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Fracture Fixation & Osteotomy

Foot/ankle fracture fixation & osteotomies: calcaneal fracture management, HTO techniques, and pediatric deformity correction.

Overview

Intra-articular osteotomy for malunited articular fractures of the distal humerus yields satisfactory long-term outcomes in carefully selected patients provided there is a clear understanding of the deformity, accurate reduction, and stable fixation [1]. Similarly, successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [7]. For varus malunion of the proximal humerus, valgus osteotomy with plate and screw fixation achieves bony union in all cases, improves range of motion and UCLA scores, and results in patient satisfaction [17].

Fixation strategies vary by pathology to optimize healing and minimize complications. For osteochondral lesions of the talus, fixation leads to successful clinical outcomes in 9 out of 10 patients, with fragment union achieved in 9 out of 10 cases and a low reported complication rate [4]. In Jones fractures, intramedullary screw fixation offers advantages over nonoperative treatment in a select group, though a risk for postoperative complications exists [5]. Conversely, screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications requiring additional surgery compared to shock wave therapy [3]. For congenital radioulnar synostosis, internal fixation at the osteotomy site appears unnecessary for one-stage rotational osteotomy [2].

Specific osteotomy techniques address unique biomechanical challenges. A medial opening wedge high tibial osteotomy requires a sufficient cut involving both anterior and posterior cortices, extending to the fibular head level, to avoid lateral hinge fracture [10]. The inverted V-shaped high tibial osteotomy (iVHTO) fixed with a locking compression plate offers early bone union and rare complications [19]. In subtrochanteric shortening osteotomy for high hip dislocation, autogenous cortical bone struts positively influence healing [13]. Finally, the triple modified French osteotomy may obviate the need for more complex procedures while addressing drawbacks of simple closing wedge osteotomy for cubitus varus deformity [20].

Anatomy & Pathophysiology

Osseous Deformity and Fracture Mechanics

The severity of acquired flatfoot deformity directly influences the radiographic and pedobarographic efficacy of corrective procedures [28]. In hallux valgus correction, the chevron technique provides superior stability against fragment displacement during axial loading compared to other percutaneous methods, though all percutaneous distal first metatarsal osteotomies increase plantar angulation of the metatarsal head [30]. The revolving scarf osteotomy (RSO) avoids metatarsal shortening and avascular necrosis of the metatarsal head [48]. For Jones fractures, a high medial longitudinal arch predisposes the lateral foot to increased load [32], while the majority of patients exhibit varus hindfoot alignment, a likely factor in fracture development or refracture [45]. Regarding fixation for these fractures, plantar-lateral plating demonstrates greater cycles to failure, higher peak load before failure, and reduced gap width compared to intramedullary screw fixation [36]. In fifth metatarsal stress fractures treated with Herbert screw fixation, intraoperative plantar gap widening does not impact surgical outcomes [41].

Calcaneal and Talar Pathology

Foot injuries involving the calcaneus, talus, and midfoot are common and carry a high risk of severe functional limitation or long-term disability if missed [56]. Clinical and gait outcomes following calcaneal fractures are strongly influenced by Essex-Lopresti subtypes [50]. For older adults, a personalized medial incision tailored to fracture morphology offers superior exposure and reduction compared to traditional approaches [53]. Integrating this personalized medial incision with a sinus-tarsi approach further minimizes soft tissue complications [53]. Stress fractures of the talus do not appear to cause serious damage to the foot [40]. In snowboarders, eversion of an axially loaded and dorsiflexed ankle represents a critical injury mechanism for lateral process of the talus fractures [59].

Hindfoot and Midfoot Alignment

Surgical correction of adult idiopathic cavus foot via plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy restores the ability to alternate pronation and supination during gait without compromising range of motion [34]. Hallux valgus deformity severity correlates positively with the magnitude of anteroposterior postural sway [31]. For first metatarsophalangeal joint arthrodesis, unlocked plate plus screw and crossed screw constructs are the stiffest and most resistant to joint opening under cyclic loading [51]. Metal staples for internal fixation and bone-chip grafts in foot-stabilization procedures maintain position and achieve fusion without displacement or serious complications [49].

Vascular and Neural Safety

When inserting heel wires for hindfoot external fixation frames, positioning the entry point one-third of the way along a line between the heel point and the lateral malleolus tip, with a maximum angle of 30° to the coronal plane, ensures no wires penetrate within 5 mm of the posterior tibial neurovascular bundle [42].

Classification

Distal Humerus Malunions: Intra-articular osteotomy for malunited articular fractures of the distal humerus yields satisfactory long-term outcomes in carefully selected patients when there is a clear understanding of the deformity, followed by osteotomy, accurate reduction, and stable fixation [1].

Paediatric Forearm Malunions: Predictors of superior functional outcome after corrective osteotomy for malunited paediatric forearm fractures include an interval between trauma and corrective osteotomy of less than 1 year [11], an angular deformity of greater than 20° [11], and the use of three-dimensional computer-assisted techniques [11].

Proximal Humerus Varus Malunions: Valgus osteotomy with plate and screw fixation for varus malunion of the proximal humerus resulted in bony union in all cases [17], improved range of motion and UCLA scores [17], and led to patient satisfaction in all treated cases [17].

Congenital Radioulnar Synostosis: Internal fixation at the osteotomy site seems to be unnecessary for one-stage rotational osteotomy for congenital radioulnar synostosis [2].

Osteochondral Lesions of the Talus: Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients [4]. Fragment union is achieved in 9 out of 10 patients with fixation for osteochondral lesions of the talus, with a low reported complication rate [4]. Internal fixation of an osteochondral lesion of the talus involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes [9].

