BackgroundGlucagon-like peptide-1 receptor agonists (GLP) are widely prescribed for type 2 diabetes mellitus (T2DM) and obesity, with established metabolic and anti-inflammatory benefits. Their musculoskeletal impact, particularly on joint-specific outcomes such as ankle osteoarthritis (OA), remains poorly defined.MethodsUsing the TriNetX database, we conducted a retrospective cohort study of adults treated from 2016 to 2020 with a minimum 5-year follow-up. Two main cohorts were analyzed: obese (body mass index [BMI] ≥30 kg/m2) and T2DM patients. The primary outcome was the development of ankle OA, while secondary outcomes included interventions such as joint injection, total ankle arthroplasty (TAA), and ankle arthrodesis. Propensity score matching balanced age, sex, race, BMI, HbA1c, comorbidities, and socioeconomic variables. Subgroup analyses stratified the obese cohort by BMI groups (30-34.9, 35-39.9, 40-44.9, ≥45 kg/m2).ResultsAfter matching, 2363 obese and 37 737 diabetic patients were included. In obese patients, GLP use was not associated with a significant increase in the risk of ankle OA (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 0.9-1.5). In diabetic patients, GLP use was associated with a higher risk of ankle OA (OR = 1.3, 95% CI = 1.2-1.4) and joint injection (hazard ratio [HR] = 1.3, 95% CI = 1.1-1.4). No differences were observed in the risk of surgical outcomes, including TAA or arthrodesis. Subgroup analysis revealed no consistent stepwise increase in OA risk across BMI strata in GLP users, whereas non-users demonstrated higher OA risk with increasing BMI.ConclusionThe GLP use was associated with an elevated risk of ankle OA in diabetic but not obese patients, without increased risk of surgical intervention. These findings highlight the importance of considering mechanical and biologic mechanisms unique to the ankle when assessing OA progression.Level of EvidenceLevel III: Retrospective cohort study.

Background/Objectives: Nonunion after tibiotalocalcaneal (TTC) arthrodesis remains challenging, especially in revision settings where union rates are substantially lower than in primary procedures. Biological adjuncts are commonly used to enhance healing, yet most described methods employ fibular onlay struts and cancellous autograft. To our knowledge, intramedullary placement of a fibular autograft for ankle fusion has not previously been reported. This study presents a revision of TTC arthrodesis nonunion treated with this technique and summarizes existing evidence on revision ankle arthrodesis, fibular grafting, and bone marrow aspirate concentrate (BMAC). Methods: We report a revision TTC arthrodesis nonunion managed with a decorticated intramedullary fibular autograft spanning the tibiotalar canal, supplemented with cancellous iliac crest autograft and BMAC. A review of PubMed, Scopus, and Google Scholar (search date: 1 September 2025) was performed to identify studies addressing revision ankle fusion, fibular grafting techniques, and BMAC use in foot and ankle arthrodesis. Primary outcomes included union and complications, with CT-based assessment prioritized when available. Results: At 3 months, radiographs and CT demonstrated progressive osseous bridging consistent with fusion; the patient achieved pain-free weight-bearing without complications. Conclusions: Intramedullary fibular autograft in revision TTC arthrodesis is a novel biological-mechanical strategy that leverages endosteal contact and axial stability while augmenting osteogenesis with cancellous autograft and BMAC. The review supports the biological plausibility and safety of this approach and underscores the importance of CT-based assessment.

Synthetic graft supplements such as Augment (recombinant human platelet-derived growth factor-BB [rhPDGF-BB] and beta-tricalcium phosphate [β-TCP]) are increasingly used to promote fusion in foot and ankle arthrodesis. However, mid- to long-term outcomes remain underreported. This study assessed union rates and time to union with and without graft supplementation in ankle and subtalar fusions. A retrospective review of 112 patients from 3 centers was conducted. Patients who received synthetic grafts formed the case group; those without any graft formed the control group. Postoperative radiographs and CT scans were used to assess union status and time to union. Statistical analysis was performed using SPSS (P < .05 significant). Patients receiving graft supplementation had significantly faster union (160.5 ± 116.2 days) than controls (248.4 ± 282.3 days, P < .01). Nonunion rates did not differ significantly between groups (P = .71). Synthetic graft supplementation accelerates time to union in ankle and subtalar arthrodesis, potentially enabling earlier recovery and reduced rehabilitation costs. Further research is warranted.Level of Evidence: 3.

