Foot and ankle surgical research – marching forwards

Listen to Andrew Duckworth, Arul Ramasamy, Daniel Marsland and Fares Haddad discuss The Bone & Joint Journal Foot & Ankle Special Issue, published in March 2026.

Papers discussed:

Management of the failing ankle arthroplasty

Suture button compared with ventral augmentation in unstable syndesmotic injuries

Outcomes and classification of total talus replacements

Long-term patient-reported outcomes comparing unstable ankle fractures with and without a posterior malleolus fracture

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Transcript

[00:00:00] Welcome, everyone, to our BJJ podcast series. I'm Andrew Duckworth, and a warm welcome back to you all from your team here at The Bone & Joint Journal. As always, we'd like to thank you all for your continued comments and support, as well as a big gratitude to our many authors and colleagues who take part in the series that highlights just some of the great work published by our authors each month.

So today for our podcast, I have the pleasure of being joined by three authors from an editorial paper published in the March edition of the BJJ highlighting a range of foot and ankle papers we published in the journal that month. Now, before I introduce our guests, I do have a quick message from our sponsors for this episode, the International Hip Preservation Society.

If there's anyone listening with an interest in the hip, you may like to know about the 2026 annual scientific meeting of ISHA, the International Hip Preservation Society, which is back in Europe this year. The meeting will be held in Bruges, Belgium on 8th to the 10th of October, and there'll also be a range of pre-conference activities on offer on the 7th of October, including a basics in hip and arthroscopy programme aimed at early career professionals. Registration is open now, and you can register via the ISHA website at ishaso c.net.

So back to [00:01:00] today, first I have the pleasure of being joined by our specialty editor for foot and ankle and defence professor of trauma orthopaedics, Arul Ramasamy. Arul, great to have you with us. Thanks, Ducks.

Good to be here. Thanks for the invitation. Secondly, joining Arul is Mr. Daniel Marsland, who is a consultant orthopaedic surgeon in Hampshire and co-editor who led the development of this foot and ankle series. Dan, great to have you with us. Yeah. Thank you, Andrew. Thanks for the opportunity to talk about foot and ankle surgery.

That's great. And it's great to have you with us, Dan. So finally, we are delighted to welcome back our awesome Editor-in-Chief here at the BJJ, Professor Farres Haddad. Prof, great to have you with us. Ducks, thank you, and thank you again for doing this. It's great to be here. So Prof, this editorial is based on a range of papers that we've published in the journal, and this was following a call we made regarding foot and ankle manuscripts.

So how did this sort of process come about? This is all part of our central mission. As we are the journal for trauma and orthopaedics nationally and internationally, and we wish to cover the whole depth and breadth of trauma and orthopaedics for clinically active practising surgeons. Putting the sort of [00:02:00] translationally relevant work out there in all specialties.

And whilst we see a huge volume of hip and knee work and trauma work at the core of what we publish, because that is mostly what is submitted, there is some really good quality foot and ankle surgery going on worldwide, and there's a great deal to learn from that. And so we wanted to encourage, if you like, the smaller subspecialties to come together to produce material that we can place in one supplement so that we can look at that and really focus down on those areas.

At the end of the day, we wanna encourage the best researchers in every facet of trauma and orthopaedics to engage with the journal to publish in the BJJ and also in the BJO and BJR and to regard us as their home from that perspective. So I'm, immensely grateful to Arul who, leads our editorial team for Foot and Ankle, but also to Dan for engaging with the [00:03:00] community and encouraging some very good papers that some of which we're going to be discussed today to be in the journal.

I think at the end of the day, what we would like to see is the foot and ankle community e- embracing what our society does, what our journals do, and teaching us, but also learning from other specialties, because I think there's a lot to be learned from cutting across orthopaedics and across to other specialties rather than just looking inwardly down in a subspecialty.

No, ab- a- absolutely, Prof. Totally agree. And just before we move on to though speaking to Arul and Dan, obviously these are papers that have gone through the peer review process, haven't they? They've gone through that same sort of bar that we aim for. A- absolutely. And we did this, some, some of our, some of your listeners and so our readers will recall we did something similar with shoulder and elbow last year.

So the, we encourage the submission of these papers. We contact key authors. But ultimately, it is the same robust peer review process that Arul and Dan and others lead for us. And, just to put it in [00:04:00] perspective for our listeners, we, we process well over two and a half thousand papers a year.

We are front rejecting probably about 50% now. We're not far off 50%. The number's creeping up, and then when a foot and ankle paper comes in, I will look at it. If it passes muster, it will go through to Arul, who will then help us find the reviewers and then feedback. And I, and I apologize to Arul and Dan.

