Background: Isolated fibula Weber B/Supination-External Rotation (SER) stage 4 fractures, with deltoid ligament rupture, are considered unstable. However, assessment of stability remains controversial. We conducted a cadaveric study to define the effect of damage of the superficial and deep deltoid ligament, and the distal tibiofibular syndesmosis on ankle stability. The pathologies represented were associated with SER type ankle fractures. Methods: Eight fresh frozen lower leg cadaveric specimens were tested: a) with manipulation (external rotation applied force) and b) using an axial loading machine with a force of 750N, after lesions were induced. The stages of dissection included: 1) Trans-syndesmotic fibula osteotomy and anterior inferior tibiofibular ligament (AiTFL), 2) posterior inferior tibiofibular ligament (PiTFL), 3) superficial deltoid (SDL), 4) deep deltoid (DDL) and 5) interosseous tibiofibular ligament (IoTFL). Clinical photographs and videos were recorded and Computerised Tomography (CT) imaging was obtained in all stages. Results: Findings were consistent in all cadavers. Specimens were stable when loaded after sectioned lateral column, PiTFL and superficial deltoid ligament (stages 1-3), with no medial clear space (MCS) opening on CT images. Additional dissection of deep deltoid ligament revealed talar shift, with widening of MCS on CT. Lastly, sectioning of the interosseous tibiofibular ligament resulted in subluxation of the ankle indicating severe instability. Conclusion: In isolated trans-syndesmotic fibula fractures SDL injury did not result in detectable instability. These fractures become unstable when DDL was sectioned and grossly unstable when IoL was torn. Thus, complete syndesmosis disruption needs to be considered in the management of these injuries.

Background: While weight-bearing computed tomography (WBCT) has been crucial in analyzing total ankle arthroplasty (TAA) positioning, its specific impact on the foot's medial column alignment is under-researched. Advances in image analysis software, enabling semi-automatic segmentation, 3D modeling, and semi-automatic angle measurements, have enhanced foot and ankle assessments' accuracy and reliability. This study aims to compare preoperative and postoperative alignments of the foot's medial column to evaluate TAA's corrective capabilities in this area and determine the reliability of these measurements. Materials and Methods: The study included 42 patients who underwent isolated TAA, with both preoperative and postoperative WBCT scans. Two raters measured eight angles related to the longitudinal arch's sagittal angle, forefoot abduction/adduction, intermetatarsal angles, and tarsometatarsal angles across two sessions to assess TAA's corrective impact on the medial column. Results: Statistically significant improvements were found in the longitudinal arch's sagittal angle, forefoot abduction/adduction angles, and sagittal tarsometatarsal angle postoperatively. The intermetatarsal and axial tarsometatarsal angles showed no significant change. Interclass correlation reliability analysis revealed good to excellent interobserver and intraobserver reliability. Conclusion: The use of WBCT, combined with semi-automatic analysis, shows significant potential for isolated TAA to correct deformities within the foot's medial column. The high reliability of these semi-automatic measurements suggests that WBCT, integrated with image analysis software assessing the entire lower limb, could enhance preoperative planning for TAA positioning. This approach ensures accurate ankle alignment and aids in planning additional hindfoot and forefoot realignment surgeries, potentially improving surgical outcomes and extending TAA's longevity

Background: This study investigates the long-term effect of an I/III collagen bilayer matrix (AMIC) in treating osteochondral lesions (OCL) of the talus. Methods: The 10-year results of a prospective, single-center cohort study are presented. All patients underwent an open AMIC procedure without malleolar osteotomy for OCL. Data analysis included demographics, MRI, intraoperative details, EFAS-, AOFAS Hindfoot Score, and Foot-Function-Index (FFI-D) pre-, one-, five-, and ten years following surgery. The primary outcome variable was the longitudinal effect of the procedure. Results: 21 (45%) out of 47 patients treated from 2010 to 2012 met the inclusion criteria (8 (38%) female, 13 (62%) male patients with a mean age of 37±15 years (15-62 years) and a BMI of 26±5 kg/m² (20-38 kg/m²). The defect size was 1.4 cm²±0.9 cm² (0.2-4.0 cm²). The defect location was medial in 76%, central in 10%, and lateral in 14%. 95% of the patients received additional procedures. The FFI-D decreased significantly from pre- to one-year post-operative (56±18 vs. 33±25; p=0.003), with a further, non-significant decrease between the one-, five-, and ten-year follow-up (33±25 vs. 24±21 vs. 15±12; p=0.457). Similar results were found for the other scores. The FFI subscale of sports activity did not significantly change compared to the preoperative situation with limitations, especially in running and jumping. Age, BMI, and lesion size significantly correlated to the FFI and its subscales. Conclusion: PROMS after AMIC are stable for at least 10 years. The detailed analysis of the FFI and EFAS Score showed constant limitations in sports activities.

The treatment of ankle fractures involving the posterior malleolus (PM) has changed in favor of open reduction and internal fixation (ORIF). The need for additional syndesmotic stabilization has decreased. However, there are still doubts about the diagnosis and treatment of residual syndesmosis instability. The aim was to evaluate the effect of fixation of the PM and to assess the need for additional stabilization methods. It was hypothesized that ORIF of the PM would not sufficiently stabilize the syndesmosis, but that additional syndesmotic reconstruction would restore kinematics. Eight unpaired fresh-frozen lower legs were tested in a six-degree-of-freedom robotic arm with constant loading (200N) in neutral position, 10° dorsiflexion, 15° plantarflexion and 30° plantarflexion. The specimens were evaluated in the following order: intact state; osteotomy of the PM; transection of the anterior inferior tibiofibular ligament (AITFL) and interosseous tibiofibular ligament (IOL); ORIF of PM; additional syndesmotic screw; combination of syndesmotic screw and AITFL augmentation; AITFL augmentation. A complete simulated rupture of the syndesmosis caused a translational (6.9mm posterior and 1.8mm medial displacement) and rotational instability (5.5° external rotation) of the distal fibula. This could be restored with ORIF of the PM in neutral ankle position, whereas sagittal and rotational instability remained in dorsi- and plantarflexion. In complex ankle fractures, ORIF of the PM is essential to restore syndesmotic stability. However, residual syndesmotic instability can be detected by a specific posterior shift of the fibula on stress testing. In these cases, an anatomical AITFL augmentation is biomechanically equivalent to a syndesmotic screw.

