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What's New — Ankle — September 2026

17 new articles published this month.

Themes: Achilles Tendon Repair & Tendinopathy · Ankle Ligament Injury & Instability · Endoscopic & Arthroscopic Techniques · Charcot Ankle & Limb Salvage · Gait Recovery After Ankle Fracture · Peroneus Longus Graft Evidence

Digest generated 2026-10-04 16:28:48+00:00.

Highlights

Achilles Tendon Repair & Tendinopathy

This theme covers the spectrum of Achilles tendon pathology, from acute rupture repair to chronic tendinopathy and reconstruction. Biomechanical testing of four suture techniques in a porcine model addresses which construct best supports early mobilization and weight-bearing protocols [4]. A minimum 5-year follow-up of a randomised trial shows both radiofrequency microtenotomy and physical therapy yield significant, durable improvements in chronic midportion Achilles tendinopathy [8]. For chronic ruptures with large defects, a technical note describes reconstruction using a doubled peroneus longus free graft with interference screw fixation and side-to-side tenodesis to preserve eversion strength [11]. Additionally, professional soccer data identify prior lower-extremity injury as a risk factor for Achilles rupture, reinforcing the role of kinetic-chain factors [16], while cadaveric work shows plantaris tendon resection increases dorsiflexion, particularly with insertions close to the Achilles [17].

Ankle Ligament Injury & Instability

Management of ankle ligament injuries and chronic instability features prominently this month. An expert opinion reframes the deltoid ligament as a tri-articular medial stabilizer spanning tibio-talar, subtalar, and talo-navicular joints, warning that neglecting its broader role risks post-traumatic plano-valgus deformity [13]. A state-of-the-art review addresses five key questions on arthroscopic management of ankle ligament injuries, positioning arthroscopy as the gold standard for syndesmosis assessment and anatomic repair [14]. In chronic lateral ankle instability, a 290-patient cohort identifies generalized joint laxity as an independent predictor of postoperative resprain after anatomic reconstruction with gracilis tendon autograft [12]. Finally, a methodological exchange debates the Ankle-GO score's validity for predicting lateral ankle sprains in elite basketball players [9, 10].

Endoscopic & Arthroscopic Techniques

Minimally invasive technical innovations around the ankle are highlighted. Endoscopic resection of a sinus tarsi ganglion extending to the anterolateral ankle combines ganglionectomy with sinus tarsi debridement through the same portals, offering faster recovery and reduced recurrence [3]. For intrasheath peroneal tendon subluxation caused by a flat retrofibular groove with a low-lying peroneus brevis muscle belly, endoscopic groove deepening with muscle resection provides cosmetic, pain, and recovery advantages over open surgery [6]. A cotton-swab-anchored suspension technique enables hands-free lower extremity sterilization during surgical preparation, reducing staff strain and improving efficiency [2]. Novel assistive devices, a sizing template and impactor rod, improve accuracy and outcomes in autologous osteochondral transplantation for talar osteochondral lesions [15].

Charcot Ankle & Limb Salvage

Complex reconstruction in neuropathic and infected ankles is represented by a series of 55 patients with neglected, infected Eichenholtz stage III Charcot neuroarthropathy of the ankle. Using a one-stage limb-salvage protocol based on distraction histogenesis principles, featuring a 'corticotomy-first' technique and non-radical debridement with circular external fixation, the authors demonstrate a feasible alternative to below-knee amputation even in the presence of active or quiescent osteomyelitis. This work addresses one of the most challenging problems in foot and ankle surgery, where traditional management has often defaulted to amputation.

Gait Recovery After Ankle Fracture

This theme captures postoperative rehabilitation evidence following ankle fracture surgery. A correction notice amends Figure 5 of the original study on gait recovery after ankle fracture surgery managed with early mobilization and weight-bearing, replacing an incorrectly displayed frontal-plane ankle plot with the correct transverse and sagittal ankle, knee, and hip plots. The underlying study informs rehabilitation protocols emphasizing early weight-bearing after surgical fixation of ankle fractures.

Peroneus Longus Graft Evidence

A comprehensive review evaluates the peroneus longus tendon as an autograft for ACL reconstruction, synthesizing anatomical, biomechanical, and clinical evidence. Although initially viewed with caution due to its role in foot and ankle biomechanics, the peroneus longus provides reliable graft characteristics with short- to mid-term outcomes comparable to established autografts and generally favourable donor-site function. The review addresses donor-site complications and patient selection, though the predominantly retrospective and heterogeneous evidence base limits definitive grading of the evidence.

