What's New in Foot and Ankle Surgery.

Abstract

This article provides a summary of research pertaining to orthopaedic foot and ankle surgery, published from September 2018 to September 2019. The included studies were published in The Journal of Bone & Joint Surgery, The Bone & Joint Journal, Foot & Ankle International, Foot and Ankle Surgery, The BMJ, Clinical Orthopaedics and Related Research, the Journal of Pain Research, the Journal of Orthopaedic Trauma, the Journal of Orthopaedic and Sports Physical Therapy, BMC Musculoskeletal Disorders, and The American Journal of Sports Medicine. The Forefoot Hallux Rigidus Midterm outcomes of a synthetic cartilage, polyvinyl hydrogel implant for the first metatarsophalangeal joint in advanced hallux rigidus were prospectively assessed for 112 patients in a noninferiority, randomized clinical trial (RCT)1. Measures included a visual analog scale (VAS) for pain, the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale, the FAAM Sports subscale, active great toe dorsiflexion, and radiographs. Clinical and safety outcomes observed at 2 years were maintained at 5.8 years. A shorter operative time was demonstrated for synthetic cartilage implant compared with arthrodesis (35 and 58 minutes, respectively) in the treatment of advanced hallux rigidus2. The patients treated with the implant were permitted to bear weight at 1 week and recover with a soft dressing, whereas patients who had arthrodesis were immobilized in a cast or boot for ≥6 weeks. Hallux Valgus In a prospective cohort study, minimally invasive chevron-Akin (MICA) surgery (n = 50) and open scarf-Akin surgery (n = 48) demonstrated similar improvements with respect to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, VAS for pain, and radiographic outcomes at minimum 2-year follow-up3. Each group had 3 cases of moderate stiffness (range of motion [ROM], 30° to 74°). Extension increased by 10° in the MICA group. Reoperation was required for 13 (26%) of the patients in the MICA group and 4 (8%) in the scarf-Akin group, including 11 cases of hardware removal, 5 cases of secondary resection of the residual medial prominence, and 1 case of a postoperatively dislocated fracture with MICA that required reoperation. Among groups treated with Akin osteotomy fixation with staples (n = 43), screws (n = 47), or transosseous sutures (n = 48), AOFAS Ankle-Hindfoot scores improved similarly, with no cases of delayed union or nonunion4. Suture fixation was advantageous regarding cost and potential complications. Scarf osteotomy with fixation using 2 screws (n = 50), 1 screw (n = 55), or no screws (n = 64, including 20 with transosseous sutures) demonstrated similar degrees of correction, AOFAS Ankle-Hindfoot Scale scores, and rates of complications5. Sutherland and colleagues evaluated hallux valgus from a public-health perspective in a study of 95 patients who completed preoperative and postoperative patient-reported outcome measures (PROMs) and reported a significant difference in patient-reported health after surgery6. The cost per quality-adjusted life year was relatively inexpensive and changed on the basis of patient age and sex. Hallux valgus surgery was deemed cost-effective overall and offered significant health benefits to the patient. A prospective comparative study of 87 patients demonstrated that longer wait times for hallux valgus surgery were associated with smaller gains in the Foot and Ankle Outcome Score (FAOS) domains of pain and ADL, indicative of poorer postoperative outcomes7. Among 80 patients awaiting bunion surgery for a mean of 34.9 weeks, high pain levels and compromised foot function did not change significantly from the beginning to the end of the waiting period8. Midfoot Injuries and Lisfranc Fractures Over 5 years at a university hospital, 233 (75.9%) of 307 midfoot injuries were Lisfranc injuries, 56 (18.2%) were Chopart injuries, and the remainder were combined injuries9. The primary mechanism of injury was low-energy trauma. The amount of energy and mechanism of trauma were not associated with injury severity9, although in a previous report10, higher-energy trauma increased the risk of additional, adjacent foot fractures or