Background Weber B fractures often show unstable gravity stress tests but stable weightbearing radiographs (classified SER4a), suggesting partial deltoid ligament injury with an intact deep posterior tibiotalar ligament (dPTTL). Conversely, a dPTTL rupture is assumed if both radiographs are unstable (classified SER4b). However, the state of the dPTTL in SER4a vs. SER4b has yet to be studied. This study assessed the prevalence of dPTTL injury using direct visualization during arthroscopy of SER4a and SER4b fractures. Methods We conducted a prospective study on 20 adult patients with Weber B/SER4a-b ankle fractures having unstable gravity stress tests or unstable weightbearing radiographs (medial clear space 4.0 millimeters or larger). Blinded assessors evaluated the dPTTL using minimally invasive arthroscopy under local anesthesia. Intact dPTTL was defined by normal ligament visualization with tensioning and medial joint space closing with ankle dorsiflexion. Results Based on radiographic criteria, 15 patients were classified as SER4a and five as SER4b. Arthroscopy showed an intact dPTTL in 14 out of 15 SER4a injuries. In one SER4a patient, arthroscopy revealed dPTTL disruption despite a weightbearing radiograph with 3.9 millimeters of medial clear space. All SER4b injuries revealed dPTTL disruptions with arthroscopic assessment. Conclusions In Weber B fractures evaluated arthroscopically, the dPTTL is typically intact in cases where weightbearing radiographs are stable despite unstable gravity stress tests. Conversely, complete dPTTL disruption was consistently observed in cases where both tests were unstable. These findings support the hypothesis that a stable weightbearing radiograph indicates an intact dPTTL.

Introduction: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The graft reconstructs the anterior talofibular and calcaneofibular (CFL) bundles. As the CFL calcaneal insertion is extra-articular, it makes it difficult to locate. Some techniques use radiography or surface anatomy. However, they can only offer an approximate identification of the actual CFL footprint, and they do not protect the sural nerve (SN). In contrast, an ultrasound technique allows direct visualisation of the insertion point and, of the sural nerve. Our study aimed to assess the reliability, accuracy and safety of ultrasound visualisation while performing calcaneal insertion of the CFL. Materials and methods: This anatomical study was carried out on 15 ankles. Ultrasound identification and dye injection of the sural nerve were performed. Then, a needle was positioned at the level of the CFL calcaneal insertion. After dissection, the dye was found in contact with the SN and, the needle, in the CFL calcaneal insertion area, in every ankle The mean distance between the SN and the needle was 4.8 mm (range 3-7 mm). Discussion and conclusion: A pre- or intra-operative ultrasound technique is a simple and reliable procedure to locate the CFL calcaneal footprint and drill the tunnel in a lateral ligament reconstruction safely. The tunnel should preferably be performed obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve, while allowing an accurate anatomical positioning of the calcaneal tunnel.

Introduction: The literature on the classification and optimal management of Chaput fractures is evolving. Hence, we performed a CT-based 3D fracture mapping study to identify these fractures' morphological characteristics. Methods: This study included adult patients who had an ankle fracture with a Chaput component. CT scans were obtained, 3D models were generated and superimposed over a statistical shape model of the right tibia, and fracture lines were marked. The footprints of proximal and main bands of the AITFL and Basset’s ligament were also marked on the template tibia. An automated script was used to determine the fragment size, fracture surface area, and involvement of the tibial plafond, tibial incisura, AITFL, and Basset’s ligament. Results: 76 patients, 21 males and 55 females were included in this study. Cluster analysis identified two distinct groups of fractures, each with two unique subgroups. We present this as a modification of the existing classification system. The first group consisted of sub-centimetric extra-articular avulsion fractures, n=47. Of these, 19% (n=9) did not involve the AITFL, which we termed as Type 1a, and 91% (n=48) involved the AITFL, which we termed Type 1b. The second group consisted of large intra-articular fractures. Of these 23% (n=6) involved only the incisura, which we termed as Type 2a; 77 % involved both the incisura and the tibial plafond and were termed as Type 2b. Conclusion: We propose a modification of the existing classification of Chaput fractures based on quantitative fracture mapping which may prove beneficial in surgical decision making.

Abstract Introduction YouTube is frequently used by patients and physicians for information. To our knowledge, there is no study evaluating the quality of YouTube videos in ankle impingement syndrome (AIS). The aim of this study was to evaluate and compare the quality of YouTube videos in anterior and posterior AIS. Methods YouTube videos on anterior and posterior AIS were evaluated and compared by two European Foot and Ankle Society (EFAS) member orthopedic surgeons using The Journal of American Medical Association (JAMA), DISCERN (Quality Criteria for Consumer Health Information), Global Quality Score (GQS) and Ankle Impingement Syndrome Specific Score (AISSS). Results 50 videos about anterior ankle impingement syndrome and 43 videos about posterior ankle impingement syndrome were evaluated. The mean duration of videos related to anterior ankle impingement syndrome was 354.70 seconds (± 314.28) and the mean number of views was 27,166.08 (± 54,898.69). The mean duration of videos related to posterior ankle impingement syndrome was 1594 seconds (± 424.94) and the mean number of views was 15,309.89 (± 47,916.02). When evaluating the quality of video content using scoring systems, videos related to anterior AIS have higher average JAMA, GQS, and DISCERN scores than those related to posterior AIS. However, this difference is only statistically significant for the DISCERN score (p= 0.045). Conclusions The quality of YouTube videos in anterior and posterior ankle impingement syndrome is not sufficient.