Articles by Theme

Achilles Tendon Repair & Tendinopathy (5)

4. Weigand L, Liebrand B, Scheible S, et al. Biomechanical comparison of innovative suture techniques for repair of Achilles tendon rupture in a porcine flexor tendon model. Archives of Orthopaedic and Trauma Surgery 2026. doi:10.1007/s00402-026-06508-9

This biomechanical study compared four suture techniques for Achilles tendon rupture repair (Bunnell, Bunnell with pretension, PARS-to-PARS, and PARS with anchor) using a porcine flexor tendon model. The study aimed to identify which construct provides sufficient stability to support early mobilization and weight-bearing rehabilitation protocols. Findings inform surgeon selection of biomechanically stable repair techniques compatible with progressive postoperative rehabilitation.

8. Jirde Ali H, Meknas K, Kartus J, et al. Both Radiofrequency Microtenotomy and Physical Therapy Provide Significant Improvements in Patients With Chronic Midportion Achilles Tendinopathy at a Minimum 5‐Year Follow‐Up. Arthroscopy, Sports Medicine, and Rehabilitation 2026. doi:10.1002/ars2.70061

This minimum 5-year follow-up of a randomised controlled trial compared bipolar radiofrequency microtenotomy (RFM) versus physical therapy (PT) for chronic midportion Achilles tendinopathy in 25 of 38 originally enrolled patients. Both groups showed significant improvements in VAS pain and FAOS scores, with the RFM group achieving significantly better VAS at follow-up. Both treatments provide durable long-term improvement, supporting either as a viable option for this condition.

11. Maffulli N, Benelli C, Cacciuni N, et al. Reconstruction of chronic Achilles tendon ruptures using a doubled peroneus longus tendon free graft and interference screw fixation: a technical note. Journal of Orthopaedic Surgery and Research 2026. doi:10.1186/s13018-026-07162-y

This technical note describes a tissue-preserving reconstruction for chronic Achilles tendon ruptures with large defects (Myerson Type II/III) using a doubled free autologous peroneus longus tendon graft fixed with an interference screw in a calcaneal tunnel, combined with distal side-to-side tenodesis to the peroneus brevis to limit eversion weakness. The technique avoids hamstring graft harvest and flexor hallucis longus transfer, making it applicable even to patients with prior ACL reconstruction. It offers surgeons an alternative reconstructive option with potentially reduced donor-site morbidity, though formal clinical outcome data are needed.

16. Khan HA, Rosenberg A, Penvose I, et al. Prior Lower Extremity Injury as a Risk Factor for Achilles Tendon Rupture in Professional Soccer Players. Orthopaedic Journal of Sports Medicine 2026. doi:10.1177/23259671261481002

Using Transfermarkt injury data from 2001 to 2025, this cohort study of 1362 professional soccer players with complete Achilles tendon ruptures compared prior injury histories with an injured, non-rupture reference population to quantify risk ratios by anatomical group. The study tested the hypothesis that prior lower-extremity injuries elsewhere in the kinetic chain disproportionately precede Achilles rupture. The findings may help identify professional soccer players at elevated rupture risk based on injury history, informing screening and prevention strategies.

17. Rougereau G, Delaigue F, Sadoun M, et al. Plantaris tendon resection increases ankle dorsiflexion independently of knee position, with greater effect in tendons inserting close to the Achilles. Orthopaedics & Traumatology: Surgery & Research 2026. doi:10.1016/j.otsr.2026.104913

In 18 cadaveric feet, plantaris tendon resection significantly increased ankle dorsiflexion regardless of knee position, indicating the plantaris acts as an ankle-level (not knee-dependent) restrictor of motion. The dorsiflexion gain was greater when the tendon inserted close to the Achilles tendon. Clinically, this supports assessing the plantaris tendon, and considering its resection, in patients with equinus or gastrocnemius tightness refractory to standard release procedures.

