Background: We aimed to present the characteristics of older patients with Achilles tendon sleeve avulsion (ATSA) and the clinical outcomes of Achilles tendon reattachment, with or without tendon lengthening. Methods: This study enrolled 13 consecutive patients who underwent operative treatment following the diagnosis of ATSA between January 2008 and December 2019. The inclusion criterion was: patients' age at operation ≥65 years. For all patients, AT reattachment was performed using two 5.0-mm suture anchors with an inflamed distal stump resection. A V-Y advancement or turn-down flap was performed in 9 patients when the distal stump could not reach the calcaneal tuberosity by pulling it distally in the 30° plantarflexed ankle position. Results: All patients sustained ATSA due to minor trauma, except for one who slipped during mountain climbing. Interestingly, due to pre-existing pain, a local steroid injection was administered at AT insertion prior to injury in 11 of 13 patients (84.6%). Postoperatively, the mean visual analog scale score and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were 3.08±1.50 (range, 1–7) and 77.54±13.10 (range, 48–93), respectively. The rate of fair or greater (excellent or good) subjective clinical outcomes was 84.6% (11 patients). Conclusions: We confirmed that successful clinical outcomes could be achieved with AT reattachment with or without lengthening of the ATSA, even in older patients. Adequate lengthening procedures should be combined when the gap is too wide to reattach after inflamed distal stump resection.

The study aimed to analyze the success of various revision interventions after total ankle replacement (TAR). The endpoint was a further revision surgery. Between 2006 and 2020, we performed 122 revision surgeries after TAR. The follow-up included the radiological course, clinical results, and the EFAS score. Patient demographics, indication for revision, and surgical details were analyzed. The median age in the cohort was 60.93 ± 11.52 years (95% CI: 59.09, 62.78). 55 patients were female (54.08%) and 67 (54.92%) male. We included all patients prospectively in the German TAR database. The average follow-up was 70.37 ± 46.76 months. Polyethylene wear (42.62%, n=52), loosening (23.77%, n=29), malalignment (8.20%, n=10), and periprosthetic infection (7.38%, n=9) represented the most frequent indications. 14.75% of the patients needed a second revision procedure during the follow-up period. EFAS Score was 12.51 ± 5.53, EFAS Sports Score was 2.97 ± 3.04. Patients with simultaneous axial correction had the lowest failure rate during the FU period (3.45%). A single exchange of the polyethylene inlay (n=35) was related to a second revision in 33.9%. In patients with a complete exchange of all components (n=26), the failure rate during the FU was 3.85%. The high failure rate of inlay replacement alone suggests that the procedure does not eliminate the underlying pathology. Increased polyethylene wear should always include a search for the cause since mechanical problems must be assumed. If it is possible to address the problems causing the failure of the implant, the results of a revision procedure are good.

Introduction: Total ankle replacement (TAR) became a popular surgical solution for end-stage ankle osteoarthritis (OA). Consequent to increased number of primary implantations, failed ankles are evermore challenge for surgeons. Nowadays, maintenance of the ankle and hindfoot functionality is first and foremost. Despite revision arthroplasty has been described as a viable option, the available literature on long-term outcomes is scarce. The aim of this study was to investigate long-term survival of revision ankle arthroplasty in a uniquely large cohort using the mobile-bearing HINTEGRA prosthesis. Materials and Methods: We conducted a single-center retrospective cohort study included 116 patients (117) ankles following revision ankle arthroplasty from July 2000 to March 2010. Survival analysis was performed. Clinical outcomes including pain on visual analog scale (VAS), American Foot and Ankle Ankle-Hindfoot Score (AOFAS), ankle range of motion (ROM) and patient`s satisfaction were assessed preoperatively and at the last follow-up. Results: The mean follow-up time from initial revision arthroplasty to latest follow-up was 15.0±3.0 years (range 11.2 – 20.5). The cumulative survival of the revised ankles at 5, 10 and 15 years was 81±4%, 74±4%, and 70±4%, respectively. Pain on VAS declined from median 6(0 - 10) to 2 (0 - 10) (p<.0001)), and the AOFAS score improved from 43±17 to 70±20 (p<.0001)). Conclusion: Revision ankle arthroplasty yields acceptable survival rate and results on long-term, however lower than primary TAR. Careful preoperative planning is crucial to achieve the desired results. The study provides unique information for foot and ankle surgeons and possibly influence decision-making process.

Background: Given the growing number of primary total ankle replacements (TAR), an increase in failed ankles and consecutive revisions might be expected. Achieving a stable and balanced ankle while preserving the remaining bone stock, are crucial in revision TAR. We used a novel 3-component ankle that is converted to a fixed-bearing 2-component once the components have found their position given by the individual anatomy. The purpose of this study was to determine the short-term results of this concept in revision TAR. Methods: This retrospective cohort study included 57 patients (57 ankles, mean age 63±13 years) treated for failed TAR with the HINTERMANN Series H2© implant. Survival analysis was performed. Clinical and radiological outcomes were assessed preoperatively and at the last follow-up. Clinical outcomes included pain on VAS, AOFAS ankle hindfoot score and patient satisfaction. Radiological outcomes were tibial articular surface angle, tibiotalar surface angle, talar tilt angle, anteroposterior offset ratio and signs of radiolucency and/or loosening. Results: The median follow-up was 2 (2.0 to 4.0) years. The cumulative incidence for secondary revision after 1 and 2 years was 5.1% (95%CI 0-11) and 7.4% (95%CI 0-14) respectively. The AOFAS score increased from median 54 (range 9-94) to 75 (19-98) (p=0.00001), satisfaction from moderate to good (p=0.0017). There was no evidence of loosening or radiolucency. Conclusion: Results of the novel semi-constrained implant design on short-term are encouraging, with a satisfactory survival rate and acceptable revision rate. The fixation concept without extended fixation features was shown to last against increased shear forces.

Case: A 38-year-old male patient presented with severe pain in the left ankle after having undergone total ankle arthroplasty (TAA) surgery for hemophilia caused ankle osteoarthritis (OA) 13 years earlier. Radiographic evaluation showed implant loosening and extensive osteolytic lesion with a severe bone defect on medial tibia. After having reconstructed the medial tibial plafond including the medial malleolus using structural femoral head allograft, revision TAA was performed using a three-component ankle. The evolution was uneventfully, and at last follow-up after 4 years, the allograft was fully integrated, with stable components. Conclusion: Revision TAA is feasible with resurfacing components at tibial side also in the presence of severe bone loss, as long as the components can be firmly fixed to genuine bone, making intramedullary fixation with additional scarifying of bone not necessary. A stable ankle joint is, however, mandatory.

Objectives The study aims to determine whether ankle ligament reconstruction is necessary to relieve clinical ankle instability symptoms in patients with an MRI proven ligament ruptures. Methods This was a single centre retrospective case series of 25 patients with ankle instability and ligament tear on MRI scan who underwent arthroscopic ankle procedures from January 2015 to December 2018. Mean follow-up was 3 years evaluating recurrence of symptoms. Results Mean age was 34 years. The majority of patients were males (16/25). Of the 25 patients, 23 had ATFL tear, and 2 had deltoid ligament tear on MRI scan. Examination under anaesthesia revealed that ankles were stable in 13 and unstable in 12 patients. 19 (76%) patients had clinical improvement from arthroscopic ankle debridement. 6 patients needed ligament reconstruction. 2 patients had ligament reconstruction at the initial setting and 4 at a later stage. Amongst stable ankles, 2 patients had ligament reconstruction, and in unstable ankle group, 4 patients received reconstruction. Conclusion Our study has shown that in patients with MRI proven ligament tear and clinical instability, a ligament reconstruction was not required in most patients. The instability symptoms were relieved by arthroscopic ankle debridement, suggesting an element of the functional component along with ligament rupture.

Background: Total ankle arthroplasty (TAA) is an alternative to ankle arthrodesis for the treatment of end-stage arthritis while maintaining greater ankle motion and functionality. However, the literature has shown that articles written by design surgeons present biased results. The purpose of this study is to compare reported TAA outcomes between studies conducted by design and non-design surgeons. Methods: A comprehensive search of MEDLINE for all articles published between 1996 and 2021 was conducted with a minimum two-year follow-up. Meta-analytic pooling of group results across studies was performed, including patient-reported outcome measures (PROMs). Fifty-two implant groups met inclusion criteria, of which eight were authored by a design surgeon. In total, 4,693 subjects were included with a mean age of 59.89 years. Results: At mean follow-up of 68.91 months, the reoperation rate was 25.2% (design=23.5%, non-design=25.5%, p=.843), revision rate was 9.3% (design=9.0%, non-design=9.4%, p=.935), and conversion to arthrodesis rate was 5.0% (design=2.5%, non-design=5.5%, p=.243). None of these rates differed between groups. According to the COFAS Reoperations Coding System (CROCS), most reoperations were not around the ankle (Code 1: 76.65%). Mean postoperative plantarflexion (p=.007) and mean preoperative dorsiflexion (p=.006) were significantly greater among non-design surgeons’ reports. The implant survival rate at one, two, five, and ten years was 97.7% (design=98.5%, non-design=97.6%, p=.732), 96.5% (design=97.0%, non-design=96.4%, p=.865), 92.1% (design=96.4%, non-design=91.3%, p=.865), and 79.2% (design=87.9%, non-design=76.3%, p=.070), respectively. Conclusion: In the reporting of TAAs, design surgeons do not appear to be biased. Postoperative outcomes were better in design surgeon studies, but none were significantly different.

Background: With a reported screw removal rate of 9-47% following subtalar (ST) or ankle arthrodesis, an added economic and surgical burden is imposed on both the patients and the healthcare system. The purpose of this study is to determine if there are any outcome differences when using headless, variable-pitched screws [Acumed, Hillsobro, OR] or headed screws [Stryker, Kalamazoo, MI] in ST or ankle arthrodesis. Methods: A retrospective chart review identified 120 patients (123 feet) who underwent ST (n=93) or ankle (n=30) arthrodesis by a single fellowship-trained foot and ankle surgeon at an academic medical center during 2015-2020. These patients met inclusion criteria and had minimum three months of follow-up. Mean follow-up duration was 1.22 (range, 0.25-4.96) years. Overall, 66 procedures used headless screws and 57 used headed screws. Results: There was no difference in mean follow-up or any postoperative patient-reported outcome measure between groups. However, there were statistically significant differences between groups among rates of nonunion (headless=18.2%, headed=35.1%; p=.033), reoperation (headless=12.1%, headed=33.3%; p=.005), and hardware removal (headless=4.5%, headed=31.6%; p<.001). Also, the number of screw issues (i.e., broken, displacement, impingement) with headed screws neared significance (headless=0.0%, headed=5.3%; p=.097). Furthermore, of the five patients who underwent revision arthrodeses for nonunion, headed screws were removed in each. Conclusion: The use of headed screws in ST or ankle arthrodesis is associated with significantly higher rates of nonunion and hardware removal, as compared to headless screws. These results suggest headless, variable-pitched screw fixation for ST and ankle arthrodesis procedures may offer improved outcomes.

Background: Chronic ankle instability (CAI) is commonly encountered by orthopaedic foot and ankle surgeons. This study aimed to investigate the association between psychiatric diagnosis and CAI, and whether having a diagnosed psychiatric illness impacts the treatment outcomes of CAI. Methods: A retrospective review was conducted of 276 patients (280 ankles) treated between 2005 and 2021 at an academic medical center by a fellowship-trained foot and ankle orthopaedic surgeons, of which 56 underwent surgery, and 130 had a concomitant psychiatric diagnosis (i.e., anxiety=111, depression=105, post-traumatic stress disorder [PTSD]=19, obsessive-compulsive disorder [OCD]=6, bipolar disorder [BPD]=5). Results: Psychiatric patients had worse preoperative PROMs. However, this cohort improved significantly postoperatively across all patient-reported outcome measures (PROMs). In particular, the Foot and Ankle Outcome Score (FAOS) Total increased by 35.28% (preop=57.29%, postop=77.50%, p=.011) and the Foot and Ankle Ability Measure (FAAM) Total by 49.86% (preop=45.87%, postop=68.74%, p=.027). The relative change of pre- to postoperative FAOS and FAAM scores was greater among those with mental illness in all but FAOS Sports and Recreation. However, the absolute value of all postoperative PROM was lower among those with mental illness, aside from the FAOS Symptoms and Stiffness score. Patients with psychiatric illnesses more often failed conservative measures and subsequently underwent surgery (p=.231). Conclusion: CAI patients with mental illness had lower preoperative PROMs; however, their PROM improvement was greater than those patients without mental illness. Generally, postoperative PROMs were higher in patients without mental illness. Providers and patients should be aware of these important difference in patients with CAI.

Background: When patients fail conservative management for chronic lateral ankle instability, a Broström procedure is often recommended. The purpose of this study was to investigate the postoperative trends between Broström operation recipients and those patients also undergoing suture tape augmentation, revision surgery, and NanoScope usage. Methods: We conducted a retrospective review of 125 patients treated with a modified Broström by a single fellowship-trained foot and ankle surgeon at an academic medical center between 2016 and 2020. Overall, 39 patients received suture tape augmentation, 95 underwent a primary Broström, and 24 were operated on with a NanoScope. Various demographics, medical history, patient-reported outcome measures (PROMs), and postoperative outcomes were collected. Average follow-up was 1.0 years (0.25-4.58). Results: There were no differences in any postoperative PROMs (i.e., FAOS, FAAM), follow-up, or complication rate between suture tape augmentation cohorts. The only significant difference between cohorts pertained to the proportion of patients who underwent a reoperation specifically for incision and debridement (suture tape=71.4%, no suture tape=0.0%; p=.013). When analyzing the primary and revision Broström operation cohorts, there were no differences in any postoperative PROM, follow-up duration, or complication. Finally, there was no difference in any PROMs, complications, or reoperation rate for the NanoScope cohorts, but follow-up duration was significantly longer for those whose procedures did not use a NanoScope (NanoScope=0.71 years, no NanoScope=1.13 years; p=.003). Conclusion: Neither suture tape augmentation or revision status was found to affect postoperative outcomes of Broström patients. Patients who received suture tape augmentation experienced fewer deep infections.

Background: The Pain Catastrophizing Scale (PCS) is a measure of intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. The purpose is to compare baseline PCS scores with other baseline PROMs in patients with plantar fasciitis (PF) or chronic ankle instability (CAI). Methods: We retrospectively reviewed 201 patients who reported at least one pre-treatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon’s clinic. Demographics, comorbidities, treatments, other baseline patient-reported outcome measures (PROMs) (e.g., Visual Analogue Scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale-8 [SSS-8]), and postoperative outcomes were recorded. Results: The PCS total score and its subscores significantly correlated with each PROM. Higher PCS total score significantly correlated with worse VAS (p<.001), SF-12 mental (p=.007), PDI total (p<.001), and SSS-8 (p<.001). Only the PCS magnification subscore was significantly greater among the 41 patients who underwent surgery (p=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (p=.012), magnification (p=.006), helplessness (p=.008), and total (p=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (p=.005; p=.003; p=.006; p=.003). Conclusion: Significant correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI could be at risk for poor treatment outcomes. PCS scores could be used to tailor treatments for such high-risk patients.

Introduction: In varus-type osteoarthritis of the ankle (VAOA), it is known that the subtalar joint compensates in valgus/eversion for the malalignment of the tibiotalar joint. Previous studies were mainly based on X-ray measurements and peritalar changes that extend to the subtalar and Chopart joints when tibiotalar arthrodesis is performed is still unclear. Distance Mapping (DM) can produce a 3D point-to-point distance map of joint interactions from cone beam weight bearing CT (WBCT) images. The purpose of this study was to quantify the peritalar changes occuring when the tibiotalar joint is fused. Methods: We included 14 patients (15 feet) who underwent arthrodesis for VAOA. The average postoperative follow-up period was 6.6 months. Foot alignment (Foot Ankle Offset (FAO)) was measured from WBCT datasets pre and postoperatively. The pre to post op shift vectors of the weighted distance maps center points were measured for the tibiotalar, subtalar, calcaneocuboid and talonavicular joints. Results: FAO improved significantly from preoperative (-12.9±7.4 %) to postoperative (-6.4±3.9 %). The DM vectors were 4.9±2.8 mm (lateral direction) for the tibiotalar joint; 0.86±0.93 mm (posterior) and 0.77±1.26 mm (medial) for the subtalar joint; and 2.85±1.74mm (medial) and 3.78±2.26mm (plantar) for the talonavicular joint. Discussion: The main finding was that foot alignment was improved following tibiotalar arthrodesis with peritalar compensation, more so in the talonavicular than in the subtalar joint and not in the calcaneocuboid joint. Our results suggest that flexibility of the talonavicular joint may be necessary when arthrodesis is performed on VAOA to contribute to the alignment correction.

Aim: . The aim of this study is to evaluate the functional outcome of AMIC procedures in patients who have been diagnosed with osteochondral injury of the Talus. Materials and methods: 25 patients were identified . Surgical interventions included ankle arthroscopy, micro fracture, bone grafting to fill out defects, and open AMIC was carried out using chondroguide and fibrin glue according to the Geistlich technique. Any associated lateral ligament instability was treated simultaneously with a Modified Bostrom Gould procedure. Functional outcomes were evaluated using pre and post operative AOFAS and VAS scores. Pre-operative MRI scans and x rays were also performed. I Results: This study included 14 males and 11 female patients who had surgery between January 2015 and March 2019. The average age of the patient at operation was 37 y years . There were 10 medial lesions and 14 lateral lesions. T. Average follow up was 24 months. The mean pre op AOFAS score was 34.68 with a range of 26-40, with a post operative mean score of 84.08 with a range from 63-94. The average pre and post op VAS scores were 8 and 3, respectively. . The mean difference was found to be statistically significant with a mean difference of 45.32 in preoperative and post operative scores(p<0.05). The correlation between size of lesion and postoperative outcome w was found to have mild negative correlation. Conclusion: Medium term results have shown encouraging results from open AMIC procedures for the treatment of osteochondral lesions of the talus.

Objective: To assess the results of using short harvest flexor hallucis longus tendon transfer with bio-tenodesis screw fixation in treatment of chronic Achilles tendon ruptures. Methods: A retrospective analysis of 32 patients (n=32) was done at University Hospital of North Tees and Hartlepool NHS trust . The patients included were those who had a preoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and were treated with a single incision. short harvest flexor hallucis tendon graft for a chronic tendo achilles rupture, a biotenodesis screw (PEEK screw) was used in fixation. Each patient was contacted and a post operative AOFAS score was done at various stages of their recovery and the results were compared to their pre op status. Results:There were more males (n=23) than females (n=9) involved in the analysis. The mean duration from injury to presentation was 14.87 weeks, the gap size between the ruptured ends was > 5 cm A mean follow up period of 31 months period showed improvement in AOFAS scores, The statistical analysis was done using the Wilcoxon Signed Ranked Test and the results were significant (p<.001). It was a Level 3 Study. Conclusion: Transfer of FHL to the calcaneum with a bio-tenodesis screw for the treatment of chronic Achilles tendon ruptures allows correct tensioning and secure fixation. The procedure has low morbidity and good functional results. The majority of patients were able to return to daily working activities with minimal restrictions. Making it the gold standard treatment for this condition.

