Introduction/ Purpose The aim of the study was to assess 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle as part of a complex surgical approach. Methods In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at the ankle treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue. Results One hundred and twenty-nine patients with 136 chondral lesions were included in in the study. The chondral lesions were located as follows (n (%)), medial talar shoulder only, 62 (46); lateral talar shoulder only, 42 (31); medial and lateral talar shoulder, 7 (10); tibia, 18 (13). The average for lesion size was 1.8 cm2, for VAS FA 45.7 and for EFAS Score 9.8. 2FU/5FU was completed in 105 (81%)/104(81%) patients with 112/111 previous chondral lesions. VAS FA improved to 79.8/84.2 and EFAS Score to 20.3/21.5 (2FU/5FU). No parameter significantly differed 2FU and 5FU. Conclusion AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores at 2FU/5FU. 2FU and 5FU did not differ.

Background: Anterior talofibular ligament (ATFL) insufficiency encompasses situations in which (i) frequent sprains cause ATFL loss, as evidenced by ATFL non-visualization on preoperative magnetic resonance imaging, or (ii) minimal healthy ATFL tissue for repair is left after the removal of the large os subfibulare. Suture tape implantation (STI) can be indicated for these cases rather than conventional ligament repair. To investigate the incidence of postoperative re-sprain in patients who underwent STI for ATFL insufficiency and to identify risk factors influencing the occurrence of postoperative re-sprain. Methods: A total of 68 patients who underwent STI for ATFL insufficiency from January 2016 and December 2021 were retrospectively evaluated. The minimum follow-up duration for inclusion was 2 years after surgery. All included patients were divided into two groups according to the presence of postoperative re-sprain during the follow-up period. Multiple clinicoradiographic parameters were measured, and binary logistic regression analysis was performed to determine the factors influencing postoperative re-sprain. Results: Postoperative re-sprain occurred in 27.9% of the 68 patients, and multiple re-sprains persisted in 10.3%. Postoperative re-sprain was more likely to occur in patients who smoked after surgery (odds ratio [OR], 3.510), had generalized ligament laxity (OR, 4.364), and engaged in occupations requiring high physical activity levels (OR, 4.421), including soldiers, professional athletes, athletic students, and postmen. Conclusion: After STI for ATFL insufficiency, extra caution is warranted in patients with risk factors, necessitating meticulous attention to their care.

Background: We investigated whether arthroscopic treatment of posteromedial OLTs can be accomplished solely through anterior ankle arthroscopy. We hypothesized that specific conditions may prompt posterior ankle arthroscopy. Methods: We retrospectively reviewed videos of patients who underwent primary arthroscopic microfractures for OLTs on the posteromedial talar dome between 2010 and 2021. We focused on whether visualization of the posteromedial OLT was adequate through the anteromedial or anterolateral portal in the anterior ankle arthroscopy group (posteromedial or posterolateral portal in the posterior ankle arthroscopy group). We assessed whether a sufficient microfracture technique was feasible during surgery. Results: Seventy-nine patients were included in this study, among which 62 and 17 were assigned to the anterior and posterior ankle arthroscopy groups, respectively. Posteromedial OLTs were fully observed through the anteromedial portal in 79.0% of cases and better observed through the anterolateral portal (93.5%). Only four patients (6.5%) showed limited visualization and underwent an insufficient microfracture procedure. In two of these patients, we observed challenges in advancing the arthroscope and other devices owing to the narrow joint space even with sufficient distraction, whereas the remaining two showed infeasibilities derived from far posterior locations. In contrast, microfractures via posterior ankle arthroscopy were successfully performed in all patients (100%). Conclusions: When surgically treating patients with posteromedial OLTs, we recommend considering anterior ankle arthroscopy unless a combined pathology requires surgical intervention for the posterior ankle. Posterior ankle arthroscopy should be selectively utilized only for far posteromedial OLTs or in patients with narrow joint space, even with sufficient distraction.

Background: Due to the variability in evidence supporting either trans-syndesmosis fixation or deltoid ligament repair in unstable ankle fractures with medical clear space (MCS) widening makes it unclear which surgical technique leads to the best patient outcomes. The goal of our systematic review and meta-analysis was to compare clinical outcomes of trans-syndesmotic fixation versus anatomic deltoid ligament repair in the management of unstable ankle fractures with MCS widening. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized in this study. A comprehensive and systematic search was conducted using the PubMed, Embase, Web of Science and Cochrane Library databases. Outcomes investigated in this review included the rates of syndesmotic malreduction, removal of hardware, postoperative complications including wound issues, and functional/pain scores. Results: A total of five studies were selected in this review, with 280 unstable ankle fractures with MCS widening: 165 for the trans-syndesmotic fixation group and 115 for the anatomic deltoid ligament repair group. Compared to the trans-syndesmosis fixation group, the deltoid repair group showed significant lower rates of syndesmotic malreduction rates and removal of hardware: 6.5% (4/61) Vs. 27% (16/59) (RR=0.26, 95% CI=[0.10, 0.68]), and 2.6% (3/115) Vs.54.5% (90/165) (RR=0.06, CI=[0.02, 0.14]), respectively. No significant differences were found between the two groups in postoperative wound complications, reoperations, and functional scores including AOFAS and VAS pain score. Conclusions: Based on our findings, anatomic deltoid ligament repair may be more suitable for addressing MCS widening in the management of unstable ankle fractures compared to trans-syndesmosis fixation.

Introduction This systematic review and meta-analysis aims to examine the effect of surgical timing on postoperative wound complications, specifically investigating the significance of a 24-hour cutoff point. Methods This literature review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines utilizing databases including PubMed, Embase, Web of Science, and the Cochrane Library, carried out on January 30, 2024. The inclusion criteria for studies were as follows: (1)Research comparing clinical outcomes following surgical fixation for ankle fractures between early and delayed fixation groups, specifically using a 24-hour cutoff point, and (2)Reports of at least one of the following outcomes: postoperative wound complications: superficial/deep infection, length of stay in the hospital, and fixation failure. Exclusion criteria were patients with open fractures, polytrauma, pilon fractures, physeal fractures, or fractures of the talus/calcaneus, and those initially treated with an external fixator. Results Eight studies with 1183 patients were included in our review. Early fixation was performed for 572 patients while delayed fixation for 611 patients. Compared to the delayed fixation group, the early fixation group showed a significant lower postoperative wound complication rate: 4.4% (23/525) Vs. 10.5% (60/571) (RR=0.37, 95% CI=[0.22, 0.60]), and a significant shorter length of stay in the hospital: standardized mean difference (SMD)=-1.28, CI=[-2.09, -0.47]), respectively. Conclusion Based on our results, early surgical intervention within the first 24 hours should be considered to mitigate the risk of postoperative wound complications and shorten the length of stay in in management of ankle fractures.

Background: Main objective of this research is to know if there is a different survival rate between fixed bearing (FB) and mobile bearing (MB) total ankle replacement (TAR). Methods: A systematic search was performed in PubMed, Cochrane, EMBASE and ClinicalTrials.gov databases to identify published studies from August 2018 to September 2022 including results for FB and MB TAR survivorship. Inclusion criteria included 1) primary TAR in one or both feet in which implant could be identified, 2) a minimum of 20 procedures reported, 3) reported implant survivorship or calculable and 4) a minimum of 12 months follow-up for level 1–3 studies or 60 months for level 4 studies. Results: 3902 ankles in 28 studies were included. 719 were FB and 3104 MB with an overall survivorship of 94% (95% CI [0.89; 0.97]) and 89% (95% CI [0.86; 0.92]) respectively. After subgroup analysis, we did not find differences among both groups (p = 0.429). Meta-regression analysis showed that longer follow-up was associated with lower survival rates in MB group (p = 0.000) while no other relationships were found with other factors (age, level of evidence or conflict of interests). Conclusions: No differences in survival rates between both groups were found. Age and other studied confounders were not found to be related with implant survivorship. However, longer follow-up was found to be related with lower survival rates. Studies with longer follow-up and higher level of evidence are needed to confirm results.

Background: Total ankle replacement (TAR) is an established method of treatment for end-stage ankle arthritis. TAR malalignment is a common cause of failure, either by increasing the risk of component loosening, cyst formation or polyethylene fracture. Methods: We present a case of a 57-year-old female patient who underwent TAR eight-years ago. The TAR was positioned in varus, although in a parallel position between the tibia and talar components. She developed increasing pain along her medial ankle, with no response to conservative treatment. Standing weightbearing anteroposterior, lateral and Saltzmann views, as well as CT-scan, demonstrated the TAR varus position but with adequate interface between TAR components and bone, without any signs of polyethylene wear or bone cysts. We decided to perform a lateral closing wedge supramalleolar osteotomy combined with a lateral malleolus osteotomy, in order to realign the TAR. Results: At 24-month follow-up, the Visual Analog Scale for pain (VAS-Pain) decreased from 8 (preoperatively) to 0. The Foot and Ankle Outcome Score (FAOS) increased from 12% (preoperatively) to 96%. The patient is very satisfied with the result, as she kept mobility of her ankle and avoided complex TAR revision or ankle fusion. Radiographic assessment demonstrates a normally aligned TAR with complete union of the osteotomies. There was no postoperative complications, including wound problems, hardware related issues or neurovascular injuries. Conclusion: This report illustrates how supramalleolar osteotomy is a valid option for malaligned TAR, avoiding complex TAR revision or conversion to ankle fusion, relieving symptoms and improving midterm clinical scores.

Introduction Magnetic Resonance Imaging (MRI) stands out as a potent tool for assessing ATFL (Anterior Talofibular Ligament) injuries, providing insights into the state of lateral ankle ligaments and associated pathology. Ligament intensity exhibits a robust negative linear correlation with material biomechanical strength properties. To address ATFL injuries, the arthroscopic modified Broström procedure with internal bracing has gained popularity, offering a swifter return to daily activities. Method We prospectively enrolled 100 patients diagnosed with ATFL injuries and performed arthroscopic modified Broström procedures with internal bracing. Pre-operative and 6-month post-operative MRIs of the injured ankle were obtained. AOFAS scores were recorded 1st, 2nd, and 4th months postoperatively. The ATFL morphology was categorized into four groups: Increased intensity, wavy-shaped, discontinuity, and non-visualization. Result The mean preoperative AOFAS score was 81.4. At the 2-month and 4-month follow-up, the mean AOFAS scores improved to 96.3 and 98, respectively. The 6-month post-operative MRI revealed a solid linear band crossing from the talus to the fibular insertion for each repaired ATFL. Notably, 76 out of 98 ankles (78%) exhibited low signal intensity of the ligament. The rate of low signal intensity on postoperative MRI was significantly lower in those with discontinuous or nonvisualised quality on preoperative MRI (50.0%) compared to the wavy/enhanced intensity group (84.6%). Discussion and conclusions Regardless of the pre-operative ATFL morphology, the arthroscopic modified Broström procedure with internal bracing yields favorable functional outcomes and restores the morphological integrity of the ATFL.

INTRODUCTION: Specific risk factors for Achilles tendon repair complications such as tobacco use and diabetes have been well-reviewed in current literature. However, the impact of demographic disparities such as race and gender on the 30-day postoperative complication of an Achilles tendon repair has not been extensively reported. Accordingly, we sought to investigate whether demographic disparities in 30-day postoperative Achilles repair outcomes exist and to what extent. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database was queried for patients undergoing repair of Achilles tendon rupture from 2012 to 2021. A multivariate logistic regression was conducted for each complication to evaluate whether demographic factors were associated with complications after adjusting for various variables (age, obesity rate, diabetic/nondiabetic, smoker/nonsmoker, ASA class). Medical complications included deep vein thrombosis (DVT), superficial surgical site infection (SSI), deep SSI (dSSI), wound disruption after surgery/dehiscence, readmission rate and reoperation rate. RESULTS: A total of 6333 patients who underwent Achilles tendon were included in the study, 25% (N=1607) were women, 49.0% (N=3101) reported as White, 21.1% (N=1336) as Black/African American and 29.9% (N=1896) as Other. Following a multivariate analysis, neither race or gender of the patient were associated with a difference in rates of any evaluated complications. Only race demonstrated a significant difference in the rate of superficial SSI (χ2 = 7.21; p=.0272) following multivariate analysis. CONCLUSION: This study highlights advancements in the delivery of equitable care, but we recognize that there continues to be disparities in surgical care which requires strong and worthwhile solutions.

Unnecessary repeat MRI scans are costly and do not advance patient care. Our objective was to analyse the frequency of inappropriate repeat MRI Scans and assess the impact of introducing a protocol for repeat MRI requests. This was a retrospective audit of 1322 MRI scans performed in our foot and ankle unit between 01/10/2019-31/10/2022. Repeat MRI was defined as any scan within 3 years of MRI on the same area of the body. For all scans we investigated the clinical appropriateness and the impact of scan on patient management. Scans were deemed appropriate if they were part of a clinical trial, for tumour/infection/stress-fracture monitoring, for new trauma, pre-operative planning, following agreement in MDT or following changes in clinical symptoms. The initial audit demonstrated high rates of inappropriate MRI scans. Therefore, a protocol was introduced and re-audited over 6 months. In the initial audit 45% of repeat MRI scans were inappropriate. Following introduction of the protocol, inappropriate scans fell from 45% to 12% (p=0.001). No inappropriate scans influenced patient management in either cycle. The scans deemed appropriate by the protocol influenced patient management in 68% in the initial audit and 77% in the re-audit (p=0.48). The average time between scans increased from 13.1 months, to 21.1 months in the re-audit. The initial audit demonstrated that inappropriate repeat MRI scans were common and seldom impacted patient management. The MRI protocol significantly reduced the number of inappropriate MRI scans. Furthermore, this reduced the burden on radiology services and resulted in financial savings.