Ankle Ligament Injury & Instability (5)

9. Wu Z, Liu C, Wu W. Methodological Concerns Regarding the Ankle-GO Score for Predicting Lateral Ankle Sprain in Elite Basketball Players: Letter to the Editor. The American Journal of Sports Medicine 2026. doi:10.1177/03635465261456224

The authors raise methodological concerns about Hardy et al.'s prospective study of the Ankle-GO score for predicting lateral ankle sprains in elite basketball players, noting that the observed AUC (0.71) fell below the expected value used for sample size estimation and that the multivariable logistic regression model with 3 predictors was based on only 17 injured ankles, violating the recommended 10-events-per-predictor rule. They argue these limitations risk overfitting and may compromise the validity of the model's predictive performance. Clinically, they caution against adopting the Ankle-GO score for risk stratification until the model is adequately powered and externally validated.

10. Hardy A, Tassery F, Allaire T, et al. Methodological Concerns Regarding the Ankle-GO Score for Predicting Lateral Ankle Sprain in Elite Basketball Players: Response. The American Journal of Sports Medicine 2026. doi:10.1177/03635465261456229

In their response to Wu et al.'s critique, Hardy and colleagues defend their prospective cohort study of the Ankle-GO score in elite basketball players, citing literature (including Vittinghoff and McCulloch) suggesting the rule of 10 events per variable can be relaxed in certain logistic regression contexts. They also reference guidance on internal and external validation of prediction models to support their analytical approach. The exchange underscores that clinical use of the Ankle-GO score should await further validation studies.

12. Liu H, Li J, Su T, et al. Generalized Joint Laxity Is an Independent Predictor of Postoperative Resprain Following Anatomic Reconstruction Using Gracilis Tendon Autograft for Patients With Chronic Lateral Ankle Instability. Orthopaedic Journal of Sports Medicine 2026. doi:10.1177/23259671261477818

In a retrospective cohort of 290 chronic lateral ankle instability patients undergoing anatomic reconstruction with gracilis tendon autograft (minimum 24-month follow-up), the authors examined generalized joint laxity (GJL, based on age and Beighton score) as a risk factor for postoperative resprain. GJL was found to be an independent predictor of postoperative noncontact resprain and recurrent instability. Clinically, assessing for generalized laxity may help identify patients at higher risk of failure after lateral ankle ligament reconstruction and inform preoperative counseling.

13. Fleury C, Acker A, Dubois-Ferrière V, et al. Deltoid ligament injury: thinking beyond the ankle – an expert opinion. EFORT Open Reviews 2026. doi:10.1530/eor-2025-0268

This expert opinion reframes the deltoid ligament as a tri-articular stabilizer of the tibio-talar, subtalar, and talo-navicular joints rather than an isolated ankle structure, synthesizing anatomical, biomechanical, and clinical evidence. The authors argue that neglecting this broader role can lead to irreversible post-traumatic plano-valgus or plano-abductus foot deformities. They recommend systematic recognition and appropriate management of deltoid ligament injuries in both acute and chronic settings, whether treated conservatively or surgically.

14. Lopes R, Guillo S, Bauer T. Arthroscopic Management of Ankle Ligament Injuries: A New Gold Standard?. Orthopaedics & Traumatology: Surgery & Research 2026. doi:10.1016/j.otsr.2026.104873

This review addresses five key questions on arthroscopic management of ankle ligament injuries, concluding that arthroscopy enables precise diagnosis of ligament status and associated lesions and is now the gold standard for syndesmosis assessment. Acute-phase arthroscopic repair by ligament suture may be considered in high-demand athletes or with associated lesions, while chronic instability despite rehabilitation warrants arthroscopic repair or reconstruction with autograft/allograft. The findings support a more active arthroscopic role in both acute and chronic ankle ligament surgery.

Endoscopic & Arthroscopic Techniques (4)

2. Zhou C, Hu Z, Sagar L, et al. Cotton‐Swab‐Anchored Suspension Technique for Hands‐Free Lower Extremity Limb Sterilization During Surgical Preparation. Arthroscopy Techniques 2026. doi:10.1002/atn2.70276

This technical note describes a cotton-swab-anchored suspension technique for hands-free lower extremity limb sterilization during surgical preparation, using a sterile Kerlix bandage looped around the ankle and suspended from an IV pole. The method eliminates manual limb holding, reduces occupational strain on surgical staff, and allows quick release without instruments. It offers a cost-effective, reproducible alternative for various lower extremity procedures.