The anterolateral approach to the distal tibia, used in lateral supramalleolar osteotomies, fibula osteotomies or pilon fractures, provides extensive exposure of the distal tibia and fibula. To avoid bleeding, care must be taken with the peroneal artery and its perforating branches (PBPA) that emerge through the interosseous membrane. Scarce literature is available describing its distribution. The objective of this study is to provide anatomical description of the PBPA at the anterolateral approach to the distal tibia and to determine safe zones. Fourteen fresh-frozen lower extremities were injected with red-colored latex at the popliteal artery. The mean age was 84.2 years-old (SD:75.8-92.6), and 8/14 were females. An anterolateral approach was performed systematically with careful dissection to identify all PBPA. The number of branches and its distance to the tip of the lateral malleolus were recorded. Thirteen (92.8%) of the specimens had three branches or fewer, ranging from 6.2-12.8cm to the tip of the lateral malleolus. Three areas were considered based on the risk of PBPA injury: “high risk” between 9.6-10.6 cm, where 10/14 specimens (71.4%) had a branch; “low risk” between 11.4-12.6 cm, with only 1/14 specimens (7.2%) presenting a branch; and “no risk” in three ranges (<6.2cm, 7.3-8.5 cm, and >12.8cm), where no branches were found in any of the specimens. According to our anatomical study, the area located 9.6-10.6cm from the tip of the lateral malleolus should be avoided when performing osteotomies and placing retractors while the regions of <6.2 cm, 7.3-8.5cm, <12.8cm present no risk of vascular injury.

Introduction Syndesmotic reduction and instability are typically assessed using anteroposterior (AP) radiographs. These assessments are influenced by foot rotation, but little is known about their accuracy in the lateral view. This study hypothesizes that fibular station in the sagittal plane changes significantly with leg rotation. Methodology This cross-sectional, retrospective study analyzed digital lateral ankle X-ray images from CT scans of 15 ankles. Images were imported into 3D modeling software (3D Slicer), where neutral position and varying degrees of internal and external rotation were digitally reconstructed. Anterior and posterior fibular stations were measured across these rotations, yielding a total of 135 measurements. Correlations between fibular station and leg rotation were assessed using Pearson correlation coefficients and linear regression. Results Of the 15 CT scans, 13 were from male patients and 2 from female patients. The anterior fibular (AF) station showed a decreasing trend with internal rotation and an increasing trend with external rotation. The posterior fibular (PF) station exhibited the opposite trend. Anterior fibular ratios (AF/TW and AF/PW) decreased with internal rotation and increased with external rotation. Posterior fibular ratios (PF/TW and PF/PW) showed no significant changes with rotation. The correlation coefficients for AF and PF stations with rotation were -0.28 (p=0.001) and 0.19 (p=0.03), respectively. Conclusion Leg rotation significantly affects lateral fibular station parameters, necessitating neutral leg positioning for accurate syndesmosis reduction assessment. Posterior ratios, being less impacted by rotation, may serve as more reliable indicators. Accurate standardization of leg rotation during radiographic assessment is crucial for reliable measurements.

Introduction Foot and ankle alignment plays a pivotal role in human gait and posture. Traditional assessment methods, relying on 2D standing radiographs, present limitations in capturing the dynamic 3D nature of foot alignment during weight-bearing and are prone to observer error. This study aims to integrate weight-bearing CT (WBCT) imaging and advanced deep learning (DL) techniques to automate and enhance quantification of the 3D foot and ankle alignment. Methods Thirty-two patients who underwent a WBCT of the foot and ankle were retrospectively included. After training and validation of a 3D nnU-Net model on 45 cases to automate the segmentation into bony models, 35 clinically relevant 3D measurements were automatically computed using a custom-made tool. Automated measurements were assessed for accuracy against manual measurements, while the latter were analyzed for inter-observer reliability. Results DL-segmentation results showed a mean dice coefficient of 0.95 and mean Hausdorff distance of 1.41 mm. A good to excellent reliability and mean prediction error of under 2 degrees was found for all angles except the talonavicular coverage angle and distal metatarsal articular angle. Conclusion In summary, this study introduces a fully automated framework for quantifying foot and ankle alignment, showcasing reliability comparable to current clinical practice measurements. This operator-friendly and time-efficient tool holds promise for implementation in clinical settings, benefiting both radiologists and surgeons. Future studies are encouraged to assess the tool's impact on streamlining image assessment workflows in a clinical environment.

Purpose To establish parameters and propose a radiographic classification for foota dduction/supination deformities to assist the indication of Garceau procedure. Secondly, to investigate whether the outcome of Garceau surgery depends on the initial treatment used, peritalar release, or the Ponseti method, and verify the maintenance of correction until skeletal maturity. Methods Prospective cohort study, with follow-up evaluations in 2009 and 2019. Fifty-three consecutive patients (71 feet) with idiopathic congenital clubfoot were divided into two groups according to the initial treatment used: peritalar release (group I) or Ponseti method (group II). All patients underwent Garceau procedure. The patients were evaluated clinically and radiographically using the American Orthopedic Foot Association (AOFAS) score for ankle and hindfoot. Results In the first clinical evaluation, the mean score on the AOFAS was 87 points in group I and 86 points in group II. In the second evaluation, group I had mean AOFAS of 92 points and group II of 94 points. No statistical differences were found between the two groups. In the radiographic evaluation, the adduction deformity obtained an average correction of 4° in group I and 3.6° in group II; in supination deformity, the average depression of the first metatarsal head in relation to the ground was 6.7 mm in group I and 7.5 mm in group II, indicating the correction was maintained until skeletal maturity. Conclusion Garceau transfer is capable of correcting residual deformities in adduction/supination of mild and moderate degrees, regardless of the initial treatment, and maintaining the correction until skeletal maturity.

