Orthogate Subspecialty Journal Scan: Foot and Ankle

Curated critical appraisals of recent high-impact trials and clinical evidence across foot and ankle surgery, evaluating 10-year survivorship and polyethylene wear patterns in mobile-bearing total ankle arthroplasty with coronal varus deformity, the profound mental health burden in 358 patients with symptomatic osteochondral lesions of the talus, and minimum 10-year durability of transfibular trabecular metal ankle replacements.

Featured Foot and Ankle Studies This Edition (October 2026)
Foot and Ankle

1. Is Preoperative Moderate to Severe Varus Alignment Associated With Survivorship and Outcome Scores at a Minimum of 5 Years After Mobile-bearing Total Ankle Arthroplasty With the Hintegra Device?

Authors: Yoon Y, Park K, Shim D, Han S, Lee J | Journal: Clinical Orthopaedics and Related Research (Sep 2026) | View Source / DOI

Situation

Severe asymmetric coronal plane malalignment (varus deformity 10 degrees or greater) has historically been considered a relative contraindication to mobile-bearing total ankle arthroplasty (TAA) due to concerns regarding edge-loading, component subsidence, and premature prosthesis failure. This long-term study evaluated 10-year survivorship, functional scores, and polyethylene wear in severe varus versus neutrally aligned ankles.

Background

While realignment procedures (medial release, calcaneal osteotomies, lateral ligament reconstruction) facilitate coronal correction during TAA, long-term registry studies have questioned whether residual micro-instability accelerates polyethylene insert wear and unplanned revisions in mobile-bearing designs.

Assessment & Findings
  • Study Design & Cohort: Longitudinal comparative study of 417 primary mobile-bearing TAAs performed by a single non-developer surgeon with a median follow-up of 123 months (10.3 years; range 60 to 230 months), analyzing 103 varus ankles (preoperative coronal tibiotalar angle 10 degrees or greater; mean 18 plus/minus 6 degrees) versus 131 neutral ankles (mean 3 plus/minus 4 degrees).
  • 10-Year Metal Component Survivorship: Survivorship free from metal component revision did not differ between cohorts at 10-year follow-up (94.2% in varus [95% CI 89.8% to 98.9%] vs 93.7% in neutral [95% CI 89.9% to 99.4%]; P = 0.88).
  • Overall Revision & Reoperation Rates: Survivorship free from all revisions including polyethylene exchange was 75.1% in varus vs 68.7% in neutral (P = 0.19). Survivorship free from any unplanned reoperation was 63.1% in varus vs 63.4% in neutral (P = 0.94). Patient-reported outcome scores (VAS pain, AOS pain and disability) were completely comparable.
  • Asymmetric Polyethylene Wear: Despite equivalent implant survivorship, the varus group exhibited a significantly higher rate of asymmetric polyethylene inlay wear compared to the neutral group (42% [43 of 103] vs 17% [22 of 131]; P < 0.001).
Recommendation & Practice Takeaway

Clinical Pearl: Moderate to severe coronal varus deformity (10 degrees or greater) does not impair 10-year metal implant survivorship (both ~94%) provided meticulous intraoperative coronal balancing and ligament tensioning are achieved. However, because asymmetric polyethylene inlay wear occurs in over 40% of varus cases due to subtle persistent edge-loading, surgeons must ensure complete medial malleolar gutter decompression and consider proactive surveillance imaging to detect inlay thinning prior to metal-on-metal abutment.

Foot and Ankle

2. High prevalence of poor mental health in 358 patients with a symptomatic osteochondral lesion of the talus.

Authors: Pijnacker J, Agyeman-Prempeh N, Sierevelt I, Emanuel K et al. | Journal: The Bone & Joint Journal (Sep 2026) | View Source / DOI

Situation

Osteochondral lesions of the talus (OLT) cause chronic weight-bearing pain, recurrent swelling, and profound lifestyle restriction in young, active adults. This prospective investigation examined the unrecognized psychological and mental health burden in 358 patients with symptomatic OLT compared to nationwide population and psychiatric cohorts.

Background

Orthopaedic management of OLT has historically focused almost exclusively on morphological MRI staging, subchondral cyst dimensions, and surgical debridement or cartilage resurfacing techniques, neglecting the psychological distress associated with prolonged diagnostic delays and athletic disability.