Y- Th- they'll occasionally get some noise on social media from pseudo academics who hold perspectives that are inflexible and that frankly will never fix. But actually, w- a- at the end of the day, they do a phenomenal job of managing that process and then giving us back the good papers to make the final decision on.

But you can rest assured, if a paper's in the journal, it's been through a very robust process. Oh, absolutely, Prof. I couldn't agree more. And Arul, if that's a nice move, it moves me to yourself. Building on what Prof has just said there, what are your own experiences of this, of the, as our specialty editor for Foot and Ankle?

Yeah. Ducks, I think [00:05:00] it's been really encouraging to see the breadth of the submissions we are now seeing in foot and ankle surgery I think historically, foot and ankle can sometimes feel a bit fragmented as a research field. People do a bit of trauma, a bit of diabetes, a bit of arthroplasty, and often they're sent to different journals, and it's really diffi- and they all ses- sit in separate silos.

But the truth is that our specialty has also moved on. Yeah. The papers we've received and selected reflect that change in our clinics. People don't just have a trauma or arthritis or infection. That can often be the same patient. The same patient you first treated with an ankle fracture develops arthritis five, ten years down the line, has an arthroplasty, and then might need a reconstruction or a revision.

So I think our research has to really reflect that complexity. Yep. And as specialty editor, what I'm really looking for is not just novelty, but clinical usem- usefulness. Is this a paper that helps the surgeon make a better decision? Does it define the [00:06:00] patient group more clearly, or does it use meaningful outcomes?

Because a lot of foot and ankle surgery does live in the gray. There's a lot of uncertainty. We have a lot of heterogeneity in our groups, lots of crossover in pathology, and really understanding whether a procedure is the right thing for the right patient is very tricky. So I'm hopeful that this special edition really brought quite a lot of those papers together.

We had a wide spectrum of stuff, and I think that's important. And I think as we move forward, as our specialty becomes more patient-centred, more reconstructive, more data-driven, we need those sort of papers that kind of guide us as we move forward. No, absolutely. I couldn't agree more. And like you say, I think one, one of the core missions of the journal is, Fares talks about and that you've just described yourself, is producing that high-quality evidence, but also that it's very relevant to our clinical practices and all of our clinical practices day-to-day.

No, I couldn't agree more. And Dan, before we move on to some of the papers that Arul and you have kindly discussed with us, what were some of the, briefly some of the key themes that you saw out of the submissions and the, and those that were eventually accepted? Yeah. Before I start, I'll just say thank you to Arul for [00:07:00] inviting me on board as guest editor and kind words from Fares.

And it is a good opportunity to showcase what is new in, in foot and ankle. But in terms of theme, it's interesting. There was no particular theme in the papers that were submitted, and we had a high volume of papers submitted. But I suppose that reflects our modern-day life as a foot and ankle surgeon.

Look at any theatre list, there are often no two cases the same in a single day of operating, and that was reflected in the pathology in the papers that were submitted. In, in all the submissions, what is common to them all is it's all completely relevant to modern-day practice.

Yeah. Whether that is something like the acute diabetic foot, which is treated by foot and ankle surgeons, or the general orthopaedic surgeon who's on call. Ankle trauma- ... is still treated by most orthopaedic surgeons, these are common conditions that we see day-to-day, but at the same time other rare conditions at the other end of the spectrum, ankle arthritis is post-traumatic- secondary to trauma 20 to 30 years ago. So pretty much [00:08:00] all the cond... I'm on call this week as the consultant of the week and the week before doing elective work, but I've pretty much seen every condition in this special edition in the last week of practice. Yeah. I think that- So it's all highly relevant.

No I totally agree. And I think that's the interesting thing about all our s- the way we've sub-specialised, but actually there's a lot of people who are not foot and ankle specialists that still manage a lot of these things day-to-day, as you very much described, and I think that's a really important point, and I think that's why the journal can bring all this d- day-to-day.

That's really interesting. Arul, anything you'd add to that before we move on to some of the selected papers? Yeah. I think one of the themes that I really picked up on, on this edition is, i- is we're moving away from those very simple yes/no questions that we used to have in foot and ankle surgery.

It's not just a question of do you put a screw or a button? Do you fuse or replace? Do you fix or you don't fix? And I think those little nuances are becoming more and more important in foot and ankle surgery. And and I think the better question is how do we do that? Which treatment for which patient for what pattern of [00:09:00] injury, and how do we measure outcomes?