The aim was to demonstrate that Supramalleolar osteotomy is a valuable treatment method in eccentric ankle arthritis in young and middle aged since it is an under-utilised procedure. We retrospectively analysed the outcome of it performed over 12 year period. We also compared the results of recently introduced computer-assisted PSI Integrated custom-made implants with standard implant. Data was analysed from 47 patients over a period of 12 years of which 40 were by standard implant and 7 by computer assisted custom implant. 29 varus, 18 valgus deformity. The mean age was 57 (26-79 y/o), male:female ratio was 27:19. Mean follow-up was 15.25 months for standard implants; For the computer-assisted procedures the follow up range is 24 to 2 months. TAS, TTS and TT angels were measured pre and post-operatively. Fixation using a plate with/without bone graft or custom-made implant was performed by a single surgeon. MOXFQ and AOFAS questionnaires were completed pre and post-operatively. All followed similar rehabilitation programme. Average radiological healing time was 24.3 weeks. MOXFQ score improved from 55.17 to 25.11 and AOFAS from 20.16 to 56.21. Complications were 2 non-unions, 1 stress fracture. 8 patients require fusion/replacement between 3-5 years. The PSI Integrated computer-assisted case gave improved accuracy than standard method with better scores but with a smoother approach for the surgeon. Our results are comparable to similar studies. Being a joint preserving technique, Supra Malleolar Osteotomy should be considered either as an interim or definitive procedure especially with the development of computer assisted technologies.

INTRODUCTION: Changes in bone density (BD), particularly sclerosis, around Osteochondral Defects (OCD) of the talus have been described. However, data on distal tibia BD near these defects are lacking. Weightbearing computed tomography (WBCT) quantifies BD using Hounsfield units (HU). This study aimed to analyze mechanical stress distribution in the distal tibia and talus through BD distribution using HU. METHODS: Retrospective comparative study including patients with talar OCD as primary diagnosis or incidental finding. In WBCT images, the VOI matched the OCD width and depth, extending 5mm below and 5mm above the tibial plafond. HU distribution was obtained along three perpendicular lines (anterior, central, posterior), dividing values into four segments: talus, osteochondral lesion, joint space, and tibia. The process was repeated on the opposite non-lesion side as a control. RESULTS: Thirty-two talar OCD patients were included. Fifty-two percent were symptomatic, and 48% with an incidental finding. There was not significant difference in mean HU between symptomatic and incidental OCD patients. In controls, the talus had higher HU average than the tibia, but in OCD patients the tibia demonstrated higher HU than the talus. When comparing the HU in the tibia between OCD and controls, the OCD patients demonstrated significantly increased BD (474.34 vs 382.32)(p<.0001). DISCUSSION AND CONCLUSION: Our results show significantly increased BD compared to controls, even among asymptomatic cases. This finding could potentially explain the pain symptoms, as well as the subsequent occurrence of mirror OCD in the tibia (kissing lesion). Future studies are necessary to further elucidate this issue.

Purpose: To compare the clinical results of an arthroscopic lateral ligament repair with biological augmentation between patients with a BMI ≥ or < 30. Methods: Sixty-nine patients with an isolated lateral ankle instability were treated with an arthroscopic anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER). Patients were divided into two groups according to their BMI: ≥ 30 (Group A; n=26) and <30 (Group B; n=43). Patients were pre-and post-operatively evaluated, with a minimum of 2 years follow-up, using the Karlsson Score. Characteristics of the patients, complications, ankle instability symptoms recurrence, and satisfaction score were recorded. Results: In group A, median Karlsson Score increased from 43.5 (Range 22-72) to 85 (Range 37-100) at follow-up. Complications were observed in 7 patients (27%). Nineteen patients (73%) reported that they were “very satisfied”. In group B, median Karlsson Score increased from 65 (Range 42-80) to 95 (Range 50-100) at follow-up. Complications were observed in 4 patients (9%). Thirty-three patients (77%) reported that they were “very satisfied”. Pre-operative and at last follow-up Karlsson Score, results were significantly different between the two groups. There was no significant statistical difference in favour of satisfaction score, complications between the two groups. Conclusion: ATFL repair with biological augmentation using IER gives excellent results for patients with BMI ≥ 30. Compared to patients with BMI <30, they present a slightly lower preoperative and postoperative Karlsson score, however, with a similar satisfaction rate, but are at higher risk of transient superficial peroneal nerve dysesthesia.

Background: Ankle fusion is the benchmark procedure in refractory cases of ankle arthritis. Aim: The aim of this work was to compare different outcome measures of arthroscopically assisted ankle fusion and mini-arthrotomy ankle fusions. Methods: This prospective study included 30 patients with post-traumatic ankle OA, who were treated by ankle fusion. Patients were divided regarding the adopted procedure into two groups, 15 patients in each group. Group A was treated using arthroscopic assisted ankle fusion and Group B using single incision mini arthrotomy ankle fusion. They were evaluated clinically with AFOAS, visual analogue scale of pain pre and post operatively, time of union, complications and satisfaction. Results: The results were satisfactory in 12 patients in group A and 11 patients in group B. While three patients (20%) in group A and four patients (26.6%) in group B had unsatisfactory results according to AFOAS and VAS. Sound solid ankle fusion was achieved in 13 (86.6%) ankles in group A with a mean fusion time of 14.4 weeks (range from 12-18 weeks) and 11 (73.3%) ankles in group B with a mean fusion time of 14.5 weeks. Two ankles in group A (13.3%) and four ankles in group B (26.6%) had non-union. Conclusion: No difference was found between single-incision mini-arthrotomy and arthroscopic assisted ankle fusion. Minimally invasive ankle arthrodesis (particularly arthroscopic assisted technique) offers a good option for the minimally deformed arthritic ankle.