Background: Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. The purpose is to evaluate cost and efficiency differences in ankle fracture open reduction and internal fixation (ORIF) at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective study was performed at an academic medical center, involving four orthopaedic surgeons (ASC=5, hospital=5). Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. Retrospective cost data was obtained from 181 surgical cases using our institution’s existing cost accounting system (ASC=34, hospital=147). Results: Total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p<.001), pharmacy (ASC=$112.18, hospital=$349.74; p<.001), radiology (ASC=$17.67, hospital=$227.98; p<.001), and therapy (ASC=$28.23, hospital=$130.91; p<.001). Medical supply costs were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p<.001). Preoperatively, nurse assessment (ASC=14.65 min, hospital=5.10 min; p=.030) and patient transport to the operating room (ASC=1.20 min, hospital=2.60 min; p=.014) significantly differed. Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), although there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Direct costs appear to be lower at the ASC for ankle fracture ORIF, although efficiency of care delivery seems similar between locations. Improvement could be obtained in the preoperative nurse assessment and regional nerve block administration.

Treatment of isolated congenital pseudarthrosis of the fibula (ICPF) is challenging due to recalcitrant non-union and no consensus about the best treatment plan exists. We report a case of isolated congenital fibular pseudarthrosis with valgus deformity of the ankle. A 11-year-old girl presented with pain and valgus deformity of the left ankle. The patient had already undergone two failed plate-screw fibular osteosynthesis. Radiographs revealed pseudarthrosis at the distal third of the fibula with a normal tibia (ICPF type 3 of Dooley). Our surgical aim was to restore fibular length and obtain a stable tibiofibular relationship to prevent valgus instability of the ankle which was caused by fibular non-union and defect. The patient underwent proximal fibular osteotomy after excision of the pseudarthrosis. Schanz screws were then inserted to transfer the fibular segment through the unilateral external fixator. Distal schanz screws of the fixator were attached to the tibiofibular joint and tibiofibular fixation was achieved. External fixator was removed and weight-bearing was allowed at the end of 3rd month. Her latest follow-up radiographs at postoperative 6th month showed fusion across the tibiofibular syndesmosis and union at the ICPF area. Her foot was plantigrade, she could walk freely without any sign of ankle instability at first year follow-up. Knowing the failure risks and unsuccessful osteosynthesis history of our patient, we composed a new treatment modality, providing the combination of two different techniques, thus can increase the success rate and can provide stability even if one of the two components of the treatment fails.

Aim-MBG repair has limitation of strength of repairing rein jury.Internal brace augment the MBG repair.The aim of the study is to evaluate outcome of MBG repair with IB augmentation. Methods Retrospective analysis OF 72 patients with CLAI who underwent MBG with IB augmentation between Nov 2017 and Oct 2019. Patient were evaluated with VAS, MOXFQ questionarre, subjective satisfaction and return to pre injury activity. Results 61 patients were included in the study with mean age of 37.5+-14.7 years. The Follow up duration 12 mean 14.+- 8 months.Mean Post operative VAS score improved to 6.3+-1.1 from 1.7+-1.4, MOFXQ improved from 62.1 TO 18.2 , both of which were statistically significant. 90% patient return to pre injury activity with mean time of 12.5+-2.3 weeks. The patient satisfaction showed excellent to good outcome in 90%. Conclusion The present study found the use of IB brace for MBG repair in CLAI showed good to excellent functional outcomes and patient satisfaction.

Ankle sprains constitute almost 30% of the sports related injuries in the paediatric age group, commonly involving the anterior talo-fibular ligament (ATFL) and less frequently the calcaneo-fibular ligament (CFL). Most patients recover well conservatively, however, a small proportion require surgical reconstruction of the ATFL. The Modified Brostrom Gould (MBG) procedure with InternalBrace™ augmentation is well documented in literature for adult population but has not been published in the paediatric population. We present our small series of eight children with chronic ATFL injury, which failed conservative treatment and underwent MBG with InternalBrace™ augmentation. This was a retrospective, single centre study. The inclusion criteria were skeletally immature patients with persistent symptoms at 6 months following injury and failed conservative / physiotherapy treatment. Their average age was 15 (range 11-18) years; predominantly girls (6); time since injury 10 (6-27) months; follow up 21 (14-29) months. One patient had hypermobility; one had an associated syndesmotic injury (Stablised at the time of surgery), and one underwent an AMIC procedure. The Visual Analogue Scale (VAS) for pain improved from 8 to 1; MOxFQ scores improved from 64 to 7. Seven out of the eight patients returned to their normal sporting activities at the final follow-up. One patient still felt instability at 17-month follow-up. Overall MBG with InternalBrace™ augmentation is an excellent procedure for chronic ankle injuries in the paediatric population as it allows patients to mobilise early and takes into account the hyperlaxity that is concurrent in this age group specially in girls and athletic group.

Equinus foot deformity is a very common pathology affecting the gait of patients with cerebral palsy. Operative correction is the therapy of choice to treat a fixed pes equinus. However, which surgical method should be preferred is still a topic of debate. The option to do lengthening on different levels of the M. triceps surae results in different postoperative outcomes. The purpose of this study is to determine whether surgical pes equinus correction results in a measurable loss of strength, and if there are differences depending on the surgical procedure. This study is a retrospective analysis of patients with CP who received instrumental 3D gait analysis before and after surgical pes equinus correction. Patients were divided into 3 operation groups: Strayer surgery, Baumann surgery, and Achilles tendon lengthening. Data from adults, adolescents, and children were included. A total population of 228 patients with 369 operated legs was analyzed. To compare the surgical interventions, an analysis of covariance (ANOVA) was used. Dorsiflexion in swing and stance phases significantly improved in all groups postoperatively. The Strayer and the Achilles tendon lengthening group showed higher postoperative dorsiflexion than the Baumann group. However, no loss of strength is to be expected with the Baumann method. Maximum power improves in this group postoperatively. There´s a 8% loss of calf muscle strength in the Strayer group. In Conclusion there are differences in postoperative results in ROM and Power regarding the operative techniques. Strayer surgery is not recommended due to loss of calf muscle strength.

Pes equinus is a common deformity in cerebral palsy (CP) patients. There is widespread agreement on how to treat equinus foot deformity, but there is a clear lack of consensus in the literature on how to properly identify and diagnose equinus foot in CP. Therefore, we performed this study to evaluate functional gait analysis changes in different dorsiflexion groups (0°, 5°, 10°, and 15°) and in two subgroups of CP patients (unilateral and bilateral). This retrospective study included CP patients with varying degrees of dorsiflexion that were clinically measured. We further subdivided patients into unilaterally and bilaterally affected individuals and also included a healthy control group. All participants underwent 3D gait analysis. Our goal was to determine the degree of dorsiflexion where the changes in range of motion (ROM) and ankle moment and power during gait were most evident. Then, a subgroup analysis was performed according to the affected side. We analyzed 71 and 84 limbs in unilaterally and bilaterally affected subgroups. Results show that patients with clinically 0° dorsiflexion barely reached plantigrade position in 3D gait analysis. Differences in ROM were observed between subgroups. Ankle moment was quite similar between different subgroups but to a lower extent in the unilateral group. All CP patients had reduced ankle power compared to controls. Overall, this study indicates that the cutoff value for defining functionally relevant equinus foot in CP patients is 5° dorsiflexion.

Introduction Syndesmotic injury can occur isolated or in conjunction with ankle fractures. Generally, it follows a mechanism of pronation and external rotation. The incidence in the context of sprains or ankle fractures is easily misdiagnosed or under-reduced. There is little literature about chronic syndesmotic injuries, so much controversy about its treatment. Material and methods From 2012 to 2015 we treated 8 patients with ankle fractures with chronic involvement of syndesmosis. We reviewed the following items: initial lesion, right diagnosis, initial treatment, time of transindesmal screw removal, and type of subsequent surgeries. We performed clinical-radiological controls and we used the AOFAS test and the Manchester-Oxford test to assess the outcomes. Results 2 of the patients were diagnosed and treated correctly but the treatment failed, either by insufficient synthesis or by early withdrawal. The other 6 patients were not diagnosed so the treatment was insufficient (conservative or the syndesmosis was not synthesized during surgery). We had to reoperate twice most of the patients not treated initially, while only one surgery was needed in the patients who had the syndesmosis treated at the beginning. The AOFAS average was higher than 80 points at 25,3 months follow up and satisfaction was good and excellent in most of the patients. The Manchester-Oxford index was 14,06 at 82,6 months of follow up. CONCLUSIONS Our clinical results are good despite delayed treatment and reoperations. Literature recommends treatment of all the chronic syndesmotic injuries, including when osteoarthritis is present, except when there is severe affectation of the function.

Background: Needle arthroscopy – performed with a nanoscope [Arthrex, Naples, FL] – has recently been introduced as an alternative to traditional arthroscopy. This study aims to use time-driven activity-based costing (TD-ABC) to compare the single-use nanoscope to the reusable 2.7-millimeter small joint arthroscope in performing ankle arthroscopy. Methods: Prospectively, 29 arthroscopy procedures with one of two fellowship-trained foot and ankle surgeons at an academic medical center were hand-timed (arthroscope=12, nanoscope=17). Using TD-ABC, we calculated procedure costs with each device. Costs of reprocessing reusable equipment ($128.78/use), operating room (OR) cost per minute ($36.14/min), sterile processing ($0.47/item), department and OR labor ($1.67/min), and maintenance ($96.00/use) were gathered from literature values and facility accounting systems. Results: Equipment opening (arthroscope=13.47min, nanoscope=5.59min; p=.021), incision to joint space (arthroscope=1.95min, nanoscope=1.00min; p=.002), and total intraoperative (arthroscope=15.99min, nanoscope=9.91min; p=.037) times were significantly different between devices. OR turnover time did not differ (arthroscope=34.14min, nanoscope=29.05min; p=.292). There was no difference in total cost between scopes regarding the costs of purchase and refurbishment, sterile reprocessing, OR turnover, and device setup, though standard arthroscope use was more costly (arthroscope=$1,906.68, nanoscope=$1,894.92; p=.945). Excluding OR turnover time, however, the total cost of the reusable arthroscope was $678.75, as compared to $845.10 for the nanoscope (p<.001). With the exclusion of OR turnover cost, the overall nanoscope procedure was less costly when the scope purchase price was less than $486.65. Conclusion: Ankle arthroscopy utilizing a traditional arthroscope is 0.62% more expensive than with the nanoscope and takes significantly longer to set up.

Background: Joint arthrodesis can be more challenging in smokers, as it can increase their risk of complication. This study aims to determine which complications, if any, are associated with tobacco use in patients undergoing ankle or hindfoot arthrodesis. Methods: Using the National Surgery Quality Improvement Program (NSQIP) database, we identified 1135 adult patients undergoing ankle (n=385), pantalar (n=43), triple (n=246), or subtalar (n=569) fusion between 2005 and 2020. Subjects were classified as nonsmokers (n=942) or smokers within one year prior to surgery (n=193). Demographics, medical comorbidities, and 30-day complication (e.g., wound breakdown, surgical site infection), readmission, and reoperation rates were compared between groups. The cohort was predominantly male (50.2%) and white (87.9%), with a mean age of 56.23 (range 18-89) years. Results: Of demographics and medical comorbidities, only age significantly differed between groups (smoking=49.57 years, nonsmoking=57.59 years; p<.001). The cohort smoked, on average, 7.37 (range, 0-90) pack years. Pack years for the smoking and nonsmoking groups were 20.85 and 3.65, respectively (p<.001). 30-day complication (smoking=6.7%, nonsmoking=5.4%; p=.549), readmission (smoking=5.5%, nonsmoking=3.3%; p=.173), and reoperation (smoking=3.1%, nonsmoking=2.0%; p=.346) rates did not differ between groups. Conclusion: Our study found that patients who smoke within one year of surgery are not at increased risk of complication in the first 30 days following ankle or hindfoot fusion, as compared to nonsmokers. This finding is unexpected as smoking has often proven to adversely affect surgical outcomes. However, studies with follow-up beyond 30 days are needed to compare union rates and patient satisfaction between smokers and nonsmokers.

Background: Malnutrition, or hypoalbuminemia, is defined as a serum albumin level less than 3.5 g/dL. This study aims to investigate the effect of hypoalbuminemia on the rates of complication, readmission, reoperation, and mortality following total ankle arthroplasty (TAA). Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007-2019 to identify 831 TAA patients (low albumin=48, normal albumin=783). Demographics, medical comorbidities, concomitant procedures, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. Common concomitant procedures included gastrocnemius release (20.4%), Achilles tendon lengthening or shortening (15.6%), and calcaneal osteotomy (5.4%). The cohort was predominantly male (50.8%) and mean age was 63.6 (range, 20-87) years. Results: The groups were demographically similar. Hypoalbuminemia patients were significantly more likely to have insulin-dependent diabetes (low=10.9%, normal=2.4%; p=.008) and use steroids for a chronic condition (low=21.7%, normal=6.5%; p<.001). LOS was significantly greater among the low albumin group (low=2.42 days, normal=1.84 days; p=.038). The hypoalbuminemia cohort was also found to have significantly shorter operative times (low=141.6 minutes, normal=165.7 minutes; p=.006). Complication (low=0.0%, normal=3.7%; p=.175), readmission (low=2.2%, normal=2.6%; p=.877), and reoperation (low=2.1%, normal=0.9%; p=.413) rates did not differ between groups. Conclusion: The results of this study show that malnourished patients are not at an increased risk for 30-day complication, readmission, or reoperation following TAA, despite having a worse preoperative comorbidity profile. Further research should be conducted with longer follow-up periods to analyze long-term TAA outcomes in malnourished patients.

INTRODUCTION:Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. METHODS:A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI . All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. RESULTS: A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion:Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair.

Background There is no consensus on the angle targeted for in varus ankle deformity after supramalleolar osteotomy (SMOT). The aim of this study was to investigate which obtained correction has the best clinical outcome after valgus SMOT. Methods A systematic review was conducted according to PRISMA guidelines with studies being eligible for inclusion when described symptomatic varus ankle osteoarthritis, using any valgus SMOT technique, describing radiological alignment and clinical outcome at baseline and after at least 12 months follow-up. Risk of bias was assessed using the McMaster University Occupational Therapy Evidence-Based Practice Research Group quality assessment tool. The electronical databases PubMed, EMBASE and Cinahl were used as data sources. Included cohorts were categorized according to the mean obtained medial distal tibia angle (MDTA; ranged between 87° and 100°). A linear mixed effect model was used for individual patient data to assess the association between the MDTA and the (difference in) clinical outcome. Results Thirty studies including 33 patient cohorts with 922 ankles were identified. At a mean follow-up of 4 years no differences in clinical outcome between 5 correction categories (valgus (over)correction; neutral; varus (over)correction) were found. Individual data of 34 ankles showed no relationship between obtained MDTA and clinical outcome either. Conclusion This review could not demonstrate an optimal degree of MDTA correction after valgus SMOT. Results were hampered by several limitations in data, biased low quality studies and highlights the widespread use of unreliable 2D radiological alignment measures such as the MDTA.

The modified Broström procedure (MBP) is an initial treatment for symptomatic chronic ankle instability (CAI) patients. This study aimed to compare the proprioception and neuromuscular control ability of both affected and unaffected ankles at the time of return to sports after MBP for patients with scores of normal controls. 75 individuals (40 who underwent MBP, 35 normal controls) participated. The dynamic balance test scores were significantly higher in the affected ankle of the patients than in the controls (1.5 ± 0.6° vs. 1.1 ± 0.4°, p < 0.003). The time to peak torque for dorsiflexion (60.8 ± 13.9 ms vs. 52.2 ± 17.5 ms, p < 0.022) and eversion (68.9 ± 19.1 ms vs. 59.3 ± 21.1 ms, p < 0.043) was significantly delayed in the affected ankle of the patients than in the controls. The dynamic balance test and time to peak torque in CAI patients remained significantly reduced at the time of return-to-sport after MBP. Clinicians and therapists should be aware of potential deficits in proprioception and neuromuscular control when determining the timing of return to sports after MBP.

We aimed to analyze the differences in static (including conventional and modified [single-leg heelraise balance]) and dynamic postural stability and muscle endurance between patients with chronic ankle instability (CAI) and healthy controls, and to determine the reliability and usefulness of the single-leg heel-raise balance test in patients with CAI. In total, 26 patients with CAI and 26 healthy controls were enrolled. Postural stability was assessed using a postural stabilometry system. Muscle endurance was measured in dorsiflexion and plantarflexion using an isokinetic device. Modified static postural stability (P < 0.001) and dynamic postural stability (P < 0.001) were significantly poorer in the affected ankles of patients with CAI than in the controls. Plantarflexion endurance was significantly lower in the affected ankles of the patients with CAI than in the controls (P = 0.023). Modified static postural stability significantly correlated with plantarflexion endurance in both groups (CAI group: r = − 0.470, P = 0.015; healthy controls group: r = − 0.413, P = 0.036). Plantarflexion endurance was a significant risk factor for modified static postural stability in both the CAI group (R2 = 0.221, P = 0.015) and healthy controls (R2 = 0.170, P = 0.036). Given the reliability of the modified static postural stability test, clinicians and therapists should consider using it to assess improvements in postural stability and muscle endurance in patients with CAI before and after rehabilitation.

Background: The aim of this study was to compare the strength and reaction time of the quadriceps, hamstring, and GCM muscles and foot pressure between patients with PF and normal controls. Methods: A total of 21 PF patients and 21 normal controls were enrolled. Muscle strength was measured by the peak torque per body weight. Muscle reaction time was evaluated by the acceleration time (AT). Foot pressure and posture were assessed by pedobarography. Results: The strength of the quadriceps was significantly lower in the affected ankles of the PF group than in the control group (p=0.005). The AT of the quadriceps and hamstring muscles was significantly increased in the affected ankles of the PF group than in the control group (quadriceps: p=0.012, hamstring: p=0.001), while the AT of the GCM muscle was significantly decreased (p=0.009) and significantly correlated negatively with quadriceps muscle strength (r=−.598, p=0.004) and AT (r=−.472, p=0.031). Forefoot (p=0.001) and hindfoot (p=0.000) pressure were significantly greater, with the VV index showing hindfoot valgus, in the affected ankles in the PF group compared to the control group (p=0.039). Conclusions: This study demonstrated weakness and delayed reaction time of the quadriceps and hamstring muscles, with a rapid reaction time of the GCM muscle, in patients with PF. Clinical relevance: Clinicians and therapists should assess the function of the quadriceps and hamstring muscles when planning the management of PF patients without muscle tightness.