Total ankle arthroplasty (TAA) is increasingly used as a motion-preserving alternative to ankle arthrodesis for end-stage ankle disease. The Salto Talaris fixed-bearing prosthesis was designed to enhance joint kinematics while minimizing bone resection and reducing complications seen in earlier implant generations. This study reports midterm clinical outcomes, including survivorship, complications, reoperation and failure rates in a large, single-surgeon cohort. A retrospective review was conducted of 1121 primary TAAs performed in 1023 patients (98 bilateral) between May 2008 and December 2022. Patients with a minimum of 2-year clinical follow-up were included and any patients who failed or passed away before then were accounted for. Data included demographics, comorbidities, preoperative ankle diagnosis, ancillary procedures, intra- and postoperative complications, and patient-reported outcomes measures (PROMs). Complications were identified and then classified by the Glazebrook system (low-, medium-, high-grade). Reoperations and revisions were coded according to the Canadian Orthopaedic Foot and Ankle Society reoperations coding system. The mean age at the index TAA surgery was 65.5 (range, 28.7-94.4) years, with osteoarthritis being the most common diagnosis. The average follow-up was 5.5 (range, 2-17.2) years. Key PROMs showed statistically significant improvements from preoperative to latest follow‑up (Veterans RAND 12-Item Health Survey physical component summary, +10.1 [95% CI 8.83-10.77]; Ankle Osteoarthritis Scale [AOS] pain, -29.2 [95% CI 25.43-29.72]; AOS disability, -32.8 [95% CI 29.32-33.80]; visual analog scale for pain, -36.8 [95% CI 32.6-40.7]; all P < .001). Implant survivorship was 94.6% at the time of this report. A total of 240 ankles (21.4%) experienced at least 1 complication. Secondary reoperations occurred in 134 ankles (12.0%), with 61 ankles failing (5.4%) and leading to a revision TAA, conversion to arthrodesis, or an explant to antibiotic spacer. Most failures were due to high-grade complications including aseptic loosening (22/61) and deep infection (19/61). Among the failed ankles, 2 patients ultimately underwent a below-the-knee amputation. In this large cohort, the Salto Talaris TAA was associated with improvements in patient-reported quality of life, activity, and pain, and showed high survivorship with relatively low failure (5.4%) and reoperation (12.0%) rates at an average of 5.5 years after index surgery.

The aim of this study is to investigate the psychological status of patients with end-stage ankle osteoarthritis (OA), and to evaluate the impact of ankle arthrodesis (AA) on the patients' psychological condition, as well as the influence of preoperative anxiety and depression symptoms on the clinical outcomes after AA surgery. A retrospective observational study was conducted on 62 patients with end-stage ankle OA who underwent AA treatment at our hospital from January 2019 to December 2024. Based on the patients' preoperative psychological status, they were divided into two groups: those with symptoms of anxiety/depression were included in Group A, and those without symptoms of anxiety/depression were included in Group B. The Hospital Anxiety and Depression Scale (HADS), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Visual Analogue Scale (VAS) for pain were used to evaluate the patients before surgery and at the final follow-up. Independent sample t-tests and chi-square tests were used for between-group comparisons, and paired sample t-tests were used for within-group pre-post comparisons. P < 0.05 was considered statistically significant. Of the 62 patients with end-stage ankle OA who were fully followed up, 30 had symptoms of anxiety/depression before surgery, a prevalence rate of up to 48%. All evaluation indicators for patients in Groups A and B improved significantly after AA surgery compared to before surgery, but the overall prognosis for Group A was worse than Group B. AA can effectively improve patients' pain, functional activity, and psychological condition, and there is a significant correlation between the patients' preoperative psychological status and the prognosis.

Complication rates in open versus arthroscopic ankle arthrodesis in patients with avascular necrosis of the talus.

Analysis of risk factors for sagittal plane malpositioning during primary ankle arthrodesis.