distributed musculoskeletal injury. Transarticular screw utilization in open reduction and internal fixation (ORIF) of Lisfranc fractures is concerning for damage to articular cartilage. Jastifer et al. determined the mean articular surface area of joints comprising the Lisfranc complex using digital imaging software in a cadaveric study11. Nonarticular screw trajectories large enough to allow adequate screw fixation were simulated to be plantar-medial to dorsal-lateral and approximately perpendicular to the long axis of the foot. In a retrospective comparative study, 88 feet (189 joints) underwent arthrodesis for tarsometatarsal arthritis, with the use of screws alone (n = 105), bridge plating with all screws through the plate (n = 67), or combined bridge plating and an independent compressive lag screw (n = 17)12. The overall rate of nonunion was 11.4%. Significant risk factors for nonunion were the use of a plate only, nonanatomic alignment postoperatively, and smoking in the perioperative period. Seventy (79.5%) of the patients received bone graft (autograft or demineralized bone matrix), which significantly decreased the rate of nonunion (odds ratio [OR], 0.2; p = 0.006). The study included patients with diabetes and Charcot neuroarthropathy, in whom surgeons had a strong preference for using plates; these factors did not significantly affect nonunion. The Ankle and Hindfoot Total Ankle Replacement Total ankle replacement (TAR) continues to be refined to improve longevity and patient outcomes. Among 200 Scandinavian Total Ankle Replacement (STAR; Stryker) implants, survivorship was 90%, 83%, and 76% at 5, 10, and 15.8 years of follow-up, respectively, using revision surgery as the primary end point13. Among 153 INFINITY (Wright Medical Technology) TARs, the incidence of revision was 10% at 13 months14. Common reasons for revision were deep infection (3.8%) and tibial-component loosening (3.8%). The patient population was heterogeneous; 79% required additional procedures at the time of TAR or had preexisting arthrodeses. In a consecutive series of 278 TARs, the overall incidence of postoperative complications was 41.7%, including amputation, deep infections, superficial infections, wound-healing delays, venous thromboembolism (VTE), fractures, osteolysis, aseptic loosening, subsidence, malpositioning, polyethylene fracture, edge-loading, soft-tissue injuries, pain, and stiffness15. The clinical outcome was affected in only 7.6% of the cases, as most complications were minor. In a prospective comparative series of TARs with use of the HINTEGRA (Newdeal/Integra LifeSciences) implant, patients ≤55 years (n = 38) and patients >55 years old (n = 85) had similar rates of complications (39.5% and 41.2%, respectively), overall survivorship (97% and 87.8%, respectively), and clinical outcomes, including AOFAS Ankle-Hindfoot scores and Short Form (SF)-36 physical component summary and mental component summary scores, and a VAS for pain at a mean of 78 months of follow-up16. Saito et al. performed a retrospective comparative study of patient-specific instrumentation (PSI) (n = 75) and standard referencing guides (n = 24)17. The groups were statistically similar regarding coronal and sagittal alignment of the tibial component; the talar component was not assessed. The PSI group had significantly shorter operative and fluoroscopy durations. Poor prediction of implant size was demonstrated for PSI (correct prediction of tibial component size in 73% of the cases and of talar component size in 51% of the cases). In 3 cases, PSI was abandoned in favor of standard referencing guides because of inaccuracy. Schipper et al. compared wear attributes of fixed-bearing ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (HXLPE)18. After 5 million cycles, HXLPE showed significantly less wear and significantly smaller and rounder particles compared with UHMWPE. In a separate study, HXLPE was strong enough to withstand the demands placed on the TAR bearing surface19. In a retrospective database cohort study of TAR (n = 2,993) and tibiotalar arthrodesis (n = 2,667), the 30-day readmission rate was significantly higher following arthrodesis (4.4%) compared with TAR (1.4%)20. Independent risk factors for having a readmission within 30 days included iron-deficiency anemia, coagulopathy, renal failure, nonprivate insurance, and tibiotalar arthrodesis. Shofer et al. prospectively evaluated activity levels among patients who underwent TAR or ankle arthrodesis preoperatively and 6, 12, 24, and 36 months postoperatively21. Activity level increased in both groups, initially more following TAR, but the effects evened out by 36 months, and activity levels did not correspond to PROMs. The patients who underwent ankle arthrodesis were younger (by a mean of 6.8 years) and had a greater body mass index (BMI) (by a mean of 2.9 kg/m2) than the patients who underwent TAR. Lazarides et al. retrospectively evaluated 32 patients with a remote periprosthetic fracture >4 weeks after TAR22. Implant instability was determined radiographically as evidence of osteolysis about the implant or loosening or subsidence and was confirmed operatively when feasible. Talar periprosthetic fractures were always unstable and required revision TAR or arthrodesis in every case. Periprosthetic fractures of the medial malleolus, tibial shaft, and lateral malleolus that were deemed stable were recommended for treatment with ORIF; those deemed unstable necessitated revision or arthrodesis. Nonoperative management of the periprosthetic fracture was independently associated with failure (p < 0.001), with surgery required because of osseous nonunion or malunion in >80% of the cases. Periprosthetic Infection In 2018, the Foot and Ankle Work Group of the International Consensus Meeting on Musculoskeletal Infection developed 40 consensus statements on the prevention, diagnosis, and treatment of periprosthetic infections following TAR as summarized in a supplemental issue of Foot & Ankle International23. In these consensus statements, prophylactic intravenous cefazolin administration within 60 minutes before TAR was unanimously recommended24. In patients with prior infection involving the ankle undergoing TAR, the addition of antibiotics to the cement was unanimously recommended25. Diagnosis26 and treatment27 algorithms for periprosthetic infections were also developed by the Foot and Ankle Work Group. Ankle Fractures Several studies evaluated intramedullary fibular fixation for ankle fractures. Challagundla et al. assessed the use of an intramedullary fibular rod for lateral malleolar fractures in 15 elderly patients (mean age, 74 years)28. At 12 months of follow-up, all fractures had healed, reduction was obtained and maintained with no infections, and the mean FAAM score was 78. Two patients eventually required hardware removal. A retrospective study of fibular nail use for 39 ankle fractures showed that the quality of reduction was good in 32 (82%) of the fractures, fair in 5 (13%), and poor in 2 (5%), with the poor fractures revised to a plate via ORIF29. Eight ankles required reoperation, of which 6 required fibular nail removal because of irritation and/or prominence (n = 3), deep infection (n = 1), secondary displacement (n = 1), and Charcot neuroarthropathy (n = 1). Among 342 ankle fractures managed with an intramedullary fibular nail, Carter et al. identified 20 failed cases (6%), with failure in 7 (2%) due to proximal locking-screw pull-out (device problem) and in 13 (4%) as a result of surgeon error30. Coles et al. surveyed members of the Orthopaedic Trauma Association (OTA) on current practice patterns for ankle fracture management31, with a poor overall response rate (8.4%). Best-practice recommendations included accurate syndesmotic reduction via either fluoroscopic or open methods, not removing syndesmotic screws unless the patient is symptomatic, and VTE prophylaxis only if notable risk factors are present. Syndesmosis A meta-analysis of 3 RCTs and 5 retrospective studies (total n = 397) found that functional outcomes and complications were similar for suture-button fixation and screw fixation for syndesmotic injuries, with a faster time to full weight-bearing in the suture-button group32. Although the authors recommend suture-button fixation, the conclusion is drawn from retrospective studies and only 1 RCT that tracked time to weight-bearing. With