And I think one of the things that came out of the papers that we published this time around is that it should be a call of a- call for action for other things. How do we really get classification better? How do we get better PROMs? How do we capture registry data? And really a lot of these studies are collaborative studies, and maybe with that sort of heterogeneity that we're seeing in our pap- patient population, multicentre studies are have to be both collaborative but also pragmatic enough to reflect what we see in day-to-day practice.

So I think there's been a really useful way of combining lots of different facets of our specialty into one edition. Joe, Arul, I completely agree with you, and I think a lot of this is not only good quality evidence, but it's also just a lot of it is evolving the debate and also evolving what we're gonna do, and I think that's a really positive thing about a lot of these studies that we're gonna talk about.

And that sort of nicely moves us on, Dan I'm gonna come back to yourself, we're just gonna focus on a few papers that you've selected. They're all great papers, but just something to [00:10:00] highlight, firstly the first paper you chose, Dan, was from the team in Bournemouth, and that looks at the management of the failing ankle arthroplasty, which is quite topical at the moment.

Yeah, definitely. Yeah, this is a well-timed paper because in recent years there's been a huge increase in the number of primary ankle arthroplasties that are being performed in the UK, and that's ref- a reflection of better implant design, but also the way that we put the implants in because we now have 3D-printed custom cutting jigs.

It's a much more reproducible operation than it used to be. And the majority of foot and ankle surgeons perform primary arthroplasties. But obviously naturally with that there will be an increase in revision burden. So what's good about this paper is the three senior authors, Heath Taylor from Bournemouth but Dave Townshend and Ian Sharpe also, is that they are high-volume surgeons but also have vast experience in performing revision arthroplasty.

And what we challenged them to on this paper was to bring together their [00:11:00] expertise to create an algorithm, so a standardised approach to a failing ankle arthroplasty. Obviously initially to the aim is to rule out infection, but then define whether the implant is stable or not, whether it's an im- impingement-related problem, is pain due to CIS but with a stable implant, or is the implant unstable?

Yeah. And they really bring together all that expertise into one paper. But there are, it's, it could be a big problem in years to come. The next five or ten years we may see a huge issue with the need to do revision surgery. We know in a younger age group, so people under 65, the revision rate at ten years can be in the order of 15 to 20%.

Much lower in the elderly population. But there is a demand to do these operations in younger people. Yeah ... but now with the advent of ankle arthritis networks, there should be a standardised approach to treating these injuries, and we should decide as a community who sh- should be doing this sort of surgery.

It's expensive [00:12:00] surgery, to do revision- ... arthroplasties, and probably we should consolidate it out to within each region, one particular unit should be doing this operation, which probably will bring the cost down- Yeah ... but also put the expertise in, in the right hands. Yeah, no, I think that's a really interesting point, Dan.

I think, like you say, it's a great paper and I do encourage our au- our listeners to, to go and have a look at it. And I think the way that they've brought, like you say, together their expertise and data from the literature to develop a- an algorithm. And I think again, like we were saying earlier, it may not be the final thing.

It's dev- balancing that debate and like hoping that the things that move forward with that purpose, and I think that's a really positive outcome. And Dan, if we move on to the other paper you selected, this was from the team in Munich Germany, looking at the use of suture button compared with ventral augmentation in unstable syndesmotic injuries.

Again, a quite a topical area. Yeah, the eternal debate around how best to manage a syndesmosis. Yes, absolutely. Yeah this is an interesting paper and again from a high-volume centre. So- ... team in Munich, a level one trauma unit, and it sounds like they've got a brilliant setup. So they obviously treat a [00:13:00] high volume of ankle fractures.

This particular paper was centered around a syndesmosis injury in association with an ankle fracture. But what is impressive is that for every ankle fixation that has a syndesmosis treatment - they get next day CT scan and that is not a practice that's reflected in the UK. So therefore this paper does provide very valuable data on what is happening at the level of the syndesmosis depending on the type of fixation.

But as Arul suggested earlier, the debate has moved on from the type of fixation which previously was rigid fixation with a screw. Then we moved to a suture button fixation, and the five-year data in RCT shows that a suture button is better than a screw. But still yet the most common reason to revise an ankle fracture is because of syndesmosis malreduction.

Yeah. Yeah. So the argument has now moved on, or the question has moved on to rather than perform transsyndesmotic fixation, which is non-anatomical - should we be [00:14:00] performing an anatomical repair of the AITFL with a suture tape? And what this study shows ... and the question around that would be what's the risk of overcompression?