Abstract Purpose There are numerous reconstruction techniques available for the removal of malignant tumors in the distal tibia. Various reconstruction techniques result in different MSTS functional scores and complications. Therefore, controversies regarding the best reconstructive options after limb salvage for malignant tumor of the distal tibia continues. This study aims to evaluate the outcomes of limb salvage procedures utilizing 3D-printed ankle joint arthrodesis prostheses in patients who diagnosed with distal tibia malignant tumors and declined below knee amputation. Methods We retrospectively reviewed 7 patients with distal tibia malignant tumor treated from 2020 to 2023. Each patient underwent limb salvage surgery with a 3D-printed prosthesis while preserving the subtalar joint, alongside pre- and post-operative chemotherapy. We used the Enneking and Musculoskeletal Tumor Society (MSTS) systems to stage our patients. We assessed survival, local recurrence, MSTS function and complications. Results The mean age of the patients was 20.7 years (8 to 49) and the mean follow-up was 35.4 months (18 to 58). The average resection length of the tibia was 11.7 cm (6.5 to 18). All patients were Enneking IIB. A wide margin excision was acheived in one, marginal in six. Skeletal reconstruction was performed using 3D-printed ankle joint arthrodesis prosthesis. There were no complications with deep infection, delayed wound healing or necrosis of the wound except for two cases that developed prosthetic loosening and subsequent subsidence at 12 months postoperatively. The average MSTS scores in six months after the operation was 26.7/30, with no reported cases of local recurrence or distant metastases. Conclusion For distal tibial malignant bone tumors, limb salvage is possible with a 3D-printed ankle joint arthrodesis prosthesis and preservation of the subtalar joint in carefully chosen patients. This is a safe and efficient treatment approach. Level of evidence IV, therapeutic study.

Hindfoot and ankle arthrodesis, although routinely performed for arthritis, trauma, and deformity correction, carries risks of several postoperative complications. Cigarette smoking is a well-established risk factor for impaired bone healing, but the effects of non-tobacco nicotine dependence (NTND) are poorly understood. This study aims to evaluate the association between NTND and postoperative complications following ankle and hindfoot fusion. This retrospective cohort study used the TriNetX database to identify patients who underwent hindfoot arthrodesis. Patients were categorized into NTND (International Classification of Diseases, Tenth Revision [ICD-10]: F17, excluding tobacco-specific codes) and nonsmoker cohorts. Propensity score matching (1:1) was performed to balance demographics and comorbidities. Outcomes were assessed at 90 days and 2 years postoperatively from date of surgery using risk ratios (RRs), absolute risk differences, with corresponding 95% CIs. After matching, 2172 patients were included in each cohort. NTND patients had significantly higher 90-day rates of opioid prescriptions (RR 1.20, 95% CI: 1.16-1.24), emergency department visits (RR 1.31, 95% CI: 1.10-1.57), hospitalizations (RR 1.20, 95% CI: 1.07-1.35), postoperative infections (RR 1.61, 95% CI: 1.20-2.17), and wound complications (RR 1.68, 95% CI: 1.26-2.84) (all P < .05). At 2 years, NTND patients experienced increased rates of pseudoarthrosis (RR 1.52, 95% CI: 1.37-1.68), mechanical implant failure (RR 1.42, 95% CI: 1.21-1.67), infection-related implant failure (RR 1.39, 95% CI: 1.12-1.71), and periprosthetic fractures (RR 1.59, 95% CI 1.36-1.87) (all P < .05). No differences in revision arthrodesis rates were observed. NTND is associated with increased short- and long-term complications following hindfoot fusion, suggesting that vaping may negatively impact surgical recovery. Surgeons should incorporate NTND considerations in preoperative risk assessments and promote cessation strategies to optimize patient outcomes.

Innovations in foot and ankle arthrodesis: Biological and biomaterial approaches to reducing non-union and the challenge of preclinical models.