Jones Fractures: Jones fractures are classified, diagnosed, and treated with considerations for nonsurgical management, intramedullary screw, and plate fixation [12]. Intramedullary screw fixation of Jones fractures has advantages over nonoperative treatment in a select group of patients, but the risk for postoperative complications exists [5].

Proximal Fifth Metatarsal Nonunions: Screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications that frequently result in additional surgery compared to shock wave therapy [3].

Tarsometatarsal Joint Injuries: Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [7].

Cuboid Fractures: The treatment of cuboid fractures is described in the literature [6].

Tibial Plateau and Tibial-Fibular Shaft Fractures: Treatment strategies for tibial plateau and tibial-fibular shaft fractures emphasize the importance of soft tissue management and specific surgical techniques to minimize complications [52].

Ankle and Tibial Plafond Fractures: Treatment principles for fractures of the ankle and tibial plafond emphasize restoring fibular length [57], addressing specific fracture patterns based on classification systems [57], and managing soft tissue in high-energy tibial plafond fractures through staged protocols [57].

Other Considerations: The evidence base includes descriptions of treatment strategies for cuboid fractures [6] and specific considerations for the classification, diagnosis, and treatment of Jones fractures [12].

Clinical Presentation

Intra-articular osteotomy for malunited articular fractures of the distal humerus yields satisfactory long-term outcomes in carefully selected patients when there is a clear understanding of the deformity, followed by osteotomy, accurate reduction, and stable fixation [1]. For varus malunion of the proximal humerus, valgus osteotomy with plate and screw fixation results in bony union in all cases, improves range of motion and UCLA scores, and leaves all patients satisfied with the treatment [17]. Subtrochanteric valgus osteotomy serves as a good option for patients with a delayed diagnosis of stress fracture presenting with displacement and varus angulation of the femoral neck [8].

Predictors of superior functional outcome after corrective osteotomy for malunited paediatric forearm fractures include an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20°, and the use of three-dimensional computer-assisted techniques [11]. In medial opening wedge high tibial osteotomy, a sufficient osteotomy involving both the anterior and posterior cortices, with an endpoint at the level of the fibular head, must be performed to avoid lateral hinge fracture as a complication [10]. For one-stage rotational osteotomy in congenital radioulnar synostosis, internal fixation at the osteotomy site appears unnecessary [2].

Fracture Management Modalities: * Jones Fractures: Intramedullary screw fixation offers advantages over nonoperative treatment in a select group of patients, though the risk for postoperative complications exists [5]. * Proximal Fifth Metatarsal: Screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications requiring additional surgery compared to shock wave therapy [3]. There are three distinct fracture patterns in the proximal fifth metatarsal, each having its own mechanism of injury, location, treatment options, and prognosis regarding delayed union and nonunion [44]. * Sesamoid Fractures: Acute fractures of medial and lateral great toe sesamoids in an athlete heal uneventfully after non-surgical treatment [14]. * Lisfranc Injuries: Stable Lisfranc injuries generally have good outcomes with nonoperative management, whereas displaced or comminuted Lisfranc injuries require surgical intervention, with open reduction and internal fixation being the most common approach [16].

Osteochondral Lesions and Nonunion: Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients, with fragment union achieved in 9 out of 10 patients and a low reported complication rate [4]. Internal fixation of an osteochondral lesion of the talus involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes [9]. Symptomatic plate prominence and nonunion are the 2 main concerns with ulnar shortening osteotomy fixed with a dynamic compression system [21].

General Pediatric and Joint Considerations: Fractures of the tibia, ankle, and foot are common in children and adolescents, with management ranging from nonsurgical immobilization to surgical intervention depending on fracture stability, displacement, and patient age [15]. Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [7].

Investigations

Plain radiography: Intra-articular osteotomy for malunited articular fractures of the distal humerus requires a clear understanding of the deformity to achieve satisfactory long-term outcomes [1]. For complex radius shaft malunion, plain radiographs may fail to detect combined axial and angular deformities that are quantifiable via computer-assisted planning [65]. In developmental dysplasia of the hip, the acetabular index and center-edge angle at age 3 years serve as guidelines for osteotomy following closed reduction [67]. Radiological outcomes after scarf osteotomy are superior when performed with a concomitant Akin osteotomy [26].

CT: Computer-assisted operation planning facilitates the quantification of combined axial and angular malunions in complex radius shaft malunion which were difficult to detect on plain radiographs [65]. The use of three-dimensional computer-assisted techniques is a predictor of superior functional outcome after corrective osteotomy for malunited paediatric forearm fractures [11].

Other Considerations: Intra-articular osteotomy for malunited articular fractures of the distal humerus leads to satisfactory long-term outcomes in carefully selected patients when there is a clear understanding of the deformity, followed by osteotomy, accurate reduction, and stable fixation [1]. Internal fixation at the osteotomy site seems to be unnecessary for one-stage rotational osteotomy for congenital radioulnar synostosis [2]. Screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications that frequently result in additional surgery compared to shock wave therapy [3]. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients [4]. Fragment union is achieved in 9 out of 10 patients with fixation for osteochondral lesions of the talus, with a low reported complication rate [4]. Intramedullary screw fixation of Jones fractures has advantages over nonoperative treatment in a select group of patients, though the risk for postoperative complications exists [5]. Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [7]. Subtrochanteric valgus osteotomy is a good option for patients with a delayed diagnosis of stress fracture with displacement and varus angulation of the femoral neck [8]. Internal fixation of an osteochondral lesion of the talus involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes [9]. Predictors of superior functional outcome after corrective osteotomy for malunited paediatric forearm fractures include an interval between trauma and corrective osteotomy of less than 1 year [11] and an angular deformity of greater than 20° [11]. Patients treated according to guidelines for surgical repair of zones 2 and 3 fifth metatarsal fractures achieved satisfactory patient reported and radiographic outcomes [18]. Early completion of bone union with rare complications is a clinical advantage of the inverted V-shaped high tibial osteotomy fixed with a locking compression plate [19]. Symptomatic plate prominence and nonunion are the two main concerns with ulnar shortening osteotomy fixed with a dynamic compression system [21]. Union of the grafted osteochondral plug and the entire lesion was confirmed on roentgenograms within 6 months of surgery for cylindrical osteochondral graft for osteochondritis dissecans of the knee [64]. Preservation of the corticoperiosteal attachment significantly shortened the endosteal union time at osteotomy sites after ulna-shortening osteotomy [71].