3. Pan X, Lui TH, Hong J, et al. Endoscopic Resection of Sinus Tarsi Ganglion Extended to the Anterolateral Ankle. Arthroscopy Techniques 2026. doi:10.1002/atn2.70307

This technical note presents endoscopic resection of sinus tarsi ganglion extending to the anterolateral ankle, combining ganglionectomy and sinus tarsi debridement through the same set of portals. The minimally invasive approach is indicated for symptomatic ganglia recalcitrant to conservative treatment. Reported advantages include faster recovery and reduced recurrence compared with open excision.

6. Pan X, Lui TH, Slocum AMY, et al. Endoscopic Retrofibular Groove Deepening and Resection of a Low‐Lying Muscle of the Peroneus Brevis for the Management of Intrasheath Subluxation of Peroneal Tendons Associated With a Low‐Lying Peroneus Brevis Muscle. Arthroscopy Techniques 2026. doi:10.1002/atn2.70249

This technical note describes endoscopic retrofibular groove deepening combined with resection of a low-lying peroneus brevis muscle belly for intrasheath peroneal tendon subluxation caused by a constricted fibro-osseous tunnel. The minimally invasive approach addresses both the abnormal groove morphology and the space-occupying muscle. Advantages include less soft tissue trauma, decreased pain, early mobilization, reduced peritendinous fibrosis, and faster recovery.

15. Chen Y, Li M, Fang Z, et al. Design and Application of Two Novel Assistive Devices in Autologous Osteochondral Transplantation for Talar Osteochondral Lesions: A Technical Note. Orthopaedics & Traumatology: Surgery & Research 2026. doi:10.1016/j.otsr.2026.104875

The authors designed two novel assistive devices, a sizing template for graft orientation and an impactor rod for graft insertion, to improve autologous osteochondral transplantation for large talar osteochondral lesions, and evaluated them in a retrospective series of 34 patients. At a mean follow-up of 69 months, VAS pain decreased from 7.1 to 1.4, AAS and FAAM scores significantly improved, and mean MOCART score was 72.6. The devices facilitated surgical accuracy and yielded good clinical and imaging outcomes, though the level IV evidence limits firm conclusions.

Charcot Ankle & Limb Salvage (1)

7. Hosny GA, Elmesalamy N, Abdelnaser A. Neglected infected Charcot neuroarthropathy of the ankle: limb salvage using a one-stage reconstruction by distraction histogenesis principles. International Orthopaedics 2026. doi:10.1007/s00264-026-07016-6

This case series reports 55 patients with neglected infected Charcot neuroarthropathy of the ankle (Eichenholtz stage III) treated with a one-stage limb-salvage reconstruction using corticotomy-first technique, non-radical debridement, and distraction histogenesis principles with circular external fixation. Functional weight-bearing and limb preservation were achieved in the large majority, including patients with active infection. This approach offers a feasible alternative to below-knee amputation for these complex cases.

Gait Recovery After Ankle Fracture (1)

1. Bauer L, Schlegel AS, Scheuer A, et al. Correction: Recovery of gait after ankle fracture surgery following early mobilization and weight-bearing. Archives of Orthopaedic and Trauma Surgery 2026. doi:10.1007/s00402-026-06513-y

This is a correction notice for a previously published article on gait recovery after ankle fracture surgery with early mobilization and weight-bearing. Figure 5 was incorrectly displayed and has been replaced with corrected versions showing ankle transverse, ankle sagittal, knee sagittal, and hip sagittal views. No new clinical data are presented; readers should refer to the corrected figures for accurate kinematic interpretations.

Peroneus Longus Graft Evidence (1)

5. Okutan AE, Budhiparama N, Herbort M, et al. Peroneus longus tendon autograft for anterior cruciate ligament reconstruction: Current evidence, donor‐site complications and patient selection. Knee Surgery, Sports Traumatology, Arthroscopy 2026. doi:10.1002/ksa.70616

This review summarizes current evidence on the peroneus longus tendon (PLT) as an autograft for ACL reconstruction, including anatomical, biomechanical, and clinical data along with donor-site considerations. Available comparative studies show broadly similar short- to mid-term outcomes to established autografts with generally favourable donor-site function, though the predominantly retrospective evidence base does not establish equivalence or noninferiority. The PLT expands graft options without compromising the injured knee, but questions remain regarding sport-specific ankle performance in high-demand athletes and long-term donor-site consequences.

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