Introduction: Osteochondral Lesions of the Talus (OLT) may progress into a cascade of cartilage degeneration. While edge-loading on the surrounding tibiotalar articular surfaces has been proposed as principal determinant of cartilage degeneration, the pathophysiological pathways have not yet been clarified. The present study aims to evaluate the patient-specific influence of OLTs on the mechanical behaviour of the surrounding cartilage of the talus and tibia. Methods Patient-specific 3D models from 36 patients with an OLT, derived from weightbearing CT, were used to analyse the contact stress on the tibiotalar articulation using Discrete Element Analysis (DEA). A matched, virtual healthy control group was developed for each talus. Mean- , peak contact-stress and contact area were calculated during simulated ankle flexion. Results The mean talar contact-stress was elevated in the OLT cases, with a notable correlation between ankle flexion and OLT location. Edge loading occurred predominantly in anteromedial lesions during dorsiflexion (2.9 MPa (IQR: 1.3) for OLT versus 2.4 MPa (IQR: 0.9) for the controls), while posteromedial lesions were mostly loaded during plantarflexion (3.5 MPa (IQR: 1.7) for the OLT versus 2.9 MPa (IQR: 1.1) for the controls). Conclusion OLTs influence the whole-joint articular contact mechanics of the ankle, leading to increased stress on both the talus and the opposing tibia. More specifically, a clear pattern of edge-loading on the surrounding OLT cartilage was found. Anterior lesions had the highest stresses in neutral and dorsiflexion, while posterior lesions experienced higher stress during plantarflexion.

Introduction: Zinc and magnesium are crucial for bone health, with deficiencies potentially impairing bone metabolism and repair. This study is the first to examine sex-related differences in trace element levels during the initial stages of fracture healing. Understanding these differences may lead to more effective treatments or supplementation strategies. Methods: After inducing a closed mid-diaphyseal femur fracture in male and female BB Wistar rats, fractured and intact contralateral femurs were collected at 1-, 3-, and 7-days post-injury. 10 mm segments were resected from the center of the callus, and similar regions were taken from contralateral femurs. Control femurs were harvested from non-fractured rats. Samples were analyzed via inductively coupled mass spectrometry, and t-tests compared fractured femurs to control and contralateral femurs, with p-values adjusted for multiple comparisons. Results: Zinc levels were significantly lower at the fracture site for 1-, and 3-day male groups compared to controls (p<0.01). In females, zinc levels remained relatively stable across time points, with a notable non-significant decrease at the fracture site for the 7-day group. Magnesium levels were significantly lower at the fracture site for 1-day and 3-day male groups compared to controls (p<0.01). In females, magnesium levels showed minor fluctuations, with a slight non-significant decrease at the fracture site for the 7-day group. Conclusion: This study highlights sex differences in early fracture healing, with distinct temporal patterns in zinc and magnesium levels. These findings enhance our understanding of the roles of these trace elements in fracture healing and may inform future therapeutic approaches.

While most total ankle arthroplasty (TAA) utilize an anterior approach for implantation, the Zimmer Trabecular Metal implant is unique in that it utilizes a transfibular approach. This allows for a shallow resection depth and insertion of a curved prosthesis design, mimicking the native tibiotalar joint. We present the largest midterm study to date analyzing the survivorship, clinical, and radiographic outcomes of transfibular TAA at a minimum of 5-years follow-up. A total of 130 ankles (122 patients, average age 60.8 years-old, 50.8% females) with average 5.9 years (range, 5.0-10.1) follow-up were included. PROMs included SF-12 physical (PCS) and mental (MCS) component scores, Ankle Osteoarthritis Scale (OAS), pain Visual Analog Scale (VAS). Radiographic outcomes included ROM, coronal/sagittal alignment, and periprosthetic lucency using a 12-zone system. Adverse events were reported using the Canadian Orthopedic Foot and Ankle Society Reoperation Coding System (CROCS). Postoperative PROMs included SF-12 PCS: 41.5; SF-12 MCS: 54.9; VAS: 2.3; AOS Pain: 19.1; AOS Disability: 28.5. Postoperative tibiotalar ROM was 7.4° dorsiflexion, 17.3° plantarflexion. 26 (20%) ankles had a single zone of radiolucency; none had more than 7 zones. There were 3 (2.3%) cases of cysts, no cases of subsidence, septic/aseptic loosening, or fibular non-union. Reoperation rate was 36.2% (n=47) at average 26.7 months, most commonly removal of fibula hardware (n=28, 21.5%), medial gutter debridement (n=18, 13.8%). There were 5 (3.8%) cases of acute infection treated with I&D and metal component retention. Overall implant survival, defined by retention of the metal components, was 100% at final follow-up.

Introduction/Purpose: Ankle sprains are one of the most common injuries amongst ballet dancers and may lead to chronic ankle instability. Certain ballet positions can further increase the risk of bone and soft tissue injuries. While injuries occur frequently, there is little understanding of the biomechanics of the foot/ankle in ballet. This study used weightbearing computed tomography (WBCT) and distance mapping to describe ankle joint mechanics in various ballet positions. Methods: Bilateral WBCT scans were taken of five healthy professional ballerinas in five different positions: control/neutral, first position, fifth position, plié, and relevé (en pointe). A semi-automatic software was used to segment models of all bones proximal to the first distal phalanx. Talar dome and gutter articulations were selected manually, and distances along the entire tibiofibular interface and gutter articulations were calculated. Results: Syndesmotic widening was greatest in first position at 5 cm above the tibiotalar joint (Mean: 9.39 mm). The relevé position consistently had the greatest syndesmotic narrowing. The anteromedial gutter had the largest range in regard to distance, with greatest joint space width in fifth position (Mean: 4.99 mm) and narrowest in plié (Mean: 2.68 mm). More specifically, in fifth position the anteromedial gutter space was 71% wider than the control position. Conclusion: This study is the first of its kind to mechanistically describe the ankle as it relates to ballet dancing. Future research with larger cohorts and more WBCT stress positions is needed to comprehensively understand the foot and ankle joint mechanics in this demanding sport.