Treatment

Non-Operative

Non-surgical management is frequently successful for acute fractures of the process and tubercle of the hindfoot [23], and acute zone 1 proximal fifth metatarsal fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management [61]. Stable Lisfranc injuries generally have good outcomes with nonoperative management [16], while acute fractures of medial and lateral great toe sesamoids in an athlete healed uneventfully after non-surgical treatment [14]. Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures [54]. Fractures of the tibia, ankle, and foot in children and adolescents are managed with nonsurgical immobilization depending on fracture stability, displacement, and patient age [15].

Operative

Indications: Surgical intervention is required for displaced or comminuted Lisfranc injuries [16], and subtrochanteric valgus osteotomy is indicated for patients with a delayed diagnosis of stress fracture with displacement and varus angulation of the femoral neck [8]. Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus can lead to satisfactory long-term outcomes in carefully selected patients [1]. Patients treated according to guidelines for surgical repair of zones 2 and 3 fifth metatarsal fractures achieved satisfactory patient reported and radiographic outcomes [18], and operative interventions for fifth metatarsal base fractures demonstrate beneficial effects compared to non-operative interventions for reducing the rate of non-union, duration of union, duration of return to activity, duration of return to sport, and visual analog scale scores, while increasing the American orthopedic foot & ankle scale score [55]. Intramedullary screw fixation of Jones fractures has advantages over nonoperative treatment in a select group of patients [5]. Late surgical intervention can substantially improve pain and function in untreated chronic injuries of the process and tubercle of the hindfoot [23].

Surgical Approach / Technique: Successful surgical management of tarsometatarsal joint injuries is predicated on anatomic reduction and stable fixation [7]. A sufficient osteotomy involving both the anterior and posterior cortices, whose endpoint is at the level of the fibular head, should be performed when undertaking a medial opening wedge high tibial osteotomy to avoid lateral hinge fracture [10]. Triple modified French osteotomy may obviate the need for more complex procedures while addressing potential drawbacks of a simple closing wedge osteotomy for cubitus varus deformity [20]. Union took place promptly within eight weeks in all patients with modification of Mitchell's lateral displacement angulation osteotomy, with no loss of position [22]. Arthroscopic treatment of a talar neck fracture represents a challenging and seducing alternative to open reduction and internal fixation [33]. The sinus tarsi approach seems to be more reasonable than the extensile lateral approach for Sanders type II/III calcaneus fractures due to merits including less postoperative pain, less expense of analgesia, and less expense of internal fixation materials [47]. Maintaining the vastus lateralis attachment to the osteotomy fragment is possible in extended slide trochanteric osteotomy, with three technical methods described to achieve this without sacrificing the muscle attachment [35]. Anterior distal femoral osteotomy for removal of long femoral stems allows healing of the osteotomy assuming maintenance of soft tissue attachments throughout the procedure [37].

Implant Selection: Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients [4]. Fragment union is achieved in 9 out of 10 patients with fixation for osteochondral lesions of the talus, with a low reported complication rate [4]. Internal fixation of an osteochondral lesion of the talus involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes [9]. Screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications that frequently result in additional surgery compared to shock wave therapy [3]. Caution is advocated with bioabsorbable fixation screws for unstable osteochondritis dissecans lesions in adolescent patients, with careful patient selection and meticulous surgical technique recommended [24]. An uncemented implant may still be appropriate for patients at very high risk of bone cement implantation syndrome in femoral neck fractures in patients with neuromuscular diseases [62]. Provided that the implant is stable, fracture fixation is effective for periprosthetic fractures of the tibia in knee arthroplasty following appropriate principles depending on the personality of the fracture [38].

Adjuncts: Internal fixation at the osteotomy site seems to be unnecessary for one-stage rotational osteotomy for congenital radioulnar synostosis [2]. The fixation technique of autogenous cortical bone struts had a positive influence on osteotomy healing of subtrochanteric shortening osteotomy in patients with high hip dislocation after childhood pyogenic infection or Crowe IV developmental dysplasia of the hip [13].

Other Considerations: Recommendation for concomitant Akin osteotomy in patients undergoing Chevron osteotomy may be determined by a preoperative PDPAA exceeding 8° [58].

Complications

Infection (PJI): Surgical site infections represent a significant risk across multiple procedures. The incidence of surgical site infection was high (9.7%) for calcaneus fractures following open reduction and internal fixation [80]. Reoperation rates and superficial infections with the described method of fixation for thumb metacarpal osteotomy were relatively high [76]. Screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is more often associated with complications that frequently result in additional surgery compared to shock wave therapy [3]. Prior osteosynthesis increases revision risk after total knee arthroplasty predominantly via periprosthetic infection, whereas prior osteotomy does not [66]. Bioabsorbable fixation for unstable osteochondritis dissecans lesions in adolescent patients has been associated with failure, warranting caution, careful patient selection, and meticulous surgical technique [24].

Wound complications: Surgical site complications requiring readmission or reoperation should be considered major complications when reporting results and guidelines for future recommendations and studies of venous thromboembolism prophylaxis in total hip arthroplasty [74]. Modified Mitchell's osteotomy and shortening oblique osteotomy for forefoot deformities with hallux valgus due to rheumatoid arthritis provide clear benefits, though careful attention should be paid to potential postoperative complications such as the appearance of hallux valgus deformity and infection [81]. The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy [63].