Objective:This study aims to investigate changes in vibration sensations in patients who develop ATFL rupture following acute ankle sprain, examining the usability of proprioceptive measurement methods and exploring their place in diagnosis. Materials and Methods:Osseous pathologies were ruled out and rupture diagnosis was then determined by ultrasound examination. Subsequently, vibration measurements were performed on both ankle ATFL traces using a 128 Hz tuning fork. Data were compared with a healthy population and a group of patients with ankle lateral edema following acute sprain without rupture. Results:Included in this study were 81 participants, with 48 males and 33 females.Among the 27 patients with ATFL rupture, additional CFL injuries were present in 9 cases and additional PTFL injuries (Grade 2-3 ) were present in 5 cases. The mean duration of tuning fork-assisted vibration on the injured side for patients with ATFL rupture was 5,72 second while on the healthy side it was 7,87 second. This difference was statistically significant (p=0.001).The average vibration duration for these cases at the 12th week was found to be 7,65 second which was statistically significant (p=0.001). The rate of chronic instability was 25.9% (n:7) Conclusion:After an acute ATFL rupture, the impaired proprioception also affects the vibration sense of the individuals, resulting in decreased vibration duration in the damaged tendon. Improved proprioception was demonstrated through vibration measurements,indicating the restoration of vibration sense.The tuning fork-assisted vibration measurement technique appears to be usable as a proprioceptive measurement method and can be employed as an adjunct method for diagnosis

Background - Distal tibialis anterior tendinopathy (DTAT) is a chronic condition that may lead to functional impairment and secondary forefoot deformities when left untreated. Current clinical practice is guided by case reports and small retrospective case series; little consensus exists on which treatment protocol is most effective. This study aims to assess a conservative treatment consisting of PRP-infiltration and walking cast immobilization. Methods - This prospective study included 18 patients (18 feet), recruited between September 2020 and September 2022 at our institution. Ultrasonography was performed; leukocyte-poor PRP was infiltrated around the tibialis anterior tendon insertion. Walking cast immobilization was used for 3 weeks after infiltration, followed by eccentric exercises and gastrocnemius-soleus muscle complex stretching. Clinical findings, visual analog scale (VAS), Foot Function Index (FFI), and American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores were recorded at inclusion, 6 and 12 weeks after PRP-infiltration. One-way repeated measures ANOVA was performed over time for FFI, AOFAS, and VAS scores. Results - Tendon thickening and hypoechogenicity were most commonly reported in ultrasonography. Significant improvement from baseline VAS (VASrest: 4.71±2.7, VASactivity: 5.66±2.5) to 12 weeks follow-up (VASrest: 2.14±2.7, VASactivity: 3.34±2.5) was found. AOFAS and FFITotal improved significantly from baseline (AOFAS: 66.9±3.3, FFITotal: 32.9±3.3) to 6-week follow-up (AOFAS6w: 79.4±3.3, P =.019; FFITotal: 19.4±3.3, P =.011). No statistically significant further improvement was found from 6 to 12 weeks’ follow-up. Two patients chose operative treatment because of persisting symptoms. Conclusion - We found that PRP-infiltration with walking cast immobilization was associated with general early symptom improvement.

INTRODUCTION: We report our surgical and patient reported outcomes for a cohort of single surgeon consecutive fibula nails with proximal and distal locking fixation. METHODS: We retrospectively reviewed prospectively collected data on 41 patients that were implanted with Fibulock® Fibula Nail (Arthrex, Naples, Florida, USA). Intraoperative reduction quality was noted and patients were followed postoperatively with radiographs assessing maintenance of reduction, healing, and complications. Patient reported outcome questionnaires were collected preoperatively and then again at 3, 6, 12, and 24 months postoperatively. The Foot and Ankle Ability Measure (FAAM) assessed the patient’s functional status, The Visual Analogue Scale (VAS) was used to evaluate pain. RESULTS: All 41 patients had approximately one year of postoperative follow-up and some patients up to two years of follow-up (14.68 months ± 5.92). There were 25 females and 16 males. The average age at the time of surgery was 47.17 years (± 16.00) and the average BMI was 27.28 (± 6.10). Medical history is shown in figure 1. The type of facture pattern is tabulated in Figure 2. Statistical analysis revealed a significant difference between preoperative and postoperative FAAM scores overall (+67.52, p < 0.001), within ADL (+68.07, p <0.001), and sport (+65.95, p < 0.001). Also, there was a significant difference between preoperative VAS and postoperative VAS (-4.73, p < 0.001). DISCUSSION AND CONCLUSION: Our findings support the use of intramedullary fibula nails as a viable alternative to traditional plate and screw fixation, offering improved patient outcomes and fewer hardware-related complications.

Background: Ankle fractures are a frequent injury in the adult population and a quarter of all ankle fractures are classified as unstable, requiring surgical intervention. Plate-and-screw construct is the traditionally used fixation method for fibula fractures. The use of an intramedullary nail is an alternative fixation method, with current literature supporting very low complication rates and hardware removal surgeries. The purpose of this study was to evaluate the outcomes, including complication rates and implant removal rates, using a fibula nail with both proximal and distal fixation capabilities by an experienced surgeon. Methods: We retrospectively reviewed 203 consecutive fibula nail cases from a single surgeon using a mini-open technique for anatomic reduction. Demographic, operative, clinical, and radiographic outcome data were analyzed, specifically examining complication rates and need for implant removal. Results: In total, 203 fractures were treated with a fibula nail and were included in our retrospective analysis. The average age was 47.3 years (range, 29-82) and the average body mass index was 28 (range, 22-34). All fractures healed. We identified 2 cases of superficial wound infection, 1 superficial peroneal nerve irritation, and 1 case of implant removal. 2 fractures were converted to a plate intraoperatively prior to a technique modification which has prevented this occurrence. No deep infection, delayed union, or nonunion occurred. Conclusion: Our data support that fibula nails with proximal and distal locking capabilities offer an alternative to plating with the potential for lower complication rates and lower need for implant removal.

Introduction Arthroscopic tibiotalocalcaneal arthrodesis with retrograde nail is a minimally invasive technique which is performed in patients with osteoarthritis who do not improve with conservative treatment. The advantage of this technique is less hospital stay and lower complication rate compared to open techniques. Material and methods A retrospective descriptive study of 8 patients undergoing arthroscopic tibiotalocalcaneal arthrodesis by posterior approach between 2016-2023 with retrograde nail in our hospital. We analyzed functionality data measured with the American Orthopedic Foot and Ankle Scale (AOFAS), degree of satisfaction, consolidation time and rate, discharge time and main complications. Results An average hospital stay of 3.43±0.53 days was observed and patients had good functionality and low complication rate. We obtained 86% rate of tibiotalar consolidation in the period of 10 weeks and a rate of subtalar consolidation about 71% in 20 weeks. Patients were non-weight bearing for 4 weeks with a splint and then they were allowed partial-weight bearing with orthopedic boot until 10th postoperative week. We found main complications in two patients: one of those had to be reoperated due to complications in the surgical wound and the other one presented tibiotalar pseudoarthrosis although without clinical repercussion. Conclusion Arthroscopic panarthrodesis by posterior approach offers very good results with a high rate of bone consolidation, few complications and minimal non-weight bearing time. This technique could be used in patients without major deformities, especially in those at high risk of complications of the surgical wound as diabetic foot because of the decrease in them observed.

Introduction: Trans-fibular total ankle arthroplasty (TAA) has demonstrated promising outcomes in recent studies. However, comparative data on the performance of Trans-fibular TAA in patients with rheumatoid arthritis (RA) versus osteoarthritis (OA) are lacking. This study aims to compare the therapeutic outcomes of Trans-fibular TAA in RA and OA populations. Patients and Methods: We conducted a retrospective cohort study at our institute, evaluating patients who underwent Trans-fibular TAA from January 2019 to April 2022. The study included 46 ankles, with 29 from RA patients and 17 from OA patients. Outcome measures utilized included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q), a patient-reported outcome tool, and the Japanese Society for Surgery of the Foot (JSSF) scale, comparing preoperative scores with those at 3, 6, 12, and 24 months postoperatively. Additionally, both the SAFE-Q and JSSF scores were directly compared between the RA and OA groups at each time point. Complication rates were also documented and analyzed. Results: Improvements in all SAFE-Q subscales and the JSSF scale were significant at 3 or 6 months post-operation, and these improvements were maintained up to 2 years in both groups. Comparative analysis revealed significantly higher scores in the OA group in the 'Physical function' and 'Shoe-related' subscales of SAFE-Q at the 2-year postoperatively. Complications included malleolar fractures (OA: 3, RA: 2) and infections (deep: OA: 1, RA: 1; superficial: RA: 2). Conclusion: Both groups showed good clinical outcomes up to 2 years post-operation, with the OA group performing better in some patient-reported outcomes.

Introduction. Our aim was to analyse whether a short course of corticosteroids is useful in reducing the ‎delay of ‎definitive surgery in trimalleolar ankle fractures.‎ Methods. We retrospectively analysed patients admitted between January 2020 ‎and ‎December 2022 for a trimalleolar ankle fracture. One group received methylprednisolone 1mg/kg ‎every 24 ‎hours for 3 days at the discretion of the admitting physician and the other did not. We excluded patients with ‎chronic corticosteroid ‎treatment, patients treated with external fixation as the definitive treatment and patients with associated lesions. ‎Delay to surgery and ‎postoperative complications during the first year were assessed.‎ Results. Of a total of 57 patients, 23 (40.4%) received methylprednisolone with a ‎mean ‎age of 55.35 years (±17.79) while the group that did not receive treatment was 57.38 years (±16.96). No ‎differences were found in the type of fractures between both groups (p=0.145) using ‎Lauge-Hansen ‎classification with PER4 fractures being the most frequent in both groups. There ‎were also no differences in ‎dislocations or subluxations on admission (p=0.483), open fractures (p=0.145), or the use of external fixation ‎‎(p=0.146). The mean delay to definitive surgery was 7.82 ‎days (±4.71) in the group that did not receive ‎corticosteroid and 7.57 days (±3.88) in the group that ‎did (p=0.829). Complications rate during the first year ‎of follow-up was similar in both ‎groups (p=0.874).‎ ‎ Conclusion. In our sample, methylprednisolone was not associated with a decrease in time to surgery, and it did ‎‎not appear to increase the risk of postoperative complications.‎

Aims: The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Methods: We reviewed a total of 37 ankles that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results: Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, four ankles did not show further progression, resulting in an overall 91.9% success rate(34 of 37) at a mean follow-up period of 47.5 months(24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up(p<0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% at the medial malleolus, 65.1% at the tibia, and 81.2% at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation(p=0.001). Conclusion: Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting.

Introduction Anterior ankle arthroscopy is a common and safe procedure for ankle pathology, but is not free from complications like neurovascular injury, tendon rupture or infection. Material and Methods We present a case of an active 27 years old male patient who underwent anterior ankle arthroscopy due to anterior ankle impingement. Two months after surgery, he felt a sudden snap directly over the anterior ankle joint, with immediate pain and inabilty to extend the lesser toes. Subsequent dynamic ultrasonography demonstrated an extensor digitorum longus tendon high-grade rupture. Results We decided for an anterior ankle open approach, and after extensor digitorum longus complete rupture confirmation, with a gap around one centimeter (with the ankle placed in a neutral position), performed direct suture of the tendon, augmenting it with a peronial tertius tendon autograft harvested from the same ankle. The three years follow-up demonstrates an asymptomatic patient, punctuating zero on the Visual Analog Score for Pain and 89/100 on the Foot and Ankle Outcome Score (FAOS). Discussion Extensor digitorum longus rupture is a rare complication of anterior ankle arthroscopy, and is commonly attributed to iatrogenic injury caused by the arthroscopic shaver blade or radiofrequency instruments. Diagnosis is based on clinical evaluation and can be confirmed by ultrasonography or magnetic resonance imaging. Conclusion Late rupture of extensor digitorum longus is a rare complication of anterior ankle arthroscopy. Timely diagnosis permits direct tendon repair, and augmenting this repair with a peronial tertius tendon autograft can lead to high patient satisfaction and functional status.

Purpose: This study examined whether preoperative radiological evaluations can predict syndesmotic instability according to the lateral malleolus fracture pattern in supination-external rotation-type ankle fractures. Materials and Methods: This study enrolled 132 patients (132 ankles) with supination-external rotation stage 3 and 4 ankle fractures. Three-dimensional computed tomography was used for the morphological classification of the lateral malleolus fractures. A long oblique fracture was defined when the posterior cortical bone height of the fracture was 4.5 cm or more from the plafond of the distal tibial articular surface. A short oblique fracture was defined when the height was less than 4.5 cm. The demographic characteristics and syndesmotic instability of the two groups were evaluated. Results: Short oblique fractures were confirmed in 102 cases, and long oblique fractures were confirmed in 30 cases. Long oblique fractures occurred at a statistically significantly higher incidence in younger ages and among males compared to short oblique fractures. Syndesmotic instability was more common in long oblique fractures. Conclusion: In supination-external rotation-type ankle fractures, syndesmotic instability was observed in approximately 13%. Specifically, when the fracture pattern of the lateral malleolus is long oblique, the incidence of syndesmotic instability is approximately three times higher than in short oblique fractures. Therefore, meticulous evaluations of the lateral malleolus fracture pattern and establishing an appropriate treatment plan before surgery are crucial.

Introduction: Although internal fixation surgery of displaced ankle fractures is amongst the most commonly performed operations, there is little published on long-term outcomes. The true incidence of post-traumatic osteoarthritis (PTOA) requiring intervention is not well known. This study aims to establish the incidence of complications and long-term outcomes, specifically the development of arthritis. Furthermore, it aims to determine the effect of patient characteristics on these outcomes. Method: Between January 2009 and December 2010, 330 patients underwent ankle fixation. Patient demographics, comorbidities and complications including infection, non-union, further surgery, and PTOA were recorded. Two proportion hypothesis testing was used to establish whether patient characteristics affected outcomes. Results: There was a 1.2% and 1.5% incidence of superficial and deep infection respectively. 21.5% (71/330) underwent further surgery with 1.5% requiring revision fixation and 17.6% removal of metalwork. The latest clinical information showed 3.6% (12/330) developed PTOA with only 5 patients requiring surgery including three ankle fusions. There was a statistically significant increase in delayed union rates (P=0.041) in smokers. There was a higher rate of deep infection, delayed union and revision surgery in diabetic patients and higher rates of PTOA and requirement for surgical management of PTOA in overweight patients, although these did not reach statistical significance. Conclusion: Our results show low incidences of short-term complications and development of arthritis in the long-term following internal fixation of ankle fractures. In our study, smokers had higher rates of delayed union but there was no significant correlation between patient characteristics and comorbidities on other outcomes.

Background: Maisonneuve fracture involves the disruption of the syndesmosis and necessitates surgical intervention. The aim is to restore fibula length and stabilize the syndesmosis. Classic manual reduction may be strenuous to maintain during the syndesmosis fixation. Hence, we report our method of reduction with a distraction technique that provides mechanical advantages. Case Presentation: We present a case series of 3 patients with Maisonneuve fracture where indirect fibula reduction was achieved via a novel distraction technique with instruments. Case 1 and 2 suffered an isolated high fibular fracture whereas Case 3 had concomitant ankle fractures. Syndesmosis disruption was confirmed with intraoperative Cotton's and external rotation test. All 3 cases underwent dual tightrope fixation of the syndesmosis. To achieve the reduction, a 3 hole plate was applied on the distal fibula fragment with a cortical screw applied over the most proximal hole. Subsequently, a 5mm Steinmann pin was drilled into the lateral tibial. The entry point of the tibial pin is immediately anterior to the fibula and 2cm proximal to the applied fibular plate. An edged lamina spreader was used to apply distraction between the plate and the Steinmann pin. Temporary reduction is held with a quadcortical K-wire, followed by tightrope fixation through the middle and inferior holes of the fibular plate. Clinical Outcomes: Postoperative imaging showed normal talocrural angle and presence of the fibula dime sign. Discussion: This technique provides mechanical advantages in strength and stability, holding the reduction whilst freeing up the surgeon's hands to perform the syndesmosis fixation.