the increasing cost of health care, this conclusion should be scrutinized. Removal of syndesmotic fixation screws had no effect on ankle dorsiflexion in 21 patients33. Dorsiflexion was measured on radiographs intraoperatively, immediately before and following implant removal, and 3 months postoperatively. Thus, ankle range of motion should not be the sole indication for syndesmotic implant removal. Syndesmotic reduction is considered important for achieving good clinical outcomes. A retrospective cohort study of 87 patients found that an anterior tibiofibular distance of >2 mm on computed tomography (CT) scans 2 years after syndesmotic reduction was correlated with poorer Olerud-Molander Ankle Scores and AOFAS Ankle-Hindfoot scores34. Approximately 20% of AOFAS and Olerud-Molander Ankle Scores were missing at the time of final follow-up. Osteochondral Lesions of the Talus Several studies evaluated microfracture for the treatment of osteochondral lesions of the talus (OLTs). In 64 of 70 patients treated with arthroscopic microfracture for OLT (mean lesion size [and standard deviation], 1.1 ± 0.7 cm2; no OLTs were >1.5 cm), VAS and AOFAS Ankle-Hindfoot scores improved significantly up to 2 years postoperatively, stabilized, and were maintained at 3 and 4 years of follow-up35. Six of 70 patients worsened or showed no improvement at the 6-month follow-up and were excluded from the analysis. The overall success of arthroscopic microfracture based on good-to-excellent AOFAS Ankle-Hindfoot scores was reported by 88.6% of patients at 2 years. In a prospective cohort study of 101 patients with an average lesion size of <1.5 cm2 and treated with microfracture alone (n = 52) or microfracture + autologous iliac crest bone marrow aspirate concentrate (BMAC) (n = 49)36, both groups reported significant improvement in FAOS pain, sport, activities of daily living, and quality-of-life subscores at a minimum of 36 months of follow-up. The revision rate was 28.8% in the microfracture-only cohort compared with 12.2% in the microfracture + BMAC cohort (p = 0.0145). Autologous matrix-induced chondrogenesis (AMIC) is a technique involving microfracture followed by implantation of a type I/III collagen bilayer membrane matrix (Chondro-Gide, Geistlich Pharma). The charts of 33 patients who had undergone AMIC for OLT were retrospectively reviewed at mean of 4.7 years of follow-up37. Tegner and VAS for pain scores improved significantly, and 26 (79%) of the patients returned to sport. The magnetic resonance observation of cartilage repair tissue (MOCART) score did not correlate with otherwise good clinical outcomes. A high proportion of patients (58%) required reoperation for hardware-related symptoms following medial malleolar osteotomy, but no revisions for failure of AMIC were performed. This study lacked a control group, with potential selection bias introduced with subjects lost to follow-up. An ongoing prospective case series of matrix-associated stem cell transplantation (MAST) for OLTs was updated by Richter and Zech38. Autologous concentrated pelvic bone marrow combined with a collagen I/III bilayer membrane matrix (Chondro-Gide) was secured in the OLT with fibrin glue. At 5 years of follow-up, 100 (83%) of the patients remained, with an average OLT size of 1.7 cm2. Visual-Analogue-Scale Foot and Ankle scores remained stable compared with 2-year outcomes. In 49 (48%) of 102 previous lesion locations, no lesion was visible by magnetic resonance imaging (MRI) at follow-up. While promising, these results are confounded by additional simultaneous procedures and hindered by the lack of a control group. Shimozono et al. compared outcomes between autograft (n = 16; nonarticular portion of the ipsilateral femoral condyle) and allograft (n = 25; fresh osteochondral) used to treat OLTs of >1.5 cm2 or in patients in whom previous microfracture had failed39. The autograft group fared significantly better on the FAOS, SF-12, and MOCART scores, and demonstrated less chondral wear, less cyst formation, and a lower rate of revision surgeries (0% compared with 25%) compared with the allograft group. Chronic Ankle Instability Rigby and Cottom retrospectively found that