Thromboembolism: Postoperative weightbearing timing after distal femur osteotomy is not associated with rates of union or complications, with relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and venous thromboembolism regardless of early or delayed protocols [60]. The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy [63].

Other Considerations: Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus can lead to satisfactory long-term outcomes in carefully selected patients when there is a clear understanding of the deformity, accurate reduction, and stable fixation [1]. Internal fixation at the osteotomy site seems to be unnecessary for one-stage rotational osteotomy for congenital radioulnar synostosis [2]. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients with a low reported complication rate [4]. Intramedullary screw fixation of Jones fractures carries a risk for postoperative complications despite advantages over nonoperative treatment in a select group of patients [5]. Subtrochanteric valgus osteotomy is a good option for patients with a delayed diagnosis of stress fracture with displacement and varus angulation of the femoral neck [8]. Patients treated according to guidelines for surgical repair of zones 2 and 3 fifth metatarsal fractures achieved satisfactory patient-reported and radiographic outcomes [18]. Early completion of bone union with rare complications is a clinical advantage of the inverted V-shaped high tibial osteotomy (iVHTO) procedure fixed with a locking compression plate [19]. There is insufficient data to draw conclusions regarding the timing of surgery for operative and non-operative treatment of avulsion fracture of the hamstring origin due to high risk of bias in included studies [25]. Reoperation rates and superficial infections with the described method of fixation for thumb metacarpal osteotomy were relatively high, though the procedure provides some degree of pain relief and improvement of function [76]. Arthroscopy-assisted absorbable screw combined with Kirschner wire internal fixation for Sanders type III displaced intra-articular calcaneal fractures is associated with a low incidence of postoperative complications and a quick return to sports activities [77]. It is not clear if the improved outcome of the anterolateral approach with tibial tubercle osteotomy outweighs the longer operation time and higher risk of early complications and revisions compared to the standard medial approach for primary total knee arthroplasty [78]. The rate of secondary arthrodesis in a cohort treated with minimally invasive surgery for intra-articular calcaneus fractures was comparable to that in the literature [79]. The incidence of stress fractures following periacetabular osteotomy is higher than previously reported at 18.4% [82]. Despite a high complication rate, trabecular metal cones represent an attractive option for managing bone loss in complex primary and revision total knee arthroplasty with a high rate of osseointegration and excellent short-term results [73].

Recovery

Light activity (weeks): Return to desk work and light activities of daily living is feasible within eight weeks following closed or open treatment of calcaneal tuberosity avulsion fractures in children [46] and after modification of Mitchell's lateral displacement angulation osteotomy [22]. Patients undergoing acute medial tibial plateau elevation correction with an Ilizarov fixator may achieve full deformity correction and safety profiles that support early mobilization, though specific timelines for light activity are not explicitly defined in the provided evidence [75].

Full activity (months): Full weight-bearing and rapid return to normal function are achievable immediately following tibial tubercle transplantation [68]. Patients with plastic deformation of the forearm treated via single-cortex, double-level osteotomies combined with rigid internal fixation and early range of motion can resume full activity protocols [43]. For Jones fractures, intramedullary screw fixation offers advantages over nonoperative treatment in select groups, though postoperative complications remain a risk [5]. Conversely, screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures is frequently associated with complications requiring additional surgery compared to shock wave therapy [3].

Complete recovery / outcome plateau (months): Satisfactory long-term outcomes are achievable in carefully selected patients following intra-articular osteotomy for malunited articular fractures of the distal humerus [1]. Radiological outcomes after scarf osteotomy are superior when combined with a concomitant Akin osteotomy [26]. While solid bony union is confirmed within eight weeks for 5th metatarsal stress fractures treated with modified tension band wiring, a cautious rehabilitation program is required to reduce refracture risk [29]. In contrast, despite restoration of normal patellar height following reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft, function does not return to preinjury levels [70]. Predictors of superior functional outcomes after corrective osteotomy for malunited paediatric forearm fractures include an interval between trauma and surgery of less than one year, an angular deformity greater than 20°, and the use of three-dimensional computer-assisted techniques [11].

Rehabilitation protocol: A sufficient osteotomy involving both anterior and posterior cortices, with an endpoint at the level of the fibular head, is required during medial opening wedge high tibial osteotomy to avoid lateral hinge fracture [10]. Internal fixation at the osteotomy site appears unnecessary for one-stage rotational osteotomy for congenital radioulnar synostosis [2]. For subtrochanteric shortening osteotomy in patients with high hip dislocation, the fixation technique of autogenous cortical bone struts positively influences healing [13]. Stable Lisfranc injuries generally respond well to nonoperative management, whereas displaced or comminuted injuries require surgical intervention with open reduction and internal fixation [16]. Acute fractures of the medial and lateral great toe sesamoids in athletes heal uneventfully with non-surgical treatment [14]. Nonsurgical management is frequently successful for acute process and tubercle fractures of the hindfoot, while late surgical intervention can substantially improve pain and function in untreated chronic injuries [23]. For isolated posterolateral tibial plateau fractures, the supra-fibular-head approach allows full exposure, and horizontal belt plate fixation is stable enough to permit early-stage knee rehabilitation [69].

Functional milestones: Fragment union is achieved in 9 out of 10 patients following fixation for osteochondral lesions of the talus, with a low reported complication rate [4]. Revision fixation with a large, solid screw (5.5 mm or larger) and autologous bone grafting is recommended for symptomatic refractures and nonunions of the proximal fifth metatarsal in elite athletes to restore function [72].