Objective: evaluate and report the variation in descriptions and currently accepted terminology for the individual bands comprising the deltoid and spring ligaments in anatomical dissection studies. Methods: literature search for cadaveric studies identifying anatomical variations in the deltoid and spring ligament complexes was conducted using PubMed and Medline databases. The inclusion criteria encompassed human cadaveric dissection studies with measurement of individual deltoid and spring ligament bands, human cadaveric studies, English language and full-text availability. The following studies were excluded: animal studies, articles describing surgical repair approaches and radiological assessment studies without cadaveric dissection. The demographic data, parameters of individual components as well as the morphological structure of individual deltoid bands were summarised. Results: Out of the 18,208 studies from the database search, 11 articles were included in this study. 13 additional studies were obtained from the bibliographies, resulting in a total of 24 studies with 528 ankles evaluated. Conclusion: Due to the complexity of their anatomical relationships, the deltoid and spring ligaments should be described as a single entity: the ‘deltoid-spring ligament complex’. Its gross morphology can be described as triangular, trapezoidal, and rectangular. It can be differentiated into the deep deltoid and the superficial deltospring ligament which are connected. The latter encompasses the superficial deltoid and superomedial part of the spring ligament. The deep plantar ligament or ‘the inferior spring ligament’ are separate entities reflecting their discrete natures and histological difference. The superficial deltospring ligament can be divided into contiguous segments with variable bands (thickening but not true ligaments

Background: Lateral ankle sprains are the most common injury in sports. Up to 40% of patients fail conservative treatment, developing chronic lateral ankle instability. In recent years, arthroscopic Brostrom repair has gained increasing popularity to address the challenges of performing open repair. However, evidence has been equivocal regarding its clinical outcomes when compared to an open approach. Aim: Compare arthroscopic and open approach to provide additional perspective when managing chronic lateral ankle instability Methodology: Systematic review and meta-analysis with trial sequential analysis (from inception to 10 June 2023) searching PubMed, Embase, Scopus, Cochrane. Registered on PROSPERO (CRD42023389626). Primary outcomes: Mean difference of functional and clinical outcomes (American Orthopaedic Foot & Ankle Society score, Karlsson score, visual analog scale) Secondary outcomes: Risk ratio of complications Results: Arthroscopic Brostrom is clinically more effective compared to the open approach based on post-operative American Orthopaedic Foot & Ankle Society scores. Pooled post-operative American Orthopaedic Foot & Ankle Society scores was higher in arthroscopic group (MD = 1.08, 95% CI: 0.19 - 1.97, p = 0.02, 12 studies) Pooled post-operative Karlsson scores and visual analog scale scoresdid not reach statistical significance. Discussion: Arthroscopic Brostrom approach confers better functional outcomes compared to the open approach, with both groups having low, non-significant complication rates between each other. Other factors such as availability of resources, expertise, and manpower need to be considered as well. Nonetheless, the absence of statistically significant differences between complications in both arthroscopic and open Brostrom procedures suggest they are safe and viable options.

This prospective cohort study including adults with end-stage ankle osteoarthritis compares a 1 to 2-year outcome of total ankle replacement (TAR) to that of non-operative management (NOM). The primary outcome is measured by VR-12, FAOS (5 subclasses), patient satisfaction, and PCS short form. Statistical analysis was performed using one-way ANOVA as well as t-tests. 295 index procedures were included in the PROMs analysis of which 138 surgical (47,40%) and 152 non-operative (52,60%). Among the non-operative group, 85 patients (56%) were not offered surgical treatment and 72 patients (44%) decided to delay their surgery by more than 1 year. At 1-year follow-up, the treatment survival was 80,9% in the delayed surgery group and 94,4% in the not offered group. In the surgical group, there was 1 failure (99,3% survival). A significantly (P<0,001) worse FAOS pain score at follow-up was seen for the delayed group (61,6) compared to the not offered (69,1) and surgical group (78,1). Similarly, FAOS QoL was significantly (P<0,01) lower for the delayed group (39,6) compared to the surgical group (58,3) with an average difference of 19.7 points (95%CI 9.9 - 29.4). Between the not offered (50,1) and surgical group (58,3) there was a not significant (P=0,12) average difference of 8.2 points (95%CI -2.3 - 18.6). We conclude that TAR is superior to NOM regarding pain treatment for end-stage ankle osteoarthritis. Conservative treatment remains a valid option in end-stage osteoarthritis, however, if TAR is indicated and surgery is delayed these patients suffer worse outcomes during the delay time.

Chronic lateral ankle instability (CLAI) is prevalent in sports, traditionally treated with open surgery – modified Broström-Gould. Recently, arthroscopic treatment has gained interest, though studies are limited. This study introduces a new arthroscopic CLAI repair technique using knotless anchors, comparing its outcomes to existing literature and evaluating postoperative improvements in clinical and functional scores. Data was collected from 36 patients (64% male, 36% female, mean age 27.5) who underwent arthroscopic repair with a knotless anchors system. Evaluations were conducted preoperatively, and at 6 and 12 months postoperatively, measuring variables such as age, sex, Visual Analog Scale (VAS), American Orthopaedics Foot and Ankle Society Score (AOFAS) Ankle-Hindfoot Scale, Karlsson-Peterson score, patient satisfaction, and surgical complications. Results indicated significant improvements in VAS, AOFAS, and Karlsson-Peterson scores (p < 0.001) at both 6 and 12 months. The AOFAS score increased from a median of 61.0 preoperatively to 96.0 at 6 and 12 months. The Karlsson-Peterson score improved from a median of 45.0 preoperatively to 95.0 at both postoperative intervals. Patient satisfaction at 12 months was high, with 91.7% very satisfied and 8.3% satisfied, and only two minor complications reported. No significant impact of age or gender on outcomes was found. The new arthroscopic technique with knotless anchors demonstrated excellent short-term postoperative recovery. Future research should compare this technique with open Broström-Gould surgery and other arthroscopic methods using knot systems.

Introduction: Ankle arthrodesis is considered in cases of advanced arthrosis, arthroplasty failure or other. Objectives: Illustrate a clinical case that was used twice on the same patient in different phases. Materials/methods: The bibliography related to ankle arthrodesis was reviewed and the clinical file of the illustrated case was consulted. Results: A 56-year-old man presents with a 2-year history of intense pain in the right ankle. Past history refers to a work accident(2003) resulting in a fracture of the tibial pilon-osteosynthesis was performed. Due to progression to osteoarthritis and disabling pain, he underwent ankle arthrodesis. Later, in 2007, he underwent disarthrodesis and total ankle arthroplasty. At the appointment(2022), evidence of astragaline loosening, bone cysts, lateral malleolus stress fracture and subastragaline arthrosis. He underwent prosthesis extraction and calcaneo-tibial arthrodesis with a nail (anterior approach) and space filling with a tricortical iliac graft and a cadaveric allograft (lateral approach). The surgery was uneventful. No isolation in microbiology. The patient evolved favorably, with superficial infection (empiric antibiotic-therapy), use of a walker-boot and consolidation with progression to full weight bearing at 12 weeks. He only complaints of dysmetria(2cm), managed with height compensation. AOFAS Ankle-Foot Scale:74. Conclusions: Constraints for ankle arthrodesis and arthroplasty present some overlap. Calcaneo-tibial arthrodesis presents itself as a surgical alternative in cases of ankle arthroplasty failure, namely as an alternative to revision arthroplasty. The results are predictably a stable, painless limb with functional gait. In the presented case (18months follow-up) the patient is well adapted, without limitations in ADLs, with autonomous gait.

Background Total Ankle Arthroplasty (TAA) is an effective solution in the end-stage ankle arthritis. New generation’s implants have demonstrated encouraging intermediate clinical results: modern systems have either a fixed-bearing (FB) or a mobile-bearing (MB) design. Literature shows no clear evidence about the differences between the two types of prostheses. Objectives The aim of the study is to compare FB and MB prosthesis systems, specifically evaluating for each group (i) the revision rate in terms of conversion to arthrodesis, replacement TAA and below-knee amputation; (ii) minor events that still required surgery; (iii) and to provide an overview of total ankle replacement, including its advantages and disadvantages. Study Design & Methods A systematic review of the literature was performed. The Preferred Reporting Items for Systematically Reviews and Meta- Analyses (PRISMA) was followed. Retrospective and prospective studies were evaluated and added to the final reference list. Indeed, all case reports, case series and systematic reviews were excluded. Results Forty-six articles were included in the review. Relevant data were systematically collected. A meta-analysis was conducted among similar data, showing the failure risk and revision rate among the two different groups. No significant statistical differences were found in terms of complications rate. Conclusions TAA is a challenging procedure both technically and for the high revision rate. Both types of ankle prostheses, with mobile-bearing or fixed-bearing, appear to be valid options for the treatment of ankle arthritis, with an intermediate risk of short, medium, and long-term complications.

Introduction Chronic lateral ankle instability often follows traumatic rupture or pathological laxity of the lateral ankle ligament complex. While MRI is useful in identifying complete ligament tears, it may not reliably detect incompetence in pathologically elongated ligaments. This study aims to determine if EUA is a superior diagnostic tool compared to MRI scans in accurately diagnosing chronic lateral instability. Methods We conducted a prospective case analysis of 50 symptomatic patients who underwent lateral ligament reconstruction for chronic ankle instability. Each patient underwent both EUA and MRI scans prior to surgery. EUA was performed in the operating theatre under general anaesthesia, using image intensifier guidance to conduct anterior drawer stress and talar tilt tests. MRI scans were independently evaluated by two experienced musculoskeletal radiologists. Results EUA indicated complete insufficiency of the ankle in all 50 patients, as evidenced by positive anterior drawer and talar tilt tests. MRI scans reported complete ligament rupture in 17 patients (34%), thickened ATFL (Anterior Talo-Fibular Ligament) and CFL (Calcaneo-Fibular Ligament) ligaments in 18 patients (36%), and an intact lateral ligament complex in 15 patients (30%). Conclusion EUA, in conjunction with symptomatic instability, appears more reliable in assessing lateral ligament instability compared to MRI scans. While MRI is valuable for identifying additional pathologies such as osteochondral lesions, peroneal tendon subluxation or tear, and syndesmotic injuries, it is less effective for evaluating hyperlaxity and elongated lateral ligaments. Therefore, EUA should be considered a critical diagnostic tool in managing patients with chronic lateral ankle instability.

Background Foot and ankle injuries are one of the most orthopedic leading causes of emergency department (ED) admissions. The purpose of this study is to analyze, through 5 years of data collection, differences in number and type of admission of foot and ankle trauma to the ED in the pre-pandemic period, during the COVID-19 emergency, and in the post-pandemic period. Methods 5 years data were collected on admissions to the ED of the University Policlinic A. Gemelli, using the regional GIPSE system. Data was extensively collected and analyzed to obtain epidemiological and clinical evaluation. Result In the pre-pandemic period, 2228 ED accesses were recorded, including 1138 males with a mean age of 37 years and a mean of 2.8 accesses per day, with an average surgical treatment of 4.5%. During the COVID period the total number of accesses was 981, with an average surgical treatment of 10.4%. In the post-COVID period, 578 accesses were collected, with an average surgical treatment of 9,1%. Conclusions During the pandemic period due to Covid-19 was noted a substantial decrease in total admissions per day to the ED, but an increase in more complex codes, as evidenced by the percentage increase in surgical admissions compared to total admissions during the pandemic; the average age of users gradually increased. Total hospitalization data remained overlapping in the post-pandemic period, probably due to the global impact of the pandemic. Covid-19 radically and concretely changed people's living habits and priorities for accessing the ED.

Background Tillaux – Chaput tubercle fractures in adults often go unnoticed in ankle trauma. This study aimed to identify clinical and radiological factors associated with these fractures to develop a decision aid for CT diagnosis. Methods This case-control study included 72 patients with bimalleolar fractures who underwent both radiography and CT scans. The case group consisted of 28 patients with Tillaux – Chaput fractures, and 44 served as control. Socio-demographic, clinical data and injury mechanisms according to Arimoto and Forester's algorithm were compared using univariate and multivariate analysis to identify predictive factors. Results Tillaux-Chaput factures were missed on standard radiographs in 60% of the cases. Predictive factors of Tillaux-Chaput fractures were age > 60 years, injury on the dominant side, and Pronation – External Rotation injury mechanisms. Conclusion In the absence of routine CT scan for ankle fracture preoperative assessment we recommend a CT scan for elderly patients with ankle fractures on the dominant side, particularly with stage III or IV Pronation-External Rotation mechanisms.

OBJECTIVE: To analyse the outcomes of 44 cases of tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail. METHODS: This retrospective study reviewed 44 surgeries performed between 2017-2023, evaluating aetiology, surgical technique, consolidation, postoperative complications, and clinical outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) and Ankle-Hindfoot Scale and the Visual Analogue Scale (VAS) for pain. RESULTS: The cohort included 26 women and 17 men, with an average age of 59 years. The most common aetiology was severe post-traumatic arthritis (52%), followed by poliomyelitis sequelae, Charcot neuroarthropathy, clubfoot, and neurological injuries. Surgeries were performed in the supine position, using anterior (54.5%) or lateral approaches with fibular resection (29.5%). Hindfoot malalignment was present in 75% of patients. Primary arthrodesis was performed in 2 cases. We do not prepare the subtalar joint. Bone grafting was used in 34% of cases, with 11 cases using femoral head allograft and 4 cases using fibular autograft. The average surgical time was 132 minutes. Consolidation was achieved in 97.7% of cases, with a median radiographic consolidation time of 20 weeks. One patient developed pseudoarthrosis. CT scans in 22 cases showed complete tibiotalar fusion. Superficial dehiscence was the most common complication (9 cases), and one patient had a deep infection. The average AOFAS score was 67/100, the average VAS score was 3/10, and all patients would undergo surgery again. CONCLUSIONS: Tibiotalocalcaneal arthrodesis with retrograde intramedullary nail is a reliable option for managing advanced arthritis with or without malalignment, providing stability, high consolidation rates, and few major complications.

Introduction : Tibio-talar fusion is the gold standard for the treatment of end-stage arthrosis. The anterior plate and isolated screw fixation is mechanically the most stable and achieves a higher consolidation rate. The study aims to evaluate the performance and safety of the Neofuse® In2Bones® anterior plate arthrodesis. Method : This is a one-year prospective multicentric European study. The primary outcome measure is tibio-talar consolidation. Secondary outcome includes radiographic measurements, functional results and scores, clinical stability and fusion, as well as device safety evaluation. Results : The preliminary study results on 35 patients who completed follow-up are presented. Fusion was achieved in 97.1% of cases (34/35) with a mean time of 3.9 months. Patients returned to work/daily activities at 5.3 months. At one year, 100% (35/35) are stable with 91% (32/35) of normo-axial hindfoot. Comparing pre-operative and post-operative scores at one year showed a significant improvement : 7 vs 2 for VAS, 29 vs 74.2 for AOFAS, 6 vs 17 for EFAS, 27.2 vs 36.4 for SF12, all with p<0.001. The one-year radiographic results showed mean frontal, sagittal and tibia axis-to-talus alignments of 91.1° (79-98), 104° (88-122) and 36.3 (27-45) respectively. Conclusion : The Neofuse® In2Bones® tibio-talar arhtrodesis device demonstrates excellent results in this preliminary study. The fusion rate of 97.1% is comparable to the literature. The study reports no complication directly related to the device. The surgical objective of achieving consolidation in a good position as well as clinical objectives of painlessness and stability are perfectly met.