patient-satisfaction, VAS for pain, and AOFAS Ankle-Hindfoot scores were similar for an “all-inside” arthroscopic Broström repair (n = 30) and a classic open Broström-Gould repair (n = 32)40. The arthroscopic group had a shorter mean time to weight-bearing: 12 days compared with 22 days in the open-repair group. At a mean follow-up of 28 months, 30 (93.8%) of 32 patients with chronic lateral ankle instability rated their outcomes as excellent or good following anatomic reconstruction of the lateral ligament using the anterior half of the peroneus longus tendon as a free tendon graft41. They also had decreased pain scores, and significantly reduced mean talar tilt (14.1° to 3.4°) and anterior drawer displacement (13.8 to 3.6 mm). Intra-Articular Injections Among 1,708 patients who received an intra-articular corticosteroid injection into the tibiotalar or subtalar joint, 99 (5.8%) developed 104 adverse events within 90 days42. Common adverse events were flare (75%) and skin reaction. Study limitations include the retrospective design and potential underreporting if patients visited another health-care provider. Pes Planus The authors of a prospective comparative study of weight-bearing CT (WBCT) reported good interobserver and intraobserver reliability for axial, coronal, and sagittal-plane measurements among 19 patients with adult-acquired flatfoot deformity, as performed by investigators with varying clinical experience after a training protocol43. Significant differences in measurements were observed for the medial cuneiform-first metatarsal angle and the navicular-medial cuneiform angle. In 61 patients (63 feet) with stage-II adult-acquired flatfoot deformity who received a medial cuneiform (Cotton) osteotomy as part of their reconstruction, those with mild plantar flexion (i.e., cuneiform articular angle [CAA] of ≥−2°) had statistically and clinically better FAOS symptom, ADL, sports, and quality-of-life subscales compared with moderate plantar flexion (CAA of <−2°) at a minimum of 2 years of follow-up44. Soft Tissues Achilles Tendon In a retrospective chart review, eligible patients underwent open (n = 560) or minimally invasive surgical (n = 55) repair of acute Achilles tendon ruptures. One in 9 developed a postoperative complication including wound-healing problems (5.0%), symptomatic VTE (5.7%), and sural nerve injury (1.9%)45. The rate and type of complications were similar between the 2 groups. Patients treated by trauma surgeons were more likely to have complications compared with those treated by subspecialty surgeons. Tobacco use and advanced patient age were also associated with higher complication risk. Plantar Fasciitis In a prospective study of 2 patient cohorts with plantar fasciitis in whom 6 months of nonoperative treatment was unsuccessful, the authors analyzed the effect of a single methylprednisolone injection (n = 20) or two 4-mL injections of platelet-rich plasma (PRP) concentrate (n = 20)46. VAS pain and AOFAS Ankle-Hindfoot scores improved significantly (p < 0.0001) in the PRP group at a mean of 33 months of follow-up. The steroid group had worse AOFAS Ankle-Hindfoot scores compared with the PRP group at 6 months of follow-up. Plantar fascia thickness decreased in both groups as evaluated on ultrasound and MRI, attributed to a reduction in overall inflammation. Molund et al. conducted an RCT evaluating stretching alone (n = 20) compared with stretching and proximal medial gastrocnemius recession (n = 20) in patients with chronic (>12 months) plantar heel pain47. The operative group demonstrated significantly greater improvements (p < 0.05) in AOFAS Ankle-Hindfoot, SF-36, and VAS pain scores compared with the nonoperative group at 12 months of follow-up. Ankle dorsiflexion increased by a mean of 4.5°. The groups were similar regarding Achilles function and calf weakness. Pedobarography demonstrated increased forefoot plantar pressure in the operative group. Patient-Reported Outcomes Liu et al. validated the Ankle Osteoarthritis Scale (AOS) in a prospective comparative study and found that the AOS was a strong measure of pain and dysfunction for preoperative evaluation of patients with end-stage ankle arthritis48. Hung et