral ankle ligament injuries. Further well-designed, adequately powered prospective studies with standardized PRP protocols and longer follow-up are warranted. LEVEL OF EVIDENCE/METHODS:

BACKGROUND:Minimally invasive surgery (MIS) chevron osteotomy has emerged as an alternative to the traditional open chevron (OC) osteotomy for hallux valgus correction, aiming to achieve similar deformity correction with reduced soft-tissue trauma and faster recovery. However, the relative clinical and radiographic outcomes of these techniques remain debated. METHODS:A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. PubMed, EMBASE, and Cochrane databases were searched through June 2025 for randomized controlled trials (RCTs) and cohort studies comparing MIS and OC osteotomies in patients with hallux valgus. Only studies explicitly describing a percutaneous, burr-based V-shaped Chevron osteotomy were included. Primary outcomes included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Visual Analog Scale (VAS) pain scores, radiographic parameters: hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) and complication rates. Random-effects meta-analyses were performed, with subgroup analyses at early (≤6 months), mid-term (6-12 months), and long-term (>12 months) follow-ups. RESULTS:=23 %). CONCLUSION/CONCLUSIONS:This systematic review and meta-analysis demonstrate that MIS Chevron osteotomy provides clinical and radiological outcomes comparable to those of open Chevron osteotomy. Differences in pain scores, angular correction, and complication rates were small and not clinically meaningful. These findings suggest that MIS Chevron is a safe and effective alternative to open Chevron osteotomy.

BACKGROUND/UNASSIGNED:Hallux varus is an uncommon pathology with no consensus regarding outcomes following the various surgical techniques available for its management. The purpose of this systematic review was to evaluate clinical outcomes, radiographic parameters, and complications following surgical management of hallux varus. METHODS/UNASSIGNED:During August 2025, the PubMed, Embase, and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following surgical management of hallux varus. RESULTS/UNASSIGNED:Eleven studies comprising 152 patients (159 feet) were included. Among patients treated with soft-tissue procedures, the weighted mean age was 53.5 ± 5.1 years with a weighted mean follow-up time of 35.3 ± 11.1 months. The weighted mean American Orthopedic Foot and Ankle Society (AOFAS) score improved 25.6 points, with corresponding improvements in hallux valgus angle (HVA) of 17.5°. The complication and failure rates were 18.9% and 11.3%, respectively. In the osteotomy cohort, the weighted mean age was 52.4 ± 6.0 years and the weighted mean follow-up time was 44.3 ± 15.6 months. The weighted mean AOFAS score improved 23.7 points, with improvements in of 24.5°. The complication and failure rates were 1.7% and 3.3%, respectively. In the arthrodesis cohort, the weighted mean age was 63.3 ± 0.7 years and the weighted mean follow-up time was 44.2 ± 30.1 months. The mean AOFAS improved 51 points, with improvements in HVA of 25.2°. The overall complication and failure rates were 10.7% and 3.6%, respectively. CONCLUSIONS/UNASSIGNED:Surgical management of hallux varus is associated with meaningful improvements in clinical outcomes and radiographic alignment across a range of operative techniques. No technique could be definitively identified as superior given the absence of comparative studies and variability in reported outcomes. Future studies should prioritize prospective, comparative designs with standardized outcome measures and long-term follow-up to better establish optimal management strategies for hallux varus. REGISTRATION/UNASSIGNED:CRD420261280842 (Prospero identifier). LEVEL OF EVIDENCE/UNASSIGNED:IV, systematic review.

BACKGROUND:Freiberg's disease is a rare osteochondrosis of the metatarsal head that can cause progressive pain, deformity, and loss of function. The two most widely used joint-preserving surgical options for advanced disease are dorsiflexion closing wedge metatarsal osteotomy (DCWMO) and autologous osteochondral transplantation (AOT). To date, no meta-analysis has directly compared these procedures. This systematic review and meta-analysis aimed to evaluate functional, radiographic, and complication outcomes of AOT versus DCWMO in Freiberg's disease. METHODS:A systematic search of PubMed, Embase, and Cochrane Library was conducted in August 2025 according to PRISMA guidelines. Inclusion criteria were clinical studies comparing or reporting outcomes of AOT or DCWMO in Freiberg's disease. Risk of bias was assessed using JBI Critical Appraisal Tools. Pairwise meta-analyses were performed for comparative studies evaluating American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analogue scale (VAS) pain, range of motion (ROM), and complications. Single-arm pooled analyses were conducted for AOT and DCWMO separately to provide context for within-group improvements and complication rates. Random-effects models were applied throughout. RESULTS:Sixteen studies involving 259 toes were included: 62 treated with AOT and 197 with DCWMO. Three comparative studies (n = 70) demonstrated significantly greater functional gain with AOT (AOFAS mean difference [MD] 7.15, 95 % CI 4.29-10.02; I²=0 %) and superior dorsiflexion both postoperatively (MD 7.85°, 95 % CI 4.40-11.29; I²=0 %) and in terms of gain from baseline (MD 7.46°, 95 % CI 3.77-11.14; I²=0 %). Absolute postoperative AOFAS and VAS pain scores were similar between groups, as were improvements in plantarflexion. DCWMO consistently shortened the metatarsal head (pooled mean 1.76 mm), whereas AOT preserved or slightly increased length (-0.20 mm). Complications were significantly lower with AOT (risk difference -0.20, 95 % CI -0.35 to -0.04; risk ratio 0.23, 95 % CI 0.05-0.96). Single-arm pooled analyses confirmed large improvements in AOFAS (∼25 points) and VAS (∼5 points) for both groups, with pooled complication rates of 1 % for AOT and 6 % for DCWMO. CONCLUSION/CONCLUSIONS:Both AOT and DCWMO provide meaningful pain relief and functional improvement in advanced Freiberg's disease. However, AOT demonstrated superior functional gains, greater preservation of motion and metatarsal length, and fewer complications, suggesting it may represent the preferred joint-preserving option, particularly for Smillie stage III-IV disease. Future prospective comparative trials with standardized outcome reporting and exploration of lower-morbidity donor graft sources are warranted to refine surgical decision-making. LEVEL OF EVIDENCE/METHODS:Level II, systematic review and meta-analysis.