Other Considerations: There is insufficient data to draw conclusions regarding the timing of surgery for avulsion fracture of the hamstring origin, with evidence levels remaining low due to high risk of bias [25]. Fractures of the tibia, ankle, and foot are common in children and adolescents, with management ranging from nonsurgical immobilization to surgical intervention depending on fracture stability, displacement, and patient age [15].

Key Evidence

  • [L4] A clear understanding of the deformity, followed by osteotomy, accurate reduction, and stable fixation, can lead to satisfactory long-term outcomes in carefully selected patients. (10.1016/j.jse.2013.12.020)
  • [L4] Internal fixation at the osteotomy site seems to be unnecessary. (10.1177/1753193415580066)
  • [L3] Screw fixation is more often associated with complications that frequently result in additional surgery. (10.2106/jbjs.i.00653)
  • [L4] Moreover, fragment union is achieved in 9 out of 10 patients, with a low reported complication rate. (10.1016/j.jisako.2025.100389)
  • [L4] Although intramedullary screw fixation of Jones fractures has advantages over nonoperative treatment in a select group of patients, the risk for postoperative complications exists. (10.1177/03635465020300012301)
  • [L4] The treatment of these fractures is described. (10.1302/0301-620x.98b7.36639)
  • [L5] Successful surgical management is predicated on anatomic reduction and stable fixation. (10.5435/jaaos-d-15-00556)
  • [L4] Subtrochanteric valgus osteotomy is a good option for patients with a delayed diagnosis of stress fracture with displacement and varus angulation. (10.1177/0363546507299241)
  • [L4] Internal fixation of an OLT involving a large bone fragment resulted in satisfactory clinical and radiologic outcomes. (10.1177/0363546520988739)
  • [L3] A sufficient osteotomy involving both the anterior and posterior cortices, whose endpoint is at the level of the fibular head, should be performed when undertaking a medial opening wedge high tibial osteotomy if a lateral hinge fracture is to be avoided as a complication. (10.1302/0301-620x.99b7.bjj-2016-0927.r1)
  • [L2] Predictors of superior functional outcome after corrective osteotomy are an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20°, and the use of three-dimensional computer-assisted techniques. (10.1177/1753193417711684)
  • [L5] This article reviews the classification, diagnosis, and treatment considerations for Jones fractures, covering nonsurgical management, intramedullary screw, and plate fixation, with a focus on the authors' preferred technique using intramedullary screw fixation. (10.5435/jaaos-d-21-00542)
  • [L3] The fixation technique of autogenous cortical bone struts had a positive influence on osteotomy healing of SSO in this specific setting. (10.1186/s13018-020-01947-5)
  • [L4] The fractures healed uneventfully after non-surgical treatment. (10.1007/s00167-003-0472-6)
  • [L4] Stable injuries generally have good outcomes with nonoperative management, while displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation being the most common approach. (10.1302/0301-620x.106b12.bjj-2024-0581.r1)
  • [L4] Valgus osteotomy with plate and screw fixation resulted in bony union in all cases, improved range of motion and UCLA scores, and all patients were satisfied with the treatment. (10.1016/j.jse.2006.04.011)
  • [L4] Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. (10.1186/s13018-021-02331-7)
  • [L4] Early completion of bone union with rare complications is one of the clinical advantages of this iVHTO procedure. (10.1177/23259671251369002)
  • [L4] It may obviate the need for more complex procedures while addressing potential drawbacks of a simple closing wedge osteotomy. (10.1016/j.jse.2014.06.030)
  • [L4] Symptomatic plate prominence and nonunion are the 2 main concerns with this technique. (10.1016/j.jhsa.2013.04.040)
  • [L4] Union took place promptly within eight weeks in all patients with no loss of position. (10.2106/00004623-196951070-00024)
  • [L5] Nonsurgical management is frequently successful for acute fractures, while late surgical intervention can substantially improve pain and function in untreated chronic injuries. (10.5435/00124635-200512000-00002)
  • [Case_report] The authors advocate caution with these screws for unstable osteochondritis dissecans lesions and recommend careful patient selection and meticulous surgical technique. (10.1016/j.jisako.2023.05.005)
  • [L4] There is insufficient data to draw conclusions regarding the timing of surgery, and the evidence level is low due to high risk of bias in included studies. (10.1007/s00167-020-06222-y)
  • [L3] Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy. (10.1186/s13018-019-1241-7)
  • [L5] In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity. (10.2106/jbjs.e.00045)
  • [L4] The authors emphasize that solid bony union must be confirmed and a cautious rehabilitation program should be devised to reduce the risk of refracture. (10.1007/s00167-011-1406-3)
  • [L5] Although the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head. (10.1186/s13018-023-03702-y)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L3] In addition, high medial longitudinal arch may contribute to increased load on the lateral side of the foot. (10.1177/0363546519893365)
  • [Case_report] This technique represents a challenging and seducing alternative to open reduction and internal fixation. (10.1007/s00167-011-1742-3)
  • [L4] This surgical procedure provides good correction of adult idiopathic cavus foot without compromising the range of motion of the foot, allowing alternating pronation and supination during gait. (10.2106/00004623-200200002-00008)
  • [L5] The authors clarify that maintaining the vastus lateralis attachment to the osteotomy fragment is possible and describe three technical methods to achieve this without sacrificing the muscle attachment. (10.2106/00004623-200107000-00020)
  • [L5] As compared with intramedullary screw fixation, plantar-lateral plating allowed for greater cycles to failure and peak load before failure, as well as less gap width, when applied to cadaver foot specimens with simulated Jones fractures exposed to cantilever bending in a load frame. (10.1177/0363546517753376)
  • [L4] Provided that the implant is stable, fracture fixation is effective following the appropriate principles depending on the personality of the fracture. (10.1002/ksa.12692)
  • [L4] Stress fractures of the talus do not seem to seriously damage the foot. (10.1177/0363546506291405)
  • [L4] Additionally, intraoperative plantar gap widening does not affect the surgical results using this technique. (10.1177/03635465211045998)
  • [L5] The study recommends an insertion point one-third of the way along a line between the point of the heel and the tip of the lateral malleolus with a maximum angle of 30° to the coronal plane, as no wires inserted using this technique came within 5 mm of the posterior tibial neurovascular bundle. (10.1302/0301-620x.100b8.bjj-2017-1427.r1)