Background Endoscopic flexor hallucis longus (FHL) transfer can be used in the management of acute Achilles tendon rupture. A cadaveric study demonstrated greater strength can be achieved using an FHL transfer with interference screw and cortical button slide technique compared to an interference screw alone. Objectives Demonstrate this novel technique to be a safe and effective treatment method. Methods The complications and patient related outcome measures (PROMs) of 10 patients who underwent Achilles tendon rupture repair using the aforementioned technique were reviewed. Validated scoring systems were utilised (EQ-5D, Manchester.Oxford Foot Questionnaire (MOxFQ) and Visual Analogue Score for pain (VAS Pain)) with results collected via the BOFAS Amplitude registry pre-operatively and at 6 monthly intervals post-operatively. Results Mean (SD) age at time of surgery is 58 (16.3) years. EQ-5D improved from a mean (SD) of 0.48 (0.35) pre-operatively to 0.76 (0.26) at 6 months and 0.98 (0.05) at 12 months post-operatively. Similarly, VAS Pain improved from an average of 40.6 (30.9) pre-operatively to 15.4 (27.2) and 2.2 (4.3) at 6 and 12 months respectively. Improvements in MOxFQ were reported across all three domains post-operatively also. One patient developed tibial nerve neuritis: no further complications were reported. Conclusion This endoscopic method is safe, effective and provides a stronger repair. Early patient data shows improvements in quality of life, pain and specific foot and ankle outcome measures following surgery. Further studies are required with longer term follow up and greater patient numbers. Clinical comparison to standard interference screw fixation should also be undertaken.

Introduction: Ankle osteoarthritis (OA) and osteochondral lesions of the talus (OLT) can be managed conservatively with different strategies with surgery reserved for failures of conservative management. Objectives: Describe the effects regarding pain relief and possible complications of hyaluronic acid (HA) injection in patients with ankle OA and OLT. Methods: Observational study of patients with ankle OA and OLT that had an ultrasound guided HA injection by the radiology department between January 1st 2020 and December 1st 2023 in our center and a minimum follow-up of 6 months. Patients' visual analog scale (VAS) at baseline, 3 months and 6 months after injection were recorded. Exclusion criteria were administration of another medication (except mepivacaine) or biological therapy and incomplete data collection during follow-up. Results: 137 patients were referred to the radiology department for an ultrasound guided injection. Fifty-eight patients (63 ankles) that received HA injection for ankle OA and OLT were identified. Thirty-seven (42 ankles) were included. Baseline VAS score was 7.98 ± 1.37; 5.76 ± 2.14, and 6.64 ± 2.07 at 3 and 6 months post injection respectively (p<0.05). Patients reported a mean of 7.9 ± 7.81 months with some pain relief. Patients mean age was 59.6 (range 32-83) and mean follow-up was 18.8 ± 12.1 months. Eleven (26.2%) patients received a second HA injection and 7 (16.6%) underwent surgery during follow-up. No complications were recorded in this series. Conclusion: HA injections is a safe treatment that may provide a temporary pain improvement in patients with ankle OA and OLT.

The most commonly medial malleolus osteotomy used are Chevron(OMM-C) and Oblique(OMM-O). A bony "safety zone" with less cartilage is described for this technique, however, the difference between the two techniques and the impact of the surgeon's experience is not described. The objective is to quantify tibial articular cartilage damage according to type of osteotomy and surgeon experience. Surgeons with 20 years (C1) and 3 years (C2) of experience. Osteotomy angulation was measured, photographic recording of tibial plateau determining distance (mm) between "safety zone" and osteotomy; percentage of cartilage area involved. 28 cadaveric legs. Median angulation of OMM-C 54.5º and OMM-O 59º. According to surgeons C1 and C2, median OMM-C angulation 54º and 56º with no differences; OMM-O 52º and 64º with differences (p=0.0017) respectively. Presence of 63.5% of cartilage in "safety zone". More secure location medial to the "safety zone" in OMM-C versus OMM-O and in C2 versus C1. Median compromise of 0% and 1.1% of the tibial plafond area for OMM-C and OMM-O respectively, with no differences. No differences according to surgeon and osteotomy. In this study, there were no differences in angulation between osteotomies, neither according to surgeon in OMM-C, but there was a greater cutting angulation in OMM-O of the less experienced surgeon. The "safety zone" was confirmed at 63.5% cartilage. OMM-C was located more medial to the "safety zone", towards the medial malleolus, versus OMM-O. Both osteotomies had low involvement of the articular cartilage area with no differences between osteotomies or surgeons.

A glomus tumor is a painful soft tissue neoplasm arising from the glomus body. The tumor usually presents itself with a triad of symptoms: pain, touch and cold sensitivity. The most common site of occurrence is the nail bed of the hand; other locations are far less common. Presentation in the ankle is rare. In the present study, we report a case of a patient with a glomus tumor at an atypical site, the Achilles tendon. A 75-year-old man presented to our department with a history of 6 months severe pain in the area of his right Achilles tendon, provoked by palpation or wearing shoes. Physical examination showed a painful, 1 cm large mobile lump at the medial border of the Achilles tendon. Gentle palpation of the lump provoked severe pain. Magnetic resonance imaging showed a non-specific change at the Achilles tendon, which could represent fluid collection. Rupture or calcifications of the Achilles tendon were excluded. The patient underwent surgical excision of the mass. Surgical exploration revealed a well-defined blue lesion on the Achilles tendon, approximately 1 cm in diameter. The lesion was excised and sent for histopathological examination. Gross examination revealed a flat solid grey-brown oval mass measuring 12 x 8 x 4 mm. A histopathologic diagnosis was reported as a glomus tumor. At the one-month follow-up visit, the patient presented pain free and could wear regular shoes.

Purpose: Rotational ankle instability can be diagnosed in up to 18% of cases of chronic ankle instability. It is caused by injury to the deltoid ligament secondary to chronic deficiency of the lateral collateral ligament. This prospective observational study aimed to investigate clinical outcomes following arthroscopic all‐inside medial and lateral ligament reconstruction for rotational ankle instability. Methods: A prospective observational study of consecutive patients undergoing arthroscopic all‐inside medial and lateral ligament reconstruction with minimum 6‐month follow‐up. The primary outcome was a validated patient‐reported outcome measure (PROM), the Manchester‐Oxford Foot Questionnaire. Secondary outcomes included EQ‐5D, European Foot and Ankle Society score and complications. Results: Between 2020 and 2023, 12 patients underwent primary reconstruction for rotational ankle instability with pre-and post‐operative PROMs collected. The mean ± standard deviation age was 33.9 ± 7.2 years + mean follow‐up was 1.9 ± 1.2 (range: 0.5–3.8, interquartile range: 0.9–3.0) years. There was a significant improvement in all Manchester‐ Oxford Foot Questionnaire scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ‐5D‐5L Index, VAS and VAS Pain. There was one complication—a superficial peroneal nerve injury which resolved with corticosteroid injection. Conclusion: The arthroscopic all‐inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9‐year follow‐up.

Introduction:Autologous Osteochondral Transplantation (OAT) effectively treats talus osteochondral lesions, enhancing functionality and promoting a return to sports. This study evaluates clinical and functional outcomes, complications, and patient satisfaction post-OAT, and examines the return to work and sports. Methods: Observational, retrospective study. Includes patients treated with OAT for talus osteochondral lesions from 2011 to 2022. Inclusion criteria: Patients over 18, minium one year of follow-up. Exclusion criteria: Previous ipsilateral knee pain or surgery, infections, advanced osteoarthritis, rheumatologic diseases. Demographics, injury mechanism, sports activity, lesion details, associated procedures, consolidation time, follow-up, and return to activities were recorded. Clinical outcomes were assessed using AOFAS, Lysholm, Tegner, VAS scores. Patient satisfaction, return to sports, and complications were evaluated. Statistical significance was p < 0.05. Results: 37 patients (median age 36, 78.37% male), median follow-up was 24 months. Lesions were primarily sports-related and medially located, with a median area of 150mm². Postoperative outcomes showed significant improvement: AOFAS ankle scores increased from 54.45 to 95.81, and ankle VAS scores decreased from 7 to 1.59. Knee VAS and Lysholm scores averaged 1.81 and 98.78, respectively. Return to work averaged 2.29 months, and return to sports 6.53 months, with 37.5% changing sports activity. Tegner scores slightly improved from 5.4 to 5.45. Complications were minimal, with one case of knee hemarthrosis and one anterior ankle arthroscopy. Conclusion: OAT for talus chondral lesions is a safe and effective treatment with positive clinical outcomes, low complication rates, high satisfaction, and a high return to sports, without increased knee morbidity.

Background Osteochondral lesions of the talus are common in patients suffering even minor trauma; timely diagnosis and treatment can prevent the development of early osteoarthritis. The objectives of this systematic review and meta-analysis were to evaluate the effects of additional procedures on arthroscopic ankle microperforations for osteochondral lesions. Methods A systematic literature search was conducted using PubMed-Medline, Cochrane Central, and Google Scholar to select clinical studies analyzing the efficacy of platelet-rich plasma (PRP), hyaluronic acid (HA), and bone marrow concentrate (BMC) procedures. Ten articles following PRISMA guidelines with a total of 464 patients were included in this review. Quality assessment using MINORS was performed, and all studies demonstrated high quality. Results The results of the systematic review showed benefits in all patients undergoing infiltrative therapy with PRP, hyaluronic acid, and BMC. The best results in terms of AOFAS score and VAS scale were found in patients undergoing PRP injection. The meta-analysis showed improvements in pain relief and return to daily activities in patients undergoing arthroscopic microperforations and PRP, although not reporting statistically significant results (p = 0.42). Conclusion All treatment strategies reported better scores compared to the control groups. Among the various treatments analyzed, the addition of PRP appears to be the most valuable probably for the larger population receiving this treatment, showing excellent outcomes in pain reduction, clinical outcomes, and return to daily activities.

Introduction Ankle microinstability (AM) is often an underdiagnosed condition resulting from injury to the superior bundle of the anterior talofibular ligament (ATFL) without evident laxity on physical examination. Various modifiable and nonmodifiable risk factors influence ankle stability, such as sports activity, BMI, strength deficits, age, axial deformities, previous trauma, and congenital joint laxity. The proprioceptive alteration, in addition to ligament damage, plays a significant role in functional ankle instability. Research has shown that individuals with a history of ankle injury experience deficits in proprioception, leading to an increased risk of new ankle sprains. Diagnosis and treatment Diagnosing AM can be challenging, as clinical examination may not reveal significant laxity. Stress radiography and arthrometry are valuable tools for assessing ankle laxity. Magnetic resonance imaging (MRI) helps evaluate associated injuries and cartilage damage, although it may not always detect small superior fascicle ATFL lesions. Arthroscopy remains the gold standard for diagnosing and treating microinstability and associated injuries. Conservative treatment is the initial approach. Surgical treatment is considered when conservative measures fail. Different surgical procedures, are available to address the type and severity of ATFL injury. The choice of procedure depends on the specific patient and injury characteristics. Conclusion In conclusion, AM is a challenging condition that can lead to various ankle problems. Diagnosis and treatment require a comprehensive approach, considering the type and severity of the injury, associated pathologies, and individual patient factors. Further long-term studies are needed to refine treatment strategies for different ATFL lesions.

Aims: Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced, however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT. Methods: We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum 1-year follow-up. Standard preoperative radiography and magnetic resonance imaging (MRI) were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately 1 year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain Visual Analog Scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results: All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 ± 1.53 to 63.5 ± 22.6 (P = 0.025) in 10 patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and 2 patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (P ≤ 0.003). Conclusion: PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study.

Introduction: Trimalleolar fractures are complex injuries requiring precise surgical intervention to restore ankle stability and function. This study aims to analyze the relationship between tibiofibular overlap and baropodometric measurements post-surgery in patients with trimalleolar fractures and concomitant syndesmotic injury. Materials and Methods:This retrospective study included 28 patients (mean age 41.82 ± 13.32 years) who underwent surgery for trimalleolar fractures between 2018 and 2022. Postoperative evaluations were conducted with a mean follow-up period of 37.04 ± 10.33 months and included baropodometric measurements and radiographic measurements of tibiofibular overlap. Correlation analyses were performed to determine the relationships between these parameters. Results: Significant data were found between tibiofibular overlap and various baropodometric measurements on the operated foot. Notably, there were significant positive correlations with medial hindfoot force-time ıntegral, maxforce, peakpressure, and the maximum force and peak pressure of the 2nd and 3rd metatarsal heads (p<0.05) Conclusion: This study emphasizes the critical role of achieving optimal tibiofibular overlap in surgical interventions for trimalleolar fractures. Increased tibiofibular overlap is associated with improved baropodometric outcomes, particularly in the medial hindfoot and metatarsal regions, indicating that patients achieve a more normalized gait as the overlap increases. These findings highlight the importance of precise radiographic assessment and syndesmosis repair in the management of trimalleolar fractures. Keywords: Trimalleolar fractures, baropodometry, syndesmosis injury, tibiofibular overlap, plantar pressure, postoperative outcomes.

Introduction and Objectives: Osteochondral talus lesions often need surgical intervention based on lesion size and articular cartilage integrity. We aim to assess the medium to long-term clinical-radiological evolution of the lesions treated by filling with allograft -in cystic lesions with intact cartilage- and with fresh frozen osteochondral allograft when there is chondral involvement. Materials and Methods: We conducted a retrospective study on patients with surgically treated osteochondral talus lesions. Arthritis severity was measured using Van Dijk's classification initially and at follow-up's end. We also assessed VAS, AOFAS, joint mobility, reintervention rates, and graft consolidation via CT or MRI. Results: Ten patients were included: four with bone allografts and six with frozen osteochondral allograft transplantation. Follow-up averaged 4 and 7 years. No significant complications or progression were noted. Cystic lesion fillings showed no arthritis progression, with a final VAS of 1.25 and AOFAS of 87. Osteochondral allograft patients had a 17% arthritis progression rate, moving from Van Dijk's grade II to III, with a final VAS of 2.1 and AOFAS of 77. Joint mobility was full in both groups. Graft consolidation was 100% in cystic lesion group. Only 17% showed partial consolidation and another 17% had no consolidation in the osteochondral allograft group. Half of the osteochondral allograft patients required reintervention. Conclusion: Fresh-frozen allografts are beneficial for filling cystic lesions and osteochondral transplants in talus injuries over the medium to long term, though the latter show slightly inferior clinical and radiological outcomes.