BACKGROUND/UNASSIGNED:Knee ligament injuries are common in elite rugby union players and are associated with performance limitations. However, comparative data on long-term performance and career patterns after isolated anterior cruciate ligament (ACL) versus medial collateral ligament (MCL) injuries remain limited. METHODS/UNASSIGNED:A retrospective review of elite rugby union players who sustained an isolated partial or complete ACL or MCL tear from 2013 to 2025 was performed. Data were collected from rugby databases and media reports, and included player demographics, injury characteristics, and performance metrics. A Wilcoxon signed rank test was used to compare pre-injury and post-injury performance metrics, with a p value < 0.05 determined as statistically significant. RESULTS/UNASSIGNED:Twenty-eight players sustained ACL injuries and 23 sustained MCL injuries. At 9.8 ± 3.1 months, 96.4% of ACL-injured players returned to sport, while 100% of MCL-injured players returned at 1.9 ± 2.1 months. ACL-injured players demonstrated significant declines in games played, tries, and points scored in the season following injury. Over time, performance largely stabilized, but total seasons played decreased. Players with MCL injuries demonstrated short-term performance declines but played a. similar number of seasons before and after injury. Re-injury occurred in 17.9% of ACL cases and 13.0% of MCL cases, with greater re-injury frequency and shorter intervals between injuries in the ACL cohort. CONCLUSION/UNASSIGNED:ACL injuries in elite rugby union players were associated with longer return to sport (RTS) times and fewer post-injury seasons despite recovery of performance metrics. MCL injuries allowed faster RTS and preserved career length but were associated with decreased performance. Re-injury led to further performance decline in both cohorts. These findings highlight distinct patterns of career and performance impact following ACL versus MCL injury in elite rugby union players. LEVEL OF EVIDENCE/UNASSIGNED:IV.

Minimally invasive surgery (MIS) has revolutionized foot and ankle care by emphasizing delicate tissue handling, reduced postoperative pain, and faster recovery through small incisions and precise instrumentation. The evolution of MIS spans 4 distinct historical "seasons," from its early development in the mid-20th century to its global resurgence in the 2010s, driven by improved techniques, education, and international collaboration. Today, MIS extends beyond hallux valgus correction to include complex procedures such as first metatarsophalangeal joint, subtalar joint, tibiotalar joint, and tibiotalocalcaneal arthrodesis, with evidence demonstrating comparable or superior outcomes to open approaches. This review details the history of MIS in foot and ankle orthopedics and how this paradigm shift continues to redefine standards and improves outcomes in foot and ankle surgery.

CONTEXT/BACKGROUND:Although ankle sprains are among the most common musculoskeletal injuries, prior studies have not systematically reviewed the educational quality of related YouTube videos. We aimed to evaluate the characteristics, sources, and educational quality of YouTube videos addressing ankle sprains. DESIGN/METHODS:Cross-sectional analysis of online material. METHODS:We performed 4 independent YouTube searches on ankle sprains and recorded the top 25 results for each search. After screening 100 videos, we included 73 total videos for final analysis. We evaluated video content using 3 validated tools: Global Quality Scale (GQS), the Patient-Friendliness Scale, and the Journal of the American Medical Association criteria. RESULTS:A total of 73 YouTube videos accumulated over 20.7 million views (mean: 283,546). Videos received 14.8 likes and 1.04 comments per 1000 views. Among included videos, the mean GQS score measured 3.75, Patient-Friendliness Scale score measured 3.48, and Journal of the American Medical Association score measured 1.19, indicating good accessibility, moderate educational quality, and poor transparency. Physicians produced the highest overall quality and transparency (GQS: 3.89, Journal of the American Medical Association: 1.50). Rehabilitation-focused content emerged as the most common theme (36%), maintaining good quality and accessibility (GQS: 3.77, Patient-Friendliness Scale: 4.23). CONCLUSION/CONCLUSIONS:YouTube offers wide access to ankle sprain information, yet video quality, accessibility, and transparency remain low. Physician-created and rehabilitation-focused videos demonstrated superior educational value, although highly viewed videos did not correspond with higher quality. These findings highlight the need for more reliable, high-quality ankle sprain content on online platforms.

BACKGROUND:Acute Achilles tendon ruptures (AATRs) are devastating injuries for athletes, yet outcomes in elite rugby union players remain poorly characterized. HYPOTHESIS/OBJECTIVE:Elite rugby union players who sustain AATRs will demonstrate significantly reduced performance metrics postinjury compared with preinjury levels. STUDY DESIGN/METHODS:Retrospective case series. LEVEL OF EVIDENCE/METHODS:Level 4. METHODS: value <0.05 was determined as statistically significant. RESULTS: = -0.47 to -0.72). CONCLUSION/CONCLUSIONS:AATRs in elite rugby union players were associated with significant declines in performance metrics in both the immediate postinjury season and across subsequent seasons. These findings highlight the substantial performance impact of AATRs and support the need for improved position-specific prevention strategies and targeted postinjury rehabilitation protocols. CLINICAL RELEVANCE/CONCLUSIONS:Clinicians can use these findings to counsel rugby athletes and teams on prognosis, treatment decisions, and realistic performance expectations after AATRs.