In foot and ankle pathology, evaluation with conventional radiological imaging may be diagnostically inconclusive, as structural changes can appear non-specific or inconspicuous. This is a particular issue in the context of previous injury or ankle surgery, where there are additional alterations to the complex anatomy and biomechanics. Single-photon emission computed tomography (SPECT) is a nuclear imaging technique that produces a 3D representation of physiological activity. Combined with the anatomical imaging of CT, hybrid SPECT/CT promises improved diagnostic value. A previous review suggests that ankle SPECT/CT improves diagnosis (48-62%), can lead to a change in management (40-79%), and the majority of patients demonstrate a symptomatic improvement following treatment based on SPECT/CT (92%) Adult patients who underwent SPECT/CT scanning in one centre from 2017-2021 were identified retrospectively. 125 patients were identified (mean age 57.6, 45.6% female). 12% and 14% had had a non-diagnostic CT and MRI in the previous 12 months respectively. In 77.6% of patients, SPECT was of diagnostic benefit. 50 patients underwent SPECT for arthroplasty-related reasons. Of those, 64% were for assessment of loosening (50% positive); 6% were for assessment of infection (33% positive). 42% showed other pathology, and 24% showed no cause for the symptoms. SPECT was deemed to have been of diagnostic benefit in 86% of these patients. The findings of this report support the current literature regarding the use of SPECT for evaluation of ankle pain. In particular in the context of total ankle arthroplasty, SPECT was deemed to have been of benefit in 86% of cases.

The treatment of end-stage ankle osteoarthritis (OA) and associated hindfoot deformities remains a major challenge for the orthopedic surgeon. Numerous techniques and surgical approaches are proposed for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis, from arthroscopic to open, as well as numerous devices proposed for the internal fixation (retrograde intramedullary nail, cannulated screws, plates and screws). The aim of this study was to retrospectively analyze the preliminary results at 18 months with a new Ankle Fusion Plating System in a group of 20 patients with severe OA and deformities (mainly post-traumatic OA, rheumatoid arthritis and failure of previous ankle arthroplasty). Demographic characteristics and past medical history of the patients were collected and analyzed to identify the cause of the pathology. The degree of OA and deformity were quantified based on an X-ray of the foot and ankle in 2 projections in orthostatic position and CT examination. Pre- and postoperatively at 3, 6 and 12 months, clinical-functional scores (AOFAS, SF-36, VAS, ROM and FFI) and radiographic parameters (anterior distal tibial angle, calcaneal moment arm, medial distal tibial angle) were evaluated. All patients showed clinical and radiographic fusion at an average of 12 weeks (range 10-18), with improvement in pain and functional scores, without major surgical complications and/or infections. Despite the limitations of our study, the results with this new set of plates showed good results in terms of bone consolidation, post-operative complications, improvement of pain and quality of life in patients with severe OA and deformities of the ankle and hindfoot.

Peroneal intrasheath instability is a painful popping sensation and audible clicking of the lateral ankle. This condition is not commonly reported, and its exact incidence remains unknown. Consists of a transient retromalleolar subluxation of the peroneal tendons, with an abnormal motion of the peroneal tendons relative to each other, with the superior peroneal retinaculum intact. Diagnosis requires high clinical suspicion given that on a physical examination there is no dislocation over the lateral malleolus of the peroneal tendons. Static studies such as resonance magnetic imaging can often be reported as normal. Dynamic ultrasound is the best imaging study to evaluate peroneal instability when the superior peroneal retinaculum is intact, for diagnosing peroneal intrasheath instability. The goal of this study is to evaluate and describe how to reach the diagnosis and the surgical technique for the treatment of this pathology, where peroneal groove-deepening procedure and retinaculoplasty of the superior retinaculum are performed. The retinaculoplasty comprises the formation of two flaps - the proximal flap was placed between the two peroneal tendons, preventing intrasheath dislocation; the distal flap was placed in a native location, superficial to the peroneal tendons to prevent dislocation of the tendons over the lateral malleolus. In this report, we describe a three cases of theses pathology. One received conservative treatment and two received successful surgical treatment with the technique mentioned above. At the end of the surgical procedure, were checked for congruence, mobility and complete stability of the peroneal tendons.

Background: The purpose of this study was to assess total blood loss after total ankle arthroplasty (TAA) and to identify correlated factors. Methods: A total of 103 cases (99 patients) of TAA for end-stage ankle osteoarthritis were enrolled in this study. Perioperative total blood loss was divided into intraoperative and postoperative blood loss. The patient-related variables evaluated for total blood loss were age, sex, body mass index (BMI), American Society of Anesthesiologists Classification score, comorbidities, history of previous ankle surgery, preoperative use of anticoagulants, platelet count and prothrombin time/international normalized ratio. Operation-related variables including type of anesthesia, operation time, TAA implant, and procedures performed in addition to TAA (if any) were evaluated to analyze correlations with total blood loss. In addition, the rate of transfusions after surgery was identified, and risk factors for transfusion were statistically analyzed. Results: The total blood loss was mean 795.5 ± 351.1mL, which included 462.2 ± 248.5mL of intraoperative blood loss and 333.2 ± 228.6mL of postoperative blood loss. Sex, TAA implant, and additional bony procedures performed along with TAA were significantly correlated with total blood loss, but the other variables were not significant. Transfusions were administered for 4 cases (3.8%) but no risk factors for transfusion could be identified. Conclusion: This study demonstrated that male sex, use of TAA implants with a larger cutting surface, and bony procedures performed in addition to TAA were associated with an increase in total blood loss after TAA.

Supramalleolar osteotomy (SMO) is an effective treatment for intermediate-stage varus ankle osteoarthritis (OA). This study aimed to investigate how clinical outcomes were associated with radiological changes and cartilage regeneration shown on arthroscopy before and after SMO in patients with intermediate-stage varus ankle OA. Twenty-six cases with intermediate-stage varus ankle OA underwent SMO with at least 1 year of postoperative follow-up. Clinical assessment was performed preoperatively and postoperatively using the visual analog scale (VAS), American Orthopedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, and their associations with postoperative changes in tibial ankle surface angle (TAS), talar tilt, tibial lateral surface angle, and heel alignment ratio. The degrees of cartilage regeneration in the tibia plafond and talar dome were observed via second-look arthroscopy. Afterward, their associations with the corresponding clinical outcomes were analyzed. There were significant changes in the TAS, talar tilt, and heel alignment ratio (p < .001, for all). However, there were no significant changes in the tibial lateral surface angle (p = .864) at the final follow-up compared to its preoperative value. Postoperative changes in TAS (p = .013) and the degree of cartilage regeneration (p = .028) in the talar dome significantly influenced the final follow-up AOFAS score. Changes in the TAS angle and the degree of cartilage regeneration after SMO were predictors of clinical outcomes after SMO. In particular, greater changes in the TAS angle corresponded to better clinical outcomes.

This study sought to confirm that compared to the traditional open Broström-Gould repair, the arthroscopic all-inside Broström-Gould repair of chronic ankle instability (CAI) would produce comparable radiological and clinical outcomes in high-demand patients. This retrospective study included high-demand patients, as determined by a pre-injury Tegner Activity Scale (TAS) score ≥6, who underwent arthroscopic or open Broström-Gould repair and were followed up for ≥2 years. Patients were divided into the arthroscopic all-inside Broström-Gould repair group (AS Group) and open Broström-Gould repair group (Open Group). Perioperative radiological assessments were performed. The TASs, Foot and Ankle Outcome Scores (FAOSs), Karlsson and Peterson (K-P) scores, and American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores were evaluated clinically. A total of 65 cases (31 from AS Group and 34 from Open Group) were included in the study. There were no differences in age, sex, body mass index, pre-operative anterior talar translation, talar tilt, signal-to-noise ratio, FAOS, K-P score, or AOFAS score between the two groups. The preinjury median TAS was 7 ± 0.6 and unchanged at final follow-up in both groups. Postoperative stress radiographs showed improvement but the groups did not differ significantly. The FAOS, K-P score, and AOFAS scores improved in each group. However, clinical scores did not differ between the two groups. Both traditional open Broström-Gould repair and arthroscopic all-inside Broström-Gould repair, for CAI in high-demand patients, yielded comparable radiological and clinical outcomes. Clinically, arthroscopic all-inside Broström-Gould repair may represent a viable surgical alternative to open Broström-Gould repair for high demand patients.

Introduction: Recently, it is expected that the progression of ankle osteoarthritis (OA) could be predicted through quantitative evaluation with weight-bearing computed tomography (WBCT). This study aimed to assess the change of tibiotalar joint space with the progression of varus ankle OA using the distance mapping analysis from three-dimensional (3D) bone reconstruction of WBCT. Methods: A total of 133 of ankles were divided into 3 groups according to the modified Takakura classification. The 3D models were produced from the WBCT and distance maps representing joint surface configuration were generated for the tibiotalar joint. Results: There was a significant decrease in surface-to-surface distance at the anterior half of the medial gutter and the anteromedial corner of the talar dome in the moderate OA group compared to the control group. Also, a significant decreases of the surface-to-surface distance were founded at the medial and central portion of the talar dome both anteriorly and posteriorly in the severe OA group compared to the control group. There was no significant difference in distance at the posterior half of the medial gutter and the lateral portion of the talar dome between any groups. Conclusions: The joint space of ankle under distance mapping analysis on WBCT scans showed decrease with the progression of ankle arthritis. Especially, the cartilage wear in the anteromedial part of ankle joint seems to be pronounced on early stage. The cartilage wear in the center of ankle joint occurred severely regardless of anterior or posterior aspects of ankle joint on late stage.

Introduction In treatment of ankle arthritis, varus deformity is an important factor in determining supramalleolar osteotomy(SMO), arthroplasty, and ankle fusion. However, there is a question whether varus deformity is constant anterior to posterior. Therefore, 3D morphological analysis of tibia plafond was done to study the main form of varus deformity. Methods Retrospective review was performed on 21patients with talar tilt angle higher than 7degrees and takakura stageII, IIIa. We analyzed weight-bearing AP radiograph and weight-bearing CT. In x-ray, angle between plafond and medial gutter was measured. In CT sagittal, angle of tibial articular surface was measured at medial and lateral side. We defined difference of the angles(medial, lateral) more than 9degrees as type A. In axial CT, angle of internal surface of medial malleolus to tibia plafond axis was measured and we defined type B more than 106degrees. Tibia plafond was divided into 144points(9compartments) and height was analyzed. Results 12patients(57%) were type A those deformity was concentrated on anteromedial side. 11patients(52%) were type B those deformity focused on medial malleolus. 7patients(33%) were both type A,B and 5patients(24%) neither type A nor B. In addition, results by dividing plafond into 9compartments showed anteromedial compartment was weared 2.3mm more than posteromedial compartment. Conclusion Deformity of plafond is not symmetrical in antero-posterior, mainly concentrated on anterior side. If SMO is performed in the medial central region in type A varus, results might be poor. It would be necessary to analyze the type of varus deformity and determine the osteotomy site correctly when SMO

Background: Arthroscopic microfracture for osteochondral lesions of the talus (OLT) has shown good functional outcomes. However, some studies have reported that functional outcomes deteriorate over time after surgery. Purpose: To use various functional scoring systems to evaluate functional outcomes in a large sample of patients with OLT treated by arthroscopic microfracture. Methods: The study cohort consisted of 165 ankles that underwent arthroscopic microfracture for small to midsized OLT. The mean lesion size was 73 mm^2 (range, 17-146 mm^2), and the mean follow-up period was 6.7 years (2.0- 13.6 years). TThe Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, visual analog scale (VAS) for pain, and 36-Item Short Form Health Survey (SF-36) were used to compare the functional outcomes between the preoperative and final follow-up assessments. Results: The mean FAOS significantly improved in regard to all subscores. The AOFAS ankle-hindfoot scale showed an improvement from 71.0 points preoperatively to 89.5 points at the final follow-up. The VAS score showed an improvement from 6.2 points preoperatively to 1.7 points at the final follow-up. The mean SF-36 score improved from 62.4 points preoperatively to 76.2 points at the final follow-up (P<.001). 22 ankles (13.3%) underwent repeat arthroscopic surgery for evaluation of repaired cartilage status. Conclusion: Arthroscopic microfracture showed good functional outcomes and improved quality of life with maintenance of satisfactory outcomes at a mean follow-up of 6.7 years. Therefore, arthroscopic microfracture seems to be reliable as a first-line treatment for OLT at an intermediate-term follow-up.

Objective: to utilize a 3D Weightbeating-CT distance-mapping algorithm to objectively assess syndesmotic position in a cadaveric model simulating different patterns of syndesmotic malreduction. Methods: Four-below-knee Specimens underwent sequential WBCT-imaging in four different conditions: native normal ankle, syndesmotic instability, malreduced, and released conditions. Implant utilized allowed initial rigid screw-type-fixation. WBCT-images were segmented, and syndesmotic incisura and gutter distances were assessed using a 3D distance-map algorithm. The syndesmotic position was compared between normal, unstable, malreduced, and released positions. Results: When comparing normal to unstable condition, we observed significant widening of the syndesmotic posterior aspect (p=0.004). Overall, all four malreduced positions lead to significantly decreased tibiofibular distances when compared to the unstable state, consistent with syndesmotic over-compression (p=0.01), particularly in the posterior aspect of the joint (p=0.04). This over-compression was also more pronounced in the anterior displacement (31.5%) and internal rotation malreductions (23.1%). In the released flexible position we found a non-significant trend towards widening of the tibiofibular distances (p=0.08) when compared to the malreduced conditions, indicating partial restoration the syndesmotic relationship. Compared to normal, the lateral gutter demonstrated significant widening in the unstable condition (p=0.02), narrowing in the malreduced state (p=0.04), and widening in the released position (p=0.002). Conclusion: We observed significant widening when the syndesmotic ligaments were sectioned, followed by significant tibiofibular narrowing in the malreduced and fixed rigid states. When the implant fixation was released, we observed a trend towards restoration of normal syndesmotic alignment, with relative widening that was however not significantly different from the malreduced rigidly fixed state.

Bone marrow derived cell transplantation (BMDCT) technique basing on bone marrow aspirate concentrate (BMAC) provided satisfactory results for treatment of osteochondral lesions of the talus (OLT). However, no studies evaluated the relationship between the therapeutic effect of this arthroscopic technique and the number of mononuclear cells (MNCs) in BMAC. Aim of this study was to investigate the impact of the number of cells in BMAC on the clinical outcome of a BMDCT in patients with OLTs. In 143 consecutive patients with OLTs (area >1.5 cm2) treated with BMDCT, BMAC was harvested from the posterior iliac crest and seeded onto a hyaluronic acid membrane. For 100 of these patients, 2 ml of bone marrow aspirate (BMA) and 2 ml of BMAC was collected and used for MNCs count. A statistical analysis was performed to investigate the influence of the number of MNCs on clinical outcomes. Mean AOFAS score improved from 58.3 ± 13.4 preoperatively to 87.4 ± 15.9 at 60 months (p < 0.0005). BMA from the iliac crest contained a mean of 27.7 ± 8.9 x 103/μL MNCs and the BMAC contained 151.6 ± 56.4 x 103/μL MNCs. Higher number of MNCs both in BMA (p = 0.021) and in BMAC (p = 0.007) positively correlated with AOFAS score at 36 months of follow-up. BMDCT obtained satisfactory clinical results up to 60 months of follow-up in patients with OLTs. The number of MNCs in BMAC seems to positively influence the clinical outcome obtained with this procedure.

Introduction Step count and activity monitoring serve as a tools to measure improvement in functional ability in patients undergoing TAR. Activity monitoring using wearable sensors provide additional information on physical activity and energy expenditure in addition to step counts using a pedometer. The aim of this study was to study physical activity patterns in the real life environment in patients who underwent Total Ankle Replacement. Patients and Methods 10 patients who underwent a TAR (2017- 2019) included . Exclusion criteria refusal of consent, previous reconstructive surgery to foot, h/o infection, peripheral vascular disease, neurological disease and other joint replacements. patients were provided with ActivPAL TM activity monitor sensor to wear over a period of 7-days along with a self-reported diary to record the activity patterns. This assessment was carried out pre-operatively and 2 years post-operatively. Data from the sensors were downloaded and activity patterns were analysed. Results 10 patients (7 males, 3 females). Mean age of patients were 65.16 years . average 7-day period of activity monitoring, there was a trend for improvement in Sitting / Lying from 121.36 to 132.56 (p=0.367) and Standing 25.53 to 33.23 (p=0.411), this did not achieve statistical significance. Step count improved from 8.8 hrs to 10.8 hrs (p=0.05); from pre-op to 2 years. Energy expenditure (metabolic equivalents) improved from 192.3 to 219.5 (p=0.033). The improvement in step count and energy expenditure achieved statistical significance. Conclusion At 2 years post-operatively, TAR patients showed considerable improvement in step count and energy expenditure compared to pre-operative levels.

Objective To develop and describe computational methods to objectively quantify radiographic changes associated with ankle-OA apparent on low-dose WBCT-images. Methods We analyzed two patients with ankle-OA and one healthy-control that had all undergone WBCT of the foot-and-ankle. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification by plain-weight-bearing-radiographs. For each ankle, the subsequent analysis focused on a volume-of-interest (VOI) centered on the-tibiotalar-joint. Within the VOI, the initial-computational-analysis focused on measuring the-3D-joint-space-width (JSW). Subsequent analyses utilized WBCT-image intensity (Hounsfield Unit, or HU) profiles along lines perpendicular-to-the-subchondral-bone/cartilage interface of distal-tibia extending across the entire VOI. The HU-intensity-profiles were recorded, and graphical-plots of HU-distributions were generated for each-line. These plots were then used-to-calculate HU-contrast, a novel measure of the regional variation in bone-density. Results The average JSW was 3.89 mm for healthy-control-ankle, 2.69mm for mildly-arthritic-ankle (KL 2), and 1.57 mm for severely-arthritic-ankle (KL 4). The average HU-contrast was 72.31 for healthy-control-ankle, 62.69 for mildly-arthritic-ankle, and 33.98 for severely-arthritic-ankle. One projection in severely-arthritic-ankle had JSW and contrast values of 0 due to complete joint-space-loss along with projection 4, which corresponds in this case to the postero-lateral part of the joint. Conclusion We presented a novel computational assessment-of-ankle-osteoarthritis using low-dose WBCT-imaging. We were able to demonstrate differences between normal-ankles and ankles with mild-and-severe-OA using JSW and HU-contrast-measurements. This methodology represents an important step toward a more-reliable-OA-assessment when compared to the current standard qualitative evaluations, potentially serving as a starting-point for the development of a more robust osteoarthritis-staging-system.