The number of revision surgery after TAA and ankle arthrodesis is rising. The salvage procedure for these cases is the tibiotalar arthrodesis with augmentation. There is currently no primarily stable implant on the market to fill the bone voids and defects that occur after explantation of TAA or revision of pseudarthrosis after ankle arthrodesis. We present a new device to adress this specific problem showing six cases that underwent surgery of that kind. The implant ist a hygrostatic threedimensional crosslinked titanium cage that can be combined with intramedular nailing or extraarticular plating osteosynthesis. The principle of this technique has been succesfully used in spine surgery for years.

Charcot arthropathy presents as a debilitating condition marked by progressive joint deterioration, primarily afflicting the foot and ankle, resulting in the formation of distorted and unstable ankles. Typically, advanced deformities necessitate the use of external fixators and gradual correction to mitigate potential neurovascular complications. Here, we document the case of a 68-year-old woman with diabetes mellitus, hypertension, and end-stage renal failure, who exhibited painless progressive deformity of her right ankle over two years. Her mobility was severely impaired, relying on a wheelchair for movement. Clinical assessment revealed an 80-degree valgus deformity of the right ankle, accompanied by bony protrusions on the medial side, with dry skin but no ulceration noted. Radiographic examination depicted severe valgus deformity, complete talus destruction, distal fibula fracture, and loss of the lateral distal tibial plafond. She underwent tibiocalcaneal fusion using a hindfoot arthrodesis nail and iliac bone grafting during the consolidation and remodeling phase. Four months post-operation, radiographs indicated evidence of fusion, permitting partial weight-bearing with a walking frame. After one year, the patient regained ambulatory function without assistance, with radiographs confirming complete fusion. Notably, no complications such as skin or soft tissue infections, or neurovascular injuries were encountered. This case underscores the successful correction of severe ankle deformities and the restoration of a stable and functional foot in Charcot arthropathy patients through tibiocalcaneal arthrodesis employing a hindfoot nail.

Introduction: Osteochondral lesions of the talus (OLT) are common findings following both acute ankle trauma and chronic ankle instability. In the most recent systematic reviews, the AMIC technique showed good results, providing significant improvement in patient outcome scores. Aim of this study is a clinical and radiologic 10 years follow-up of a series of patients treated with AMIC technique for OLTs. Materials and Methods: The study evaluated 19 patients who underwent surgery with AMIC technique between 2011 and 2015 for 20 osteochondral lesions of the talus. A clinical 10 years follow up included PROMS such as EFAS score, Foot Function Index (FFI) Manchester Oxford Foot Questionnaire (MOxFQ). The MOCART 2.0 score was used for the radiologic 10 years follow-up. Results: The PROMs showed the following results: EFAS: 19.750 (SD 4.644), MOxFQ: 9.550 (SD 12.992), FFI: 16.150 (SD 20.879), MOCART 2.0: 44.750 (SD 12.055). The results were compared with the data present in the literature and showed overlapping values. The Pearson correlation between the PROMs and the results of the MOCART 2.0 score was evaluated and none of the PROMS showed a significant correspondence with the MOCART 2.0 results. Conclusions: AMIC method has proven to be an effective treatment for OLTs at 10 years of follow-up. However, the PROMs values do not correspond to the MOCART 2.0 score.

Background Total talus replacement (TTR) has become a notable treatment option for patients with talar avascular necrosis (AVN). However, the effectiveness of pure titanium prostheses remains less explored. This study aims to evaluate the clinical outcomes of TTR using a pure titanium prosthesis. Methods From May 2021 to May 2024, 25 patients with talus AVN underwent TTR at Inha University Hospital using customized 3D-printed pure titanium prostheses (Cubelabs, Seoul). 14 patients with a follow-up period exceeding six months were included for analysis. Evaluations of clinical and radiological outcomes were conducted preoperatively and at 3, 6, 12, 24, and 36 months post-operation. Outcomes assessed included VAS, Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), EQ-5D, and patient satisfaction. Data were analyzed using Wilcoxon signed rank tests. Results The average follow-up duration was 10.3 months (range, 6–36 months). Preoperative VAS pain scores averaging 8.27±0.81 decreased to 1.42±1.95 (range, 0-7) at final follow-up. FAOS significantly improved from 20.1±11.3 to 67.01 ± 20.9(P < 0.05), and FFI scores decreased from 83.8±10.1 to 21.51±17.58 (P<0.05). EQ-5D increased from 0.48±0.22 to 0.78±0.15. Range of motion improved from 37.1±20.7 degrees to 93.9±21.7degrees. 11 patients(76%) were very satisfied, 3 were satisfied(24%). No significant complications were reported. Conclusion: Short-term outcomes for TTR using pure titanium prostheses are promising, with significant improvements in pain and function without major complications. Extended follow-up is required to assess long-term outcomes and durability.

Ankle joint-preserving surgery, specifically supramalleolar osteotomies (SMOT), is an effective therapeutic option for treating ankle osteoarthritis in young patients. There is a lack of evidence in the literature regarding its indications and, especially, mid to long-term outcomes. The objective of this study is to evaluate the functional and radiological results one year postoperatively and postoperative survival in a series of patients treated with SMOT. A retrospective study was conducted, including 18 patients (18 ankles) who underwent SMOT between 2018 and 2021. Radiological variables, such as the correction of the anterior tibial surface angle (TAS) one year postoperatively, were evaluated. To assess functional outcomes, we used the Manchester Oxford Foot Questionnaire (MOXFQ) and the visual analog scale (VAS) for pain, preoperatively and at the one-year follow-up. We also evaluated the survival of the osteotomy at the end of the follow-up. The mean follow-up time was 47 months (SD:9). In varus ankles, the preoperative TAS of 83° (SD: 2.6°) was corrected to 92° (SD:2.5°), achieving overcorrection in 37.5% of cases. In the valgus ankle group, the preoperative TAS of 93° (SD:3.4°) was corrected to a postoperative TAS of 85.3° (SD:6.1°), achieving overcorrection in 70% of cases. The survival rate of SMOT was 88% at 4 years of follow-up. Functionally, the mean VAS decreased from 58.2 (SD:16.9) to 35.67 (29.0) (p=0.05), and the MOXFQ showed statistically significant improvement in all domains (p<0.05). SMOT lead to good functional and radiological results one year after surgery, with high mid-term survival.

Introduction: Low ankle sprains are a prevalent issue, often involving the anterior talofibular ligament (ATFL). While there is increasing attention on ligamentous injuries in ankle sprains, cartilaginous injuries are frequently overlooked. This article aims to (1) evaluate the significance of magnetic resonance imaging (MRI) in ATFL injuries to detect concurrent osteochondral lesions of talus (OLT) as well as associated ligamentous injuries; (2) determine the importance of clinical presentation and its correlations with risk of concomitant OLT in low ankle sprains. Material and Methods: We performed a retrospective analysis of 129 patients who underwent ATFL reconstruction. The patient data were reviewed to assess the incidence of OLT and other injuries concurrent with ATFL injury. Additionally, we examined the pre-operative clinical symptoms to identify any signs that could indicate the presence of OLT, prompting clinicians to consider a preoperative MRI scan for these subsets of patients. Results: A total of 31.8% (n=41) of patients with ATFL injuries of varying degrees were found to have concurrent OLT.. Further subset analysis of this group revealed that 78% (n=32) of these patients exhibited joint line tenderness, compared to 34.1% (n=30) of patients in the group without concurrent OLT. Of note, symptoms of instability appear to be comparable between both groups (75.6% with OLT vs 83% without OLT). Conclusion: This study concludes that patients with symptoms of joint line tenderness and chronic instability (>3months) should have a pre-operative MRI study as they are more likely to have concomitant OLT injury.

Introduction/ Purpose High energy tri-malleolar ankle fracture remains a challenge due to its propensity for wound complications. Commonly used postero-lateral and direct medial approach has its own drawbacks. The postero-lateral approach offers adequate visualisation of the deeper posterior malleolus but limited access to the fibula proximally and makes direct lateral plating difficult. Whereas the direct medial approach may lead to closure and wound complications as incisions are often directly over the fixation. This study proposes a new curvilinear incision for both the postero-lateral and medial approaches to overcome the challenges of exposure and wound healing. Methods On the medial malleolus, a curvilinear incision around the medial malleolus with a broad base posterior flap over angiosomes derived from posterior tibial artery(PTA) is designed. This allows full exposure and eventual flap coverage over the medial malleolus, without having the incisions centered over the implants. On the lateral malleolus, a curvilinear postero-lateral incision over fibular was designed based on the anterior perforating and calcaneal branches of peroneal artery(PA). This incision creates an anterior flap over the fibula distally. Outcomes measured in this series includes time to healing, wound related complications and need for surgical intervention. Results In our early series of five consecutive patients with closed tri-malleolar ankle fractures treated with a dual surgical incision, all of them required three malleolar fixations with plates and screws. Recovery for this group were uneventful, with no wound related complications that requires surgical interventions. All patients in this series exhibit excellent reduction and fixation radiographically.

Background: Total ankle arthroplasty (TAA) remains an excellent treatment option for end stage ankle osteoarthritis. We present the longer-term results of a modern design TAA. Methods: TAA was performed in 102 consecutive ankles (96 patients) in an independent, prospective, single-surgeon series. Implant survival, patient-reported outcome measures (PROMs) and radiographic outcomes are presented at a mean of 11 years (range 5-15 years). Results: Eighty-one ankles (77 patients) were included at an average age of 70 at the time of their operation. Eight of 81 ankles (10%) underwent revision or reoperation. Four were major revisions to fusion or revision TAA: one due to infection, one due to unexplained pain, and two due to migration of the talar component. Two other ankles underwent other revision operations – one liner exchange with a minimally-invasive heel-shift osteotomy for varus liner wear and one fractured liner was exchanged. Two ankles underwent re-operations: one had subtalar fusion and grafting for a cyst-related talar fracture, one required curettage and grafting for tibial bone cysts. With all-cause revision as an endpoint, implant survival was calculated using Kaplan-Meier curves as 92.4% at 5 years and 89.9% at 10 years. If a TAA survived to five years without revision, survival at ten years was 96.1%. Conclusions: This series demonstrates excellent radiographic and patient-reported outcomes for a modern-design TAA at 11 years with a revision rate similar to that previously published.

Infrasyndesmal ankle fractures are generally stable injuries that usually consolidate with conservative treatment with plaster. Avulsion fractures, even if they do not consolidate, are not usually clinically symptomatic, however, larger Weber A fractures can generate symptomatic instability in the patient. A 38-year-old male athlete came to the clinic with instability of the right ankle. He had an infrasyndesmal fracture of the right ankle 5 months ago that had not consolidated. On examination, he presented marked instability with walking, referring diffuse pain on the external side of the ankle and insecurity. During normal walking, he did not present symptoms, but during running he began to feel instability and pain. On examination, the non-union area was clearly palpable and painful. The hindfoot had a normal axis. X-rays showed an atrophic non-union of the external malleolus. We offered surgical management due to the instability during sports. Using a lateral approach, the area of pseudoarthrosis was located, refreshed and crest graft was provided. Then a compression hook plate was applied. The patient was left uncharged and immobilized with a suropedic splint for 6 weeks. After this, partial weight-bearing was authorized progressively. The patient evolved favorably and was asymptomatic 6 months after surgery with the fracture consolidated Generally, these fractures consolidate; those that do not, it is postulated that it may be due to anatomical variations in the blood supply of the external malleolus. Surgical management of symptomatic cases, open reduction and internal fixation together with bone graft, usually resolves the symptoms in most cases.

Tibiotarsal osteoarthritis is a highly disabling pathology, affecting 3.4% of the general population. When refractary to conservative treatment, the surgical approach varies between arthrodesis and arthroplasty, with arthrodesis being historically the preferred therapy. The emergence of modern implants has changed this paradigm. In recent studies, although arthroplasty continues to be associated with higher rates of complications, it has revealed excellent results in terms of mobility, functionality and implant survival. We present six cases of patients with tibiotarsal arthrosis who underwent total ankle arthroplasty with “QUANTUM Total Ankle prosthesis with OrthoPlanify - Patient Specific Instrumentation” in which preoperative images were used to produce 3D bone models and specific cutting guides. These are four females and two males, aged between 60 and 70 years, with an average AOFAS Ankle-Hindfoot Score of 33 / 100. All of them underwent total ankle arthroplasty with this system, between 2023 and 2024, in the same institution and by the same surgical team. During the follow-up period, there was a significant improvement in pain complaints, mobility and function, with an average gain in AOFAS Ankle-Hindfoot Score 40, with no complications recorded. Although it is not yet established as first line, new generations of ankle arthroplasty are changing the treatment of this patology. Total Ankle Arthroplasty with personalized cutting guides is designed to facilitate the procedure, decrease surgical time, improve mobility and increase stability based on patient's specific anatomy. More studies and follow-up time are needed to establish and confirm the advantages of this technique.

Purpose: To present the surgical technique of tibio talar calcaneal (TTC) arthrodesis applied to failed total ankle arthroplasty (TAA) cases, highlighting variations in femoral head allografts. Material and Methods: This study involves four patients who underwent TTC fusion after failed TAA. The surgical technique consists of placing the patient laterally with a thigh tourniquet, performing a lateral ankle approach with fibular osteotomy, removing implants, debriding the wound, and achieving fusion with a retrograde intramedullary nail under fluoroscopic guidance. Differences among cases were in using femoral head allografts to address bone defects. In the first case, the femoral head allograft was placed en bloc. In the second case, the femoral head was split into two parts to fit the defect. In the third case, the femoral head was ground into cancellous chips to fill the void. The fourth case involved a more significant bone defect from total talus replacement, filled with ground femoral head chips. The postoperative protocol included immobilisation in a circular cast, non-weight-bearing for six weeks, followed by gradual weight-bearing until the 12th postoperative week. Results: The American Orthopaedic Foot and Ankle Society (AOFAS) scores increased in all cases, with no wound complications noted. Only one case, the one with the ground femoral head, had a delayed union. Conclusions: TTC arthrodesis is a salvage procedure for failed TAA. Femoral head allografts can be adapted based on specific case requirements. This technique requires expertise in foot surgery and thorough preoperative planning for successful outcomes.

Background: Alterations in ankle’s articular contact mechanics serve as one of the fundamental causes of significant pathology. Nevertheless, computationally intensive algorithms and lack of bilateral weightbearing imaging have rendered it difficult to investigate the normative articular contact stress and side-to-side differences. Purpose: The aims of our study were two-fold: 1) to determine and quantify the presence of side-to-side contact differences in healthy ankles and 2) to establish normative ranges for articular ankle contact parameters. Methods: In this retrospective comparative study, 50 subjects with healthy ankles on bilateral weight-bearing CT were confirmed eligible. Segmentation into 3D bony models was performed semi-automatically, and individualized cartilage layers were modelled based on a previously validated methodology. Contact mechanics were evaluated by using the mean and maximum contact stress of the tibiotalar articulation. Absolute and percentage reference range values were determined for the side-to-side difference. Results: Amongst a cohort of individuals devoid of ankle pathology, mean side-to-side variation in these measurements was < 12 %, while respective differences of > 17 % talar peak stress and > 31 % talar mean stress indicate abnormality. No significant differences were found between laterality in any of the evaluated contact parameters. Discussion: Understanding these values may promote a more accurate assessment of ankle joint biomechanics when distinguishing acceptable versus pathological contact mechanics in clinical practice.