al. determined that the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and FAAM Sports subscales were sensitive and responsive to changes in patient-reported health in a foot and ankle orthopaedic patient population (n = 785)49. A Level-I diagnostic study of 3,069 foot and ankle orthopaedic patients determined that the minimal clinically important difference (MCID) for the PROMIS PF ranged from 3 to 30 (median, 11.3); for the PROMIS PI, it ranged from 3 to 25 (median, 8.9); and for the FAAM Sports subscale, it ranged from 9 to 77 (median, 32.5)50. For high-stakes decisions in clinical practice (e.g., surgery referrals), the median values should be used. Bernstein et al. found that the PROMIS PI domain was superior to both the PROMIS PF and the traditional numeric pain rating scale (NPRS) for preoperative assessment of pain level and functional ability in foot and ankle patients51. An AOFAS position statement supported the use of validated PROMs for the assessment of general health, function, and treatment outcomes52. The AOFAS support use of the PROMIS PF or Lower Extremity (LE) domains in combination with other domains, such as the PROMIS PI, as well as disease-specific measures. Clubfoot In a retrospective case series, the authors reviewed the cases of 145 Nepalese children (220 feet) who had been treated for idiopathic clubfoot with the Ponseti method between the ages of 1 year and 5 years53. At a minimum of 10 years of follow-up, 138 (95%) of the 145 children demonstrated lasting results, with 210 (95%) of the 220 feet achieving a plantigrade foot. Only 3% complete relapses occurred, although residual deformities were common. Surgical treatment, most typically a percutaneous Achilles tendon release, was required in 96% of the feet. A commentary by Wright54 on the above study suggested that clubfoot deformity might prompt unnecessary surgery in “high-income settings,” as some deformity is compatible with good function. Diabetes and Charcot Neuroarthropathy Ford et al. retrospectively evaluated 25 patients with midfoot Charcot neuroarthropathy treated with intramedullary beams55. At a minimum of 1 year of follow-up, 21 (84%) of the patients achieved an ulcer-free, stable, plantigrade foot with use of 2 beams. Fifteen (60%) of the patients required reoperation for deep infection (n = 6), recurrent ulceration (n = 4), recurrent deformity (n = 3), wound dehiscence (n = 1), or hardware failure (n = 1). Six patients (all with preoperative ulceration) developed deep infections postoperatively; 4 went on to amputation. An open ulcer at the time of surgery had an increased incidence of infection, and was predictive of postoperative infection (p = 0.04). Midfoot Charcot arthropathy is a difficult clinical problem, and comparative studies of fixation methods are needed. The diagnosis and treatment of foot infections and osteomyelitis in patients with diabetes are challenging. Pinzur found that an erythrocyte sedimentation rate (ESR) of 60 mm/hr had a sensitivity of 74% and a specificity of 56% and a C-reactive protein (CRP) level of 7.9 mg/dL had a sensitivity of 49% and a specificity of 80% for the diagnosis of osteomyelitis in patients with diabetes-related foot infections in a receiver operating characteristic (ROC) curve analysis56. While the ESR was better for ruling out osteomyelitis initially, the CRP level helped distinguish osteomyelitis from soft-tissue infections in those with a high ESR value. Mijuskovic et al. prospectively determined that culture of biopsy specimens obtained from patients requiring toe or forefoot amputations overestimated the incidence of osteomyelitis, with a 41% false-positive rate (i.e., positive culture with negative histological analysis) attributed to cross-contamination from adjacent soft tissue57. Upcoming Educational Events Events related to foot and ankle surgery sponsored by the AOFAS include the AOFAS Annual Meeting, September 9 to 12, 2020, in San Antonio, Texas. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 27 other articles with a higher Level of Evidence grade relevant to foot and ankle surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area. Evidence-Based Orthopaedics Albin SR, Koppenhaver SL, Marcus R, Dibble L, Cornwall M, Fritz JM. Short-term effects of manual therapy in patients after surgical fixation of ankle and/or hindfoot fracture: a randomized clinical trial. J Orthop Sports Phys Ther. 2019 May;49(5):310-9. Epub 2019 Feb 13. Approximately 3.8 months following ORIF for an ankle and/or hindfoot fracture, patients receiving standard physiotherapy with exercise and gait training were randomized to additionally receive either manual therapy (fracture-specific adjacent joint mobilization to decrease stiffness, n = 40) or sham manual therapy (control, nonspecific, light soft-tissue mobilization, n = 32). Only 3 treatments of similar duration for both groups were performed over 7 to 10 days. At the time of final follow-up 7 to 10 days after the last treatment, both groups had similar range of motion, gait, and balance outcomes. The control group had significantly greater gastrocnemius muscle stiffness compared with the manual therapy group. Alvarez CM, Wright JG, Chhina H, Howren A, Law P. Botulinum toxin type A versus placebo for idiopathic clubfoot: a two-center, double-blind, randomized controlled trial. J Bone Joint Surg Am. 2018 Sep 19;100(18):1589-96. Sixty-six infant patients with idiopathic clubfoot underwent onabotulinum toxin A (BTX-A) injection (n = 33) or placebo injection (n = 33) into the gastrocnemius-soleus muscle at the time of hindfoot stall; two-thirds responded to treatment (i.e., ≥15° of dorsiflexion) at 6 weeks post-injection. The remainder (including placebo cohort) received a rescue BTX-A injection at 12 weeks after the first injection, followed by a third BTX-A rescue injection or surgery (Achilles tendon lengthening [3 feet] or posteromedial release [2 feet]) if no response after 2 doses. All participants demonstrated ≥15° of dorsiflexion at 2 years of follow-up. This study highlights the potential for BTX-A injections to improve ankle dorsiflexion in idiopathic clubfoot, but more frequent follow-up is required. The lowest minimum dose of injection still needs to be identified. Arcângelo J, Guerra-Pinto F, Pinto A, Grenho A, Navarro A, Martin Oliva X. Peri-prosthetic bone cysts after total ankle replacement. A systematic review and meta-analysis. Foot Ankle Surg. 2019 Apr;25(2):96-105. Epub 2017 Nov 29. In 21 studies representing 2,430 TARs, osteolytic periprosthetic cysts developed in 430 (18%) of the cases. Significantly higher proportions of cysts were associated with nonanatomic implant designs (due to increased shear stress), mobile-bearing articular surfaces (increased polyethylene wear), hydroxyapatite-coated implants (elevated calcium levels found in osteolytic lesions), and nonstemmed tibial implants (possibly because of less overall stability). The main limitations of the assessed studies included the lack of a specific definition of a periprosthetic cyst, inconsistent reporting of revision surgery due to periprosthetic cysts, and variability in diagnostic imaging used to quantify and diagnose the cysts. Bahrami MH, Raeissadat SA, Barchinejad M, Elyaspour D, Rahimi-Dehgolan S. Local ozone (O2-O3) versus corticosteroid injection efficacy in plantar fasciitis treatment: a double-blinded RCT. J Pain Res. 2019 Jul 24;12:2251-9. Patients with plantar fasciitis symptoms of at least 3 months’ duration and not relieved by first-line conservative therapies were randomized to receive methylprednisolone (n = 23) or oxygen-ozone solution (n = 21) injection. The corticosteroid group demonstrated significantly greater improvements in VAS pain, FAAM score, and pressure-pain threshold than the ozone group at 1 week post-injection. At 1 month, VAS pain and FAAM scores showed no significant differences between the groups, but the pressure-pain threshold remained significantly higher in the corticosteroid group. By 3 months of follow-up, none of the scores showed significant differences between groups. Cazzell S, Stewart J, Agnew PS, Senatore J, Walters J, Murdoch D, Reyzelman A, Miller SD. Randomized controlled trial of micronized dehydrated human amnion/chorion membrane (dHACM) injection compared to placebo for the treatment of plantar fasciitis. Foot Ankle Int. 2018 Oct;39(10):1151-61. Epub 2018 Jul 30. Th