Background: Next-generation DNA sequencing (NGS) technologies have made it possible to better characterize “normal” host flora. Using NGS, this study aims to determine whether a unique microbiome exists in human ankle tissues and whether components of the ankle microbiome impact patient outcomes. Methods: A prospective study recruited 33 patients undergoing total ankle arthroplasty (TAA, n=24) or ankle arthrodesis via an anterior approach (n=9) during 2020-2021 with one of two fellowship-trained foot and ankle surgeons at an academic medical center. During the operation, the surgeon would swab five layers of the ankle for analysis at MicroGen Diagnostics [Lubbock, TX, USA]: skin (n=33), retinaculum (n=32), tibialis anterior tendon (n=32), joint capsule (n=32), and distal tibia (n=33). Demographics, medical comorbidities, surgical indication, postoperative complications, and readmission and reoperation rates were collected from patient records. Results: Of the 162 swabs sent for NGS, 19 (11.7%) indicated 27 bacteria were present (positive). The most common organisms were Cutibacterium acnes (40.7%) and Staphylococcus epidermidis (11.1%). The most bacteria were found in the retinaculum (29.6%). No postoperative outcome was associated with the presence of bacteria, or the number of bacteria or affected layers. Similarly, complication, 90-day readmission, and reoperation rates did not differ if a subject’s NGS profile was positive or negative. Conclusion: This study found that C. acnes and S. epidermidis were most commonly found in the ankle microbiome. There is no evidence that patients presenting with these bacteria at the time of surgery are at a higher risk of failure following TAA or ankle arthrodesis.

Background: The triple hemi-section step cut percutaneous Achilles lengthening technique proposed by Hoke is the method most commonly used in treating mild Achilles contracture. The purpose of this cadaveric study was to introduce a 5-step (quintuple) percutaneous hemi-section technique and to evaluate the efficacy and safety of the quintuple compared to the triple cut technique. Methods: Ten matched pairs of above-knee specimens were randomly assigned to the triple and the quintuple hemi-section groups. The dorsiflexion angle, the tendon lengthening, the load needed to achieve the maximum ankle dorsiflexion and any rupture of the Achilles were measured with optical markers on a universal testing machine (Instron). Results: The quintuple procedure achieved more lengthening than the triple group, reflected in both the maximum dorsiflexion (16.58 vs 10.53 degrees) and lengthening of the tendon (34.41mm vs 11.36mm), with less load required to reach the maximum ankle dorsiflexion (222.9N vs 334.6N), and less number of Achilles rupture (0 vs 2). Conclusion: The quintuple lengthening is safe and has an increased capacity for tendon lengthening compared to the triple hemi-section technique. Excessive force on the foot attempting to gain more dorsiflexion using the triple cut technique can be avoided with the quintuple procedure in all cases, particularly when adequate dorsiflexion cannot be obtained.

Background: This study aims to determine the impact of preoperative opioid use on complication and reoperation rates among patients undergoing an ankle or hindfoot arthrodesis, or total ankle arthroplasty (TAA). Methods: We conducted a retrospective review of 223 patients undergoing an ankle or hindfoot arthrodesis (n=143), or TAA (n=80) during 2015-2020 with a single fellowship-trained foot and ankle surgeon at an academic medical center. Common arthrodeses included hindfoot (n=71), tibiotalar (n=35), and tibiotalocalcaneal (TTC) (n=25). Data collected included demographics, comorbidities, treatment history, surgical indication, follow-up duration, complications, fusion and reoperation rates, and patient-reported outcome measures (PROMs) (e.g., 12-Item Short-Form Survey [SF-12], Foot and Ankle Outcome Score [FAOS], Pain Disability Index [PDI], 8-Item Somatic Symptom Scale [SSS-8]). Defining opioid use as being prescribed any narcotic dosage, we classified 11 patients as preoperative opioid users. The average follow-up duration was 1.44 (range, 0.25-4.98) years. Results: Patients with preoperative opioid use were significantly more like to continue usage at 90 (r=0.893, p<.001) and 180 (r=0.913, p<.001) days following surgery. Postoperatively, preoperative opioid users had significantly more infections (user=18.18%, non-user=0.00%; p=.001), wound complications (user=27.27%, non-user=4.69%; p=.011), and reoperations (user=18.18%, non-user=3.13%; p=.040). When analyzing postoperative prescriptions, postoperative opioid at 90 days use was significantly associated with lower SF-12 Physical (r=-0.405, p=.049), FAOS Quality of Life (r=-0.391, p=.040), and FAOS Total (r=-0.423, p=.022) scores; and higher PDI Sexual Behavior (r=0.571, p=.013) and SSS-8 (r=0.648, p=.023) scores. Conclusion: Patients with preoperative opioid use are significantly more likely to continue postoperative opioid use, experience complications, and undergo reoperations.

Partial selective tibial neurotomy is mainly used in spastic equinovarus foot. This study analyzes baropodometric and clinical effects before and after complete tibial neurotomy, according to postoperative delays. In this longitudinal study, 23 patients undergone complete motor section of all three branches of the triceps surae. Postoperative effects were evaluated on clinical and baropodometric analysis measuring the trajectory of the center of pressure (antero-posterior displacement AP, lateral deviation LD, and posterior margin PM), compared before and after surgery between hemiparetic and healthy sides, and according to postoperative delays. After surgery (14.6 months), there were no side effects. All clinical parameters were improved. Mean satisfaction was 7.8 / 10. AP (11.8 cm to 14 cm, p = 0.0301) and PM (5.4 cm to 3.3 cm, p = 0.0041) were statistically improved on paretic side. PM was no longer statistically different between healthy and hemiparetic sides (2.8 cm to 3.3 cm, p = 0.5646). Differences in AP and PM deviations between healthy and hemiparetic sides existing before surgery (Delta AP and Delta PM) decreased as postoperative delay increased. Beyond 12 and 18 months, there was no longer difference on Delta AP (respectively 0.2 cm, p = 0.6221 and 1.1 cm, p = 0.6726) and Delta PM (0.6 cm, p = 0.5953 and 1.2 cm, p = 0.5597). This surgical technique allows clinical and instrumental improvements without complication, with good satisfaction beyond 12 months. Preoperative baropodometric differences between healthy and hemiparetic sides decrease after surgery with an improvement as the postoperative delay increases.

Introduction The most commonly used approach for posterior malleolar access is the posterolateral approach. This approach gives good access to the fibula and lateral aspect of the posterior tibia, however; there is little known on the vascular risks with this approach. Aim To assess the arterial anatomy and surrounding relations in the posterolateral approach to the ankle. Methodology Eleven cadaveric foot and ankle specimens were dissected in layers, preserving the peroneal artery, anterior (ATA) and posterior (PTA) tibial arteries. Their respective diameters, paths and anatomical relations were documented. Results The peroneal artery was consistently found between the peroneal and deep muscular compartments of the posterior leg. A wide range of anatomical variation was found in the arterial supply to the ankle; with five distinct variations found. A variable anterior perforating branch of the peroneal artery(36.36%), a superficially located peroneal artery(27.27%), a variable anastomosis between the peroneal artery and PTA(27.27%), a variable anastomosis between the ATA and peroneal artery(45.45%) and variation in the dorsalis pedis artery(36.36%). The mean proximal distance between the medial malleolus and the posterior communicating branch of the peroneal artery was 37.93mm(range:19.03-85.43mm). The mean proximal distance from the medial malleolus to the anterior peroneal perforating artery was 44.23mm(range:35.44-62.32mm). Conclusion Understanding the common variations within the ankle’s arterial anatomy can help surgeons protect these vessels from damage during the posterolateral surgical approach. The peroneal artery is immobile due to the anterior perforating artery and the communication with the PTA and should therefore be avoided during the posterolateral approach.

Introduction Fibular shortening with an intact anterior tibiofibular ligament (ATFL) and medial ligament instability causes lateral translation of the talus. Our hypothesis was that the interaction of the AITFL tubercle of the fibular with the tibial incisura would propagate lateral translation due to the size differential. Aim To assess what degree of fibular shortening would cause lateral translation of the talus. Methodology Twelve cadaveric ankle specimens were dissected, removing all soft tissue except for ligaments. They were fixed onto a specially-designed jig allowing tibial fixation and free movement of the talus. The fibula was progressively shortened in 5mm increments until complete ankle dislocation, measuring the medial clear space with each increment. Results The larger AITFL tubercle interaction with the smaller tibial incisura caused a significant increase in lateral translation of the talus. This occurred in most ankles between 5-10mm of fibular shortening. The medial clear space widened following 5mm of shortening in 5 specimens (mean=2.0725, SD=±2.5338). All 12 specimens experienced widening by 10mm fibular shortening (Mean=7.2133mm, SD=±2.2061, p<0.0001). All specimens reached complete dislocation by 35mm fibular shortening. Conclusion Shortening of the fibula causes significant lateral translation of the talus provided the ATFL remains intact. The interaction of the fibula notch with the ATFL tubercle appears to cause a disproportionate widening of the medial clear space due to its differential in size. Knowledge of the extent of fibular shortening can guide further intervention when presented with a patient experiencing medial clear space widening following treatment of an ankle fracture.

Objective To assess the capability of lateral trans-fibular approach TAR in correcting coronal-and-sagittal plane deformity and secondarily to report the ability to improve patient-reported-outcomes (PROs) following lateral TAR. Methods Retrospective-study included 14-patients that underwent lateral trans-fibular approach TAR for end-stage-AO. Average age and BMI were 63.9 years and 32.7 kg/m2. All patients had received pre-and-post-operative weight-bearing-CT-imaging on the affected foot-and-ankle. Foot-and-Ankle-Offset (FAO), Talar-Tilt-Angle(TTA), Hindfoot-Moment-Arm (HMA), and Lateral-Talar-Station(LTS) were performed. PROs were collected pre-and-post-operatively at the latest clinical follow-up including: PROMIS Global-Physical-Health-score, Tampa-Scale-of-Kinesiophobia(TSK), European-Foot-and-Ankle-Society (EFAS) score, Pain-Catastrophizing-Scale (PCS) and Foot-and-Ankle-Ability-Measure (FAAM). A multivariate regression analysis was then performed to evaluate the association between change in alignment and improvements of PROs. Results Three of 14 patients (21.4%) underwent a concomitant osseous re-alignment procedure. At an average of 16.1 months, all patients demonstrated a significant deformity correction in measurements performed: FAO (7.73% - 3.63%, p=0.031), HMA(10.93mm – 5.10mm, p=0.037), TTA (7.9o- 1.5o, p=0.003), and LTS (5.25mm - 2.83mm, p=0.018). Four of the PROsdemonstrated significant-improvement-postoperatively: TSK(42.7-34.5, p=0.012), PROMIS-Global-Physical-Health (46.1-54.5,p=0.011), EFAS (5-10.3, p=0.004), and FAAM (60.5-79.7,p=0.04). PROMIS was associated (p=0.0015) with optimization of FAO (p=0.00065) and LTS (p=0.00436), R2 of0.98). Improvements in TSK were associated with changes in the HMA(p=0.0074). Improvements in FAAM correlated(p=0.048) with improvements in FAO (p=0.023) and TTA(p=0.029). Conclusions The results suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. Clinical benefit was also demonstrated by the impacted PROs, particularly TSK, PROMIS-Global-Physical-Health, EFAS, and FAAM. Direct and strong-correlations between deformity correction measurements and significantly improved PROs were found.

Total ankle arthroplasty (TAA) is an increasingly popular treatment option for patients with end-stage ankle arthritis. The use of digital radiography and templating software in total ankle arthroplasty (TAA) continues to become more prevalent as the number of procedures performed increases every year. Recently, OrthoView (Jacksonville, FL) digital templating is frequently used in predicting the final implant size. The purpose of this study is to find out which imaging modality is the best choice to be used in OrthoView software. In this retrospective study, from December 2016 to March 2020, total 55 patient were obtained. They were all ankle arthritis patients and undergone primary Total ankle arthroplasty using Hintegra prosthesis by 2 different orthopediscs surgeon(foot and ankle specialists) in tertiary hospitals. Preoperative X-rays and computed tomography(CT) images were measured by OrthoView software, and the predictions were compared with the actual component sizes used for surgery. Gamma, Kappa analysis was used in this study. Accuracy between templating and final size varied by imaging modalities used in Orthoview software. In tibial component, CT coronal view 100% magnification image showed the most accurate result which was 0.921 the Kappa values for templating with the final size (P < .001). In templating talar component, X-ray AP view 115% magnification image was the most accurate as Kappa value 0.868 (P < .001). Surgeons should be aware that they need to choose adequate imaging modalities when templating tibial and talar component each in Orthoview software.

Total ankle replacement (TAR) is an emerging surgical option, with excellent clinical and functional results, which however is not always applicable, as in cases of severe bone loss. For such reason, research has been oriented towards innovative and customized solutions. Aim of this study is to present the preliminary results of a new custom made total talar ankle prosthesis (TTAP) with patient specific instrumentation (PSI). The new personalization process begins with a CT scan of the ankles. The images obtained from the CT scan are processed to create a 3D model of the joint based on the contralateral side, to obtain the most suitable prosthetic components for the patient's anatomy. PSI is then designed in order to fit patient's bone profiles. The final prosthetic models are printed for final checks and, once the planning is approved, they are sent to production along with the 3D printed prosthetic components. The prosthesis is then implanted using the PSI. Design, production and implantation of the TTAP were carried out in full compliance with the pre-operative planning. Post-operative radiographs showed good implant placement and alignment. The first 8 treated patients, at the mean follow-up of 9.2 months, showed good clinical and functional results in all the main prognostic scores (AOFAS, VAS, SF-36). A complete customization process for TTAP appears to provide good clinical and functional results, allowing movement preservation where it was once not possible. However, further studies are needed to confirm the real benefits of this innovative technique.

Background: Ankle arthroscopy is a common surgical procedure used for a variety of ankle pathologies. A thigh tourniquet is typically used and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. Thigh tourniquets have been linked with increased post-operative pain and complications in other lower limb orthopaedic surgeries. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy. Methods: A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2022 reporting on the use of tourniquet in ankle arthroscopy were included. Results: 180 studies were identified of which 3 (165 patients) met the inclusion criteria. All 3 studies evaluated the mean surgical time and complication rate. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Other secondary outcomes were not directly comparable between the studies. Overall quality of evidence was moderate to poor with limited data to support the routine use of tourniquet in ankle arthroscopy Conclusion: The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. There is limited data to support the routine use of tourniquet in ankle arthroscopy PROSPERO REGISTRY: CRD42021291347

Objective To evaluate the diagnostic-accuracy-of-WBCT area and volumetric-measurements in patients with-suspected chronic-Subtle-Syndesmotic-Instability-(SSI), when compared-to the gold-standard-arthroscopic-assessment. Methods Prospective-comparative-study, 11-patients with suspected SSI. Patients-were-assessed preoperatively by bilateral-standing-WBCT. WBCT-measurements-performed: semi-automatic DTFS area (1cm proximally-to-tibial-dome-apex); DTFS volumes (1, 3 and 5cm proximally-to-tibial-dome-apex). Subjects underwent-surgical-treatment including DTFS instability-arthroscopic-assessment. Confirmed unstable-cases were treated with open reduction/internal fixation. WBCT-measurements sensitivity, specificity, positive and negative predictive-values (PPV/NPV) and accuracy were-calculated using confirmed-arthroscopic-instability as diagnostic-gold-standard. Results When compared to non-injured sides, DTFS area and volumes were significantly-higher in injured-ankles at 1cm (667 vs 554mm3) and 3cm (2331 vs 2038mm3). Medial-gutter volumes were also increased in injured-sides (398 vs 370 mm3). DTFS volumes at 5cm and lateral-gutter-volumes were not different. Nine-of-eleven-patients had confirmed arthroscopic DTFS instability. Considering WBCT area-measurements, 4/11 patients were found-to-be-positive (>105mm2), including 3 true positives (+WBCT/+Arthroscopy), 1 false-positive (+WBCT/-Arthroscopy), 6 false-negatives (- WBCT/+Arthroscopy), and 1 true-negative (-WBCT/-Arthroscopy), leading to a 33.3% sensitivity, 50%, specificity, 75% PPV 75%, 14.3% NPV and 36% accuracy. When analysing WBCT DTFS volumes (1cm), 3/11 patients were found positive (>796mm3), depicting 3 true positives, 0 false positives, 2 true negatives and 6 false negatives, with resultant diagnostic accuracy of: 33.3% sensitivity, 100% specificity, 100% PPV, 25% NPV 25%, and 45% accuracy. Conclusion When compared to uninjured side, DTFS area and volumetric measurements were significantly increased in injured sides of patients with suspected SSI, including medial gutter volumes, consistent with associated deltoid ligament instability. However, interestingly, we observed a diagnostic accuracy for WBCT area and volumetric measurements to be lower than initially expected.

Backgrounds: Foot deformities can cause the development and progression of ankle osteoarthritis. This study aimed to investigate the relationship between foot deformities and medial ankle osteoarthritis by using radiographic measurements. Methods: Seventy-six ankles of 76 patients (32 men and 44 women; mean age, 69.0 years) with medial ankle osteoarthritis were included. Eleven radiographic measurements, including tibial plafond inclination (TPI), tibiotalar tilt (TT), medial distal tibial angle (MDTA), medial talar center migration (MTCM), anterior distal tibial angle (ADTA), lateral talo-first metatarsal angle (Lat talo-1MT), anterior talar center migration (ATCM), anteroposterior talo-first metatarsal angle (AP talo-1MT), talonavicular coverage, internal rotation (IR) of the talus, and mechanical tibiofemoral angle were evaluated and statistically analyzed. Results: TPI, Lat talo-1MT, and IR of the talus were significantly associated with TT in linear regression analysis. TT, MTCM, and Lat talo-1MT were significantly associated with IR of the talus in binary logistic regression analysis. MTCM was significantly correlated with TPI, TT, MDTA, ATCM, and AP talo-1MT. ATCM was significantly correlated with TPI , ADTA, and Lat talo-1MT. Conclusions: The ankle-joint incongruency (TT) and IR of the talus were associated with the coronal ankle-joint line orientation and foot deformities. Talar body migration was also correlated with ankle-joint line orientation and radiographic measurements. The biomechanical significance of these radiographic measurements require further research. Surgeons should take into account the concomitant foot deformities and talar displacement while treating medial ankle osteoarthritis.