What's the risk of malreduction? And with this very accurate way of assessing the syndesmosis through CT postoperatively, what the authors showed is that the rate of malreduction was similar in each group. Yeah. Yeah. The type of malreduction was slightly different, so with a suture button fixation, a central over, overcompression almost of the- in the ones that were malreduced, and with the AITFL reconstruction, that sometimes it could pull the fibula forward slightly in the syndesmosis. Yeah. Yeah. So it, it shows that it's reproducible, it's a nice technique, and it may well be relevant to the ligamentous injuries the sports injuries we often see in athletes where there's no fracture.

The question is should we be doing suture button fixation or augmentation of the AITFL? And I think this sort of paper goes some way to start that [00:15:00] conversation in a sports injury. So this will need to be repeated across a wider range of pathology, but it's certainly a strong start in that respect. No, I completely agree, Dan.

I think the authors acknowledge that themselves at the end, don't they, about where they think the future direction of the work go, and it is a really strong starting point and gives you some really value information there. And as you say, it's that everend- ever-ending debate of syndesmotic injuries and how we manage them.

But I think actually that- that's a positive thing. I think we should be debating these things because that's how we evolve. We don't just stop once we think we've found the a- answer, because often we haven't, and we can always try and improve things. So I completely agree. Absolutely. But, so Arul, if I maybe I could come to yourself next just to talk about the two papers you chose.

The first was the multicentre study reporting on the classification of total talus replacements, and I thought this was quite interesting. Yeah. That was- a great paper, and I think mainly because it's topical because that total talus replacement really sits on that boundary between real new innovation and getting that, developing that evidence base, which is still quite weak.[00:16:00] 

Yeah. And patients really had very few options previously. If you didn't, if you didn't have the total talus replacement, you're really looking at a TTC fusion or a talectomy or really in real extreme cases, you're having that limb salvage discussion. So it's they are patients that don't have great surgical options, and so the total talus replacement might be a good option for them.

And what we saw was, one, a great, a UK study, multicentre, where they did on 27 total talar replacements, and the results are pretty promising. Short follow-up, only 22 months, but the MOXFQ improved, VAS improved, Tegner activity scores all improved. So from a very poor baseline, they seem to get some pretty good pain relief and function.

Yeah. No, absolutely, Arul, and I th- I think it's interesting as well. It's great to highlight that sort of multicentre work as well, isn't it? Absolutely, because we're not gonna see huge numbers of these. What was interesting was that they found that the trauma group didn't do as well as the elective group, which is interesting to see.

And [00:17:00] there is a significant complication rate, three revisions, one amputation, so there is a revision rate associated with this, and we still don't know what the long-term outcomes or the what's gonna happen in terms of subsidence or joint wear or infection might be. Yeah. But I think the really important part of this is that it wasn't just a total talar replacement.

It's a combination of total talus with total ankle, total talus with fusions, so you've got this huge group of patients and, or huge indications or changes in the procedure And I think that's important moving forwards as we, as this becomes more mainstream, is that we need to have a good classification system.

'Cause otherwise the d- the papers that get published will say, "We've done 50 or 100 of these." And then you realize that when you did the subgroup analysis that there's a whole load of indications, a whole load of different procedures. So if we're not classifying them early and providing that framework, then I think it's almost impossible to compare that data, and what we then do is lose a generation of patients, or we'll go either it doesn't work or we [00:18:00] think it works, and then we go, actually, there's this particular group of patients that we should be worried about that we should focus on.

So I think that's super important part. And again, it goes back to what we wrote in the editorial, is that we need to classify these things better. We need to look at registry surveillance. I know there's issues with registry data, but we need to have some kind of format where these implants are put in, categorised properly, reported properly, and then followed up in the long term.

And I think what this paper really shows to us is that we need to set those foundations early to make sure that we don't miss something five, ten years down the line. No, I totally agree, Arul. I think that's a really my... But that was one of my big take home message of this, is that, people are gonna start to do more and more of this, aren't they?

Or they're gonna try it in their practice, and there has to be a really clear framework about what we collect and how we collect it. Absolutely. And I totally agree. I think total talus replacement is really moving that talar collapse problem from an unsolvable problem that it was before- into a reconstructive problem. But we don't know what that long-term cost [00:19:00] is, but I think it's an exciting area for us to explore, and that's why we need to get, make sure that we get those bases in terms of classification and result reporting down, done properly at the beginning rather than wait.

Yeah. Absolutely. Absolutely. And Arul we'll move on to the last paper, and again, a controversial topic. Posterior malleolar fractures, and this was from our team here in Edinburgh reporting on the long-term outcome of patients with unstable ankle fractures with and without a posterior malleolar fracture.