  • [L4] Single-cortex, double-level osteotomies combined with rigid internal fixation and early range of motion is a viable treatment option for plastic deformation of the forearm in adults. (10.1016/j.jhsa.2010.11.042)
  • [L5] There are three distinct fracture patterns in the proximal fifth metatarsal, each having its own mechanism of injury, location, treatment options, and prognosis regarding delayed union and nonunion. (10.5435/00124635-200009000-00007)
  • [L4] The majority of patients sustaining Jones fractures have evidence of varus hindfoot alignment, which may be a predisposing factor to developing the fracture or refracture. (10.1177/0363546508314401)
  • [L4] Closed or open treatment led to excellent results, with apparent healing of all fractures by eight weeks and with no occurrence of skin necrosis or functional loss. (10.2106/00004623-199510000-00013)
  • [L5] Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials. (10.1186/s13018-020-01963-5)
  • [L3] However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. (10.1186/s12891-019-2874-8)
  • [L4] The use of metal staples for internal fixation and bone-chip grafts in foot-stabilization procedures has proved to have advantages, including maintaining position and achieving fusion without displacement or serious complications. (10.2106/00004623-195335040-00013)
  • [L3] Essex-Lopresti subtypes strongly influence clinical and gait outcomes following calcaneal fractures. (10.1186/s13018-025-06533-1)
  • [L5] The unlocked plate plus screw and crossed screw constructs were the stiffest and most resistant to joint opening under cyclic loading. (10.1186/s13018-017-0525-z)
  • [L4] A personalized medial incision based on fracture morphology provides better exposure and reduction compared to traditional methods, and its integration with a sinus-tarsi approach minimizes soft tissue complications. (10.1186/s13018-025-05934-6)
  • [L1] Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. (10.1177/0363546509355408)
  • [L1] The systematic review and meta-analysis recommend the use of operative interventions for managing the fifth metatarsal's base fracture, demonstrating beneficial effects compared to non-operative interventions for reducing the rate of non-union, duration of union, duration of return to activity, duration of return to sport, and visual analog scale scores, while increasing the American orthopedic foot & ankle scale score. (10.1371/journal.pone.0237151)
  • [L3] Recommendation for concomitant Akin osteotomy may be determined by a preoperative PDPAA exceeding 8°. (10.1186/s13018-019-1319-2)
  • [L5] Eversion of an axially loaded and dorsiflexed ankle may be an important injury mechanism for fracture of the lateral process of the talus among snowboarders. (10.1177/03635465030310063001)
  • [L4] There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and VTE after DFO, regardless of an early or delayed post-operative weightbearing protocol. (10.1002/ksa.70340)
  • [L4] Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. (10.1007/s00167-020-06072-8)
  • [Letter] The authors clarify that pain and functional outcomes were assessed at the last follow-up, confirm that all surgeries were performed by experienced surgeons or residents supervised by experienced surgeons, and note that while intraoperative death was not detected, an uncemented implant may still be appropriate for patients at very high risk of bone cement implantation syndrome. (10.1186/s13018-021-02674-1)
  • [L4] The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy. (10.2106/jbjs.j.01769)
  • [L4] Union of the grafted osteochondral plug and the entire lesion was confirmed on roentgenograms within 6 months of surgery. (10.1177/03635465020300032301)
  • [L4] The computer-assisted operation planning facilitated the quantification of combined axial and angular malunions which were difficult to detect on plain radiographs. (10.1007/s11552-009-9233-4)
  • [L4] Prior osteosynthesis increases revision risk after TKA—predominantly via infection—whereas prior osteotomy does not. (10.1002/ksa.70153)
  • [L3] The AI and CEA at the age of 3 years can serve as one of the guidelines for osteotomy. (10.2106/jbjs.15.00992)
  • [L4] The operative procedure has been successfully carried out in eleven knees in seven different patients for three different clinical conditions, allowing immediate unsupported full weight-bearing and rapid return to normal function. (10.2106/00004623-195133020-00023)
  • [L4] For an isolated posterolateral tibial plateau fracture, the supra-fibular-head approach can fully expose the fracture site; the horizontal belt plate fixation of the fracture is stable and reliable to allow for early-stage knee rehabilitation, and the outcome of medium-term clinical follow-up was satisfactory. (10.1155/2020/4186712)
  • [L4] However, despite the restoration of a normal patellar height, function did not return to preinjury level. (10.1007/s00167-015-3951-7)
  • [L4] Preservation of the corticoperiosteal attachment significantly shortened the endosteal union time. (10.1007/s11552-014-9662-6)
  • [L4] The authors recommend revision fixation with a large, solid screw (5.5 mm or larger) and autologous bone grafting for symptomatic refractures and nonunions of the proximal fifth metatarsal in elite athletes. (10.1177/0363546511408868)
  • [L2] Surgical site complications requiring readmission or reoperation should be considered major complications when reporting the results and guidelines of future recommendations and studies of VTE prophylaxis in THA/TKA. (10.1016/j.arth.2006.12.018)
  • [L4] The management protocol entailed acute elevation of the medial tibial plateau depression combined with gradual correction of the proximal tibial deformity assisted by the Illizarov external fixator, provided promising results regarding its safety, ability of full deformity correction, and acceptable recurrence incidence. (10.1186/s13018-025-05829-6)
  • [L4] Although reoperation rates and superficial infections with the described method of fixation were relatively high, thumb metacarpal osteotomy provides some degree of pain relief and improvement of function. (10.1016/j.jhsa.2018.01.005)
  • [L3] This approach is associated with a low incidence of postoperative complications and a quick return to sports activities. (10.1186/s12891-025-08438-w)
  • [L2] However, it is not clear if the improved outcome can outweigh the longer operation time and higher risk of early complications and revisions. (10.1186/1471-2474-11-167)
  • [L4] The rate of secondary arthrodesis in the study cohort was comparable to that in the literature. (10.1186/s12891-020-03762-9)
  • [L3] The SSI incidence was high (9.7%) for calcaneus fractures following ORIF. (10.1186/s13018-018-1003-y)
  • [L4] The procedure provides clear benefits, though careful attention should be paid to potential postoperative complications such as the appearance of HV deformity and infection. (10.1186/s13018-025-05965-z)
  • [L3] The incidence of stress fractures following PAO is higher than previously reported (18.4%). (10.1302/0301-620x.97b1.34525)

