Giammarco Gardini

Background and Objectives: Varus ankle osteoarthritis (OA) is most commonly post-traumatic and is characterized by asymmetric degeneration and medial overload of the tibiotalar joint. Supramalleolar osteotomy (SMOT) is a joint-preserving procedure that aims to restore mechanical alignment, redistribute joint contact forces, and delay, or potentially avoid, total ankle replacement (TAR) or ankle arthrodesis (AA). However, the optimal choice of technique and amount of correction remain debated, particularly in complex multiplanar deformities. Materials and Methods: This narrative review summarizes current evidence on SMOT for varus ankle OA. Relevant clinical, radiographic, biomechanical, imaging, and surgical studies were selected and synthesized narratively, with particular emphasis on deformity classification, location of the center of rotation of angulation (CORA), joint congruency, surgical technique, clinical outcomes, complications, and treatment planning. Results: SMOT provides reliable pain relief and functional improvement in patients with Takakura–Tanaka stage 2–3A ankle OA, with reported mid-term survival rates of 88–93%. The choice of technique should be guided by the location of the deformity, the degree of talar tilt, and overall limb alignment. In selected cases, a concomitant fibular osteotomy improves talar reduction and medial unloading. Three-dimensional planning and patient-specific instrumentation may improve the accuracy of correction. Conclusions: SMOT is an effective joint-preserving treatment for varus ankle OA, provided that the deformity is accurately analyzed and patients are carefully selected. This review proposes a simplified, stepwise treatment algorithm, supported by illustrations, to help surgeons select the most appropriate osteotomy technique according to the deformity pattern.

Purpose: Osteochondral lesions of the talus are a frequent cause of ankle pain and functional limitation, particularly in physically active patients. The purpose of this prospective study was to assess patient‐reported outcomes, return to sport and work and safety after second‐generation patient‐specific focal talar resurfacing in patients with symptomatic talar osteochondral lesions. Methods: Between October 2021 and July 2023, 40 patients were screened and 20 underwent implantation of a customized focal talar resurfacing implant. Outcomes were collected preoperatively and at 3, 6, 12 and 24 months using the Foot and Ankle Outcome Score (FAOS), visual analogue scale pain at rest and during activity and the EuroQol 5‐dimension 5‐level questionnaire. Time to return to sport and work and adverse events (complications, reoperations and treatment failures) were recorded. Changes over time were assessed with repeated‐measures analysis of variance. Best‐case and worst‐case sensitivity analyses explored the impact of incomplete 24‐month follow‐up on treatment‐failure estimates. Results: Seventeen patients completed the 24‐month follow‐up. The mean FAOS total increased from 58.6 ± 16.6 preoperatively to 97.3 ± 4.9 at 24 months. Pain improved from 4.3 ± 2.7 to 0.0 ± 0.0 at rest and from 6.8 ± 1.7 to 0.1 ± 0.3 during activity. Seventeen of 20 patients returned to sport at a mean of 5.1 ± 3.2 months, and mean time to return to work was 4.2 ± 3.0 months. Three complications occurred, including one treatment failure requiring revision surgery. The observed treatment‐failure rate was 1/20 (5%). Conclusions: Patient‐specific talar resurfacing was associated with sustained improvements in pain, function and quality of life at 24 months, with high rates of return to sport and work. Larger studies with longer follow‐up are needed to confirm durability and refine patient selection. Level of Evidence: Level II.

Purpose: Osteochondral lesions (OCL) of the medial talar dome are frequently observed in progressive collapsing foot deformity (PCFD), and hindfoot malalignment is believed to influence their natural history. It is not established whether, or to what extent, a realignment osteotomy modifies the articular relationship at the site of such a lesion, nor is there quantitative guidance on the size of opening wedge to be selected. Methods: Starting from a severe PCFD case analysed via weight‐bearing computed tomography, a 3D model was created using segmentation software. In the model, a lateral calcaneal lengthening osteotomy (LCLOT) was performed 15 mm proximally to the calcaneocuboid joint: Evans Technique. Three standard LCLOT‐wedges (8–10–12 mm) were virtually applied at the osteotomy site. Results: The 3D rotation of the anterior osteotomy stump with 8 mm wedge implied, with respect to the original talar position, 6.6° of dorsiflexion, 2.9° of inversion and 10.9° of external rotation; corresponding values for the ten and twelve mm wedges were 8.6°, 5.9° and 12.6°, and 14.2°, 10.2° and 22.2°. Further distance map analysis of the calcaneal posterior facet revealed a distancing effect on the posterolateral zone of the posterior subtalar joint with each wedge size. Additionally, the distance maps of the tibiotalar joint, where a concomitant medial osteochondral lesion of the talar dome was present, showed an increase in inter‐surface distance between the medial talar zone and the mortise. This increase was progressively greater with the use of larger LCLOT wedges. Conclusions: The model confirms that Evans LCLOT produces a triplanar deformity correction, increasing the inter‐surface distance at the anteromedial tibiotalar joint adjacent to the medial OCL. Patient‐specific modelling may therefore inform preoperative planning when a talar dome OCL coexists with PCFD. Level of Evidence: Level V, preclinical simulation study.