Yeah. Ducks, it's not like you to cause trouble, but- ... I think it's a really interesting, and I agree, a slightly provocative paper because it really challenges some of that foot and ankle trauma dogma that's beginning to fit into our practice. 20 years ago, no one would touch a posterior malleolus.

You'd go to a trauma meeting, and it was always fix the inside, fix the outside, and if he looks a bit dodgy on the back, maybe think about throwing a screw from front to back. But no one went round the back, and it was you'd have to convince someone that you'd actually want to approach the ankle from a posterior approach [00:20:00] 20 years on in the trauma meeting, you almost have to convince people not to go round the back.

You have to have a really clear reason why you don't want someone to go round the back, and so that pendulum has swung. Whether we've swung it too far to that, to the other side, I don't know. But I think it's important for at least us to start questioning that, and I think that's where this paper really comes in, and I think that's where it's useful.

It does show that, you don't, maybe don't have to CT every single patient. Maybe there is a group of patients. And I totally agree, Ma- Lyndon Mason's paper and all that work on the posterior malleolus has been really useful to understand which morphology may be important.

Syndesmotic stability is important in terms of reducing that risk of postoperative or post-traumatic arthritis, I think, in the future. But we need to know which patient, which morphology, and what the right indications are, and we probably haven't quite found that balance yet. But I think some of the reassuring things are is that we've always been worried that if we don't get it right, that you get this high risk of [00:21:00] post-traumatic arthritis, which then becomes symptomatic and then requires further hindfoot surgery, which is, not great.

But what your paper has showed is actually although the post, radiographic post-traumatic arthritis rates were higher in the posterior malleolar group, it didn't mean that they had worse OMAS scores, and it didn't mean that they had higher rates of fusion or arthroplasty. Yeah. So I think that's really useful to s- to temper the argument and really provide a li- an a counterpoint to this kind of need to fix every posterior malleolus fracture that comes into the trauma room.

So I think it's a really interesting paper. It, and I think it helps balance that debate, because I think we're at risk of maybe swinging that pendulum too far to one side. And it's not without risk going round the back. There are risks. I think there's always elements of extra stiffness, more soft-tissue dissection, and whether that may cause issues in terms of functional outcomes in the shorter or longer term, we don't know.

So I think there's always a balance, and I think it's important that we have those different points of view. No [00:22:00] Arul, I think you've summed up perfectly about certainly how I feel about it, and I know my co-authors. I should highlight my colleague Nick Heinz, who's h- this was part of his higher degree.

He did a huge amount of work in this area, and I think that's really where we feel we're at. And I'm not saying that we have, or we're not saying we have the answer, and I don't think we do have the answer, and I think, like a lot of Lyndon's work, has really highlighted the posterior malleolus and brought it into the forefront and made us all look and think about it, and I think that's a really positive thing personally, and actually evolving that, that discussion about it.

But I think it's ... that's right, is we have to always reflect on what we're doing and trying to find the best, really ultimately the, just the best for our patients, isn't it? And I think that's a really positive thing, and I think evolving the debate and the discussion together is a very good thing and ultimately, like I say, is the best for our patients.

No, so thank you for highlighting that. So Prof, that sort of brings me back full circle to yourself. Just your overall thoughts on the papers published and, and the whole process of the of these special editions that we've been doing. No, I think Arul and Daniel have done a phenomenal job.

These are, papers from active groups that are sh- you know, in shaping the debate. They're getting us to think [00:23:00] harder, and they are going to influence day-to-day foot and ankle practice, be that in your trauma practice or in your complex elective practice. And at the end of the day, what we seek to do is educate our community and help people progress with the important research questions to move onto next.

Yeah. And I think some of these papers undoubtedly will do that. So I think this process to me has been a success. I'll look forward to getting more feedback from our readers and colleagues both nationally and internationally. But it's something that we will do again, and, we'll move on and do another topic next and then in a few years' time move back to foot and ankle.

But in the interim, I hope that we will continue to encourage good quality research within the foot and ankle community, w- and that foot and ankle researchers will aim high and submit to the journal. Yeah, absolutely, Prof. Guys, thank you so much for joining me. That was really good to have you all with us, and a big thank you to you and all of the authors for the efforts that have gone into producing this great set of papers for the j- for the journal and our readership.[00:24:00] 

And to our listeners, we do hope you've enjoyed joining us, and we do encourage you all to share your thoughts and comments on the various platforms. Feel free to post about anything we have discussed here today, and thanks again for joining us everyone. Take care.