Treatment of ankle osteoarthritis (OA) is controversial. The early age of onset and the lack of consensus about the moment and type of surgical intervention among experts have pointed this disease as a matter for debate. Nonunion is a rather common complication after a tibiotalar arthrodesis. Several approaches have been described in the literature for failed ankle replacement, but there are fewer salvage alternatives for a failed arthrodesis. In this article, we present two clinical cases. The first one involves a 57-year-old woman diagnosed with primary ankle OA who underwent ankle arthrodesis (AA), which subsequently resulted in nonunion. A rescue procedure was suggested, and a trans-Achilles approach using a plate for fixation was proposed. Arthrodesis was successfully achieved, and the patient remains satisfied with the outcomes. In the second case, we present a 44-year-old man with talar avascular necrosis after a AA. Due to persistent pain, a new arthrodesis via posterior approach was performed allowing good exposure of the necrosis area. No complications were reported after 2 years of postoperative follow-up. As a conclusion, in our experience, trans-Achilles rearthrodesis with a posterior plate after ankle fusion failure could be a suitable salvage option in patients in whom the anterior approach may involve soft tissue compromise.

Surgical management of traumatic talus defects: A comprehensive review.

Radiographic evaluation of ankle alignment using the hip-to-calcaneus view in patients with end-stage ankle arthritis.

Total ankle arthroplasty (TAA) is increasingly used as an alternative to ankle arthrodesis for patients with rheumatoid arthritis (RA), although its outcomes remain controversial. Using propensity score matching, this study compared clinical and radiographic outcomes of TAA for patients with RA and osteoarthritis (OA). Eighteen patients with RA were selected from 21 eligible cases and matched-using propensity score matching based on 8 baseline variables-to 36 patients with OA from a pool of 386. All patients underwent mobile-bearing TAA and were followed up for a minimum of 2 years. Clinical outcomes were assessed using the Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Short Form-36 Physical Component Summary, and a visual analog scale for pain. Radiographic outcomes and postoperative complications were also evaluated. At a mean follow-up of 7 years, both groups demonstrated improvement in all clinical outcome measures, with no significant differences between the RA and OA groups (p > 0.05). Radiographic outcomes, including postoperative tibiotalar angle, talar tilt angle, as well as the incidence values for periprosthetic osteolysis, implant subsidence, and aseptic loosening, were similar between groups. However, periprosthetic medial malleolar fractures occurred only in the RA group (3 cases, 16.7%; p = 0.033), and 2 cases of incision wound dehiscence were also observed in the RA group. No deep infections were reported in either group. Overall, reoperation rates did not differ significantly between groups. Patients with RA who underwent TAA achieved clinical and radiographic outcomes comparable to those with OA. However, periprosthetic fractures and wound complications were more common in the RA group. Further studies with larger, matched cohorts and longer follow-up are needed to confirm these findings.