Introduction. Brachymetatarsia is a fairly rare pathology that is characterized by shortening of the metatarsal (or metatarsals) bones due to premature closure of the growth plate. However, most patients suffering from this pathology require surgical treatment. Purpose of the study: to improve the results of treatment of patients with brachymetatarisis by introducing into surgical practice the method of simultaneous lengthening of the metatarsal bone using an autograft from the tubular bones of the foot. Materials and methods. This article presents a comparison of treatment results between two groups of patients. The main group of patients (40 patients, 50 feet) underwent simultaneous lengthening of the shortened metatarsal bone using autografts from tubular bones of the foot. The control group of patients (25 patients, 33 feet) underwent distraction osteosynthesis of the metatarsal bone using an external fixation device. Results. The results obtained during the study suggest the advantage of the method of one-step lengthening of the metatarsal bone using autografts from tubular bones of the foot over the distraction method. Patients in the main group had a shorter healing period compared to the control group (8.1±1.3 and 16.2±2.4 weeks, respectively), and fewer complications. Also, patients of the main group in the early postoperative period noted a high cosmetic result of the operation. Conclusions. By using the developed method of surgical treatment, we were able to significantly reduce the treatment time for patients, as well as achieve high aesthetic results.

Background: Minimally Invasive Chevron-Akin (MICA) hallux valgus (HV) deformity correction utilizes an extra-articular distal first metatarsal chevron osteotomy that is held with rigid fixation using two fully threaded screws, of which one is bicortical to provide stability. However, the necessity of two screws is debated, as is the necessity of bicortical fixation. Despite the clinical success of MICA, there is a lack of biomechanical studies assessing the stability and strength of different fixation constructs. Methods: A 3D foot finite element model was developed from computed tomography images of a female patient with moderate HV deformity. Five different screw configurations were assessed using FEA, including fourth-generation MICA fixation with 2 screws (one bicortical and one intramedullary), 2 intramedullary screws, 2 bicortical screws, 1 intramedullary screw, and 1 bicortical screw. Loading conditions involved a vertical ground reaction force applied to the midfoot, with simulated 150N and 300N loads. Stress analysis considered osteotomy displacement, maximum and minimum principal stresses, and equivalent von Mises stress for both implants and bone. Results: FEA indicated that MICA fixation with two screws (one bicortical and one intramedullary) demonstrated the lowest values for osteotomy displacement, minimum and maximum total stress, and equivalent von Mises stress on the bone and screws in both loading conditions. Conclusion: This biomechanical analysis provides valuable insights into the strength of different MICA screw fixation configurations, highlighting the superiority of classical MICA fixation configurations with two screws in terms of stability and stress distribution.

Objective: To investigate the impact of decompressive chevron osteotomy on subchondral bone density at the first MTP joint. Methods: Sixteen feet (12 patients) with hallux rigidus underwent decompressive chevron osteotomy. Pre- and post-operative standing cone beam 3DCT were assessed, and clinical data was collected. Radiologic measurements, including bone density using Hounsfield units (HU), were conducted. Statistical analyses were performed to evaluate changes and correlations. Results: Post-operative bone density significantly decreased in proximal (Pre, 650.9±149.1; Post, 312.4±115.9; p<0.001) and distal (Pre, 910.4±143.3; Post, 639.0±167.1; p<0.001) components of the first MTP (joint and the first TMT (Pre, 762.9±166.6; Post, 611.5±165.9; p=0.015) joint. No significant difference was measured at the TT joint (Pre, 497.5±143.6; Post, 534.3±130.7; p=0.463). Length of the first metatarsal (Pre, 60.4±3.4; Post, 54.3±3.0; p<0.001) and metatarsal protrusion index (MPI) (Pre, -0.9±3.0; Post, -9.0±3.6; p<0.001) significantly decreased post-operatively. Clinical assessments showed significant improvements in AOFAS scores (36.1±14.5 points) and pain on VAS scale (- 5.3±1.9). Conclusion: Decompressive chevron osteotomy leads to a significant decrease in subchondral bone density of the first MTP joint. A decrease in bone density occurs also in the first TMT joint.

Aims Ligamentous Lisfranc injuries often feature avulsion fractures of the tarso-metatarsal joint (TMTJ). A proportion of these will have a congruent TMTJ joint on initial imaging, and many of these patients will have an unstable TMTJ which requires stabilisation. The study aimed to determine the relationship between the presence of an avulsion fracture on initial imaging and instability of the first TMTJ. Methods A prospective database of Lisfranc fracture-dislocations was analysed for the presence of TMTJ1 avulsion fractures. All cases were managed with examination under anaesthesia (EUA) and stress testing under image intensification prior to fixation or arthrodesis surgery. The rate of TMTJ1 instability and the sensitivity and specificity of the presence of an avulsion in detecting instability was determined. Results 153 patients with a mean age of 35.2 years were included. 99 injuries (64.7%) had an avulsion fracture of TMTJ1 on imaging. Of these, 76.7% had a congruent joint on XR or CT scan. 91.9% of patients with an avulsion fracture demonstrated instability on EUA stress testing. Amongst the 54 cases showing no avulsion, 23 (42.6%) were unstable on EUA. The presence of an avulsion had a sensitivity of 79.8% and a specificity of 79.5% in the detection of instability. Conclusions The presence of an avulsion fracture of TMTJ1 is highly suggestive of instability. This finding should lower the threshold to perform EUA stress testing. A high proportion of Lisfranc injuries without avulsion fractures have TMTJ1 instability, and therefore the absence of this finding does not reliably exclude instability.