Background: The Zadek osteotomy (ZO) is a well-established surgical option for insertional Achilles tendinopathy. By modifying the position of the posterior calcaneal tuberosity, ZO may reduce posterosuperior calcaneal prominence, mechanical conflict at the Achilles insertion, and tensile stress on the tendon. Nevertheless, the biomechanical impact of wedge orientation and hinge position—and their relationship with underlying foot morphology—has not been clearly defined. Methods: A weightbearing computed tomography (WBCT)–based virtual simulation was performed on 60 asymptomatic feet, categorized as cavus (n = 20), neutral (n = 20), or planus (n = 20) based on the calcaneal inclination angle. Nine ZO configurations were modeled by combining 3 hinge positions (posterior, A; mid-tuberosity, B; anterior, C) with 3 wedge inclinations. Pre- and post-simulation measurements were compared for calcaneal inclination angle (CIA), talocalcaneal angles, hindfoot moment arm (HMA), hindfoot alignment angle (HAA), Fowler-Philip (FP) angle, X/Y ratio, and plantar fascia (PF) length. Results: Wedge inclination showed no significant influence on any variable ( P ≈ .99). Hinge position, however, markedly affected sagittal alignment. Hinges B and C significantly reduced CIA (hinge B −0.5° [95% CI −0.66° to −0.4°]; hinge C −2.1° [95% CI −2.26° to −1.96°], both P < .001). Hinge B showed the largest reduction in FP angle (−7.6° [95% CI −8.63° to −6.59°], P = .16) and produced the greatest increase in X/Y ratio (+0.57 [95% CI +0.46 to +0.68], P = .007). In the pre- to post-simulation analysis, HMA increased slightly with hinge B ( P = .03), and PF length increased only with hinge C ( P < .001). Subgroup analysis revealed that cavus feet exhibited the greatest sagittal correction, particularly with hinge C. Conclusion: ZO significantly affected the Fowler-Philip angle, the primary radiographic outcome, with its overall foot alignment corrective power depending principally on hinge position rather than wedge inclination. These changes occurred predominantly in the sagittal plane while sparing coronal and axial alignment. Clinical Relevance: WBCT-based virtual simulation may help surgeons tailor Zadek osteotomy hinge position to baseline foot morphology and anticipate morphology-specific alignment changes before surgery. Level of Evidence: Level IV, pre-clinical simulation case series.

Purpose: The optimal surgical approach for total ankle arthroplasty (TAA) remains debated. The anterior and lateral transfibular approaches differ in surgical exposure and may influence complication patterns. This systematic review and meta‐analysis aimed to compare revision rates, overall complication rates and specific complication profiles between anterior and lateral approaches in TAA. Methods: A PRISMA‐compliant systematic review of PubMed, Embase and Scopus databases was performed. Studies reporting complications following primary TAA performed through either approach were included if they met predefined methodological quality criteria (QualSyst score ≥ 75%). Complication rates were compared using Fisher's exact test, and correlations between complication rates and patient or surgical factors were explored. Results: Fifty‐one studies were included, comprising 7959 TAA procedures (7225 anterior and 734 lateral). Revision rates were higher in the anterior approach group (7.5% vs. 1.9%, p < 0.001), as were rates of malleolar fractures (1.7% vs. 0.3%, p = 0.001) and aseptic loosening (2.8% vs. 0.14%, p < 0.001). Deep infections were reported more frequently in lateral approach cohorts (3.1% vs. 0.57%, p < 0.001), although this finding was influenced by outlier studies. Wound complications and polyethylene‐related complications were comparable between approaches. No association was observed between complication rates and patient age, body mass index or surgical time. Conclusion: Anterior and lateral approaches in TAA appear to be associated with different complication patterns rather than clear differences in overall safety. Both approaches remain valid surgical options, but awareness of their distinct complication profiles may help guide intraoperative precautions and post‐operative surveillance. However, heterogeneity in implant design, follow‐up duration and study methodology limits definitive conclusions regarding the superiority of one approach. Level of Evidence: Level I, systematic review/meta‐analysis.

Background: Total ankle arthroplasty (TAA) is increasingly used as an alternative to arthrodesis for end-stage ankle arthritis. The extent to which implant bearing type and design evolution influence outcomes and survival remains debated. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines and registered on PROSPERO (CRD420251073944). PubMed, Embase, and Scopus were searched for English-language studies (2004-2025) reporting anterior-approach TAA with specified implant generation (I–IV) and bearing type (fixed [FB] vs mobile [MB]). Studies with a QualSyst score ≥ 75% were included. Primary outcomes were American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analogue scale (VAS), range of motion (ROM), complications, and revisions. Results: Forty-two studies comprising 4,271 implants were analyzed (FB: 1,546; MB: 2,725). Functional improvements were mainly driven by implant generation rather than bearing type. ΔAOFAS increased from 33.7 ± 22.3 in Gen II to 44.5 ± 28.3 in Gen IV (P < .001). ΔVAS varied across generations (Gen II 5.8 ± 2.1; Gen III 4.6 ± 2.8; Gen IV 5.46 ± 1.60; all P < .001 vs baseline). MB implants showed lower pre- and postoperative AOFAS scores but comparable ΔAOFAS to FB designs (36.4 vs 37.5; P = .358). MB systems provided greater pain relief (ΔVAS 5.62 vs 4.60; P < .001) but had higher revision rates (12.0% vs 6.2%; P < .001). FB implants achieved superior postoperative ROM gains in plantarflexion (+6.0° vs −2.9°; P < .001) and dorsiflexion (+2.71° vs +0.75°; P < .001). Excluding Gen I, complication rates decreased from 32.6% in Gen II to 18.8% in Gen III and 10.3% in Gen IV (all P < .01); revision rates declined from 16.5% (Gen II) and 9.6% (Gen III) to 0.5% (Gen IV) (P < .01). Conclusions: Implant generation is the primary determinant of outcomes, complications, and survival in anterior-approach TAA. Bearing type played a secondary role: MB devices provided greater pain relief, whereas FB systems achieved superior ROM recovery and lower revision risk. Fourth-generation implants yielded the most reliable results. Further prospective studies with standardized functional and kinematic assessments are warranted. Level of Clinical Evidence: Level I—Systematic Review/Meta-Analysis