One of the surgical treatment options for advanced ankle joint destruction with various etiologies is the total joint replacement. Its significant upside is the preservation of range of motion of the ankle joint and less stress on forefoot joints compared to ankle arthrodesis. Since 2022, we have been using the Zimmer Trabecular Metal Total Ankle inserted via a lateral transfibular approach. This study aims to evaluate the initial outcomes and experience with this implant. Between 2022 and 2024, 65 total ankle replacements were performed in 63 patients using the lateral transfibular approach. Long oblique osteotomy is newly performed in the frontal plane, replacing the original type of osteotomy in the sagittal plane. After releasing and removing the distal fragment of the fibula distally and dorsally, the lower limb and ankle are placed in an alignment frame, which is fixed with Steinmann pins to the calcaneus, anterior border of the tibia, and the talus bone. The centre of rotation of the ankle is identified using the side bars anchored in the frame. Using the burs, guided by Cutting Guides that are locked to the frame, the talus and distal tibia are removed. After testing, rail holes are drilled in the resected surfaces for the original implants. After releasing the tourniquet, the original components are inserted and osteosynthesis of the fibula is performed. During the study, the previously performed fibula osteosynthesis with LCP was replaced by lag screws. Postoperatively, the ankle is supported with a brace for the period of 5 weeks, after which the patient is permitted to fully weight-bear. A total of 63 patients (32 women and 31 men) were followed, in whom 65 total ankle replacements were performed. The mean age of the patient was 56 years (age range 30 to 80 years). The mean follow-up period was 14.6 ± 9.3 months (3 to 38 months). The most frequent indication was post-traumatic ankle arthritis, namely in 46 cases (70.8%). Furthermore, there were 5 patients (7.7%) with post-traumatic ankle ankylosis, 9 patients (13.8%) with primary osteoarthritis, and in 5 patients (7.7%) the indication was the damage caused by rheumatoid arthritis. Deep bacterial infection of the prosthesis requiring revision was reported in 3 cases (4.6%). Superficial infection of the surgical wound was seen in 4 other cases (6.2%), which did not require hospitalization. Plate osteosynthesis of the fibula was removed in 7 cases (13.8%), 5 times due to infection and 2 times due to soft tissue irritation. One case of asymptomatic non-union of fibula was observed. The benefit of total ankle replacement is the preservation of motion of the operated joint, whereas the complication rate is twice as high as in arthrodesis. Contraindications for ankle replacement include significant varus and valgus deformities of the ankle, ankle instability, necrosis of the talus, severe diabetes mellitus, and severe limb ischemia. The advantage of the transfibular approach is the ability to partly correct deformities of the ankle joint and the position of varus or valgus. It provides a better view of the dorsal structures of the ankle and allows accurate identification of the centre of rotation. Another advantage is the low thickness of the components, requiring minimal bone resection. The main disadvantage is the longer operative time and longer learning curve. Other disadvantages include the complications associated with osteosynthesis and fibula healing, such as non-union or soft tissue irritation by plate. The incidence of superficial and deep infection is also slightly higher compared to the anterior approach. The Zimmer Trabecular Metal Total Ankle system is one of the treatment options for ankle joint destruction provided it is correctly indicated. However, the surgical procedure is a challenge and requires an experienced surgeon. When the indication is correct, the system brings very good short-term outcomes. Nonetheless, longer follow-up period is necessary since the incidence of complications will certainly increase over time.

The effect of electrical bone stimulation on bone union in foot and ankle injuries: A scoping review.

Recombinant human platelet-derived growth factor-BB (rhPDGF-BB or pure PDGF) has been extensively studied in medicine, resulting in four FDA approvals for products based on pure PDGF for tissue regeneration applications, including stimulation of the healing of skin wounds in diabetic patients, stimulation of healing of intra-oral tissue defects, and stimulation of bone and tissue regeneration following foot and ankle arthrodesis surgery. More recently, pure PDGF has also been introduced for esthetic and cosmetic applications. Here, we review the extensive nonclinical and clinical pharmacokinetic and safety studies performed on rhPDGF-BB across diverse administration routes, including topical, injection, and surgical implantation to establish a large margin of safety. Pharmacokinetic studies confirmed that systemic exposure to rhPDGF-BB is negligible following repeated topical application, injection, or implantation, minimizing any potential for systemic risks. Biocompatibility and toxicology studies demonstrated that rhPDGF-BB applied topically to skin, implanted, or injected subcutaneously, intradermally, intramuscularly, intraperitoneally, or intravenously, one time, or repeatedly, is noncytotoxic, nonirritating, nonsensitizing, nonmutagenic, nonclastogenic, noncarcinogenic, and nontoxic. No risk of cancer incidence or cancer mortality was detected following injection, implantation, or repeated, daily topical application of rhPDGF-BB onto partial or full thickness skin wounds for up to 20 weeks, that is, 140 doses. The totality of the data demonstrates that the use of rhPDGF-BB for regeneration and rejuvenation of skin and other tissues has an excellent safety profile, a finding further affirmed by its record of safe and effective use in multiple medical indications for over 25 years.

