OBJECTIVES: To evaluate soft tissue complications and the incidence of neurovascular bundle (NVB) injury following the modified posteromedial approach (moPMA) for posterior malleolar (PM) fractures, and to describe its indications in clinical practice.

METHODS:
Design: Retrospective, observational case-series study.
Setting: Single center with a dedicated foot and ankle trauma unit.
Patient Selection Criteria: Consecutive adult patients who underwent open reduction and internal fixation (ORIF) of PM fractures (AO/OTA 44 or 43) using the moPMA between 2014 and 2024. Exclusion criteria were open or pathological fractures, prior surgery at other institutions, or incomplete clinical records.
Outcome Measures: Primary outcomes were incidence of soft tissue complications and NVB injuries, graded according to the modified Clavien–Dindo classification for foot and ankle surgery.
Secondary outcomes included fracture classification according to AO/OTA and Bartonícek–Rammelt, associated procedures and approaches, surgical staging, fixation type, follow-up, and use of intraoperative imaging.

RESULTS: The mean age was 47 years (range 18–83 years), there were 14 male and 40 female patients. The mean time from injury to surgery was 5.9 days. According to the Bartonícek–Rammelt classification, 51.9% were type C, 31.5% type B, and 14.8% type D. Most cases (77.8%) were AO/OTA 44B3. The moPMA was used in the first surgical stage in 77.8% of cases. A second approach was required in 90.7%, most commonly for fibular fixation through a lateral approach (70.4%). Associated procedures were performed in 92.6%, with fibular osteosynthesis being the most frequent (66.7%). Fixation was plate-based in 92.5%. The mean follow-up was 63.1 6 31.4 months. Hardware removal of the posterior fixation was performed in 37.1%. Soft tissue complications occurred in 4 patients (7.4%), all classified as grade IA. No NVB injuries or tibialis posterior tendon contractures were reported.

CONCLUSIONS: The modified posteromedial approach for fixation of posterior malleolar fractures demonstrated low complication rates and no neurovascular injuries, supporting its use in a wide range of posterior malleolar fractures. KEY WORDS: modified posteromedial approach, moPMA, posterior malleolar fractures, soft tissue complications

LEVEL OF EVIDENCE: Level IV. Retrospective. Descriptive. Observational case-series study.

Background: Excessive laxity of the first ray has been implicated in various foot disorders. Accurate assessment is critical to define the most appropriate treatment. However, assessment currently depends largely on clinical examination and lacks objectivity. We evaluated the performance of an automated electromechanical tool developed to measure the relative dorsal mobility of the medial column compared to the lateral rays, and assessed the intra- and inter-examiner reliability of this device.

Methods: Two examiners assessed 30 feet of 17 volunteers. Data were collected 15 times on each foot. The intraclass correlation coefficient (ICC), Bland-Altman (B&A) graphical analysis, and the standard error of measurement (SEM) were calculated.

Results: Inter-rater and intra-rater ICC values (>0.9) were excellent. The Bland-Altman analysis revealed a mean bias of 0.07 mm between examiners.

Conclusion: This novel electromechanical device has demonstrated reliability in measuring first ray laxity, supporting its use in future studies aimed at quantifying first ray hyperlaxity.

Level of evidence: Level II, Prospective Reliability Study.

Early radiologic outcome and technical details of MIS
bunionectomy using a guided trajectory system is reported here.
From April 2022 to March 2023, 20 consecutive minimally invasive
bunionectomies were performed on 17 female patients (bilateral in 3
patients) with an average age of 63.6 (range: 46 to 82). The mean
IMA improved from 14.3 degrees (SD: 3.2) to 4.6 degrees (SD: 2.0),
HVA from 28.2 degrees (SD: 6.3) to 6.7 degrees (SD: 2.8), DMAA
from 16.6 degrees (SD: 5.6) to 6.6 degrees (SD: 1.8). Preoperatively,
17 feet (89.5%) were in TSP grades 2 and 3. Postoperatively, 19 feet
(95%) improved to either TSP grades 0 and 1. The mean duration of
operative time was 50 (SD: 9.25, range: 23 to 65) minutes. No
intraoperative complications were reported. Overall, this study
provides valuable insights into the benefits of using a guided trajectory
system to improve the success of bunion correction surgeries.
Level of evidence: Level 4.

Background: Recent literature highlights the importance of treating hallux valgus (HV) as a 3-dimensional (3D) deformity.
Although 3D printing may enhance visualization of the multiplanar aspects of HV, its influence on surgical planning remains unclear. This study assessed changes in surgical plans when surgeons sequentially reviewed 2D radiographs, 3D weightbearing computed tomography (WBCT), and 3D-printed models, hypothesizing that 3D printing would have the greatest impact.

Methods: A single HV case (a 40-year-old woman, intermetatarsal angle [IMA] 21 degrees, HV angle [HVA] 47 degrees) was evaluated by 30 surgeons in a masked, stepwise manner. Surgical plans were recorded at each stage. Surgeons rated the influence of WBCT and 3D printing using a 5-point Likert scale. A follow-up survey examined the effect of these technologies on correction amplitudes.

Results: The participants were mostly early career surgeons (median age 35.5 years, 2 years in practice). WBCT was accessible to 43.3% and used in 30% of HV cases, whereas 3D printing was accessible to 23.3% and used in 6.6%. Changes in the treatment algorithm occurred in 30% of cases after WBCT and in 43.3% after 3D printing. Significant differences (P < .05) were observed for the Lapicotton procedure between radiography and WBCT, and between WBCT and 3D printing. Surgeons performing <50 HV cases annually or with >70% Foot and Ankle specialization were more influenced by WBCT. Follow-up data (n = 23) indicated that WBCT and 3D printing influenced correction amplitudes, particularly for pronation and distal metatarsal articular angle (DMAA), more than for the IMA.

Discussion: Both WBCT and 3D printing influenced surgical planning, mostly explained by changes in first ray tarsometatarsal procedures. The rotational components (pronation and DMAA) were perceived as the most significantly affected. Future studies should explore cost-effectiveness, patient outcomes, and the utility of combining WBCT and 3D
printing in other deformities requiring multiplanar corrections.

Level of Evidence: Level IV, cross-sectional survey.