Aim: Compare the wound healing rate, cost, and convenience between Negative Pressure Wound Therapy (NPWT) and Copper Oxide Dressings (COD) in the management of diabetic foot wounds (DFW). Method: A Randomized controlled trial (RCT) with 46 DFW, in whom NPWT was indicated. Twenty-three patients were enrolled in the COD and NPWT arm for three months or wound closure. The primary endpoint was wound size reduction, assessed by "Tissue Analytic" program. Secondary endpoints were convenience, application time, pain, and cost. Results: The initial wound area was 19.9±4.36 and 14.1±2.32 cm2 in the COD and NPWT arms, respectively (p=0.25). Wound size reduction was statistically significant non-inferior of the COD Arm compared to the NPWT (p=0.04) and superior in the last visit (T-test, p=0.032). 11 (47.8%) and 8 (34.8%) wounds were closed during the study in the COD and NPWT arms respectively (P=0.37). COD therapy was more convenient for the patients (Visual Analog Score [VAS] was 8.44 vs. 5.33; p=0.002) and the medical personnel (8.29 vs. 6.0; p=0.007), and less painful (1.15 vs. 2.19; p=0.67) in the COD arm compared to NPWT. The COD's mean application time was shorter (8.5 vs. 13.25 minutes; p<0.001). The cost of COD is estimated to be 84% less than NPWT treatment. Conclusion: This RCT study indicates statistically significant non-inferiority of COD dressing therapy than NPWT in terms of wound healing rate of DFW. Better convenience and reduced costs in the COD arm justify initial copper dressing attempts in patients with diabetic foot wounds before NPWT treatment.

Introduction: Middle facet subluxation (MFS) and middle facet incongruence angle (MFIA) are commonly reported as marker of peritalar subluxation (PTS) in Progressive Collapsing Foot Deformity (PCFD). In the literature MFS and MFIA are assessed a true coronal plane which differs from the plane of the middle facet. We hypothesized that changes in the plane’s of measurement would lead to changes in the MFS and MFIA and as well its “dysplastic” appearance. Method: retrospective case-control study, 89 patients with PCFD and 11 controls. Measurements of MFS, MFIA, and middle facet dysplasia were conducted using both the classical method (taking measurements in the coronal plane as described in the literature) and the new method ( taking measurements after rotation of the coronal plane until it was perpendicular to the middle facet plane). A p-value of <0.05 was considered statistically significant. Results: Significant differences were observed between the two methods across all parameters, the new method demonstrated lower MFS (25.4% vs. 40.3%, p<0.0001), lower MFIA (4.7 degrees vs. 13.1 degrees, p<0.0001), and fewer dysplastic joints (1% vs. 37%, p<0.0001) For controls, only the MFIA was significantly different (p:0.0045) between methods. Conclusion: MFS is a complex deformity influenced by multiple parameters. The new method showed lower MFS, MFIA, and dysplasia measurements compared to current classical method. When assessing MFS, surgeons should be mindful that the plane of measurement relative to the structure is critical. We suggest using a plane of measurement perpendicular to the plane of the middle facet when assessing its subluxation.

Background: While many studies were able to determine the hind- and midfoot alignment after a medializing calcaneal osteotomy (MCO), the subtalar joint alignment remained obscured by superposition on plain radiography. Therefore, we aimed to assess the hind-, midfoot- and subtalar joint alignment pre- compared to post-operatively using 3D weightbearing CT (WBCT). Methods: Seventeen patients with a mean age of 42±17 years were retrospectively analyzed. Inclusion criteria consisted of PCFD deformity corrected by a MCO as main procedure and imaged by WBCT before and after surgery. Exclusion criteria were patients who had concomitant calcaneal lengthening osteotomies, mid-/hindfoot fusions, hindfoot coalitions, and supramalleolar procedures. Image data were used to generate 3D models and compute the hindfoot (HA), midfoot (MA) - and subtalar joint (STJ) alignment in the coronal, sagittal and axial plane, as well as distance maps. Results: Pre-operative measurements of the HA and MA improved significantly relative to their post-operative equivalents p<0.05). The post-operative STJ alignment showed significant inversion (2.8°±1.7), abduction (1.5°±1.8), and dorsiflexion (2.3°±1.7) of the talus relative to the calcaneus (p<0.05) compared to the pre-operative alignment. The displacement between the talus and calcaneus relative to the sinus tarsi increased significantly (0.6 mm±0.5;p<0.05). Conclusion: This study detected significant changes in the sagittal, coronal, and axial plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings contribute to our clinical practice by demonstrating the magnitude of alteration in the subtalar joint alignment that can be expected after PCFD correction with MCO as main procedure.