Background: Retrospective review of patients with a diagnosis of Tarsal Tunnel Syndrome (TTS) treated surgically. Methods: Retrospective series of patients with diagnosis of TTS operated between 2005 and 2020 in the same center. Variables such as age, sex, side, affected nerve or branch, classification, type of imaging study, biopsy result, infection rate, recurrence rate, sequelae, among others, were analyzed. Results: We included 8 men and 2 women with an average age of 47 years (range 34-67) and an average follow-up of 62.2 months (range 2-149). All cases were related to intrinsic compression. The most frequent cause was the presence of cyst (40%) followed by perineural adhesions (20%). The Posterior Tibial Nerve was the most affected (50%) and 30% the Medial Plantar Branch. Ultrasound (70%) and MRI (50%) were the most requested studies. There were no cases of postoperative infection. There were 3 patients who presented recurrence of the lesion requiring a new surgery. Conclusions: TTS is a neuropathy involving the posterior tibial nerve or some of its branches. In general, it is caused by compression of the nerve by different structures such as accessory muscles and ganglions, among others. The diagnosis is eminently clinical, supported by imaging studies. Surgical treatment presents better results when the cause is an intrinsic compression, although variable recurrence rates are described.

Ganglion cysts are benign soft tissue tumours commonly found in the wrist, but may occur at any joint. This retrospective study looked at the risk of recurrence and complications associated with ganglion removal at the ankle and foot. Patients that underwent surgical excision of ankle and foot ganglion cysts from 2015-2022 in Scunthorpe General Hospital were reviewed to assess the recurrence and complications associated with the removal. 36 patients consisting of 31 females and 5 males had surgical excisions of soft tissue suspicious of ganglion cysts. The mean age of the patients was 41.25 years old. Symptoms were present in patients for 15.3 months on average before they were reviewed in clinic. The mean follow-up time is 29 months. 32 patients had a ganglion cyst confirmed on histology. The remaining 4 had other soft tissue lesions that include 2 angioleiomyomas, 1 neuroma and 1 plantar wart. 2 patients with histologically confirmed ganglion cysts reported having pain on follow up. Pain symptoms were assessed using the Manchester-Oxford Foot Questionnaire (MOXfQ) and Visual Analogue Score (VAS). Mean pre- and post-operation MOXfQ score was 45.5 and 10.4 respectively. The mean pre- and post-operation VAS score was 8.6 and 1.8 respectively. 4 of the patients were noted to have a recurrence of the ganglion cyst at the same site. The mean time to recurrence of the cyst after the first excision was 1.5 years.

Arthroscopic debridement is a common surgical treatment for anterolateral impingement (ALI) of the ankle. Although patients often have a history of ankle sprain, information regarding the role of ankle instability in ALI is limited. The aims were to 1) assess the clinical outcomes of arthroscopic treatment for ALI and 2) review the data regarding anterior talofibular ligament (ATFL) injury and lateral ankle instability. A literature search was performed and with the following inclusion criteria: (1) studies investigating patients who underwent arthroscopic surgery for ALI; (2) results with at least one scoring system with minimum follow-up of six months. The quality of each study was evaluated using the Oxford CEBM tool. Patient characteristics, intra-operative findings and clinical outcomes were extracted. Eight articles were included. In total, 203 patients with a mean age of 32 years (ranging from 11 to 74) were analysed. AOFAS score was used in 6 studies and scored 90.1 on average at follow-up. Two studies used original scores. One study reported arthroscopic findings of the ATFL and another study reported on residual instability after surgery. New ankle sprains during follow-up period were reported in 8.3 to 20.0% of patients in 4 studies. This review showed good clinical results of arthroscopic debridement with a grade C recommendation. Reports regarding arthroscopic observation of the ATFL and residual instability after surgery were lacking. Further investigation of what we are still calling “ALI” should be made with higher level of evidence focusing more on ATFL injury and its effect on clinical outcomes.

Abstract Purpose Ankle sprain is a common injury that can be treated conservatively, though many injured patients do not seek treat- ment or are not adequately managed, both of which can lead to subsequent chronic ankle instability (CAI). The purpose of this study was to evaluate the functional scores and complication rates of an all-inside anatomic reconstruction technique to treat CAI at a minimum follow-up of 24 months. Methods The authors retrospectively collected the records of 41 patients that underwent all-inside endoscopic anatomic reconstruction of the ATFL and CFL including demographics, complications, satisfaction, American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson score, and ankle activity score (AAS), at a minimum follow-up of 24 months. Results The study cohort, comprised 34 patients aged 35.6 ± 10.8 years, were assessed at 48.7 ± 19.0 months. AOFAS scores improved from 60.3 ± 11.9 to 94.3 ± 6.2 postoperatively. Karlsson scores improved from 49.0 ± 10.9 to 87.2 ± 10.1 postoperatively. Thirty-three (97%) patients returned to the same AAS (5.6 ± 3.1) and rated their overall satisfaction ≥ 7. One patient (3%) was reoperated to treat a hematoma, while five patients (15%) were reoperated to remove the cortical fixation device that caused discomfort. Conclusion The novel all-inside endoscopic technique for anatomic reconstruction of the ATFL and CFL grants satisfactory functional outcomes at a minimum of 24 months, and the improvements in AOFAS and Karlsson scores compared favourably to those reported for other techniques in the literature.

Introduction Vitamin D deficiency is a endemic problem in first world countries, this deficiency has worsened after COVID-19 global pandemic. Vitamin D deficiency has been relational with increased risk of fracture. Objective To determine if low level of Vitamina D is relation with ankle fracture in post-pandemic period. Material and methods. Controlled prospective observational study. Approved by ethics committee. Sample: patients admitted with a low energy ankle fracture and surgical treatment between October first, 2021 to January 31th ,2022. Vitamin D blood levels were determined at hospital admission. We used Holick classification for Vitamin D levels and AO for ankle fracture. Statistical analysis with SPSS Results 29 cases were included. Mean age 56,62 y, women 55,2%,urban environment 69%. Ankle fracture classification 50% 44B2, 32% 44B3, rest 18%. Vitamin D levels average at admission 18,86 ng/mL (deficient). 89,7% of our sample of low energy ankle fracture have vitamin D deficiency. In ankle fractures, lower levels of vitamin D were founded in patients with ages between 50 and 60 years old, living in urban environment. Discussion Any prior references were found post lockdown COVID-19 pandemic with this relation. Before it, Smith and cols determined in low energy ankle fracture that 47% were vitamin D insufficient, with 13% of patients severely deficient. In our study we have found much lower vitamin D levels in low energy ankle fracture. Conclusions We have observed a high relation between low vitamin D levels and ankle low energy fractures.

Introduction: Arthroscopic techniques for chronic lateral ankle instability (CLAI) repair have been gaining relevance as simpler and safer alternatives to open procedures, with at least equivalent functional results. The purpose of this paper is to present the intermediate results of the first described arthroscopic Broström-Gould technique. Material and Methods: In this retrospective study, the authors report a series of 45 patients submitted to arthroscopic CLAI repair, between January 2015 and August 2020. All patients were operated by an experienced ankle surgeon. The mean follow-up period was 4,4 years (21 to 81 months). We measured the post-operative CAIT, FAAM, satisfaction rate and complication and recurrence rate. Results: In our 45 patients (21 female) the mean age was 27,9 years old (13 to 55). Thirteen patients had additional pathology that was addressed during the arthroscopic procedure. One patient had superficial surgical site infection, three had transient hypoesthesia of superficial fibular nerve and one had complex regional pain syndrome, resulting on a 11,1% (5/45) complication rate. Three patients needed additional surgery for recurrent instability, resulting in 6,7% of recurrence rate. Post-operative results: at 4,4y mean follow-up, the mean CAIT score was 95% (0 to 100) and FAAM sore was 93,9% (26 to 100). 88,9% of the patients were satisfied/very satisfied. All non-satisfied patients had concomitant intra-articular lesions. Discussion: Over the last decade, significant advances have been made to effectively treat CLAI, with arthroscopic techniques gaining popularity. Our technique has been proving to be reliable, safe, with satisfactory outcomes and low recurrence rate.

Introduction The European Foot and Ankle Society (EFAS) score is a patient reported outcome for assessing pain and function after foot and ankle surgery. It is unknown how changes in EFAS scores correlate with changes in the Manchester Oxford foot questionnaire (MOXFQ). Methods Single surgeon series of 39 patients who underwent unilateral elective foot and ankle surgery. Patients completed EFAS and MOXFQ scores before and at 2 years after surgery. Results Mean age was 61 years (range 29 to 75). 55% (n=21) were female. The majority of cases were forefoot (n=14), followed by hindfoot (n=14), midfoot (n=4), combined (n=3). EFAS score improved by a mean of 9.69 points (95% CI 12 to 7.39, p=0.0001). MOXFQ Pain dimension improved by a mean of 38.9 points (95% CI 29.2 to 48.6, p=0.0001). MOXFQ Walking-Standing dimension improved by a mean of 43.3 points (95% CI 33.0 to 53.6, p=0.0001). MOXFQ Social interaction score improved by a mean of 45.4 points (95% CI 36.4 to 54.5, p=0.0001). Change in EFAS score was highly correlated with change in MOXFQ Pain dimension (Pearson r = -0.792) and MOXFQ Walking-Standing dimension (Pearson r = -0.761). There was moderate correlation between change in EFAS and MOXFQ Social interaction (Pearson r = -0.522). Conclusion EFAS score significantly improved after foot and ankle surgery and had high correlation with changes in MOXFQ Pain and Walking-standing dimensions.

Background Periprosthetic cysts occur in up to 95% of total ankle arthroplasties (TAA) and have been correlated with implant failure. The aim of this study was to determine the clinical and radiological outcomes, using CT scan, after periprosthetic cyst bone grafting and assess for minimum cyst size that should be grafted. Methods A retrospective review was performed of all TAA procedures performed between 2007 and 2014 (n=93). A CT scan was done to assess cyst size and operative planning. Eight patients with nine periprosthetic cysts larger than 1.75cm3 were grafted and specimens sent for histology. The mean time to bone grafting was 7.3 (3.8-9.5) years. Functional outcome was assessed using AOFAS ankle, VAS and SEFAS scores. A CT scan was performed at follow-up to assess graft incorporation and cyst size progression. The mean time to CT scan was 3.0 (0.7-4.7) years. Results There was no implant malalignment identified and no differences in the pre- and postoperative functional scores. Preoperatively cysts had a mean volume of 8.16 (2.04 to 14.03cm3). The mean percentage incorporation was 89% (69%-100%). Eight of the grafted cysts were considered successful on CT, with the ninth having 69% incorporation. Five cysts were not grafted, they were below 1.75cm3, and remained the same size or had minimal enlargement. Conclusion The satisfactory results in this small cohort suggests that prophylactic bone grafting may extend implant survival. We recommend that periprosthetic cysts greater than 1.75cm3 be prophylactically bone grafted, and that cysts below 1.75cm3 be monitored for progression in size.

Background and objective The COVID-19 pandemic has resulted in significantly increased waiting times for elective surgical procedures in orthopaedic surgery. Patients waiting for over 52 weeks were offered a consultant-led ‘harm review’. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. Materials and methods Data from harm review clinics at a District General Hospital in 2021 relating to patients awaiting elective foot and ankle procedures for more than 52 weeks, were assessed. Clinical data points such as change in diagnosis, need for further investigations, and removal from the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was also assessed. Results Totally, 72 patients were assessed. It was noted that 25% of patients found their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons, the most common being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. Conclusion This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

Introduction The aim of the study was to investigate plantar pressures along with gait in patients presenting with end stage ankle arthritis for potential TAR surgery. Patients and Methods 23 patients had a TAR between 2017/2019. It was a single centre study. Patients for a primary TAR . Exclusion criteria refusal of consent, previous h/o reconstructive surgery to foot, h/o infection, peripheral vascular disease, neurological disease and other LL joint replacements. Gait analysis done using TekscanTM plantar pressure analysis system. completed a questionnaire for MOX-FQ scores, they underwent a timed up and got (TUG) test and AOFAS scores. Assessments done pre-operatively. Data was analysed with SPSS IBM 28 statistical package. Results 23 patients were recruited. Mean age of patients were 65.16 years. Plantar pressure analysis and gait showed deviation from reference ranges for 1) differences in centre of pressure (COP) 2) changes to hindfoot vs. forefoot loading ratio 3) change in loading pattern at heel in KPa (p<0.05) 4) differences in gait parameters (reduction in cadence, walking velocity, increase in active propulsion time; p<0.05) 5) changes to foot progression angles. These findings correlate with MOX-FQ scores (Positive Correlation p>0.565) for pain, difficulty with walking/ standing and difficulty with social activities. Conclusion This novel study has shown that Plantar Pressure Analysis along with Spatial-Temporal Parameters of Gait is a useful tool in surgical evaluation of patients with end stage ankle arthritis. This data has highlighted the abnormal presentations in patients with ankle arthritis compared to normal reference ranges reported in literature.

Background: In current literature, the benefit of postoperative physiotherapy remains unclear. The aim of this review is to systematically assess existing literature regarding the functional outcome of postoperative physiotherapy compared to postoperative instructions by treating specialist only in the rehabilitation of patients with an ankle fracture. The secondary aim is to analyse the ankle range of motion, strength, pain, complications, quality of life and patient’s satisfaction after these two rehabilitation methods. Methods: For this review, the PUBMED/MEDLINE, PEDro, Embase, Cochrane and CINAHL databases were searched for studies that compared postoperative rehabilitation groups. Results: The electronic data search detected 18.830 articles. After exclusion, five studies with a total of 552 patients were included. Overall, no significant benefit in functional outcome of postoperative physiotherapy was seen. One study even found a significant benefit in favour of the instructions group. An exemption for beneficial effect of physiotherapy could be made for younger patients, as two studies described younger age as a factor for better functional outcome and ankle range of motion in the postoperative physiotherapy group. Patients’ satisfaction was found to be significantly higher in the physiotherapy group (p=0.047). All other secondary aims showed no significant difference. Conclusion: This review found no benefit of physiotherapy over instructions by treating specialist only. However, limited evidence suggests possible benefit for physiotherapy in younger patients in functional outcome and ankle range of motion. Further research is needed to identify the selective group of patients with an ankle fracture who could benefit from postoperative physiotherapy.

Osteonecrosis is a disruption of blood supply to the bone which results in bone cell death. Post-traumatic osteonecrosis of distal tibia rarely happens as compared to osteonecrosis that affect other parts of the musculoskeletal system. Here, we report a case of osteonecrosis of distal tibia in an adult male following an open dislocation fracture of the right ankle. Initial surgery of wound debridement with temporary external fixator was performed for ankle stabilization. Patient was then changed to internal fixation once the subcutaneous tissue permits. Subsequently after one year, he developed an ankle pain that progressively worsening which affected his daily activities. In view of this condition, a magnetic resonance imaging was done showing osteonecrosis of distal tibia, osteochondral injury of medial tibial plafond and medial talus with lateral ligament complex injuries. Autologous iliac bone grafting was applied to distal tibia and cell-free hyaluronic acid-based scaffold (Hyalofast®) used to address the bone osteonecrosis and osteochondral injury respectively. Visual analogue score (VAS), AOFAS hindfoot score and ankle range of motion improved at three months and significantly increased after six months post-operatively.

Aim of study: Ankle fractures are among the most common injuries encountered by musculoskeletal professionals. The aim of this study was to evaluate outcome and quality of life 3 and 6 months after surgically treated ankle fracture. Patients and methods: Observational prospective study of 87 patients who underwent surgical treatment for ankle fracture and who benefited from a rehabilitation program at the physical medicine and rehabilitation department of Ibn Rochd university hospital of Casablanca. Used outcome measures included: Olerud-Molander Ankle Score (OMAS), Short-Form 36 (SF-36), Foot and Ankle Outcome Score (FAOS) and gait analysis at 3- and 6-months post operatively. Results: Mean age was 52 years old (range 31-64) ,sex ratio was 3/1 and 42% of patients had a history of knee-arthritis.72% had bimalleolar fracture,33,1 % of fractures were caused by high energy traumas with 15,7 % secondary to high-speed motor vehicle accidents and 49% were associated to anterior talofibular ligament sprain. Mean OMAS was 50 at 3 months and improved to 60 at 6months, mean physical functioning using SF-36 was 60 at 3 months while mean FAOS was 53% at 3 months and improved to 72% at 6 months. 89% of the patients regained gait autonomy at 6 months. Discussion/Conclusion: Fractures of the ankle joint are among the commonest fractures in adults. Conservative or surgical treatment can be indicated depending on many factors.Early post operative rehabilitation is one of the key determinants of functional outcome on the short and long term.

INTRODUCTION: Despite the increasing numbers of ankle replacements being performed there are still limited studies on survival of which factors influence survivorship between different implants The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements and to determine the risk factors for failure of total ankle replacements METHODS: A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device inserted during ankle replacement surgery. Kaplan Meier survival analysis and Cox proportional hazards regression models were fitted to compare failure rates. RESULTS: 5,562 primary ankle replacement were recorded on the NJR between 1st April 2010 and 31st December 2018. The unadjusted 1-year survivorship of ankle replacements was 98.8% (95% CI 98.4%-99.0the 5-year survival in 2725 patients was 90.2% (95% CI 89.2%-91.1) and the 10-year survival in 199 patients was 86.2% (95% CI 84.6%- 87.6%). In univariate cox regression models age, BMI, ASA, Charlson co-morbidity score, indication for surgery were significantly associated with an increased risk of failure. In multivariate cox regression models only age (HR 0.956, 95% CI 0.942- 0.970), BMI (HR 1.032, 95% CI 1.006-1.059) and indication (HR 0.880, 95% CI 0.799-0.968) were associated with an increased risk of failure. DISCUSSION AND CONCLUSION: Ankle replacements have been demonstrated to have higher failure rates in younger patients, those with an increased BMI, and those with osteoarthritis.

Aims Total ankle replacement (TAA) use has increased among patients with end-stage ankle arthritis. The Zimmer Trabecular Metal Total Ankle Replacement was developed to be used through a lateral transfibular approach. This study collected retrospectively clinical results at a follow-up of minimum five years. Methods We retrospectively evaluated 212 patients who underwent transfibular TAA between January, 2013 and May, 2017. We excluded TAA revisions and TAA on previous arthrodesis (8). 15 patients were lost to follow-up. Patients’ clinical and radiological examinations and complications were collected. Survival analysis were performed with the Kaplan-Meyer method. Results A total of 189 patients were evaluated at a mean follow-up of 66.4 months (60 to 96). At the end of follow-up mean AOFAS ankle Hindfoot Score were 86.1 (SD 8.8), visual analogue scale for pain were 1.5 (SD 1.2), Short Form-12 Physical and Mental Component Scores were 47.3 (SD 7.5) and 52.2 (SD 8.0), and mean ankle dorsiflexion and plantarflexion were 23.9° (SD 7.7°) and 16.9° (SD 7.2°). Radiologically, the implants maintained neutral alignment without subsidence. Tibial or talar radiolucency was found in 18 patients, but none of these patients were symptomatic. At five-year follow up, 97.9% of implants were free from revision. We recorded 3 cases of failure for septic loosening and 1 case of revision due to periprosthetic fracture. Conclusion Transfibular TAA is safe and effective with a high survival rate at mid-term follow-up and satisfactory clinical and radiological results. Further studies are required to determine the long-term performance of these implants.