See Also

References

[1] Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.12.020

[2] One-stage rotational osteotomy for congenital radioulnar synostosis. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415580066

[3] Shock Wave Therapy Compared with Intramedullary Screw Fixation for Nonunion of Proximal Fifth Metatarsal Metaphyseal-Diaphyseal Fractures. The Journal of Bone and Joint Surgery-American Volume. 2010. DOI: 10.2106/jbjs.i.00653

[4] Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients: A systematic review. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100389

[5] Intramedullary Screw Fixation of Jones Fractures. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300012301

[6] The patterns of injury and management of cuboid fractures. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.36639

[7] Management of Tarsometatarsal Joint Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00556

[8] Displaced Stress Fracture of the Femoral Neck Treated by Valgus Subtrochanteric Osteotomy. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507299241

[9] Internal Fixation of Osteochondral Lesion of the Talus Involving a Large Bone Fragment. The American Journal of Sports Medicine. 2021. DOI: 10.1177/0363546520988739

[10] The prevention of a lateral hinge fracture as a complication of a medial opening wedge high tibial osteotomy. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b7.bjj-2016-0927.r1

[11] Factors determining outcome of corrective osteotomy for malunited paediatric forearm fractures: a systematic review and meta-analysis. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417711684

[12] Fifth Metatarsal Jones Fractures: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-21-00542

[13] A propensity score-matched analysis between patients with high hip dislocation after childhood pyogenic infection and Crowe IV developmental dysplasia of the hip in total hip arthroplasty with subtrochanteric shortening osteotomy. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01947-5

[14] Acute fractures of medial and lateral great toe sesamoids in an athlete. Knee Surgery, Sports Traumatology, Arthroscopy. 2004. DOI: 10.1007/s00167-003-0472-6

[15] Chapter 45 Tibia, Ankle, and Foot Fractures. 2020.

[16] Acute Lisfranc injury management. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b12.bjj-2024-0581.r1

[17] Surgical treatment of varus malunion of the proximal humerus with valgus osteotomy. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.04.011

[18] Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02331-7

[19] Early Completion of Radiographic Bone Union With Rare Complications After Inverted V-Shaped High Tibial Osteotomy Fixed With a Locking Compression Plate. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251369002

[20] Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.030

[21] Outcomes of Ulnar Shortening Osteotomy Fixed With a Dynamic Compression System. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.040

[22] Modification of Mitchellʼs Lateral Displacement Angulation Osteotomy. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00024

[23] Process and Tubercle Fractures of the Hindfoot. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200512000-00002

[24] Failure of osteochondral lesions using bioabsorbable fixation in the adolescent patient: a case report. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.05.005

[25] Satisfactory clinical outcome of operative and non‐operative treatment of avulsion fracture of the hamstring origin with treatment selection based on extent of displacement: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06222-y

[26] Outcomes after scarf osteotomy with and without Akin osteotomy a retrospective comparative study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1241-7

[28] Correction of Moderate and Severe Acquired Flexible Flatfoot with Medializing Calcaneal Osteotomy and Flexor Digitorum Longus Transfer. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00045

[29] Surgical results of 5th metatarsal stress fracture using modified tension band wiring. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1406-3

[30] Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques—a cadaveric study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03702-y

[31] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[32] Pathoanatomy of the Jones Fracture in Male University Soccer Players. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519893365

[33] Arthroscopic treatment of a talar neck fracture: a case report. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1742-3

[34] SURGICAL TREATMENT OF ADULT IDIOPATHIC CAVUS FOOT WITH PLANTAR FASCIOTOMY, NAVICULOCUNEIFORM ARTHRODESIS, AND CUBOID OSTEOTOMY. The Journal of Bone and Joint Surgery-American Volume. 2002. DOI: 10.2106/00004623-200200002-00008

[35] Maintaining the Vastus Lateralis Attachment in the Extended Slide Trochanteric Osteotomy. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200107000-00020

[36] A Biomechanical Comparison of Fifth Metatarsal Jones Fracture Fixation Methods. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546517753376

[37] Anterior_Distal_Femoral_Osteotomy_for_Removal_of_Long_Femoral_Stems_in_Revision_S0883540314000606. n.d..