Introduction: This study aims to evaluate differences with Weight-Bearing CT (WBCT) among a cohort of symptomatic Progressive Collapsing Foot Deformity (PCFD) patients with a history of pediatric flat foot (=pediatric PCFD), without (=non-pediatric PCFD), and a control group. We hypothesized that pediatric PCFD would display distinct WBCT parameters. Method: In this retrospective case-control study, pediatric PCFD was defined as flat feet since childhood, non-pediatric PCFD as foot shape changed in adulthood. 37 pediatric PCFD patients were compared to 52 non-pediatric PCFD patients and 11 control. Significance was set at a p-value < 0.05. A multivariate regression analysis was conducted to identify parameters associated with pediatric PCFD. Results: Compared to non-pediatric PCFD, the pediatric PCFD group showed a lower Foot and Ankle Offset (p<0.001), lower sagittal talus-first metatarsal angle (TFM) (p<0.001), lower axial TFM (p 0.0001), lower hindfoot moment arm (HMA)(p=0.0002), lower talonavicular uncoverage (p<0.0001), lower middle facet subluxation (p=0.0021), higher sinus tarsi (p<0.001), higher subfibular impingement (p<0.0001. Differences between the pediatric and control groups in (HMA) (p=0.053) and SF (p=0.07) were not statistically significant. When considering only WBCT parameters, multivariate regression analysis indicated that axial TFM (p:0.005), MFS (p:0.013), and ST (p:0.03) were the best predictors of pediatric PCFD. (R2 : 0.27). Conclusion: Pediatric PCFD is characterized by distinct WBCT parameters compared to non-pediatric PCFD, notably exhibiting less forefoot abduction, less middle facet subluxation a lower FAO and a hindfoot alignment closer to that of the control group. TFM, MFS, and ST stand out as parameters associated with pediatric PCFD.

Introduction Higher body mass index (BMI) levels can increase the risk of complications and poor outcomes following surgical interventions for various orthopaedic conditions, including insertional Achilles tendinopathy (IAT). However, the exact impact of BMI on postoperative outcomes for IAT is still unclear and warrants further investigation. Methods Prospectively collected registry data of 75 patients who underwent surgery for unilateral IAT were reviewed. Patients were separated into 2 groups based on BMI: normal (<30 kg/m2) and obese (≥30 kg/m2). Clinical assessment at preoperative, 6-month and 2-year follow-up was performed using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, as well as assessment of postoperative satisfaction. Results There were 47 patients in the normal BMI and 28 patients in the obese group. Both groups showed significant improvement in AOFAS score, VAS score, SF-36 PCS and MCS at 6 months and 2 years postoperatively. However, there were no significant differences in these scores between the two groups and both groups achieved similar final postoperative scores at 2 years. Wound complications were more common in obese (n = 2, 7.1%) compared to normal BMI (n = 1, 2.1%) patients, but did not reach statistical significance (p =.284). Postoperative satisfaction (p = .394) were also similar between the two groups. Conclusion Obese patients undergoing surgery for IAT can achieve similar outcomes as those with normal BMI without the increased risk of complications.

INTRODUCTION Gastrocnemius-soleus complex (GSC) tightness leads to functional pseudoequinism in the gait cycle, which translates into increased forefoot pressure. One of the most used tests to diagnose it is the Silfverskiöld test. We propose a different test to objectively evaluate the GSC shortening: In a standing position, a goniometer is used to evaluate ankle dorsiflexion. OBJECTIVES The main objective is to compare the reliability of the Silfverskiöld test versus the standing test. MATERIALS AND METHODS A cross-sectional observational study was conducted with 2 independent observers. The Silfverskiöld test was performed with goniometric measurement. Then, in standing position with both feet parallel facing forward, patients move one leg backwards with the knee fully-extended, progressively bending the knee placed in front. When discomfort appears in the calf region, a goniometric measurement is performed. Next, patients bend the knee placed backwards and same measurement is taken maintaining the heel touching the floor. Interrater reliability was assessed using the intraclass correlation coefficient (ICC) Two-way-Random-effects, mean of 2 raters, Absolute agreement (ICC2k) statistical test. RESULTS We performed 50 measurements for each test. Higher ICC was observed in the standing test (ICC=0.75) than Silfverskiöld test (ICC=0.68), making it more reliable (p<0,001). Normal dorsiflexion values in standing test ranged from 110,49º with knee extension to 119,85º with knee flexion. Patients with positive Silfverkiöld test, increased 13º in ankle dorsiflexion with standing test. CONCLUSION The standing position test could be a reliable alternative to the Silfverskiöld test in the diagnosis of GSC tightness, but more studies are needed.

Background We aimed to investigate the effect of Haglund’s deformity size on insertional Achilles tendinopathy (IAT) using a new measurement system and identify independent risk factors of IAT with Haglund’s deformity. Methods We reviewed medical records of patients with IAT and age/sex-matched patients with diagnoses other than Achilles tendinopathy. Radiographs were reviewed to identify posterior/plantar heel spur, and intra-Achilles tendon calcification, and to measure Fowler-Philip angle, calcaneal-pitch angle, and Haglund’s deformity angle/height. Multivariate logistic regression analysis was performed to identify independent risk factors of IAT with Haglund’s deformity. Results 50 patients were enrolled in the study group, equaling the size of the age/sex-matched control group. Our new Haglund’s deformity measurement system showed excellent intraobserver /interobserver reliability. No significant differences between the two groups were noted in Haglund’s deformity angle and height: 6.0° in both groups, and 3.3mm Vs.3.2mm in the study and control group, respectively. The study group had significantly higher calcaneal pitch angle, incidence of posterior heel spur, plantar heel spur, and intra-Achilles tendon calcification: 5.2° Vs.23.1°(P=.044); 81.8% Vs.36.4%(P<.001); 76.4% Vs.34.5%(P=.003); 67.3% Vs.5.5%(P<.001), respectively. Multivariate logistic regression analysis identified independent risk factors of IAT: posterior heel spur(OR=3.650), intra-Achilles tendon calcification(OR=55.671) and increased calcaneal pitch angle(OR=6.317). Conclusion Based on our results, the Haglund’s deformity size was not associated with IAT, suggesting a routine Haglund’s deformity resection may be unnecessary in the surgical treatment of IAT. If patients with Haglund’s deformity have posterior heel spur, intra-Achilles tendon calcification, or increased calcaneal pitch angle, a higher chance of IAT can be predicted.