Introduction: In lateral ligament ankle repair, the Brostrom-Gould procedure is still a gold standard. While studies showed the benefits of arthroscopy, they usually associate arthroscopic and percutaneous techniques to access the inferior bundle of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL) and the inferior extensor retinaculum (IER). The goal of this technique is to be true to the open one and to report our 5-year preliminary results. Materials and methods: Three portals are used: anterolateral and anteromedial for the anterior arthroscopy, lateral for the endoscopy. To access the extra-articular features, a working space is created with a probe through the anterolateral portal. Two soft anchors are passed through capsule, ligament and EIR. A prospective database for 43 active patients (mean age 29.4), with a 5-year minimum follow-up, that underwent the procedure, was reviewed. Results: All patients had ATFL grade 1 or 2 SFA classification. The AOFAS scores showed significant improvement from 69.6 ± 13.9 to 93.7± 10.7 and the Karlsson score improved from 59.7 ± 14.5 to 91.5 ± 14.5 at the final follow-up. Two thirds (74.4%) maintained or had improvement in the AAS at 5.41 ± 2.8 from 5.38 ± 2.8 with an average satisfaction rate of 9.1 ± 1.3. The instability recurrence was 7%. No surgical complications or reoperations occurred. Discussion and conclusion: This is the first study on all endoscopic technique with long terms results. The outcomes are excellent and maintain over time in athletes, as in open techniques, but with less complications and failure.

Introduction Lateral malleolar fractures are the most common type of ankle fractures. Locking plates are increasingly used for surgical fixation of these displaced fractures, particularly in older patients. Biomechanical studies suggest these plates increase stability of the ankle joint. This study aims to analyse the complication rate, and cost difference between locking vs one-third tubular plates. Materials and methods Patients aged 60 and above who underwent surgical fixation for lateral malleolar fractures at our District General Hospital from 2019-2024 were included in this study. Data including operative fixation, plate used, complication rates, revision surgery and metalwork removal were collected from hospital records. Results A total of 42 patients were included for analysis. 57% of patients underwent fixation with locking plates and 48% with one-third tubular plates (n=18). Overall complication rate was 29% (n=12). There was no statistically significant difference in complication rate between locking and non-locking plates (p=1) or operating surgeon (foot and ankle vs other) (p=0.6987). Of the 3 diabetic patients, 2 experienced complications. Complications were categorised as early (largely due to wound issues) or late onset (mostly due to plate irritation). A total of 6 patients required further surgery. There was an estimated extra cost of £4974 for the use of locking plates during the study timeline. Conclusion There was no significant difference in overall complication rate between locking and non-locking plates used for lateral malleolar fracture fixation despite significantly higher costs of locking constructs. Further comparative studies are required to analyse the trends and demonstrate cost effectiveness.

Osteochondral lesions of talar dome are very common finding in various posttraumatic and atraumatic ankle conditions. It is extremely important to timely recognize and treat hyaline cartilage to prevent secondary osteoarthritis, alleviate pain, and improve patient function. The main clinical characteristics are deep ankle pain and swelling, and besides clinical examination, the diagnostic gold standard is MRI, which provides information on the size, depth, and stability of the lesion, the presence of subchondral cysts and bone marrow edema, and associated injuries such as ligament lesions, impingement, or malalignment. Arthroscopic techniques allow easy access and high-quality repair of all stages osteochondral lesions, with a lower risk of postoperative complications. Microfractures are a simple, inexpensive, and effective technique, suitable for defects up to 1 cm² and depths up to 3 mm, with the lack of final formation of fibrocartilaginous tissue. Autologous matrix-induced chondrogenesis (AMIC) is a technique intended for open surgery but can be performed arthroscopically with proper preparation. Suitable for larger defects, and compatible with bone grafting, with disadvantages of higher costs and technical complexity. The minced cartilage implantation technique has an indication spectrum similar to autologous chondrocyte implantation, allows the repair of larger, and combined with bone grafting, deeper defects. It is technically somewhat demanding but is single stage, completely biological, can be combined with ligament repairs and corrective osteotomies, has relatively low cost, and the potential to form hyaline cartilage. Given the high importance of preserving hyaline cartilage, it is essential to apply a wider range of repair techniques.

Background: Runners are at a higher risk of injury due to tightness in specific muscle groups, including the hamstrings, hip rotators, and calf muscles. Previous research has extensively explored the tightness of the gastrocnemius muscle in runners, which increases their susceptibility to injuries. However, limited studies have assessed soleal tightness in runners, warranting further investigation with larger sample sizes to understand its impact on running biomechanics and injury prevention. Methods: Sixty-three healthy adults (33 runners and 30 non-runners) were included in the study and gastrocnemius tightness was measured by ankle-foot dorsiflexion index (Silverskiold test). The relation between running mileage and intrinsic gastrocnemius tightness was obtained using linear regression analysis for each study group. Results: Mean ankle-foot dorsiflexion index (ADI) among runners and non-runners were found to be 10.66+6.04 and 13.25±7.57 respectively (P=0.03). Age, gender or side (left or right gastrocnemius) did not influence ADI. Muscle tightness was found to be inversely related to running distance. Conclusion: This study observed that runners have a higher Soleal Tightness as compared to non-runners. However, future studies with a larger sample size and targeted at professional athletes are required to substantiate the effect of Soleal tightness on running biomechanics.

Osteochondral lesions of the talus (OLTs) are the most common cause of chronic deep ankle pain.They are characterized by damage to the cartilaginous and subchondral bone of the talar dome.These lesions can be a significant traumatic event or recurrent microtrauma.In current literature,there is still not enough evidence to make clear and strong guidelines for OLT treatment.Classically, operative treatment strategies could be divided into cartilage repair,cartilage regeneration and cartilagem replacement.In recent years personalized talus resurfacing is growing in popularity as a viable treatment option for OLTs and to make the link between biologics and conventional joint arthroplasty.Case report of a 36-year-old man, with a osteochondral lesion of talus treated with personalized resurfacing (Episealer) and review of literature.A 36-year-old male with an osteochondral lesion of the talus (Hepple stage 4) on MRI, underwent arthroscopy, which showed an osteochondral lesion of the talus in zones 1 and 4 and microfractures were performed. Six months post-operatively, the patient continued to experience medial ankle pain,and a new MRI showed persistence of the osteochondral lesion.The patient then underwent a personalized talus resurfacing with an Episealer implant.Currently,at two year post-operatively,the patient is asymptomatic,with complete implant integration and is performing his job without restrictions and recreational sports activity with good tolerance.The authors believe that this technique is effective and will gain increasing importance in the coming years.For this surgical technique and the use of these new implants to be safely implemented,a rigorous validation process and studies with longer follow-up are necessary.

Purpose: To perform a systematic review and meta-analysis to compare the outcomes of open versus arthroscopic repair. Methods: We performed primary electronic search across PubMed, Emabse, Scopus, and Cochrane Library databases, and looked for the comparative studies that evaluated the medial versus lateral approach in TKA for valgus knees. Statistical analyses were executed with RevMan-5.4.1. Results: This meta-analysis suggested a significant difference in Karlsson [MD 1.10; 95%CI 0.34,1.87; p=0.005] and JSSF scores [MD 1.86 ; 95% CI of 0.74,2.97; p=0.001], and talar tilt [MD 0.28; 95% CI 0.14-0.41; p<0.0001] in the open group compared to the arthroscopic repair group; however, our results failed to show a significant difference in terms of AOFAS scores [MD 0.56 (95% CI -0.06,1.18; p=0.08], overall complications [OR 0.81; 95% CI of 0.53-1.25, p=0.34], wound-related complications [OR 0.49; 95% CI of 0.22, 1.09; p=0.08], nerve injuries, knot pain, anterior drawer test, VAS score [MD -0.31; 95% CI -0.62, 0.00; p=0.05] and duration of surgery [MD -5.16; 95%CI -11.91,1.60; p=0.13] between the two procedures for the lateral ankle instability. Conclusion: Current evidence shows comparable outcomes and complications for lateral ankle instability repair either through arthroscopic or open repair.

Background Syndesmosis injury can be of a varying magnitude; little information exists about the influence of the degree of initial syndesmotic injury on functional outcomes and follow-up radiological parameters. Aims and Objectives: To identify and define morphological patterns of syndesmotic injury in ankle fractures according to a zone-based evaluation and correlate the initial degree of instability with mid-term functional and radiological outcomes. Design: Retrospective cohort study, to review a prospective question. Materials and methods:40 complex ankle fractures out of 120 ankle fractures met the inclusion criteria i.e. significant documented syndesmosis involvement needing stabilization. Injury characteristics and fracture morphology were noted and classified by validated classification systems. The syndesmosis was divided into 3 zones on axial Ct section, A, B, and C from anterior to posterior, and the degree of displacement and morphology was noted. The patients were evaluated at the final follow-up with OMS, MOXFq & SF-12 Results:22 patients had Zone A injury(widening,AITFL,Chaput,Wagstaff fractures). 22 patients had widening of ZoneB. ZoneC was involved in 30 patients. Fracture reduction was excellent in all 40 patients and syndesmosis was widened in 5 patients. There was no significant difference in outcome scores based on fracture types (SERvsPER), Posterior malleolus morphology, or based on zones of syndesmosis injury. Syndesmosis malreduction contributed to significantly poorer outcomes(SF-12,OMAS,MoxFQ) Conclusion:Despite a zonal classification of syndesmotic injury on CT and more clarity of injury patterns, we could not correlate the site and extent of syndesmotic injury with final functional and radiological outcomes.

Background:The Chaput fragment, a bony avulsion of the anterolateral margin of the distal tibia, is a less commonly discussed fracture pattern in ankle injuries. Its significance in ankle fractures and the optimal fixation technique remains unclear due to limited literature. This study aims to describe the morphology of ankle fractures with Chaput fragment and introduce a new classification system. Materials and methods: We retrospectively analyzed 33 patients with ankle fractures with associated Chaput fragment treated at our institute over a 3-year period. Data on patient demographics, fracture classification, surgical approach, and fixation method were collected, and a novel classification system for Chaput fragments was proposed. Results: Four distinct morphological types of Chaput fragment were identified (types 1–4), and three newer variants of trimalleolar fractures were identified (anterior, lateral, and medial variants). Type 1 refers to a small avulsion fragment attached to the anterior-inferior tibiofibular ligament; Type 2 is an anterolateral oblique type;Type 3 refers to an anterolateral fragment with extension into the medial malleolus and Type 4 is a comminuted Chaput fragment. Type 1 Chaput fragment was the most prevalent (60.6%), followed by Type 2 (24.3%), Type 4 (9.1%), and Type 3 (6.1%). The fixation methods ranged from screw fixation, plate fixation, and suture fixation to combinations of these techniques or even indirect stabilization with syndesmotic screws. Conclusion: Our new classification system based on morphology includes all possible variants of Chaput fracture. This preliminary data needs to be corroborated by more studies and validated by a larger number of observers

Objective: Posterior ankle arthroscopy and hindfoot endoscopy have gained popularity since Van Dijk's introduction of the two-portal technique in 2000. Due to its complexity and higher risk of complications, it remains less common than anterior ankle arthroscopy. Van Dijk's series included 328 cases with a 2.3% complication rate. This study aims to develop a simpler and safer technique for posterior ankle arthroscopy, aiming to reduce complication rates and increase feasibility, based on the largest case series in the literature. Methods: This study included 424 cases of posterior ankle arthroscopy and hindfoot endoscopy performed from 2002 to 2024. We recorded both intraoperative and postoperative complications. Our technique employs standard posteromedial and posterolateral portals, with the posteromedial portal initially used as the viewing portal and the posterolateral portal as the working portal. The posteromedial portal is created near the Achilles tendon, with the trocar aimed toward the lateral malleolus, almost parallel to the ankle joint. Results: The patient cohort was 49.3% male and 50.7% female, with a mean age of 40.1 years (range 12-76). Nine complications were recorded, yielding an overall complication rate of 2.1%. Neurological complications constituted 4 (44.4%) of the complications (2 tibial nerve injuries, 1 tibial neuropraxia, 1 sural nerve dysesthesia). Other issues included 1 flexor hallucis longus (FHL) tendon injury, 2 superficial infections, 1 tibial artery injury, and 1 posterolateral portal cyst. Conclusion: Using the posteromedial portal for viewing and the posterolateral portal for working may reduce the risk of injury to neurovascular structures and the FHL tendon.

Background: The incisura fibularis (IF) provides intrinsic stability to the ankle joint complex by interlocking the distal tibia and fibula, but the role in ankle injuries is unclear. Therefore, we systematically reviewed all literature focused on the relation between ligamentous ankle lesions and IF morphometrics. Methods: A systematic literature search was conducted according to the PRISMA guidelines and registered on PROSPERO (CRD42021282862). In general, search terms were related to ankle and syndesmosis trauma/instability in combination with anatomical morphometrics of the incisura fibularis. Studies categorizable as original research (RCT or observational) were included. Studies concerning degenerative ankle disease and cadavers were excluded. The Hawker instrument was used to assess the methodological quality. Results: Sixteen studies were confirmed eligible and consisted of a prospective cohort (n=1), retrospective comparative (n=10), and observational (n=5) study design.Several studies (n=5) identified a correlation between a shallow IF depth and a higher incidence of ankle injury. A significant difference has also been found concerning the incisura height and angle (n=3): a shorter incisura and more obtuse angle have been noted in patients with ankle sprains. The mean Hawker score of the included studies was 28 out of 36 (range=24-31). Conclusion: The majority of the identified studies found distinct morphometrics of the IF in association with ligamentous ankle lesions. However, a substantial number of studies could not identify a clear association and presented a heterogeneous methodological quality. Therefore, further prospective studies are warranted to assess the relation between the incisura morphometrics and ligamentous disorders of the ankle joint.

Introduction/Purpose The aim of the study was to assess the 5-year-follow-up (5FU) after Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral defects at the first metatarsophalangeal joint (MTP1). Methods In a prospective consecutive non-controlled clinical follow-up study, all patients with chondral lesion at MTP1 treated with AMIC+PBC from July 17, 2016 to May 31, 2017 were included. Size and location of the chondral lesions, the Visual-Analogue-Scale Foot and Ankle (VAS FA) and the EFAS Score before treatment and at 5FU were analysed and compared with previous 2-year-follow-up (2FU). Peripheral Blood Concentrate (PBC) was used to impregnate a collagen I/III matrix (Chondro-Gide, Wolhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue. Results One hundred and ninety-eight patients with 238 chondral defects were included. In 21% of patients no deformities in the forefoot were registered. The average degree of osteoarthritis was 2.2. The chondral defect size was 1.0 cm2 on average. The most common location was metatarsal dorsal (33%), and in most patients one defect was registered (74%). Corrective osteotomy of the first metatarsal was performed in 79%. 176 (89%)/164 (83%) patients completed 2FU/5FU. VAS FA/EFAS Score were preoperatively 46.8/11.9 and improved to 74.1/17.1 at 2FU and 75.0/17.3 at 5FU on average. No parameter significantly differed between 2FU and 5FU. Conclusion AMIC+PBC as treatment for chondral defects at MTP1 as part of joint preserving surgery led to improved and high validated outcome scores at 2FU and 5FU. The results between 2FU and 5FU did not differ.

