Matthew S. Conti

Background: Whether sesamoid subluxation relative to the metatarsal head occurs in hallux valgus (HV) remains unestablished. Deep transverse intermetatarsal ligament (DTML) attenuation, which spans the lateral sesamoid to the second metatarsal head, may increase transverse motion and facilitate medial sesamoid subluxation with the first metatarsal. This study aims to compare the average second metatarsal head to lateral sesamoid (2MTLS) distance between HV and control patients, which is a proxy of DTML length. We hypothesize that HV patients demonstrate an increased 2MTLS distance. Methods: Sixty-eight patients were matched into 2 groups: 34 with HV and 34 without HV. Standardized preoperative weightbearing computed tomography scans were used to measure the 2MTLS distance, hallux valgus angle (HVA), intermetatarsal angle (IMA), first metatarsal pronation, and sesamoid station. The 2MTLS distance was anatomically measured from the lateral sesamoid to the second metatarsal head. Results: The 2MTLS distance was significantly greater in HV patients compared with controls (20.90 mm vs 18.56 mm, P < .001). Similarly, the HVA and IMA were increased in HV patients ( P < .001). First metatarsal pronation and sesamoid station were significantly greater in HV patients ( P < .001). The 2MTLS distance demonstrated a moderately positive correlation with sesamoid station ( r = 0.36, 95% CI 0.06-0.60), HVA ( r = 0.40, 95% CI 0.12-0.65), and IMA ( r = 0.43, 95% CI 0.06-0.71) but was not correlated with first metatarsal pronation ( r = −0.18). Inter- and intrarater reliability for the 2MTLS measurements were ICC = 0.911 (95% CI 0.858-0.944) and 0.958 (95% CI 0.933-0.974), respectively. Conclusion: In HV patients, 2MTLS was significantly increased compared with controls. Additionally, as sesamoid station increased, the 2MTLS distance also increased. This challenges the long-standing view that the sesamoids remain anchored in HV and suggests the sesamoids subluxate. Clinically, this highlights the DTML’s role as a restraint to first metatarsal medial deviation and suggests against sectioning the ligament during lateral release. Level of Evidence: Level III, retrospective cohort study.

Background: Over the past 2 decades, orthobiologic technologies have advanced substantially and their use within orthopaedics has increased. Because the available evidence regarding efficacy remains heterogeneous, orthobiologic use is often determined by individual surgeon preference. There is currently a scarcity of data evaluating orthobiologic use among foot and ankle orthopaedic surgeons. The purpose of this study was to investigate orthobiologic use trends among members of the American Orthopaedic Foot & Ankle Society (AOFAS). Methods: Members of the AOFAS were sent a survey designed to assess orthobiologic usage, motivations for use, and treatment indications in operative and nonoperative settings. Surveyed orthobiologics included leukocyte-poor (PRP-LP), leukocyte-rich (PRP-LR), and leukocyte-unknown (PRP-UNK) platelet-rich plasma, bone marrow aspirate concentrate (BMAC), adipose-derived mesenchymal stromal cells, hyaluronic acid, recombinant human bone morphogenetic protein-2 (rhBMP-2), recombinant human platelet-derived growth factor-BB (rhPDGF-BB), amniotic membrane products, and small cell binding peptide. A total of 129 respondents completed the survey. Results: Overall, 119 of 129 respondents used ≥1 orthobiologic (92.2%; 95% CI, 86.3%-95.7%). Among orthobiologic users, the most commonly used product was BMAC (88/119, 73.9%; 95% CI, 65.4%-81.0%), followed by rhPDGF-BB (74/119, 62.2%; 95% CI, 53.2%-70.4%) and rhBMP-2 (52/119, 43.7%; 95% CI, 35.1%-52.7%). The most common indications for BMAC were revision arthrodesis (71/88, 80.7%; 95% CI, 71.2%-87.6%), osteochondral procedures (58/88, 65.9%; 95% CI, 55.5%-75.0%), and primary arthrodesis (52/88, 59.1%; 95% CI, 48.6%-68.8%). BMAC use was higher among surgeons with 1-10 vs more than 20 years of experience (80.4% vs 51.3%; adjusted P = .010). In the nonoperative setting, PRP-LR and PRP-UNK were most commonly used for tendinopathy (26/30, 86.7%, and 13/14, 92.9%; 95% CI, 68.5%-98.7% for PRP-UNK), whereas PRP-LP was most commonly used for plantar fasciitis (17/26, 65.4%; 95% CI, 46.2%-80.6%). Among non-users, 7 of 10 (70.0%; 95% CI, 39.7%-89.2%) cited lack of evidence and 5 of 10 (50.0%; 95% CI, 23.7%-76.3%) cited cost in their decision making. Conclusion: Among respondents to this AOFAS member survey, who may have been more likely to use orthobiologics than nonrespondents, orthobiologic use was commonly reported. BMAC was the most frequently reported orthobiologic, although substantial variability existed in product selection and treatment indications. These findings describe reported practice patterns among respondents and highlight the need for future studies evaluating the efficacy of orthobiologic products in foot and ankle orthopaedics. Level of Evidence : Level IV, cross-sectional study.