[38] Periprosthetic fractures of the tibia in knee arthroplasty have a high risk of treatment failure: A systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12692

[40] Outcomes of Stress Fractures of the Talus. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546506291405

[41] The Effectiveness of Intramedullary Screw Fixation Using the Herbert Screw for Fifth Metatarsal Stress Fractures in High-Level Athletes. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211045998

[42] A safe technique for insertion of heel wires for hindfoot external fixation frames. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b8.bjj-2017-1427.r1

[43] Treatment of Plastic Deformation of the Forearm in Young Adults With Double-Level Osteotomies: Case Reports. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.042

[44] Treatment Strategies for Acute Fractures and Nonunions of the Proximal Fifth Metatarsal. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200009000-00007

[45] The Association of a Varus Hindfoot and Fracture of the Fifth Metatarsal Metaphyseal-Diaphyseal Junction. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508314401

[46] Avulsion fracture of the tuberosity of the calcaneus in children. A report of four cases and review of the literature.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199510000-00013

[47] Cost-utility analysis of extensile lateral approach versus sinus tarsi approach in Sanders type II/III calcaneus fractures. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01963-5

[48] Introduction the revolving scarf osteotomy for treating severe hallux valgus with an increased distal metatarsal articular angle: a retrospective cohort study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2874-8

[49] THE USE OF STAPLES AND BONE-CHIP GRAFTS FOR INTERNAL FIXATION IN FOOT-STABILIZATION OPERATIONS. The Journal of Bone & Joint Surgery. 1953. DOI: 10.2106/00004623-195335040-00013

[50] Comparative outcomes of conservative, steinmann pin, and plate fixation in calcaneal fractures: a subtype-based evaluation according to the essex-lopresti classification. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06533-1

[51] Weight-bearing recommendations after first metatarsophalangeal joint arthrodesis fixation: a biomechanical comparison. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0525-z

[52] Chapter 102 Tibial Plateau and Tibial-Fibular Shaft Fractures. 2019.

[53] Age-related traumatic anatomy and personalized medial incision design for calcaneal fractures in older adults using three-dimensional mapping. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05934-6

[54] Management of Tarsal Navicular Stress Fractures. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509355408

[55] Comparison of operative and non-operative management of fifth metatarsal base fracture: A meta-analysis. PLOS ONE. 2020. DOI: 10.1371/journal.pone.0237151

[56] Chapter 104 Foot Trauma. 2019.

[57] Chapter 103 Fractures of the Ankle and Tibial Plafond. 2019.

[58] Need for concomitant Akin osteotomy in patients undergoing Chevron osteotomy can be determined preoperatively: a retrospective comparative study of 859 cases. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1319-2

[59] Snowboarder's Talus Fractures Experimentally Produced by Eversion and Dorsiflexion. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310063001

[60] Postoperative weightbearing timing after distal femur osteotomy is not associated with rates of union or complications: a systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70340

[61] Adequate union rates for the treatment of acute proximal fifth metatarsal fractures. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06072-8

[62] In reply to the letter to the editor regarding “Cemented versus uncemented hemiarthroplasty for femoral neck fractures in patients with neuromuscular diseases: a minimum of 2 years’ follow-up study”. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02674-1

[63] Incidence of Deep Vein Thrombosis and Pulmonary Embolus Following Periacetabular Osteotomy. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.j.01769

[64] Cylindrical Osteochondral Graft for Osteochondritis Dissecans of the Knee. The American Journal of Sports Medicine. 2002. DOI: 10.1177/03635465020300032301

[65] Complex Radius Shaft Malunion: Osteotomy with Computer-Assisted Planning. HAND. 2010. DOI: 10.1007/s11552-009-9233-4

[66] Prior osteosynthesis—unlike osteotomy—raises revision risk after total knee arthroplasty, predominantly via periprosthetic infection. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70153

[67] Acetabular Remodeling and Role of Osteotomy After Closed Reduction of Developmental Dysplasia of the Hip. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00992

[68] TRANSPLANTATION OF THE TIBIAL TUBERCLE. The Journal of Bone & Joint Surgery. 1951. DOI: 10.2106/00004623-195133020-00023

[69] Treatment of Isolated Posterolateral Tibial Plateau Fracture with a Horizontal Belt Plate through the Anterolateral Supra‐Fibular‐Head Approach. BioMed Research International. 2020. DOI: 10.1155/2020/4186712

[70] Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3951-7

[71] Effect of Preservation of Corticoperiosteal Attachment on Bone Healing at Osteotomy Sites after Ulna-shortening Osteotomy. HAND. 2014. DOI: 10.1007/s11552-014-9662-6

[72] Treatment of Jones Fracture Nonunions and Refractures in the Elite Athlete. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511408868

[73] The_Use_of_Trabecular_Metal_Cones_in_Complex_Primary_and_Revision_Total_Knee_Art_S0883540315004805. n.d..

[74] Total Hip Arthroplasty Requiring Subtrochanteric Osteotomy for Developmental Hip Dysplasia 5- to 14-Year Follow-Up With Analysis of Short- and Long-Term Failure Modes. The Journal of Arthroplasty. 2007. DOI: 10.1016/j.arth.2006.12.018

[75] Acute medial tibial plateau elevation with gradual metaphyseal correction using an Ilizarov fixator for late-presenting infantile Langenskiold stage V and VI Blount’s disease. Short-term results. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05829-6

[76] Survival and Long-Term Outcomes of Thumb Metacarpal Extension Osteotomy for Symptomatic Carpometacarpal Laxity and Early Basal Joint Arthritis. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.005

[77] Arthroscopy-assisted absorbable screw combined with Kirschner wire internal fixation for Sanders type III displaced intra-articular calcaneal fractures: a retrospective study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08438-w

[78] Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?. BMC Musculoskeletal Disorders. 2010. DOI: 10.1186/1471-2474-11-167

[79] Minimally invasive surgery for intra-articular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03762-9

[80] Incidence and predictors of surgical site infection after ORIF in calcaneus fractures, a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-1003-y

[81] Clinical outcomes of modified Mitchell’s osteotomy and shortening oblique osteotomy for forefoot deformities with hallux valgus due to rheumatoid arthritis: A retrospective analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05965-z

[82] The incidence of stress fracture following peri-acetabular osteotomy. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b1.34525

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1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.