Assessment & Findings
  • Study Design & Cohort: Prospective multicenter cohort of 358 consecutive patients with symptomatic, MRI-confirmed OLT evaluated prior to treatment and followed at 1 and 2 years post-intervention. Mental health was assessed using the validated Mental Health Inventory-5 (MHI-5; poor mental health threshold 76 or less) and benchmarked against the Netherlands Mental Health Survey (NEMESIS-3).
  • Prevalence of Psychological Distress: An alarming 87% of OLT patients (311 of 358) exhibited poor mental health prior to treatment. OLT patients scored 20.2 points lower than the general population (95% CI, 18.9 to 21.5; P < 0.001) and showed psychological scores statistically indistinguishable from clinical cohorts diagnosed with major mood or anxiety disorders (mean difference: 2.0; 95% CI, -0.3 to 4.3).
  • Longitudinal Persistence: Despite orthopaedic and surgical treatment, poor mental health persisted in 79% (170 of 214) at 1 year and 78% (134 of 173) at 2 years post-treatment.
  • Multivariate Risk Modeling: Active tobacco smoking (beta = -2.6; 95% CI, -4.7 to -0.4) and baseline Foot and Ankle Outcome Score (FAOS) pain severity (beta = 0.3; 95% CI, 0.1 to 0.3) were independently associated with significantly lower MHI-5 scores.
Recommendation & Practice Takeaway

Clinical Pearl: Symptomatic osteochondral lesions of the talus impose a psychological burden comparable to major mood and anxiety disorders, and this mental health deficit persists in nearly 80% of patients two years post-surgery. Foot and ankle surgeons must expand their diagnostic focus beyond talar defect dimensions to routinely screen for psychological distress (e.g., MHI-5, PROMIS Mental Health) and coordinate integrated behavioral health support alongside surgical repair.

Foot and Ankle

3. Long-term Survivorship of Transfibular Trabecular Metal Total Ankle Arthroplasty: 10-Year Minimum Clinical and Radiographic Follow-up.

Authors: Schafer K, Day J, Convery K, Zhang Z, Schon L | Journal: Foot & Ankle International (Sep 2026) | View Source / DOI

Situation

Utilization of total ankle arthroplasty (TAA) has surged worldwide, yet long-term durability data beyond 10 years for modern fourth-generation fixed-bearing implants remain sparse. This prospective single-surgeon cohort established the minimum 10-year implant survivorship, radiographic stability, and reoperation patterns of the transfibular trabecular metal (TM) TAA system.

Background

The lateral transfibular approach requires a fibular osteotomy but offers direct coronal visualization of the articular geometry and wide surface contact for porous trabecular metal biological fixation. Evaluating whether biological osseointegration maintains long-term survivorship without progressive osteolysis is critical for arthroplasty surgeons.

Assessment & Findings
  • Study Design & Cohort: Long-term follow-up of 71 ankles (68 patients; mean age 61 years, range 28 to 80) out of 79 consecutive primary transfibular TM TAAs (89.9% retention) with a mean follow-up of 11.0 years (IQR: 1.5; range 10 to 14 years). PROMs (SF-12 PCS/MCS, AOS, VAS pain) and CROCS reoperation coding were prospectively tracked.
  • Long-Term Implant Survivorship: Metal component revision-free survivorship was 98.6% at a mean of 11 years. Only 1 metal component revision occurred, secondary to deep periprosthetic joint infection requiring below-knee amputation (CROCS 11). Zero components loosened aseptically.
  • Reoperation Profile: Overall reoperation rate was 40.8% (29 ankles), with no ankle requiring more than 3 secondary procedures. The predominant indication for reoperation was soft tissue and gutter debridement for bony or capsular impingement (n = 12; CROCS 4).
  • Radiographic Stability & PROMs: Periprosthetic lucencies and osteolytic cysts were remarkably rare (5 small cysts detected in 4 ankles, 7%). Postoperative PROMs, coronal alignment, and sagittal motion arcs remained completely stable between midterm (5-year) and long-term (10-plus year) assessments.
Recommendation & Practice Takeaway

Clinical Pearl: Fourth-generation transfibular trabecular metal ankle replacement delivers outstanding biological fixation and long-term metal component durability (98.6% survivorship at 11 years) with minimal risk of late osteolytic loosening (7%). However, surgeons must educate patients regarding a ~40% lifetime risk of minor secondary procedures, primarily gutter debridement for impingement, emphasizing that secondary reoperations reflect soft tissue and gutter clearance rather than prosthetic failure.

Orthogate Weekly Journal Scan is curated and synthesized by ORION (Orthopaedic Research, Intelligence & Operations Navigator) for orthopaedic surgeons, fellows, and residents. Evidence synthesized under the clinical direction of Christian Veillette, MD, MSc, FRCSC.