Background The aim of this study was to compare outcome (clinical, patient-reported outcome measures, radiological, joint motion and pedographic) of total joint replacement with Roto-Glide (Implants International, Cleveland, UK) (RG) and arthrodesis (A) of the first metatarsophalangeal joint (MTP1). Methods All patients that completed follow-up (FU) of at least 24 months after RG and A before May 1, 2022 were included in the study. Preoperatively and at FU, radiographs and/or weight-bearing computed tomographies (WBCT) were obtained. European Foot and Ankle Society Score (EFAS Score), MTP1 range of motion for dorsi-/plantarflexion (DF/PF) were registered and compared pre-operatively and FU. Results Seventy RG and 72 A were included. Preoperative VASFA/EFAS Score did not differ between RG and A (Average scores, VASFA, RG/A, 50.6/45,6; EFAS Score, RG/A, 10,7/10,6; each p>0.05). Wound healing delays without further operative measures were registered in 4 (6%) patients for RG and 5 (7%) for A (p=0.67), and 5 revisions in 5 (7%) for RG and 12 in 8 (11%) for A (p=0.05). The longest available FU was higher in RG than in A (RG/A, 47/37 months on average, p<0.001). VASFA/EFAS Score at FU was higher in RG than in A (Average scores, VASFA, RG/A, 72,6/63,6; EFAS Score, RG/A, 16.1/14.1; each p<0.05). DF/PF was higher in RG than in A (Average values DF/PF RG, 36.1/14.0, A 0/0, p<0.001) Conclusion RG showed lower revision rate and higher PROMs, better joint motion (DF/PF) and more physiologic force distribution than at longer FU than A. RG is a valuable alternative for A.

Background: Current literature lacks comprehensive information comparing the clinical outcomes of plantar and dorsal approaches for Morton's neuroma excision. This systematic review and meta-analysis was conducted to evaluate and compare the clinical outcomes of neurectomy for Morton's neuroma, focusing on the differences between the plantar and dorsal approach. Methods: Our comprehensive literature review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and utilized databases including PubMed, Embase, Web of Science, and the Cochrane Library. Data investigated in this study included postoperative sensory loss, scar tenderness, reoperation, histopathology, complications, pain score, patient satisfaction, functional scores, and time to weight bearing. Results: Total eight studies were included in this study. In aggregate, 237 neuromas underwent excision using the plantar approach, while 312 neuromas were treated via the dorsal approach. A significantly higher rate of postoperative reduced sensory was found in the dorsal group: 48.5% (64/132) Vs. 62.0% (80/129) with the relative ratio (RR) of 0.79 (95% CI, 0.64-0.97). A significantly higher rate of postoperative scar tenderness was noted in the plantar group: 16.7% (32/192) Vs. 6.2% (14/225) with the RR of 2.27 (95% CI, 1.28-4.04). Regarding the histopathology, 99.3% (143/144) and 97.1% (134/138) accuracy rate was confirmed in the plantar approach and dorsal approach, respectively, with the RR of 1.02 (95% CI, 0.98-1.07). Conclusions: This study compared postoperative outcomes following Morton’s neuroma excision between the dorsal and plantar approach. We recommend detailed discussions with patients prior to surgery to weigh the advantages and disadvantages of each approach.

Background: The fibularis longus (FL) attaches to the base of the first metatarsal at the fibularis/peroneus longus tubercle (FLT/PLT). Differences in FLT morphology may reflect changes in FL function. This study aims to define the normal limits of FLT position, orientation, and size in patients with morphologically normal foot anatomy. Methods: A retrospective analysis of 131 feet without deformity in 72 patients undergoing weightbearing CT (WBCT) was conducted. Measurements included tubercle-floor distance, tubercle-metatarsal angle, and bisecting angle. Roundness of the FLT was assessed by the triangular ratio. Relative sizes of FLT to the first metatarsal (X/Y ratio) and first metatarsal to second metatarsal (XY/Z ratio) were also determined. Results: No significant side-to-side differences were found (p>0.05). Mean values were: tubercle-floor distance 28.02 ±2.63mm, tubercle-metatarsal angle 32.7 ±6.32 degrees, bisecting angle 65.58 ±6.27 degrees, triangular ratio 0.69 ±0.04, X/Y ratio 1.13 ±0.20, and XY/Z ratio 3.44 ±-0.72. Bisecting angle strongly correlated with tubercle-metatarsal angle (r = 0.840, p<0.001), indicating FLT rotation independent of foot position. ICC was >0.943 for all measurements. Conclusion: This study provides normative data on FLT morphology in individuals with normal feet. These findings can aid future studies investigating differences in patients with foot pathology, enhancing our understanding of FL's role in foot disorder development and treatment.

INTRODUCTION: Metatarsus adductus (MA) is a condition characterized as medial deviation of the forefoot with normal alignment of the hindfoot. While MA typically resolves spontaneously, its persistence can exacerbate HV deformity, complicating surgical correction. There is limited literature on the postoperative outcomes following corrective surgery for HV with coexisting MA. METHODS: A systematic review was conducted evaluating retrospective observational studies on surgical correction of HV in patients with concomitant MA. Inclusion criteria comprised: (1) patients diagnosed with both hallux valgus and metatarsus adductus, (2) studies including at least 5 consecutive patients, (3) a clear description of the surgical technique, and (4) reporting of clinical and radiographic outcomes. The quality assessment was performed using the Modified Coleman Methodology Score (mCMS). RESULTS: Thirteen studies describing 1120 surgeries met the inclusion criteria. The median follow-up duration was 20 months (12-114) and included patients had metatarsus adductus angles ranging from 14 to 23 degrees. There was a mean improvement of 7.6 degrees (3.86-10.10) in the intermetatarsal angle and 36.1 degrees (27.8-47.2) for the hallux valgus angle. Post-operatively, there was an average improvement of 36.8 points in the American Orthopedic Foot and Ankle Score. Recurrence of hallux valgus deformity was the most reported post-operative complication, averaging 18% across the included studies. CONCLUSION: Clinical and radiographic outcomes of hallux valgus correction in patients with MA appear comparable to those without this comorbidity. However, the rate of deformity recurrence was higher in patients with MA than those without as reported in the literature.

Introduction: This study reports radiographic and clinical results on patients who underwent minimally invasive transverse distal 1st metatarsal and Akin osteotomies. Methods: 192 consecutive patients (213 feet) were followed for at least one year. The average age was 56.5, average final follow-up of 13.4 months, and 86.5% (166) of patients were women. Radiographic outcomes include pre- and post-operative HV (HVA), intermetatarsal (IMA), and proximal intermetatarsal angles (pIMA). Foot and Ankle Ability Measure (FAAM) and Visual Analog Scale (VAS) scores were used to determine functional outcomes. Complication, reoperation and radiographic recurrence rates were also determined. Radiographic recurrence was defined as a change in HVA >10 degrees. Results: Additional procedures were performed on 83 feet (39%), the most common being lesser metatarsal osteotomies, which was performed in 88% of those patients. Among corrected bunions, 8.5% were classified as severe (HVA >40 degrees) and 79% were moderate (HVA >20 and <40 degrees). Average pre-op HVA and IMA were 28.4 and 12.8 degrees and improved to 8.4 and 4.2 degrees (p < 0.001). Statistically significant increases in FAAM-ADL, FAAM-Sports and VAS scores were observed (p < 0.001). There were no cases of superficial or deep infections. There were 10 radiographic recurrences, and 13 (6%) hardware removals. Conclusion: Fourth generation MIS HV surgery for the treatment of moderate and severe HV showed good clinical and radiographical outcomes. This technique has also proven to be safe and effective, with low recurrence, revision and complication rates.

INTRODUCTION: There is limited literature on the time to union following moderate and severe hallux valgus repair using minimally invasive techniques. We conducted a retrospective analysis to investigate the time to union and its relationship with cortical formation and post-operative degree of displacement of the 1st metatarsal in patients undergoing HV repair. METHODS: We retrospectively analyzed seventy-two consecutive patients with moderate to severe hallux valgus who underwent MIS 1st distal metatarsal and Akin osteotomy between 2019 and 2022. Radiographic measurements included the scale of displacement between the proximal and distal portions of the first metatarsal and the degree of cortex formation. Complete union was defined as the presence of three new cortex on postoperative X-ray films. RESULTS: On average, 2 cortices were observed at 16.9 weeks, and 3 cortices were observed at 26.8 weeks. When the metatarsal shift was greater than 50%, two cortices were observed at an average of 20.14 weeks, compared to 13.7 weeks when the shift was less than 30% (p=0.004). Further analysis of the time required to observe 3 cortices showed no statistically significant difference between metatarsal shifts greater (25.26 weeks) and less than (23.74 weeks) 50% (p=0.4734). In all patients, 4 cortices at the 6-month and 12-month time points. DISCUSSION: In patients who underwent MIS 1st metatarsal distal transverse and Akin osteotomies for HV repair, the degree of displacement between the proximal and distal portions of the 1st metatarsal is not associated with statistically significant delay in new cortical formation.

Background: Hallux rigidus of the 1MTP is the one of the most common forms of arthritis of the foot. In our opinion the interpositional arthroplasty is almost always an alternative to the fusion especially for active patients. The purpose of our study is to report the follow-up of a joint preservation, using allogenic Dura-Mater. Materials and methods: We used human allogenic Dura Mater in 80 patients from 2016 to 2023 as an interpositional graft. Also, if it was necessary to decompress the joint, we performed a shortening osteotomy of the first metatarsal bone. There were 25 male and 55 female, aged from 34 to 76 years. Analysis included clinical evaluation with the AOFAS Score and radiographic assessment. The average follow-up was 5 years. Results: The average preoperative AOFAS score was 34 (range, 30–41). The most recent AOFAS was 65.8 (range, 58–68). Preoperative dorsiflexion was 8–10◦ and 25◦ – postoperative, plantar flexion – 9◦ preoperative, and 15◦ – postoperative. There were no wound healing problems. There were no subsequent procedures or fusions performed on the 1 MTP joint. Every patient was satisfied with the surgical results. Conclusion: arthroplasty of the 1MTP Joint, using allogenic Dura Mater led to reliable pain relief and increasing the ROM. Moreover, the women have been able to wear stylish shoes with variable heel heights. We believe that this technique is an alternative to fusion of the joint.

Introduction Numerous studies have shown that surgical correction of HV is associated with improvements in scores on questionnaires assessing pain and general satisfaction in patients undergoing treatment for mood disorders. However, these results are not as good as in patients without depressive symptoms. Material and methods A retrospective study was carried out to compare the satisfaction with post-surgical outcomes in two groups of 35 patients. They underwent surgery for HV with the Scarf+Akin technique by the same surgeon, using the validated SF-12 and MOXFQ questionnaires. Results The two groups studied were homogeneous in terms of gender distribution, age and comorbidities studied (hypertension, diabetes mellitus and hypercholesterolaemia). Statistically significant differences were observed in the results of the SF-12 questionnaire (SF-12 (p<0,0001),and MOFQX (p=0,03); these showed a worse perception of the results after hallux valgus surgery in those patients taking antidepressants. Conclusion The results of this study are consistent with those of previously published studies, observing that the results in terms of satisfaction with post-surgical outcomes of HV and residual pain are worse in patients who suffer from mood disorders and require treatment with antidepressant and/or anxiolytic drugs.

Objectives:Many surgical methods have been described for correction of hallux valgus (HV),in general dictated by the severity of the deformity.The aim of the study was to evaluate mid-term outcome of patients with distal chevron osteotomy and Lapidus arthrodesis.Methods:A retrospective study of patients operated in the hospital from January 2017 to December 2018, was conducted.Two groups were identified:distal chevron osteotomy (group A) and Lapidus arthrodesis (group B).Pre-operative and mid-term postoperative radiological examination results and patient`s satisfaction were analyzed.Results:Mid-term outcome was evaluated in 49 patients(48female,1male),mean age 55.8(31-77)years,mean 63(45-81)months after operation.18 patients(24 feet)were in the group A,31 patient(35 feet)in group B.In the group A pre-operative mean hallux valgus angle(HVA)was 32.4 degrees, intermetatarsal angle (IMA) 11.5degrees,distal metatarsal articular angle(DMAA)29.5degrees;postoperative mean HVA was19.8degrees,IMA 9degrees,DMAA 16degrees(p<0.05).Mean grade of the medial sesamoid position pre-operatively was 2,postoperatively 1.In the Lapidus arthrodesis group pre-operative mean HVA was 38.1degrees,IMA 15degrees,MAA 34.1degrees;postoperative mean HVA was 16degrees,IMA 8.6degrees,DMAA 14.1degrees(p<0.05).Mean grade of the medial sesamoid position pre-operatively was2,postoperatively2.No significant difference among mean postoperative HVA,IMA,DMAA in group A and group B was identified(p˃0.05).In group A 14 patients(77.8%)were satisfied,4 patients (22.2%)were unsatisfied;in group B 23 patients(74.2%)were satisfied,8 patients were unsatisfied(25.8%)with outcome.Two patients had superficial postoperative infection,one hypertrophic scar,one metatarsalgia,one stiffness. Discussion/conclusions: Both HV patient`s groups demonstrated improvement of HVA,IMA,DMAA postoperatively. Two thirds of patients were satisfied with outcome in both groups.Patients are suggested to be informed about possible complications and risks after surgery.

Introduction: Hallux valgus (HV) is a complex multifactorial deformity of the first ray. Peroneus longus (PL) muscle is a key dynamic stabiliser of the first ray. Our theory is that HV individuals will have a different morphology of their PL insertion. Aim: To assess if there is an association between the type of PL insertion and the prevalence of HV. Methodology: Twenty-five cadaveric foot specimens were dissected to expose the insertion of PL. The head of the first metatarsal was exposed to determine the presence of morphological changes in keeping with HV. The type of PL insertion, anatomical HV status and number of tarsometatarsal (TMT) facets were all documented. Results: Seven specimens (28%) had morphological changes in keeping with HV deformity. Regarding number of insertions, there were 4 double insertions, which none had HV, whereas 33.33% (7/21) of the single insertions had evidence of HV. Regarding width of insertion to the peroneus longus tubercle, 15.38% (2/13) narrow insertions had HV, whereas 41.67% (5/12) had broad insertions. There were 2 unifacet TMT joints, 19 bifacet and 4 trifacet. HV was more common in the bifacet TMT joints (31.58%, 6/19). Conclusion: Patients with HV were more likely to have single and broad PL insertions. The pull of a narrow PL insertion may increase the stress concentration therefore having a greater effect to the lateral and downward movement of the first ray, thus preventing HV. Further research is required to understand if the morphology change is a cause or effect relationship.