Background: Ankle fractures are prevalent, with 21% to 40% of cases requiring surgical intervention. Treatment decisions regarding non-complex fractures, whether in an inpatient (IP) or outpatient (OP) setting, are often influenced by local resource availability. Although IP care is generally expected to be more expensive, the magnitude of this difference and its interpretation across heterogeneous cost definitions, health care systems, and operative settings remain unclear. This systematic review and meta-analysis evaluates the cost differences between IP and OP surgical management of isolated ankle fractures, offering evidence to guide surgeons in optimizing care pathways while minimizing health care expenditures. Methods: This PROSPERO-registered systematic review and meta-analysis (CRD420251134624) of comparative studies evaluated cost differences for OP and IP management of ankle fractures. We queried PubMed, EMBASE, and CINAHL from inception through August 17, 2025. Because of the inconsistent definition “cost” across the literature, we extracted and analyzed the cost construct as defined by each included study and performed a random effects meta-analysis of the unstandardized mean differences (standardized to a common price year/currency)and reported them with 95% CIs. Results: Seven articles were included, with a final sample size of 21,955 patients with an average age of 43.50 ± 2.87 years and a 2.5-month mean follow-up. Overall, 53.8% (n = 11 813) of patients were treated in the IP setting and 46.2% (n = 10 142) were treated in the OP setting. The mean hospital length of stay (LOS) for IPs was 2.27 ± 0.25 days across the 5 studies reporting this value (n = 5718 IP patients). The average study reported direct cost for IP management was significantly higher than OP management ($11 236.37 ± $2205.05 vs $6990.18 ± $1670.72; P = .011, CI: 1654.50, 6920.19). Qualitatively, the safety and complication profiles between IP and OP were not different among 3 studies that examined this metric. Conclusion: Outpatient ORIF for isolated ankle fractures is associated with lower study-reported economic burden than inpatient management in appropriately selected patients, without clear evidence of worse short-term safety outcomes in the available comparative literature. These findings support outpatient pathways for patients with acceptable reduction and immobilization, manageable soft tissues, limited comorbidity burden, safe non-weightbearing mobility, and reliable follow-up. Because included studies used heterogeneous economic definitions and were observational, future prospective studies should use standardized economic outcomes and longer follow-up to better define the value of outpatient vs inpatient care.