Introduction Revision ankle replacements are becoming more widespread as the number of ankle replacements increases. Despite this there is a scarcity of literature on their outcomes. The aim of this data linkage study was to determine the survivorship of revision ankle replacements Methods A data linkage study combined National Joint Registry Data and NHS Digital data with patients having linked primary and revision ankle replacement. Kaplan Meier survival analysis and Cox proportional hazards regression models were fitted to compare failure rates. Results 228 patients were included. The mean age was range 66.0 with 57.9% males, the mean BMI was 30.9, and Charlson co-morbidity score was 2.4. The mean time from primary was 2.25. 79.8% underwent revisions without cement and 20.2% with. 209 (91.7%) underwent 1 stage revision and 19 (8.3%) underwent a 2 stage revision. 17 (7.5%) patients underwent additional non-revision surgical procedures. Of the 228 revision ankle replacements 29 failed of which 9 underwent further revision, 19 conversion to fusion and 1 amputation. The overall 1 year survivorship was 95.4% (95% CI 91.6%-97.5%), 3 year survivorship 87.7% (95% CI 81.9%-91.7%), and the 5 year survivorship was 77.46% (95% CI 66.9%-85.0%). The Inbone ankle replacement was found to have a significantly better survivorship compared to other implants. Conclusion Revision ankle replacements have demonstrated high failure rates, but newer revision specific implants have improved outcomes.

OBJECTIVE: The purpose of this study was to determine the 50 most-cited articles on Achilles tendon pathologies in order to outline their characteristics and evaluate the correlation between citations and the quality of evidence. METHODS: The top 50 most-cited articles were identified and their characteristics abstracted. Their quality was assessed using the modified Coleman Methodology Score (mCMS). The correlation between the number of citations, citation rate, impact factor of the journal (JIF), year of publication, Level of Evidence (LoE), type of study, sample size and mCMS was assessed through multiple bivariate analyses. RESULTS: Mean number of citations (±SD) was 244±88.8 (range, 657-157), with a total number of citations of 12.194 and a mean citation rate of 12.6±5.4 (range, 28-3). The citation rate correlated with the number of citations (R=0.56,p<0.001), the year of publication (R=0.60,p<0.001) and the LoE (R=-0.37,p=0.022). The year of publication correlated with the LoE as well (R=-0.43,p=0.008). Also, the quality of studies correlated with the impact factor of journals (R=0.35,p=0.03) and with the LoE (R=-0.48,p=0.003), but not with the citation rate (p=0.15). Only 20 out of 39 primary studies had a prospective and comparative design, while 19 studies (48%) were classified as of poor quality (<50 points mCMS). CONCLUSIONS: Most-cited articles regarding Achilles tendon injuries have generally been published on high-impact journals. Although the impact factor positively correlates with the quality of studies, their methodology is poor in almost half of cases. Citation-based indicators do not represent robust measures of quality in studies dealing with Achilles tendon pathologies.

INTRODUCTION: The aim of this work is to determine the clinical and radiological results of patients treated for ankle instability using the non-anatomic technique with the Castaing technique. MATERIAL AND METHODS: Retrospective review of patients with ankle instability treated with the Castaing technique and who agreed to participate in the study. The visual analog pain scale (VAS) was used to measure pain and the Cumberland scale for ankle instability. Ankle osteoarthritis was classified on ankle Xrays according to the Van Dijk classification. Statistical analysis was performed using SPSS 20.0 software. RESULT: 20 patients were included, mean follow-up was 16 years. 90% scored pain level as 0 on the VAS scale. Stability measured by the Cumberland scale was 83.5%, with 80% presenting a value of 70% or more. 64.7% had lost some mobility with respect to the contralateral side and only one patient had decreased muscle balance in ankle eversion. In 6 of our patients (30%) osteoarthritis increased by one degree between the pre-surgical radiograph and the most recent one with statistically significant differences (p=0.014). However, this data does not seem clinically relevant, since 100% of the patients in this group had a value of 0 on the VAS pain scale and a median of 88.5% on the Cumberland scale. CONCLUSIONS: Patients operated with the Castaing technique have an acceptable degree of long-term stability, with good scores on the VAS scale for pain assessment. We observed radiological changes in the degree of osteoarthritis in only 3% of patients.

Introduction The aim of this study was to investigate plantar pressures changes with gait in patients presenting with end stage ankle arthritis pre and post Total Ankle Replacement surgery. Patients and Methods 11 patients who underwent a Primary TAR between 2017/2019. Exclusion criteria included refusal of consent, previous , h/o infection, peripheral vascular disease, neurological disease and other LL joint replacements. Gait analysis was carried out using TekscanTM plantar pressure analysis system and plantar pressures were recorded pre-operatively and 1 year post-operatively. Gait asymmetries were recorded in Percentage for ST parameters. Results All patients (100%) showed improvement in plantar pressures; improvement centre of pressure pattern restoration and Force percentage curve from pre-op to 1 Year. Improvement in foot progression angle was seen in 6 out of 11 patients (54.5%). Plantar pressure analysis showed deviation from reference ranges for 1) differences in centre of pressure 2) change in loading pattern at heel in KPa (p<0.05) 3) differences in gait parameters (reduction in cadence, walking velocity, increase in active propulsion time; p<0.05). These findings correlate with MOX-FQ scores (Positive Correlation p>0.565) for pain, difficulty with walking/ standing and social activities. Gait asymmetries improved (p<0.05). For step velocity (76.1 to 93.4 in 6/11 patients) and mid stance time (76.04 to 93.5% in 8/11patients); Conclusion This study has shown that TAR helps restoring centre of pressure and reduces asymmetries in step velocity and mid stance times during gait. Plantar pressure analysis is a useful tool to study improvement in function in this patient group.

Ankle inversion trauma may have severe consequences as 40-70% of patients develop chronic impairments. Physiotherapy has been shown to reduce the recurrence rate after ankle trauma, but there is no consensus on therapy content and duration. Since patients show a variety of impairments in function and activity, the aim of this study is to offer patients individualized therapy and evaluate their rehabilitation. Ten patients (26 ± 6 years) with chronic or acute ankle instability after ankle inversion trauma were evaluated during a 3-months period. The patients received individualized therapy focusing on e.g., muscle strengthening and coordination. One-limb stance performance was recorded with eyes-open and closed using Qualisys motion analysis system and assessed objectively by means of Centre of Pressure (CoP) parameters. The Foot and Ankle Ability Measure (FAAM) and Cumberland Ankle Instability Tool (CAIT) monitored daily life performance subjectively. Assessments were made in weeks 0, 3, 6 and 12 and evaluated with paired t-tests. The CoP standard deviation (SD) in anterior-posterior (AP) direction was significantly larger for the impaired foot compared to the non-impaired foot and reduced over time. The CoP-SD in medial-lateral (ML) direction and cumulative CoP in ML direction tended to be larger for the impaired foot too. The patient-reported outcome measures showed a significant reduction in daily (FAAM A) and sports (FAAM B) impairments and ankle instability (CAIT). Already after 3 weeks, effects of individualized therapy were present in objective and subjective measures and patient impairments were significantly reduced in the following weeks.

Background Although percutaneous Hallux Valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies. Methods Twenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified. Results The medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3 mm (SD 1.4) and 2.4 mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet. Conclusions The structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid damage to neurovascular and tendinous structures.

The interphalangeal coalition is common in the fifth toe and relatively less in the fourth toe. Fractures may be overlooked, which could prolong fusion and cause further pain. Although reports of conservative treatment are limited, only one case was treated surgically with painful nonunion. Here, we report a very rare case of painful nonunion after a fracture of the fourth toe interphalangeal coalition. Surgery was performed following an unpublished percutaneous procedure. The patient started full weight-bearing the day after surgery and returned to sports activity 3 months later. No postoperative complications occurred 6 months after surgery. To the best of our knowledge, this is the second report of painful nonunion after a fracture of toe interphalangeal coalition treated surgically and the first report of percutaneous surgery.

Introduction Hallux rigidis affects 1 in 40 patients above 50 years of age. Multiple treatment options are available including silastic implants, ceramic and metal arthroplasties, hemiathroplasties with Co-Cr and titanium implants with varying and limited success. The aim of our study is to evaluate the five year results of Cartiva arthroplasty for hallux rigidus and discuss the technical tips. Methods There were a total of 86 patients who underwent Cartiva interpositional arthroplasty. We were able to collect and analyse the five year functional scores for 70 patients. Mean age at the time of operation was 63.4 years (range 42–84 years). The mean follow-up was 62.6 months. The functional evaluation was done using Manchester-Oxford Foot Questionnaire (MOxFQ).The general health was assessed by EQ-5D which included EQVAS. The complications and revision rates were also documented. Results At five years follow up 93% of the patients were satisfied with the results of the outcomes of Cartiva joint replacement. The average preoperative MOxFQ, EQ-5D and EQVAS scores were 36.8, 9.4 and 75. At one year they were 19.3, 4.4 and 85 respectively. The scores after five years were 17.6, 4.8 and 80 respectively after surgery. There were no iatrogenic fractures or infections. Three patients out of 86 had revision to first MTP fusion due to ongoing pain. Conclusion Long term outcomes of Cartiva demonstrate clinical efficacy of this synthetic implant. The implant is durable, safe and is a viable treatment option to decrease pain, improve function and maintain motion for advanced hallux rigidus.

Background: The peroneus longus may theoretically become defunctioned in hallux valgus (HV). Our objective was to compare the position and morphology of the peroneus longus tubercle (PLT) in feet with and without HV. Methods: Retrospective analysis of weight-bearing CT scans was completed using 40 feet in 23 patients. Feet were divided into two groups – the ‘non-HV and the ‘HV’ group. We assessed a number of novel measurements. The tubercle-to-floor distance (T-F distance), the bisecting angle of the PLT, tubercle-to-metatarsals angle (T-MT angle) and metatarsal cross-sectional area. Results: The T-F distance was lower in the HV group (p = 0.001). The bisecting angle was significantly lower in the HV group (p=0.017). T-MT angle was lower in the HV group (p=0.041). There was no difference in the cross-sectional area of the PLT between groups. Conclusion: We have demonstrated a difference in the position of the PLT between individuals with and without HV.

Background: First metatarsophalangeal (MTP) arthrodesis is considered the standard surgical treatment of end-stage hallux rigidus (HR) and severe hallux valgus (HV). The purpose of this study was to compare patient outcomes of 1st MTP arthrodesis between HR and HV cohorts. Methods: A retrospective review was conducted at an academic medical center of patients who underwent 1st MTP arthrodesis during 2009-2021. In total, 136 patients (148 feet: HR=75, HV=47, combined=44) met the inclusion criteria of minimum three-month follow-up (mean=1.25 years). Radiographic measures included HV angle (HVA), intermetatarsal angle (IMA), and 1st-5th metatarsal width. Patient-reported outcome measures (PROMs) included Visual Analogue Scale (VAS), 12-item Short Form Survey (SF-12), Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). All were collected preoperatively, but FAOS and FAAM was also collected postoperatively. All – with the addition of Patient-Reported Outcomes Measurement Information System – were collected via a prospective phone interview at mean 3.04 years postoperatively. Results: PROMs improved overall, although the HV group significantly improved the least among PROMs. The HR group had a significantly smaller improvement in HVA (HR=-3.60degrees, HV=-17.44degrees, combined=-15.27degrees; p<.001), IMA (HR=-0.16degrees, HV=-2.80degrees, combined=-2.55degrees; p<.001), and 1st-5th metatarsal width (HR=-0.98mm, HV=-4.59mm, combined=-4.60mm; p<.001). Complication (e.g., superficial infection, nonunion) and reoperation rates did not differ by group, although both were lowest for the HR group. Conclusion: Forefoot pathology does not appear to influence subjective outcomes of 1st MTP arthrodesis. All groups showed PROM improvements postoperatively, although only the HR group continued to improve from 1-year to 3-years postoperative.

Introduction Virtual fracture clinics (VFC) have reduced pressures on trauma services. There is paucity of evidence to support the VFC model in the management of 5th metatarsal fractures; treatment remains controversial. This study assessed the management of 5th metatarsal fractures via VFC analysing safety, cost-effectiveness, satisfaction levels, clinical and patient reported outcome measured (PROMS). Methods Patients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture between January 2019 and December 2019 were included. Patient demographics, clinic attendances, complication and operative rates were analysed. Patients received standardised treatment; walker boot/full weight bearing, rehabilitation information and instruction to contact VFC if pain post 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. Cost analysis was performed. Results 126 patients met inclusion criteria. Average time to VFC review was 2 days (1 – 5). Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) Type 1 fractures, 15 (12%) Type 2 fractures and 7 (6%) Type 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; 75% regarding pain. There was 1 non-union identified. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scored more than 0. 252 clinic visits were saved with an approximate cost saving of £40,000. Conclusion Our study supports the management of 5th metatarsal base fractures in the VFC setting. With a well-defined protocol it is safe, efficient, cost effective and yields good short term patient centred outcomes.

Background: The French Association of Foot Surgery (AFCP) recently proposed a morphological classification of lesser toe deformities, describing the position of each joint (metatarsophalangeal or MTP, proximal interphalangeal or PIP and distal interphalangeal or DIP) in relation to their anatomic position in the sagittal plane. A study was designed to test its reliability for assessment of sagittal plane deformities of the second toe. Methods: In this retrospective study 55 toes (55 feet, 50 patients) were evaluated. Eleven foot and ankle surgeons assessed independently standardized photographs of each case acquired in a blinded fashion. Assessment was repeated three times, each 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated for each joint. Results: Intra- and inter-observer reliability were moderate for the MTP joint (ICC range, 0.54-0.61) (Kappa range, 0.53-0.61) and substantial for the PIP (ICC range, 0.60-0.71) (Kappa range, 0.68-0.75) and DIP joints (ICC range, 0.69-0.78) (Kappa range, 0.74-0.78). Mean assessment time±standard deviation was 35±10s per case. Conclusions: The AFCP classification proved itself reliable in the assessment of sagittal plane defomities of the second toe among eleven foot and ankle surgeons. It is based only on a visual description of the deformity, and does not provide informations on either the clinical reducibility of the deformity and the radiographic joint status.

Congenital hypertrophy of intrinsic foot muscles are rare. We report an unusual case, a 24-year-old male with a painless swelling at the plantar and medial aspect of right foot which was present since birth. The significant size of deformity and discomfort in wearing shoes were major concerns. MRI revealed expansion of multiple intrinsic foot muscles which are abductor hallucis, flexor digitorum brevis and quadratus plantae. We used Shear Wave Elastography(SWE) as an imaging technique besides MRI and ultrasonography which has not been used or published previously. Muscle shear wave velocity was measured in abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and quadratus plantaris muscles. The mean stiffness values of muscles on the affected side were significantly higher compared to healthy side. The median SWE value was 6.67 kPa (range 4.7-8.6 kPa) in healthy side, while it ranged between 9.2 and 13.4 kPa in affected side. It was decided to perform total excision of abductor hallucis and subtotal resection of flexor digitorum brevis and quadratus plantae muscles with preserving motor and sensory function by maintaining neurovascular bundle. Excess skin was also removed. Surgery was and postoperative course was uneventful. Patient was allowed to bear weight as tolerated. At a follow up at 3 months there was no recurrence and patient was satisfied with shape and size of his foot. Congenital hypertrophy of foot muscles are uncommon disorder especially if it involves multiple intrinsic foot muscles. The main aim is to relieve patients’ concerns, correcting deformities and providing comfortable shoe wear.

Purpose: The purpose of this study is to analyze the short- and long-term results of severe hallux valgus (HV) treated with a L-Reverse osteotomy. Methods: Patients treated with a L-Reverse osteotomy for severe HV between the years 2006-2015 were included. Patients were evaluated preoperatively, at 3 months and 4 or more years postoperatively. Changes in the HV angle (HVA) and intermetatarsal angle (IMA) were measured. Clinical outcomes were assessed using the AOFAS score.Radiologic assessment was done on weightbearing anteroposterior (AP) and lateral (L) x-rays prior to surgery and at short and long term follow up. Descriptive median and range of HVA and IMA were recorded. Statistical analysis was done using Wilcoxon signed-rank test for temporal comparisons. Significance was set at 0.05. Results: 52 patients included. Pre-operative IMA was 18.6° (18.3°-18.9°) and HVA was 38.8° (36.1°-41.5°). At 3 month follow up post operative IMA was 7.2° (6.4°-8-1°), evidencing a surgical correction of 11.4° (10.5-12.2) (p<0.005). HVA was 10.0° (8.4-11.8°), evidencing a surgical correction of 28.9° (26.3-31.5) (p<0.005). 28 patients completed long term follow up of 5.2 (4.2-6.1) years. IMA value was 7.1° (6.0°-8.2°), varying in 0.1° (-1.1-1.4) with initial post operative results (p=0.83). HVA value was 11.9° (8-7°-15.1°), varying in 2.0° (4.4-12.4) with initial post operative results (p=0.14). AOFAS score was 92.7 (89-4-96.1). Conclusion: This study suggests how severe hallux valgus deformity may be successfully treated using a first metatarsal distal L-Reverse osteotomy with a long-lasting correction.

Background: Hallux valgus can lead to pain, difficulty with shoe wear, and other forefoot pathologies. The purpose of this study is to evaluate the effect of the different surgical treatments for hallux valgus on the position of the 1st TMT joint. Methods: A retrospective cohort study of years 2015-2021 was conducted at an academic medical center involving two fellowship-trained foot and ankle surgeons. After excluding patients with less than three months of follow-up (mean=1.15 years, range=0.25-5.72 years), 174 patients (187 feet) were included. Procedures of interest were 1st MTP arthrodesis (n=142), Chevron and/or Scarf osteotomy (n=35), and Lapidus bunionectomy (n=10). Radiographs were evaluated preoperatively, at first weightbearing follow-up, and at final follow-up. Radiographic measures included hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), Meary’s angle, calcaneal pitch, talonavicular (TN) coverage, and foot width. Mean age was 60.10 (range, 14-81) and 77.0% of patients were female. Results: No radiographic measure differed preoperatively. At first weightbearing follow-up, DMAA (MTP=9.22 degrees, Chevron/Scarf=11.86 degrees, Lapidus=17.22 degrees; p=.001) and Meary’s angle on AP (MTP=7.84 degrees, Chevron/Scarf=6.88 degrees, Lapidus=13.14 degrees; p=.038) were significantly greatest among Lapidus bunionectomy cases, while foot width (MTP=8.91 cm, Chevron/Scarf=8.55 cm, Lapidus=8.65 cm; p=.038) was significantly greatest among 1st MTP arthrodesis cases. At final follow-up, DMAA was significantly greatest among the Lapidus bunionectomy cohort (MTP=8.95 degrees, Chevron/Scarf=12.19 degrees, Lapidus=17.92 degrees; p<.001). Conclusion: Among the three hallux valgus corrections studied, there were no long-term differences in TMT joint alignment.