Background: In the setting of revision surgery for failed primary first metatarsal-phalangeal joint (MTP1) arthrodesis, either autograft bone-block (harvested from iliac crest, tibia or calcaneus) or allograft bone graft interposition procedures have been proposed. The aim of the study was to report the clinical and radiographic results in patients undergoing revision MTP1 arthrodesis surgery with autologous first metatarsal bone graft (marquetry bone-block) as a revision procedure after failed primary arthrodesis with limited bone loss. Methods: Between February 2022 and February 2023 seven patients have been treated by the senior author with this technique. Four patients had single failure of MTP1 arthrodesis with limited bone loss. Two patients had hallux elevatus and varus after poor MTP1 fusion. The mean age at surgery was 64,8 years (range 56–71) with six females and one male. Clinical and radiological fusion was assessed at 12 weeks (range 12 – 15). AOFAS score and radiological measurements of length of the hallux (LOH) were also assessed. Results: All patients achieved pain relief and clinical fusion at 12 weeks (12-15) from surgery. There were no major complications. LOH decreased slightly (average length loss: 2 mm) in case of single failure of prior arthrodesis (range -1- -3). LOH increased after elevatus and varus correction (LOH increased of at least 7 mm). Conclusion: Autologous first metatarsal bone graft (marquetry bone-block technique) is a useful option for for managing failed primary arthrodesis with limited bone loss and deformity of the hallux.

Background: Morton's neuroma is a painful foot condition characterized by tissue thickening around the nerves leading to the toes. The primary treatments include corticosteroid injections and surgical excision, with treatment decisions often influenced by the neuroma size. However, there is limited clarity on optimal treatment approaches based on this size. Methods: This retrospective observational study analyzed data from patients with Morton's neuroma treated at our district general hospital. Neuroma sizes, treatment modalities (corticosteroid injections or surgery), and treatment outcomes were examined. The treatment protocols involved corticosteroid injections initially, and surgical excision for those not responding to conservative treatment or with large neuromas. Outcome measures included treatment distribution by neuroma size, success rates of treatments, average neuroma size leading to surgery, and neuroma count per foot. Results: The study found that smaller neuromas (0-10 mm) were primarily treated with injections, while larger ones increasingly required surgery. Neuromas measuring around 9.21 mm, on average, often necessitated surgical intervention, indicating a possible size threshold. Around 88.24% of patients with neuromas more than 9mm had success with injections primarily but required surgery later on with surgical success around 55%. Most patients had one or two neuromas per foot, with a few having multiple neuromas. Conclusion: Neuroma size significantly influences the choice and outcome of treatment for Morton's neuroma. Smaller neuromas are responsive to conservative treatment, whereas larger neuromas may necessitate surgery. Clinicians should tailor treatment strategies based on neuroma size to optimize outcomes and further refine treatment thresholds.

Hallux valgus (HV) is the most frequent deformity of the forefoot, the etiology of which remains incompletely elucidated. Morphologic risk factors are well described but the importance of soft tissues, among others medial structures, should be emphasized in the development of this deformity. During corrective surgery for HV, a fibrous structure akin to a meniscus is often seen in the metatarsophalangeal joint of the first ray. This study aimed to histologically describe this structure and compare it to the knee meniscus. We conducted a monocentric retrospective study based on 37 feet of 32 patients. Feet included presented with an intra-articular fibrous tissue during surgeries requiring a medial arthrotomy of the first metatarsophalangeal joint. Histological samples were analyzed, and comparison was made with histological samples of degenerative and injured knee menisci. Histologic analysis showed a fibrocartilaginous tissue similar to the meniscal tissue of the knee in 97.3% of cases. The tissue was fibro-chondroid connective tissue in 64.9% of the cases with the presence of collagen fibers and chondrocytes. This tissue was not intact with fissures or micro-fissures present in 89.2% of the cases. We confirmed the histological similarity of the tissue found inside the metatarsophalangeal joint with the knee meniscus. Lesions were of mechanical type without any inflammatory reaction. In the light of our findings and previous studies, it seems that this structure suffers mechanical damages as the deformity progresses. We recommend its removal in hallux valgus corrective surgery.

OBJECTIVE: First metatarsophalangeal joint (MTPJ-1) arthrodesis (MTPJA-1) is the gold standard to treat end-stage osteoarthritis of this joint. The purpose of this study was to determine whether percutaneous techniques to perform MTPJA-1 might reduce the nonunion, complication and reoperation rate as compared to the open approach. METHODS: Following the PRISMA checklist,different databases were searched, including studies reporting patients affected by MTPJ-1 osteoarthritis and undergone MTPJA-1 stabilized using crossed screws as exclusive fixation method. Data were harvested regarding the cohort , the study design, the surgical technique and the final outcome at the longest follow-up. The MINORS was used to assess the methodological quality of studies. The percutaneous (PERC) and the open (OPEN) techniques were compared in terms of nonunion, complication and reoperation rate. RESULTS: Nine studies (225 MTPJA-1 in 211 patients) were selected (PERC=130 cases, OPEN=95). In the two groups, the mean (±SD) sample size (26.6±5.1 cases in PERC, 23.7±10.2 in OPEN; p=0.33), mean age of patients (62±5.4 and 59.5±5.4 years,; p=0.26), sex distribution (81%±0.6 vs 57%±0.2 females,; p=0.17) and length of follow-up (20.8±11.6 months vs 29.5±16.8 months, p=0.19) were comparable. The pooled nonunion rate (5% in PERC vs 6% in OPEN; p=0.93), complication rate (4% vs 17%; p=0.24) and reoperation rate (3% vs 5%; p=0.74) were not significantly different. The quality of studies was moderate in the two groups (MINORS 9±1.3 points in PERC vs,11.7±3.7 in OPEN; p=0.19). CONCLUSIONS: The nonunion, complication and reoperation rate after percutaneous or open MTPJ-1 arthrodesis stabilized using two screws are not significantly different.

The objective of this study is to assess the effectiveness of calcaneal medializing osteotomy in patients with hallux valgus and symptomatic flat feet. Material and methods We conducted a retrospective cohort study. 2 groups of patients with hallux valgus and flat feet grade IIA and B: Group 1, operated by scarf and medializing osteotomy between 2016 and 2022. N 36. Average age 63 years. Mean Meary-Angle -18, angle preoperative metatarsophalangeal mean 37.7. Group 0, was created collecting all those isolated scarf surgeries carried out in the year 2022. Next we filter those that have a Meary Angle range equal to the group N 46. Meary mean -17.8, preoperative metatarsophalangeal angle mean 37.8. Preoperative weight-bearing radiographs and 6-month follow-up are evaluated. It is considered a recurrence a metatarsophalangeal angle above 20 from 6 months postoperatively. Results In the statistical study we observed that there were no differences between both groups neither in preoperative metatarsophalangeal angle nor in age (p>0.05). After medializing osteotomy there were a statistically significant change in the angles of Meary and Kite p<0.05. After surgery in group 1 the recurrence was 13.2% while in group 0 the recurrence rate was much higher (36.6%) (P<0.05). The odd ratio: flat feet with hallux valgus, only treated by scarf surgery, had a 3.8 times greater risk of recurrence than those treated with scarf and medializing osteotomy. Conclusion In our sample, flat feet was a risk factor for hallux recurrence, so it is recommended associate surgical gestures to correct flat feet.

Turf-Toe injuries encompass a wide spectrum of traumatic injuries of the first metatarsophalangeal (MTP) joint. They are produced by medial or lateral stress and forced hyperextension, which affects the plantar plate (PP). The patient will commonly complain of pain and swelling, limitation of mobility and instability. Grade III of Anderson classification requires surgical treatment. We report the case of a 38-year-old man who suffered trauma on his right great toe 3 months before. On examination, varus deformity, lateral sesamoid pain, and instability were notable. Weight-bearing radiographs revealed an avulsion-fracture of the PF, proximal displacement of the lateral sesamoid and hallux varus. MRI showed rupture of the lateral collateral ligament at the PF insertion, complete rupture of the PP with disinsertion at the level of PF and a mild joint effusion. The injury was classified as grade III, so surgical treatment was indicated. An L-shaped plantar approach was performed at the first interdigital space, finding rupture of the joint capsule, PP and lateral collateral ligament. They were reinserted into the PF with 2 JuggerKnot-1.45mm. After 10 days, the bandage was replaced by an orthosis and weight baring was allowed with rigid-soled orthopedic shoe for 6 weeks. The patient presented good functional outcomes with complete range of motion. Conclusions Turf-Toe injuries are uncommon, highly disabling, and require a high index of suspicion. Treatment is controversial, with surgery being indicated in grade III. In our experience, the reinsertion of the PP and the collateral complex in the PF presents satisfactory results.

Introduction: Since Hoffman's original description in 1911, pan metatarsal head resection has proven to be an effective and versatile procedure in treating forefoot deformity. The Hoffman-Clayton procedure is a surgical procedure that is performed to treat deformities of the foot, commonly caused by rheumatoid arthritis. Current aim is to determine the results of the performed operations in patients with forefoot deformities in rheumatoid arthritis. Methods: In our study there were included 25 patients with forefoot deformities in rheumatoid arthritis (25 patients and 28 feet) who underwent metatarsal head resection from 2018 to 2023 years. All patients underwent resections of the metatarsal heads with Kirschner wires fixation. Analysis included clinical evaluation with the AOFAS Score and radiographic assessment. Results: The average preoperative AOFAS score was 33 (range, 30–41). The most recent AOFAS was 73 (range, 61–75). There were no wound healing problems. Every patient was satisfied with the surgical results. Conclusion: the Hpffman-Clayton arthroplasty may led to reliable pain relief and patient satisfaction. We consider this operation to be very good and it guarantees normal walking and the appearance of the foot.

Background To review the return to work and sports activity of patients who have undergone open sesamoidectomy. Objectives The aim of this review was to follow the evolution after open sesamoidectomy, assessing the return to work and sports activity. We have conducted long-term follow-up for possible long-term complications. Study Design & Methods 20 sesamoidectomies have been performed in 18 patients from January 2012 to January 2020. All have a follow-up of more than 3 years with a mean of 74 months. 10 were women and 8 were men with an age range of 18 to 65 years and a mean age of 38 years. The return to work has been an average of 2 months and to sports activity of 3 months on average. Regarding the sesamoids, 14 were tibial and 6 fibular. The cause of sesamoid pain has been fractures that have not healed orthopedically, painful pseudoarthrosis of the sesamoid, and sesamoiditis with positive scintigraphy Results We have made the AOFAS scale going from 58 to 85 points. All 18 patients would undergo re-surgery. As complications we have had a section of the FHL, a hallux valgus and a hallux varus in the postoperative period without consequences. No patient has had to be reoperated for a complication. Conclusions After reviewing current bibliography and despite the black legend of this surgical technique, we believe that it is a good technique when it is well indicated. Our results are similar to those of other authors with recent publications.

Introduction and objectives Percutaneous surgery has revolutionized forefoot surgery in the last 20 years to establish itself as a comparable alternative to classic open surgery. However, it is not absent from complications. Our objective is to present a clinical case that after undergoing percutaneous hallux surgery valgus in 2006, consulted 16 years later for a painful rigid hallux claw. Material and methods This patient was first operated in 2006 by a surgeon from the F&A Unit of our hospital for hallux valgus and metatarsalgia percutaneously. In 2022, the patient is referred with painful hallux rigid claw deformity that interferes with footwear. X-ray shows partial necrosis of the base of the proximal phalanx together with a rigid dorsal metatarsophalangeal dislocation. The preoperative AOFAS test was 36 points. The patient was proposed a new rescue surgery: open metatarsophalangeal arthrodesis with the distal phalanx due to an important bone defect in the proximal phalanx. Results In March 2023, a metatarsophalangeal arthrodesis of the hallux was performed using an anatomical plate. The patient began inmediate weight bearing using a stiff sole shoe during the first month. 3 months after surgery, VAS 8 decreased to VAS 2, and the radiograph showed bone consolidation. At 12 months, the AOFAS test became 82 points. The patient was discharged with a satisfactory clinical and radiological result. Conclusion After percutaneous complication of hallux proximal phalange necrosis, open surgery of hallux arthrodesis with distal phalanx can be a good rescue option, offering a good clinical result in a medium term.

We present surgical guidelines to perform the proximal and distal scarf osteotomy cuts for hallux valgus deformity, with the correct obliquity calculated on loaded radiographs. Barouk describes the proximal and distal scarf osteotomy cuts considering exclusively the sagittal plane, choosing an obliquity of 60°. This results in a random horizontal plane cut, with the danger of obtaining an undesired effect. If we want to obtain a pure lateral transfer, without lengthening or shortening, the proximal and distal cuts in the transverse plane must be strictly perpendicular to the axis of the second metatarsal. The proposed method makes it possible to perform these cuts calculated in the surgical planning with the correct obliquity, avoiding undesired shortening or lengthening of the metatarsal. It consists of 6 guides with trapezium morphology, with a long side that should be flush with the medial diaphyseal cortex of the metatarsal and a short side. Between the long side and the two short sides, a different “K angle” is formed for each guide, between 70° and 80°. The angle K arises from the line perpendicular to the axis of the second metatarsal with the axis of the first metatarsal and can be calculated by subtracting the AIM from 90.

Background Diabetic forefoot ulcers frequently result from elevated pressure on bony prominences, neuropathy, and poor limb circulation. Treating these ulcers, particularly when infected, is challenging and can often lead to toe or forefoot amputation. This study aims to assess the efficacy and safety of minimally invasive surgical offloading for recurrent diabetic ulcers of the fifth metatarsal through minimal invasive fifth metatarsal osteotomy and bunionettectomy. Methods A retrospective cohort study was conducted on patients surgically treated for diabetic foot ulcers on the lateral or plantar side of the fifth metatarsal head between January 2020 and May 2024. Outcomes included the time to healing of the primary ulcer and surgical wound, recurrence of ulcers, length of hospital stay, postoperative complications and reoperation rates. Clinical, and radiological parameters of the feet were evaluated, and patient-reported outcome measures were collected. Results Ten feet from nine patients were included who didn’t respond successfully to conservative offloading. The mean patient age was 70 years. Five feet were classified with Wagner grade 3 wounds, three feet with Wagner grade 2 wounds and one as grade 1. Ulcers completely healed in a mean period of nine weeks postoperatively. Two patients required 6 weeks of antibiotic treatment due to preexisting osteomyelitis. One postoperative infections occurred. There was no failure of correction, and all patients returned to wearing orthopedic shoes postoperatively. Conclusion Minimally invasive offloading of the fifth metatarsal is a safe and effective procedure for treating diabetic ulcers on the fifth metatarsal head that are refractory to conservative treatment.