Background. The patient acceptable symptom state (PASS) is defined as the symptom threshold beyond which a patient is satisfied with the outcome of their surgery. PASS thresholds have been utilized throughout the orthopedics literature but have not yet been identified for hallux valgus (HV) deformity. This study aimed to establish PASS thresholds for using Patient-Reported Outcome Measurement Information System (PROMIS) scores in patients undergoing HV deformity correction. Methods. A retrospective review of 286 patients who underwent HV deformity correction was performed using data from an institutional outcome registry. PASS thresholds were determined using 2-year postoperative PROMIS scores and patient Likert scale responses to 2 validated anchor questions: the Satisfied Scale and the Delighted-Terrible Scale. The impact of patient demographics and surgical factors on the likelihood of meeting PASS thresholds were compared using independent t tests and Pearson’s chi-square tests. Results. The PASS threshold values for patients undergoing surgical management of HV ranged from 41.6 to 65.1 depending on the PROMIS domain and anchor question. For both anchor questions, the PASS thresholds for PROMIS physical function (PF) and pain intensity (PIntens) were found to be 50.3 and 41.5, respectively. Seventy-one percent (203/286) of patients met the PASS threshold for PF and 72.4% (207/286) of patients met the PASS threshold for PIntens. The PASS thresholds for the other 4 PROMIS domains varied by anchor question. Higher preoperative PROMIS scores and lower body mass index were associated with an increased likelihood of meeting the PASS thresholds. Patients who underwent first metatarsophalangeal fusion were less likely to reach the PASS threshold for the PROMIS PF domain. Conclusions. Foot and ankle surgeons may be able to use these results to guide treatment plans. Furthermore, the results may be helpful in counseling and educating patients on the likelihood of obtaining a satisfactory result following HV correction surgery. Level of Evidence: Level III, Retrospective review

Background: Pronation of first metatarsal (M1) in hallux valgus (HV) is currently the subject of a growing body of scientific research. Several methods of manual measurements have been developed, providing heterogeneous results. Our objective was to develop automatic 3D weightbearing computed tomography (WBCT) measurements in a retrospective case-control design to compare coronal rotation of M1 head relative to the ground, M1 intrinsic torsion, and valgus deviation of M1 distal articular surface (or distal metatarsal articular angle [DMAA]) in HV and controls. Methods: Forty-four symptomatic HV and 44 matched controls were retrospectively enrolled, all of whom had undergone WBCT acquisition. Bone segmentation was performed (Bonelogic 2.1 software). Two methods were developed to assess position of the M1 head. One was based on automatic geometric fitting of a cylinder on the head, and the other on automatic selection of the position of the sesamoid gutters. Similarly, 2 methods were developed to assess the position of the M1 base. One was defined using principal components analysis (PCA) of the proximal articular surface of M1, and the other using the longest diagonal of the M1 base. Results: First metatarsal head rotation relative to the ground was, respectively, 8.9° ± 8.4° (95% CI 6.1°-11.7°) and 2.1° ± 6.4° (95% CI 0.1°-4.1°) via the cylinder method ( P < .001) and 9° ± 8.3° (95% CI 6.2°-11.8°) and 0.7° ± 6.8° (95% CI −1.4° to 2.8°) via the gutters method ( P < .001) in the HV and control groups. Combining the different sets of head and base measurements, the increase in M1 intrinsic torsion in HV ranged from 2° to 5°. The DMAA was 11.4° ± 6.9° (95% CI 9.3°-13.5°) in the HV group and 5.6° ± 4.7° (95% CI 4.1°-7.0°) in the control group ( P < .001). Conclusion: Using automatic 3D WBCT measurements, we found that HV showed an increase in M1 head pronation relative to the ground of 7° to 8° greater than controls, with an increase in M1 intrinsic torsion in pronation of 2° to 5° and an increase in valgus deviation of the M1 distal articular surface of approximately 6°. Changing measurements reference points altered angular values in our study, particularly when moving from measurements based on the sesamoid gutters to gutter-independent measurements, highlighting that these methods may capture different anatomic constructs. Level of Evidence: Level III, case control study.