Background: Hammertoes are a common symptomatic lesser toe deformity. A variety of procedures have been described to treat this deformity, but there is no consensus on the best operative treatment. This systematic review aims to determine the radiographic and clinical outcomes of operative hammertoe treatment and how different operations affect postoperative outcomes. Methods: Using PubMed, Scopus, CINAHL, and Cochrane databases, we included studies reporting surgical complications, with a minimum one-year or mean two-year follow-up, including at least ten feet, and identifying the specific surgical procedure(s) and fixation used. Eighty-nine studies were screened, but only 29 met inclusion criteria. Three of the studies detailed multiple groups, yielding 32 total groups of 1,539 patients (561 feet, 2,541 toes). Mean age was 59.06 years and mean follow-up duration was 35.02 months. Common procedures were arthrodesis (n=521) and flexor to extensor transfer (n=221). Common fixation methods were Kirschner wire (K-wire) (n=625) and retained implant (n=542). Results: Amputation rate was significantly greater with implants (implant=2.8%, other=0.2%; p=.007). Although insignificant, revision rate was greater in the miscellaneous procedure group (arthrodesis=5.2%, transfer=2.2%, other=12.5%; p=.384) and lesser in the k-wire group (k-wire=6.3%, implant=11.4%, other=11.2%; p=.720). While there was no difference in infection rate, none occurred in any patient undergoing flexor to extensor transfer (arthrodesis=1.2%, other=1.9%; p=.632). Conclusion: Aside from amputation rate being significantly highest with implants, there was no difference in hammertoe treatment outcomes when accounting for various procedure types and fixation methods. Overall, hammertoe surgery is an effective treatment method with a low complication rate.

Background: First metatarsophalangeal (MTP) joint arthrodesis is commonly performed for patients with severe hallux valgus (HV), but the radiographic changes in this population are not well characterized. This study aims to evaluate pre- and postoperative radiographic measurements of HV patients undergoing 1st MTP arthrodesis, and potential risk factors for improvement. Methods: A retrospective review was conducted on 42 patients (47 feet) who underwent 1st MTP arthrodesis for HV correction between 2010 and 2020 by one of two orthopaedic foot and ankle surgeons at an academic medical center. Radiographic measurements included hallux valgus angle (HVA), intermetatarsal angle (IMA), 1st-5th metatarsal (MT) width, and interphalangeal angle (IPA). Mean follow-up was 1.35 (range, 0.3-6.1) years. Results: On average, HVA decreased 17.4 degrees, IMA decreased 2.8 degrees, MT width decreased 4.6 millimeters, and IPA increased 3.9 degrees. A greater reduction in IMA significantly correlated with increased age (r=-0.342, p=.025) and A1C (r=-0.512, p=.013), and an increase in IPA significantly correlated with increased A1C (r=0.459, p=.032). Additionally, patients with concomitant arthritis (n=7) had significantly smaller changes in IMA (arthritis=-0.4, no arthritis=-3.3; p=.042). Postoperatively, lesser changes in HVA were significantly associated with the prevalence of complications (complication=-11.7, no complication=-20.5; p=.016) and need for reoperation (reoperation=-9.0, no reoperation=-19.7; p=.011). Conclusion: In 1st MTP arthrodesis, we found that younger patients, patients with low preoperative A1C, and patients with arthritis were associated with a lesser reduction in IMA. However, only lesser changes in HVA were associated with increased complication and reoperation rates.

Swefoot, introduced 2014, is a Swedish national quality register, that covers surgery in the foot and ankle. Surgical treatment of HV vary within and between countries also in patients with the same grades of deformities. The aim of this study was to report baseline variables for patients with HV from the register. We extracted baseline characteristics, surgical procedures and patient-reported data for patients with HV entered in the registry during the period January 2014 to May 2021. In May 2019 9238 surgeries were reported to the registry. In the study we analyzed data from 6770 patients (7543 feet). 1695 of the patients were excluded due to a concomitant hallux rigidus or a reoperation. 87% of the patients were women, the average age 55 years and more than 50% of the patients were overweight. The deformity was mild in 15%, moderate in 63% and severe in 22% at baseline. 85% of the patients with a moderate deformity underwent a distal metatarsal osteotomy, 24% a combined surgery with a distal metatarsal and an Akin osteotomy. 94% of the distal osteotomies were Chevron type osteotomies. Only 1126 (15%) shaft osteotomies and 113 (1.5%) base osteotomies were reported to the register. In 13% of the cases the patients had underwent a lateral release, most of them with a severe grade of deformity. The preoperative summary score for SEFAS was 29 and EQ-5D index 0.64, i.e. low values compared to normative data for the PROMs. Conclusion: This is the first report from Swefoot regarding HV.

Injuries of the extensor hallucis longus (EHL) tendon are a rare phenomenon, with most occurring due to lacerations or penetrating injuries. Closed traumatic ruptures of the EHL are described as “Mallet injuries of the toe”. These can be classified as bony or soft mallet injuries depending on the presence or absence of a fracture at the insertion site of the EHL tendon in the distal phalanx. We present a case of a 33- year-old woman who presented with a hyperflexion injury to the left big toe with inability to extend the big toe. Ultrasound showed complete rupture of the EHL tendon with retraction proximal to the hallucal interphalangeal joint of the big toe. The patient was treated through transarticular pinning and repair using the Arthrex Mini Bio-Suture Tak with a 2-0 fibre wire. 12 months post-operatively, the patient had symmetrical EHL power and full range of motion of the toe. The lessons to be drawn from this case report are that isolated hallux mallet injuries are rare and can be easily missed in the absence of penetrating wounds. Patients who have such injuries should be investigated early with the appropriate imaging techniques such as ultrasound or MRI and treated surgically

The aim - to analyze the connection – forefoot deformities and foot function. We included 18 women, 6 men, mean age 23.3, with foot posture index (FPI)+6. Group 1 - maximal value of right foot +10, minimal +4, in the left - maximal +11, minimal +4. Group 2 - both feet maximal value +10, minimal +4. Group 1, static podometry - MAX P 894 g/cm2 (731-1124 g/cm2). Dynamic podometry-minimal MAX P value on the right foot 2131 g/cm2, maximal 2654 g/cm2 . Left foot, minimal MAX P value 2451 g/cm2, maximal 2542 g/cm2. Right foot, MAX P on the lateral part - minimal value 1001 g/cm2, maximal 1602 g/cm2; medial part -747g/cm2, maximal 1458 g/cm2. Left foot medial part - minimal value 1039 g/cm2, maximal 1686 g/cm2. Group 2, static podometry – MAX P 948 g/cm2 (699-1389 g/cm2). Dynamic podometry - right foot maximal 2977 g/cm2, minimal MAX P value 1568 g/cm2. Right foot MAX P on the lateral part - maximal 1839 g/cm2, minimal 1002 g/cm2, medial part - maximal 1664 g/cm2, minimal value 847 g/cm2. Left foot, maximal 3704 g/cm2 , minimal MAX P value 1984 g/cm2, medial part - minimal MAX P value 993 g/cm2, maximal 2374 g/cm2. Conclusions. In our study we found that MAX P value differ in dynamic podometry. The increased MAX P on the medial part of foot detection, using podometry, might be used to diagnose hyperpronation, flat transverse arch of the foot and hallux valgus development. Further studies need to be conducted.

Background Investigation and evaluation of potential and the usefulness of deep learning with subsequent image analysis for automatic measurement of HVA/IMA on radiographs, and classification the degree of severity as support for preoperative clinical decision-making. Methods 265 anteroposterior feet radiographs were included in the analysis. 181 radiographs were utilized for training (161) and validating (20) a U-Net neural network. 84 test radiographs were used for the manual and automatic measurements of hallux valgus severity determined by HVA/IMA. The reliability of manual and computer-based measurements was calculated using the ICC and SEM, and interobserver and intraobserver reliability coefficients was also compared. Decisions based on automatic measurements of these angles were compared with decisions based on manually measured angles according to the EFORT surgical treatment algorithm. Results Very good reliability between manual measurements of three researchers for HVA/IMA was achieved. For HVA, ICC=0.96-0.98. For IMA, ICC=0.78-0.95. Comparing manual against automatic measurement, the reliability was very good too. For HVA, AA-ICC and C-ICC=0.97, and SEM=0.32. For IMA, AA-ICC=0.75, C-ICC=0.89, and SEM=0.21. Coincidence of HV preoperative decision-making according to EFFORT operative treatment algorithm between our algorithm and medical doctors is comparable and amounts to 0.80. Conclusion The proposed, automatic, computer-assisted determination of angles of HV based on deep learning is an accurate method, with relevance comparable to measurements, performed manually, and can be used in clinical practice as a tool for diagnosis of HV on radiographs as well as for the classification of its deformity and demonstrated a potential for supporting preoperative surgical decisions.

Introduction The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd fingers associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both. The objective of this study is to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with second space syndrome treated with Weil's medializing osteotomy (both open and percutaneous) of the second metatarsal. Material and Methods A retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other osteotomies, treated between 2012 and 2019, is performed. Results Twenty-six patients are included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd fingers, 75% associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven percutaneous), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms improved their symptoms. Conclusion Medial translation associated with percutaneous/open Weil osteotomy appears to correct the musculo-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients.

Background: Mitchell’s osteotomy has been through various technical modifications over the years. Osteotomy stabilization methods have ranged from sutures, K-wires, bioabsorbable pins and screws. K-wires have traditionally been the common tool to splint the osteotomy but concerns with wire migration, pin-site issues and construct stability have led to use of compression screws for step-cut fixation. In this study we review existing literature and conduct a pooled analysis to compare outcomes and complication rates for these two fixation methods. Methods: Electronic English language databases were searched for adult cohort studies on Mitchell’s osteotomy using K-wire or screw fixation. Single arm retrospective, prospective and comparative studies with relevant radiographic measures, functional scores and complicates rate were included in final analysis Results: 287 procedures with K-wire fixation with mean follow-up of 32mths (10-62) were compared with 302 procedures with screw fixation with mean follow-up of 28mths (10-36). There was a similar significant improvement in post-op mean IMA and HVA angles and AOFAS scores among the 2 cohorts. K-wire cohort had a 3.1% pin-tract infection rate, while the screw cohort had a 3.3% symptomatic screw prominence rate. There was no difference in rates of deep infection, transfer metatarsalgia, recurrence, hallux varus and osteonecrosis Conclusion: Mitchell’s osteotomy can be successfully fixed either with a K-wire or compression screw with similar results for angle correction, clinical scores and complication rates. Rates of fixation specific complication such as pin-tract infection in K-wire cohort was similar to symptomatic screw prominence in the screw fixation cohort

Objective: To investigate the clinical and radiological outcome of the lesser toe deformities or fractures operated by interphalangeal joint fusion using biodegradable pins as fixation. Patients and methods: Consecutive patients operated by proximal (PIPJ) or distal interphalangeal joint (DIPJ) arthrodesis using The FreedomPin™ (Inion Ltd., Tampere, Finland) made of degradable copolymer composed of L-lactic acid and D-lactic acid, with at least 12 months of follow-up were invited to participate. The clinical evaluation included alignment, swelling and pain of the operated toes, stability of the fused joints, congruence of the MTP joints, complications, revisions, and a subjective patient satisfaction. The radiographic evaluation included weight-bearing dorso-plantar, oblique, and lateral views of the operated foot for the analysis of the alignment, bony union, implant related bony reactions and other radiological complications. Results: 21 patients (age 34-78, median 60 years) with 24 feet and 29 toes were available with median follow-up time of 26 (range 12-40) months. Clinical alignment was good in all but 1 toe. All toes were clinically asymptomatic. All patients were satisfied and would choose the same operation again. The radiological alignment was corrected in 22, partially corrected in 5, and not corrected in 2 toes. A complete radiological bony fusion was detected in 23 (79.3 %), partial in 1 (3.5 %), and no fusion in 5 (17.2 %) toes. Small peri-implant asymptomatic lytic change was detected in 1 toe. Conclusion: The FreedomPin™ bioabsorbable pin was found to be clinically and radiologically safe and reliable method for PIPJ or DIPJ arthrodesis.

Introduction Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus. Methods and analysis Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0–10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to- treat principle. Ethics and dissemination The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. Trial registration number NCT04590313.

Methodology We would like to present our early stage, retrospective case series of bunion correction using a novel implant. From 2020 to 2022, two senior foot and ankle surgeons performed a total of 39 procedures on 31 patients. 8 patients had concurrent surgery on both feet. The technique is a form of MIS bunion correction employing the Bosch osteotomy and using a new Spear locking plate system (Aplus Biotechnology, Taiwan). Akin ostetomies and other adjuvant procedures such as a gastrocnemius recession were added if deemed necessary. Exclusion criteria included patients with past history of inflammatory arthropathy, previous trauma, previous bunion surgery and Charcot arthropathy. Results Mean pre and post operative measurements showed a marked improvement. HVA from 25.06 to 5.47; IMA from 13.44 to 5.94; and sesamoid position from 4.53 to 2.42. Patients were also subjectively very pleased with the final deformity correction. Discussion A total of three complications were encountered during the initial use of the plating system related to learning curve. Two plate required readjustment with one removal 4 months post-op due to impingement. No further complications were seen after the initial learning curve. Our technique allows for good correction of pronation of the hallux as evidenced by the improvement in sesamoid position. Asian feet tend to trend towards a smaller IMA, creating technical difficulties with achieving solid fixation using the dual screw MIS method. Another advantage in comparison to more established MIS techniques is the ability to weight bear immediately post-op on a Darco shoe.

Background: The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognised to be steep however it is poorly defined in the literature. Methods: Retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction and complication rates. Results: Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p<0.05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p>0.05). Conclusion: The mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.

Background: Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the minimum five-year clinical and radio logical outcomes following third-generation MIS hallux valgus surgery. Methods: A retrospective observational single surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous Chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60 month clinical and radiographic follow up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) pre-operatively, 6 months and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, Euroqol-5D Visual Analogue Scale and Visual Analogue Scale for Pain. Results: Between 2012 and 2014, 126 consecutive feet underwent isolated third-generation PECA. The mean follow up was 68.8±7.3 (range 60-88) months. There was a significant improvement in radiographic deformity correction; IMA improved from 12.8±3.0 to 6.0±2.6, (p<0.001) and HVA improved from 28.2±7.6 to 7.8±5.1. MOXFQ Index score at ≥60 month follow up was 10.1±17.0. The radiographic recurrence rate was 2.6% at final follow up. The screw removal rate was 4.0%. Conclusion: Radiological deformity correction following third-generation PECA is maintained at a mean follow up of 68.8 months with a radiographic recurrence rate of 2.6%. Clinical PROMs and patient satisfaction levels are high and comparable to other third-generation studies with shorter duration of follow up.

Background:The effect of pre-operative anxiety and depression on the clinical outcome of hallux valgus surgery is poorly understood, with limited literature available despite the high prevalence of anxiety, depression and musculoskeletal pathology in the general population. Methods:A prospective comparative observational study of patients who underwent third-generation minimally invasive hallux valgus deformity correction (MIS HV). Patients who reported on a pre-operative EQ-5D-5L questionnaire, anxiety and / or depression (A/D) were compared to patients who reported no anxiety or depressive symptoms (Control). The primary outcome measure was the Manchester Oxford Foot Questionnaire (MOXFQ). Secondary outcome measures were the EQ-5D-5L, Visual Analogue Scale for Pain (VAS-Pain), and radiographic deformity correction. Results: Between July 2014 and January 2020, 265 feet (n=184 patients) underwent MIS HV surgery with 48 feet allocated to the A/D cohort. The A/D cohort had significantly worse pre-operative quality of life and MOXFQ scores compared to the Control cohort. Both cohorts reported a statistically significant improvement in all MOXFQ domains 2 years following surgery (p<0.001). There was no difference between the 2 cohorts for any of the MOXFQ domains at 2 years follow up. There was no difference between the cohorts for radiographic deformity correction or VAS-Pain. The A/D cohort had a worse quality of life compared to the control group at 2 years following surgery. Conclusion: This study has demonstrated that 2 years following surgery, patients with anxiety and/or depression have no difference in MOXFQ compared to those without anxiety and/or depression, despite having significantly worse symptoms pre-operatively.

Background: There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA). Methods: This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale). Results: Between September 2014 and November 2018, 106 consecutive feet (n=78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). Two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p<0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p<0.001) whilst mean HVA improved from 45.3° to 10.9° (p<0.001). Conclusion: Third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

Objective: To develop a Distance Mapping (DM) and Coverage Mapping (CM) algorithm to assess metatarsophalangeal (MTP) and metatarso-sesamoid (MS) joint interaction in HVD patients HVD and compare it to healthy controls. Methods: We included 9 HVD patients (mean age 37.1y; 6F/3M) and 5 controls (mean age 39y; 4F/1M) that underwent foot WBCT foot. Bone segmentation of WBCT images for the first and second metatarsals, first and second proximal phalanxes as well as tibial and fibular sesamoids was performed using specific software. Joint interaction with DM and CM of the first and second MTP joints, as well as MS joints were calculated. The surface of the MTP joints were divided in a 2x2 grid using principal axes to provide a more detailed analysis. P values <.05 were considered significant. Results: Examples of coverage maps for HVD patient and a control demonstrating the obvious lateral and dorsal displacement of the distance maps for joint interaction of the first MTP joint, with decreased articular coverage of the medial aspect of the joint. When comparing first MTP joint articular coverage (CMs), HVD patients demonstrated significantly decreased coverage of the dorsomedial quadrant (77%, p=0.0002), and significantly increased coverage of the plantarlateral (182%, p=0.005) and dorsolateral quadrants (44.9%, p=0.035). Conclusions: In this case-control study, we developed a Distance and Coverage Map WBCT Algorithm to objectively assess 3D joint interaction, articular coverage and subluxation in HVD. We observed significant amount of first and second MTP joint subluxation in HVD patients when compared to controls.