Introduction: This multi-centre study aimed to compare complication rates, reoperation rates, and patient-reported outcome measures (PROMs) between open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA) in treating end-stage ankle arthritis. Method: Prospectively collected data from three medical centres in the (blinded) database in a retrospective study. Patients who underwent primary ankle arthrodesis for the treatment of end-stage arthritis with a minimum of 2 years follow up and valid patient-reported outcome measures (PROMs) scores were included. Preoperative COFAS ankle arthritis type, validated PROMs including the Ankle Osteoarthritis Scale (AOS), Short Form-36 (SF-36) with 2 components (the Physical Component Summary (PCS) and Mental Component Summary (MCS)), as well as major complications including malunion, non-union, infection, amputations, and reoperations related to the arthrodesis were evaluated using CROCS (Canadian Reoperation Coding System). Results: 447 primary ankle arthrodeses were included (178 AAA, 269 OAA) with 1-15 years of follow up (average 7.13 yrs +/- 3.8). There was no difference between the two groups with respect to demographics except there were more cases of type-1 and type-4 COFAS arthritis in the OAA group, and a higher BMI in the open group. There was a 6.9% (31 cases) incidence of major complications including 3.79% (17) related operations around the ankle, 0.67% (3) deep infection, 1.78% (8) revisions due to non-union or malunion, and 0.67% (3) amputations. The arthroscopic ankle arthrodesis cohort had a better outcome score at 2 years (AOS score 22.9 +/- 19.3 vs 29.3 +/- 29.3 +/- 20.7) and 4 years (23.3 +/- 19.5 vs 34.3 +/- 22.4). From 5 to 15 years there was no difference. Conclusion: This study shows better outcomes for the arthroscopic cohort. However, differences may be less after correction for confounding factors such as surgeon, site, and COFAS grade. Revision surgery is rare in both groups.

Introduction: Outcome studies need to follow patients until a point at which the outcome is stable in either retrospective or prospective studies. The longer the time period of follow up the more likely patients will be lost to follow up. Revisions of the primary procedure may take months to years to occur. The purpose of this paper is to determine when scores stabilize after arthroscopic ankle fusion, and the distribution of time to revision. Method: Patients undergoing arthroscopic ankle fusion at one institution performed by four fellowship trained Orthopaedic surgeons were recruited and prospectively followed. Annual outcome scores were obtained. This included AOS, expectation, satisfaction, and SF 36 scores. Statistical analysis was performed to determine when each outcome score achieved a steady state. Results: 190 Arthroscopic ankle fusions were followed annually for an average of 7.2 years (range 1 to 15 years). The age at surgery was 58 +/-12 years, BMI 28.9 +/- 5.5, 66% male, 11% diabetes, and 6% smokers. There were 103 COFAS type 1, 41 type 2, 15 type 3 and 31 type 4. 5 revision fusions were performed, and 29 reoperations performed (most for hardware removal). The AOS score improved after surgery at 6 months and 1 year and was stable thereafter. The SF 36 PCS score stabilized by 6 months. The expectation score stabilized at 6 months, The satisfaction score, stiffness score and swelling score all at 1 year. Revisions on the other hand occur at an average of 2.5 years +/- 2.8 years. Conclusion: Prospective or retrospective data for outcomes for arthroscopic ankle arthrodesis only needs to be followed until 1 year. A similar result has been obtained for ankle replacement. However, if revisions are to be followed then longer term follow up is required.

Introduction Foot drop syndrome due to peroneal nerve neuropathy significantly impairs limb support and patient quality of life. The aim of this study was to evaluate the clinical effectiveness of the Bridle procedure compared to ankle arthrodesis and isolated tendon transfer. Materials and methods A retrospective analysis of 27 patients was performed, divided into a main group (n = 14, Bridle technique) and a control group (n = 13, arthrodesis or tendon transfer). Functional outcomes were assessed using the AOFAS and VAS scales, along with rehabilitation duration, orthotic use, and complication rates. The mean follow-up period was 2.3 years. Results The main group showed significantly better outcomes: AOFAS score improved from 38 to 82, VAS score decreased from 6.8 to 2.1, and the need for orthotic devices was reduced. In the control group, improvements were less pronounced (AOFAS: 37→65; VAS: 6.7→3.9). The complication rate was 14.3 % in the Bridle group versus 38.5 % in the control group. Discussion The Bridle technique restores active dorsiflexion while preserving ankle mobility. Its functional and rehabilitation advantages make it preferable in cases of isolated peroneal nerve injury without severe deformities. Conclusion The Bridle procedure is an effective joint-preserving surgical method for treating foot drop, providing superior clinical outcomes compared to alternative interventions.