Background: Hallux valgus (HV) is a complex 3-dimensional (3D) deformity of the first ray. Recurrence rates following surgical intervention for HV remain high, which may be due to unrecognized midfoot instability. Previous studies have suggested that instability at the first tarsometatarsal (TMT1) is the source of deformity, but separate work suggests that midfoot joints such as the intercuneiform (IC) and naviculocuneiform (NC) joints may also be involved. No studies have investigated whether joint space widening occurs in other joints along the medial column. The goal of this study was to compare spacing of midfoot joints between HV patients and controls. Methods: A retrospective pilot study of 20 HV patients with preoperative weightbearing CT scans were identified and matched with 20 selected control patients. Midfoot bones were segmented from scans, and 3D distance mapping was performed to evaluate regional differences in minimum joint spacing at the TMT1, IC, and NC joints. The segmented WBCT scans were uploaded to Geomagic Design X, and automated coordinate systems for each bone were calculated using a previously published open-source code in Matlab. The TMT1 joint was divided into dorsal and plantar regions, the IC joint was divided into distal and proximal regions, and the NC joint was divided into medial and lateral regions. Results: Joint spacing was greater in the proximal IC joint of HV patients (0.95 mm, IQR: 0.89-1.02 mm), compared with controls (0.61 mm, IQR: 0.48-0.76 mm, P = .006). Spacing was also greater in the medial NC joint of HV patients (1.23 mm, IQR: 1.14-1.36 mm) compared with controls (1.11 mm, IQR: 0.93-1.24 mm, P = .007). With the numbers available, no significant difference was observed at the TMT1 joint. Conclusion: HV patients demonstrated differences at the proximal IC and medial NC joints compared with controls, suggesting an association between proximal midfoot joint spacing and HV deformity. These findings highlight that structural changes in HV may extend beyond the TMT1 joint, and consideration of the broader midfoot in patients with HV may be relevant when evaluating the deformity. Level of Evidence: Level III, retrospective cohort study, case-control study, meta-analysis of Level III studies.

Background: Patient-specific instrumentation (PSI) was developed to improve accuracy and efficiency in implant placement for total ankle arthroplasty (TAA). This study represents the first to measure the accuracy of PSI regarding implant alignment and implant size in the INBONE II total ankle system (Stryker). A secondary goal was to compare radiographic and clinical outcomes between the PSI and that of a matched group of implants performed with standard instrumentation. Methods: This retrospective study of 92 patients (46 PSI and 46 non-PSI cases matched by age and sex) was performed at a single institution between 2006 and 2024, including TAA patients with INBONE II implants. Median age was 61 years (range 27-81). Median body mass index (BMI) was 29.6 (range 19.9-45.6). One surgeon performed 71% of PSI. A different surgeon performed 96% of non-PSI cases. PSI alignment (tibiotalar angle [TTA]), deformity correction (talar-tilt [TT]), radiation exposure, tourniquet, and operative time were compared to the standard jig method (non-PSI). Total fluoroscopy, tourniquet and procedure time, and preoperative and postoperative radiographs were analyzed. Results: PSI predicted the correct size in 67% (n = 31) of talus implants and 89% (n = 41) of tibial implants. Median absolute deviation in the mortise view was 1.3 (IQR 0.53-2.18) and 1.8 (IQR 1.35-3.5) in the lateral view. For both groups, postoperative median TTA deviation was less than 2 degrees and postoperative median TT was less than or equal to 1 degree. Median fluoroscopic time was 92.1 seconds for PSI and 104.3 seconds for non-PSI. PSI had a longer tourniquet (156.5 vs 134.5 minutes) and procedure time (188 vs 161 minutes) compared with non-PSI. Conclusion: In this study of stemmed TAA implants, surgeons achieved alignment generally consistent with PSI predictions. PSI adequately predicted implant size. For most cases, PSI achieved similar alignment and correction of deformity compared with standard instrumentation. PSI did not improve radiographic alignment compared with traditional instrumentation and was associated with longer operative times, possibly reflecting the primary surgeon’s early experience with the technique. Each surgeon should select PSI or the standard jig based on their experience and preference.