Orthogate Subspecialty Journal Scan: Foot and Ankle

Curated critical appraisals of recent high-impact trials and clinical evidence across foot and ankle surgery, evaluating early versus delayed weightbearing following operatively treated ankle fractures, weightbearing CT assessment of ankle-foot orthosis deformity correction in Charcot-Marie-Tooth disease, and clinical predictors of occult syndesmotic instability in osteochondral lesions of the talus.

Featured Foot and Ankle Studies This Edition (November 2026)
Level I Foot and Ankle

1. A Prospective Randomized Trial to Assess Early versus Delayed Weight Bearing Following Operatively Treated Ankle Fractures in the United States.

Authors: Obremskey W, Archer K, Gaski G, Gitajn I, Natoli R et al. | Journal: Journal of orthopaedic trauma (Oct 2026) | View Source / DOI

Situation

Multicenter prospective randomized trial comparing safety and return-to-work timelines between early (2 weeks postoperatively) and delayed (6 weeks postoperatively) weightbearing following surgical repair of ankle fractures across 19 United States trauma centers.

Background

Postoperative nonweightbearing protocols are traditionally enforced to prevent fixation loss following operative ankle fracture repair. Establishing whether early mobilization increases complication or reoperation rates while facilitating earlier vocational recovery guides evidence-based postoperative rehabilitation protocols.

Assessment & Findings
  • Study Design & Cohort: Prospective randomized study conducted across 19 trauma centers between January 2020 and October 2023 enrolling 418 adult patients (OTA/AO 44 A, B or C) undergoing surgical fixation without syndesmotic disruption. Patients were randomized to early weightbearing at 2 weeks (214 patients; mean age 47 [range 18-84], 35% male) versus delayed weightbearing at 6 weeks (204 patients; mean age 43, 36% male). Co-primary outcomes evaluated noninferiority for reoperation (hardware failure, nonunion, loss of reduction, infection, fusion) and superiority for return-to-work within 365 days.
  • Complication & Recovery Outcomes: Reoperation for complications occurred in 5 early weightbearing patients (2.3%, 95% CI: 0.3%, 4.4%) and 7 delayed weightbearing patients (3.4%, 95% CI: 0.9%, 5.9%). Early weightbearing was noninferior for complication-free survival (difference: 1.5 percentage points; 90% CI: -1.7%, 4.8%, safely excluding the -5.0% tolerance margin). Median return-to-work was 54 days (95% CI 42, 77) for early versus 69 days (95% CI 47, 89) for delayed weightbearing, but early weightbearing was not statistically superior for vocational return (hazard ratio 1.1, 95% CI: 0.8, 1.6, p = 0.475).
Recommendation & Practice Takeaway

Clinical Pearl: Immediate progression to weightbearing at 2 weeks following stable internal fixation of bimalleolar and trimalleolar fractures without syndesmotic disruption is clinically safe, with reoperation rates comparable to prolonged immobilization. While early loading did not significantly accelerate return-to-work, it safely eliminates weeks of unnecessary nonweightbearing disability.

Level II Foot and Ankle

2. Do Ankle-Foot Orthoses Reduce Cavovarus Deformity in Individuals With Charcot-Marie-Tooth Disease?

Authors: Requist M, Peterson A, Crowe L, Wilken J, Lenz A et al. | Journal: Clinical orthopaedics and related research (Oct 2026) | View Source / DOI

Situation

Prospective clinical imaging study utilizing weightbearing computed tomography (WBCT) and three-dimensional statistical shape modeling to assess whether ankle-foot orthoses (AFOs) reduce cavovarus deformity in patients with Charcot-Marie-Tooth (CMT) disease.

Background

Ankle-foot orthoses are a primary conservative intervention for cavovarus deformity in CMT disease. However, whether AFOs actively correct osseous foot posture under physiological weightbearing conditions or if orthotic footplate design impacts skeletal alignment remains uncharacterized.

Assessment & Findings
  • Study Design & Cohort: Prospective comparative study of 20 adults diagnosed with CMT disease (10 females, 10 males; mean age 49 ± 17 years) presenting between December 2023 and April 2025. Bilateral weightbearing CT scans were obtained barefoot and while wearing bilateral AFOs with shoes. Two-dimensional radiographic angles and 3D statistical shape modeling evaluated deformity across 3 footplate configurations: flat, custom, and flat with custom orthotic.
  • Radiographic & Morphological Findings: Two-dimensional measurements demonstrated a mean 3.8° increase in sagittal Meary angle and mean 3.3° decrease in calcaneal-first metatarsal angle in AFO scans relative to barefoot (p < 0.001), representing a more pronounced cavovarus posture. Statistical shape modeling showed a mean 27% increase in overall cavovarus position, 54% increase in plantarflexion, and 42% increase in midfoot elevation in AFOs compared to barefoot standing (p < 0.001). Custom footplate designs demonstrated smaller deformity accentuations than flat or orthotic footplates (p = 0.04).
Recommendation & Practice Takeaway

Clinical Pearl: Ankle-foot orthoses do not correct structural cavovarus alignment in Charcot-Marie-Tooth disease during physiological load, and unexpectedly increase cavovarus positioning on weightbearing CT. The clinical benefits of AFOs derive primarily from mechanical stabilization rather than osseous deformity correction, with custom-molded footplates minimizing deformity exaggeration compared to generic flat plates.

Level II Foot and Ankle

3. Preoperative clinical and imaging factors associated with arthroscopically confirmed occult syndesmotic instability in patients undergoing surgery for osteochondral lesions of the talus.

Authors: Jia S, Fu K, Li Z, Hao C, Fang Z | Journal: The bone & joint journal (Oct 2026) | View Source / DOI

Situation

Retrospective comparative study identifying preoperative clinical examination and imaging predictors of arthroscopically confirmed occult syndesmotic instability (OSI) in patients undergoing surgery for osteochondral lesions of the talus (OLTs).

Background

Osteochondral lesions of the talus frequently present with persistent postoperative pain. A subset of patients harbor occult distal tibiofibular syndesmotic instability that escapes routine static radiographs, necessitating preoperative risk stratification to guide targeted arthroscopic probing and potential stabilization.

Assessment & Findings
  • Study Design & Cohort: Retrospective review of 175 patients diagnosed with OLTs who underwent ankle arthroscopy between January 2021 and June 2023. Distal tibiofibular stability was probed arthroscopically, categorizing patients into OLT with OSI (36 patients, 20.6%) and OLT without OSI. Preoperative demographics, physical examination findings, and imaging characteristics were analyzed using univariate and multivariate logistic regression.
  • Predictive Biomarkers: Multivariate logistic regression identified higher BMI (odds ratio [OR] 1.811 [95% CI 1.418 to 2.312]; p < 0.001; receiver operating characteristic cut-off above 25.6 kg/m2), presence of osteophytes (OR 0.260 [95% CI 0.087 to 0.775]; p = 0.016), and Bassett's ligament hypertrophy (OR 0.108 [95% CI 0.030 to 0.387]; p = 0.001) as independent associated factors for occult syndesmotic instability.
Recommendation & Practice Takeaway

Clinical Pearl: Occult syndesmotic instability is present in 20.6% of patients undergoing arthroscopic treatment for osteochondral talar lesions. In patients presenting with a BMI greater than 25.6 kg/m2, Bassett's ligament hypertrophy, or anterior osteophytes, foot and ankle surgeons should routinely perform dynamic arthroscopic probe evaluation of distal tibiofibular translation to avoid missing unrecognized syndesmotic incompetence.

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.