The objective was to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HV, to compare semi-automatic with manual measurements in the setting of an HV, and to compare semi-automatic measurements between HV and control group. Methods: In this retrospective study, we assessed 26 patients with HVD and 19 patients without HV. Data was evaluated using software CubeVue®. In the axial plane, HVA, IMA, and IPA were measured. Inter-rater reliabilities were performed using ICC. Agreement between methods was tested using the Bland-Altman plots. Results: Intraobserver and Interobserver agreement for Manual and Semi-automatic WBCT measurements assessed by ICC demonstrated excellent reliability. However, when comparing Manual and Semi-automatic measurements for HVA, IMA, and IPA, Semi-automatic measurements showed the highest values. Agreement between manual (M) and semi-automatic (SA) methods was tested for HVA, IMA and IPA using the Bland-Altman plots. The results indicated a high correlation between the parameters calculated from the manual and semi-automatic measurements, and a strong agreement between the readers and the software. Comparison between pathological group with HV and control (standard) group without HV using semi-automatic measurements was capable of differentiating pathological (HV) from non-pathological conditions for the HVA and IMA angles (p < 0,05). Conclusions: Semi-automatic measurements are reproducible and comparable to measurements performed manually. The software differentiated pathological from non-pathological conditions when subjected to semi-automatic measurements. The development of advanced semi-automatic segmentation software with minimal user intervention is essential for the establishment of big data and can be integrated into clinical practice, facilitating decision-making.

Objective: to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HR, to compare semi-automatic to manual measurements in the setting of HR, and to compare semi-automatic measurements between a pathologic (HR) group and a control standard group. Methods: Retrospective study of 20 patients with HR. All WBCT manual and semiautomatic 3D measurements were performed using the following parameters: first Metatarsal-Proximal Phalanx Angle (1stMPP), HVA, IMA, IPA, first Metatarsal Lengths (1stML), second Metatarsal Length (2ndML), first Metatarsal Declination Angle (1stMD), second Metatarsal Declination Angles (2ndMD), and MPE. The semiautomatic 3D measurements were performed using the Bonelogic® Software. Results: Interobserver and intraobserver agreement for manual versus semi-automatic WBCT measurements assessed by ICC demonstrated excellent reliability. Manual and semi-automatic measurements were performed in individuals with HR. Strong positive linear correlation between both methods for the following parameters evaluated: HVA, (ρ = 0.96); IMA, (ρ = 0.86); IPA, (ρ = 0.89); 1stML, (ρ = 0.96); 2ndML, (ρ = 0.91); 1stMD, (ρ = 0.86); 2ndMD, (ρ = 0.95) and, MPE, (ρ = 0.87). Agreement between the manual and semi-automatic methods expressed excellent agreement between the methods. Comparison between the pathological group with HR and the control (standard) group allowed for the differentiating of the pathological (HR) from the non-pathological conditions for MPE (p < 0.05). Conclusion: Semiautomatic measurements are reproducible and comparable to measurements performed manually, showing excellent interobserver and intraobserver agreement and consistency. The software used differentiated pathological from non-pathological conditions only when submitted to semi-automatic MPE measurements.

Methodology We would like to present our early stage, retrospective case series of bunion correction using a novel implant. From 2020 to 2022, two senior foot and ankle surgeons performed a total of 39 procedures on 31 patients. 8 patients had concurrent surgery on both feet. The technique is a form of MIS bunion correction employing the Bosch osteotomy and using a new Spear locking plate system (Aplus Biotechnology, Taiwan). Akin ostetomies and other adjuvant procedures such as a gastrocnemius recession were added if deemed necessary. Exclusion criteria included patients with past history of inflammatory arthropathy, previous trauma, previous bunion surgery and Charcot arthropathy. Results Mean pre and post operative measurements showed a marked improvement. HVA from 25.06 to 5.47; IMA from 13.44 to 5.94; and sesamoid position from 4.53 to 2.42. Patients were also subjectively very pleased with the final deformity correction. Discussion A total of three complications were encountered during the initial use of the plating system related to learning curve. Two plate required readjustment with one removal 4 months post-op due to impingement. No further complications were seen after the initial learning curve. Our technique allows for good correction of pronation of the hallux as evidenced by the improvement in sesamoid position. Asian feet tend to trend towards a smaller IMA, creating technical difficulties with achieving solid fixation using the dual screw MIS method. Another advantage in comparison to more established MIS techniques is the ability to weight bear immediately post-op on a Darco shoe.

Background: Hallux Valgus Surgery success depends not only on the operative technique, but also on the care of the foot during the postoperative period. Orthopedic shoes have been developed to decrease the weight load on the first ray, an excess of which might lead to a loss of fixation or pseudoarthrosis. The goal of this study was to determine how load distribution changed as the forced applied to the foot increased, with and without an orthopedic shoe. Also, we compared to different shoe models. Methods: Pressure sensors were placed under the first metatarsal head and the heel of twenty specimens of fresh cadaveric adult feet. Two orthopedic shoes were chosen, a double padded (MS) and a reverse camber shoe (RCS). 10 kg loads were progressively applied, up to 60 kg. We first compared three instances: no shoe, MS and RCS. A secondary analysis comparing barefoot versus shoes was performed. A mean comparison was performed (ANOVA/T-student). Results: The mean pressure of the heed and the first metatarsal showed that there were significant differences between groups (P < .005). The secondary analysis (no shoe vs orthopedic shoes) showed that the pressure without shoe was significantly higher than with any orthopedic shoe (P < .005). There were no statistically significant differences between models of shoes (P = .402). Conclusion: After a surgical procedure for hallux valgus fixation, postoperative shoes should be indicated to decrease the pressure on the first metatarsal head and heel in order to avoid an overload of the postoperative area.

Objective Was to evaluate radiographic parameters associated with Hallux-Rigidus via WBR and WBCT for convergent validity and to evaluate the use of the classification system used in conventional radiography with WBCT. Methods Retrospective study. 20 symptomatic Hallux-Rigidus patient with weightbearing-radiograph and WBCT. Measured parameters included HVA, IMA, 1st-TMT-joint-version, First-and-second-metatarsal-lengths, 2nd-cuneiform-2nd-metatarsal-angle, Talus-1st-Metatarsal-angle, First-and-second-metatarsal-declination-angles, and MPE. MPE was measured as the direct-distance between 1st-and-2ndmetatarsals (modified-Horton-index). Results HVA (15.73º in X-ray vs 14.04º in WBCT), AP first-TMT-version (16.25ºvs 16.47º), 2nd-cuneiform-2nd-metatarsal-angle (24.54º vs 26.60º), Talus-1st-Metatarsal-Angle (-7.67º vs -7.89º) were not different between radiograph and WBCT. MPE was measured higher in WBCT by 0.86 mm compared to radiograph. First-metatarsal-declination-angle was lower in WBCT by 2.9° indicating increased MPE. When graded with radiographic findings, 5 (25%) patients were grade 1, 5 (25%) patients were grade 2 and 10 (50%) grade 3, when graded with WBCT, 1 (5%) patient had grade 1, 3 (15%) patients were grade 2 and 16 (80%) grade 3. When graded radiologically, subchondral cyst in proximal phalanx and metatarsal head were better delineated resulting in higher radiographic grade with WBCT. Dorsal subluxation/translation of first metatarsal at first TMT joint was observed 3 (15%) in radiograph and 9 (45%) in WBCT. Conclusions Hallux-Valgus-Angle, AP first-TMT-version, 2nd-cuneiform-2nd-metatarsal-angle, Talus-1st-Metatarsal-Angle demonstrated consistent measurements in radiograph and WBCT. MPE was measured higher in WBCT when measured with direct distance (0.86 mm) between the first-and-second-metatarsals using modified-Horton-index and first-metatarsal-declination-angle (2.9°). WBCT grading-system for HR can aid in early-detection of advanced HR with high-radiographic grades and potentially guide treatment accordingly.

Background: Percutaneous surgery of Hallux Valgus (HV) uses small skin incisions to correct forefoot deformity, and shorter recovery time and smaller rate of complications have been reported. Distal first metatarsal osteotomy is used for the correction of mild or moderate HV, and multiple surgical techniques have been described. We designed a cadaveric study to compare the resistance to axial load of two distal first metatarsal osteotomies: SERI and percutaneous chevron, both of them non-fixated techniques. The first aim of this study was to develop a systematic technique to measure the sagittal displacement on the lateral foot x-ray. Our second objective was to evaluate the resistance to axial load of both these osteotomies. Methods: Ten pairs of freshly frozen cadaveric feet were randomly assigned to one of the two investigated techniques. Pre and postoperative X-rays were obtained. After surgery, the feet were placed under progressive axial load up to 60 kg. Joint angles and bone distances were measured and statistically assessed for differences between the two techniques. Results: SERI osteotomy had a statistically higher plantar displacement, when axial load was under 30 kg. From over 30 kg there were no significant differences between techniques. Chevron osteotomy had a smaller variability on the metatarsal head displacement when placed under axial load. In both of the techniques an increase on the plantar angulation was noted. Conclusion: Although chevron technique achieves a higher stability regarding the fragment displacement during axial load, both techniques show an increase of the plantar angulation of the metatarsal head.

Introduction The Lisfranc injury remains one of the most controversial topics in foot and ankle surgery. The surgical options are diverse with flexible fixation gaining momentum in recent years. We describe two examples of success using this technique. Case reports Fifty-four-year-old female, cook. Direct midfoot trauma with swelling and hematoma. Magnetic Ressonance Imaging (MRI) revealed avulsive rupture of the plantar ligament with multiple bone fragments. She underwent reduction and flexible fixation using a MiniTightrope. Forty-year-old male, construction worker. Compressive midfoot trauma. Three months later presents with persistent swelling and pain. MRI revealed plantar and interosseous ligaments lesion with medial cuneiform in situ fracture. He underwent cuneiform fixation with one screw and flexible fixation of the Lisfranc injury. Both cases had favourable evolution with clinical and radiological resolution. Discussion An increasing number of authors advocate flexible fixation in purely ligament injuries. The tarsometatarsal joint is an amphiarthrosis and limitations of rigid fixation include iatrogenic articular cartilage injury, implant fracture and the need to remove implants. Most athlete patients treated with flexible fixation returned to their sport/recreational athletic activities and their work smoothly. It is increasingly suggested that the use of this flexible structure provides better biomechanical stability, which not only duplicates the local anatomical structure, but also makes the midfoot function return to the state close to its pre-injury earlier excluding the not unusual need for hardware removal. Conclusion Our experience in the treatment of Lisfranc injuries using flexible fixation attests to the literature as an increasingly appealing and effective method.

Objective This study aimed to test the capability of the Lapidus and the Cotton procedures in conjunction with a calcaneus-displacement-osteotomy (MDCO) to improve midfoot-abduction in the setting of a collapsed-foot. Methods Prospective-cohort-study, we analyzed patients-undergoing medial-column-instability-surgery and evaluated-preoperatively with a weight-bearing-CT-(WBCT). We included individuals receiving Lapidus bone-block-procedure or a Cotton for PCFD or Hallux-Valgus (HV). Talonavicular-coverage-angle (TNCA) was measured as a marker of midfoot-abduction. Medial-arch-collapse and forefoot-varus were evaluated by sagittal talus-first-metatarsal-angle (TFMA), and forefoot-arch-angle (FFA) was measured. Associated procedures and the correction-amount (displacement-or-wedge-size) were recorded. A multivariate-regression-analysis was executed to evaluate which-of-the-measurements influenced abduction-improvement. Results A total of 20-patients, 11-PCFD and 9-HV with a mean-follow-up of 7.5months. Bone-block Lapidus was performed-in most subjects(90%), and the median-wedge used was 9mm (5-12mm). MDCO occurred in 55% of patients. All-measured variables had improvement with surgery(TNCA: 23.74 to 10.66, p<0.0001; FFA: 6.27 to 12.67, p<0.0001; TFMA:11.73 to 4.22, p=0.0003). A correlation was found between TNCA improvement and FFA improvement (rs=0.46, p=0.0407), but not among TNCA improvement and TFMA improvement (rs=0.43, p=0.06). Size-of-the-wedge did not strongly influence the TNCA-correction (R2=0.016,p=0.0036), an improvement moderately explained by the MDCO amount(R2=0.186, p<0.0001). Conclusions This-study demonstrated correction of midfoot-abduction, translated by the TNCA, in the absence of lateral-column-lengthening-procedures. When evaluating patients submitted to first-ray-procedures (bone-block Lapidus-and-Cotton) in conjunction with MDCO, an enhancement on-the-talar-head-coverage was noted. Variables associated with arch-height and forefoot-varus (FFA and TFMA) were correlated with the TNCA improvement.Nevertheless, only the MDCO-displacement amount and not the size of the used allograft wedge could explain changes in TNCA.

INTRODUCTION Metatarsophalangeal resection arthroplasty is considered a salvage surgical procedure with notable success rates in improving the quality of life of patients with major forefoot deformities. MATERIAL AND METHODS A retrospective observational study of 26 patients (33 feet) with major forefoot deformities operated by resection of metatarsal heads was performed. The mean follow-up period was 10.1 years with all patients having at least three years of follow-up. Most patients were women (88%), with a mean age of 74.2 years, and 76.9% of the patients had a personal history of any rheumatic disease. RESULTS The mean resection spaces between the base of the proximal phalanx and the metatarsal stump at the end of the study were 1.9 mm, 2 mm, 2.7 mm, and 4.9 mm, for second to fifth rays respectively. The mean sizes of remodeling osteophytes at the end of the study were 1.6 mm, 1.4 mm, 1.1 mm, and 0.7 mm, respectively. The mean preoperative hallux valgus angle was 53.3º, decreasing up to 23.8º at the end of the study. The mean scores on the AOFAS scale were 77.5 points (range 59-88) and 20.3 points (range 7.8-43.75) on the MOxFQ scale. Significant improvements in pain values registered on the visual analog scale (VAS) and in the ability to put on shoes comfortably were also reported. CONCLUSION In our experience, the classic metatarsophalangeal resection arthroplasty continues to be a valid option as salvage surgery in patients with major forefoot deformities, with satisfactory long-term functional and radiographic results.

Background: Patients with severe hallux valgus deformity present technical and operative challenges with high rates of recurrence and residual deformity. The clinical and radiologic outcomes of percutaneous surgery for severe hallux valgus are not known. Methods: A retrospective review of consecutive patients with a hallux valgus angle (HVA) >40 degrees or intermetatarsal angle (IMA) >20 degrees who underwent third-generation percutaneous chevron and Akin osteotomy (PECA) for hallux valgus deformity correction. Results: Between December 2012 and August 2019, 59 feet in 50 patients underwent PECA. Preoperative and followup radiographic data were available for 53 feet (89.8%). Postoperative clinical patient-reported outcome measures and satisfaction results were available for 51 feet (86.4%). The mean clinical and radiographic follow-up was 3.1 years and the mean postoperative Manchester-Oxford Foot Questionnaire Index score was 15.1. There was a statistically significant improvement (P < .001) in both IMA and HVA following surgery (IMA 17.5-5.1 degrees; HVA 44.1-11.5 degrees). All patients reported they were satisfied with their outcome, with 76.8% reporting they were highly satisfied. The hallux valgus recurrence rate was 7.5%. Conclusion: Percutaneous surgery for severe hallux valgus deformity can achieve a large deformity correction, patient satisfaction, and quality of life, with reasonable rates of residual deformity and low rates of recurrence.

Background: The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity. Methods: Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Results: Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 patients (93.2%). EQ-5D-5L Index scores were significantly worse for females with HV when compared with females in the general population. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R=-0.51, p<0.001) and VAS-Pain scores (R=0.54, p<0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores. Conclusion: Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with health-related quality of life measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMs do correlate with HRQOL.

Background: There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. Objective: To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures. Methods: This is a prospective single-surgeon case series of 420 consecutive feet undergoing MICA surgery between July 2014 and November 2018. Primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D-5L Index, EQ-VAS, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, and complication rates. Results: Pre-operative and 2 year post-operative patient reported outcomes were collected for 334 feet (79.5%). At minimum 2 year follow-up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 43.9±21.0 reduced to 9.1±15.6 post-operatively (p<0.001), walking and standing; pre-operative 38.2±23.6 reduced to 6.5±14.5 post-operatively (p<0.001) and social interaction; pre-operative 47.6±22.1, reduced to 6.5±13.5 post-operatively (p<0.001). At 2 year follow-up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.3±22.4 to 8.3±16.2 post-operatively (p<0.001). 1-2 intermetatarsal angle (mean ± SD) reduced from 15.4°±3.5° to 5.8°±3.1° (p<0.001) and hallux valgus angle reduced from 33.1°±10.2° to 9.0°±5.0° post-operatively (p<0.001). Conclusion: Third-generation MICA showed significant improvement in clinical outcomes at 2 year follow-up and can be successfully used for correction of a wide range of hallux valgus deformities.

Background Hallux rigidus is a common condition, with the gold-standard surgical treatment being arthrodesis. Recently, the Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst maintaining range of motion (ROM). Current evidence for Cartiva is largely based on a single cohort with mixed outcomes. We sought to evaluate the efficacy of Cartiva as compared with arthrodesis undertaken in our centre. Methods Patients undergoing Cartiva or arthrodesis for symptomatic hallux rigidus were retrospectively reviewed. Pre-operative first MTPJ arthritis was radiographically graded. Patient reported outcomes (PROMS) were assessed using EuroQol 5-dimension score (EQ-5D-5L) and Manchester-Oxford Foot Questionnaire (MOXFQ). Results There were 33 cases (17 Cartiva, 16 first MTPJ arthrodesis, mean age 59.0±9.9 years) with a mean follow up of 2.3 years. For the arthrodesis cohort, the MOXFQ domain scores were: Index 3.9±5.8, Walking/Standing 5.1±7.6, Pain 3.2±5.0, and Social Interaction 2.6±4.0. EQ-5D-5L Index score was 0.828±0.270 and the EQ-VAS was 72.5±23.3. For the Cartiva cohort, the MOXFQ domain scores were: Index 7.7±6.0, Walking/Standing 8.9±7.9, Pain 7.1±5.0, and Social Interaction 6.4±5.4. EQ-5D-5L Index score was 0.631±0.234 and the EQ-VAS was 74.8±20.8. There was no statistically significant difference between any MOXFQ domain or EQ-5D-5L scores, despite a negative trend in the Cartiva group, which also had a reoperation rate of 23.5%. Conclusions The Cartiva SCI demonstrated no advantage over arthrodesis in PROMs, despite the presumed benefit of preserved ROM. A significant reoperation rate was also observed. Surgeons should be cautious in the use of this novel implant.

Introduction: A recent study published in Nature (Venkadesan et al.) demonstrated that coupling the transverse arch (TA) with the medial longitudinal arch (MLA) significantly increased midfoot intrinsic stiffness. Progressive collapsing foot deformity (PCFD) ultimately results in loss of stiffness and collapse of the MLA. Objectives: Assess TA curvature in PCFD and controls and evaluate its relationship with accepted PCFD measures. Methods: A retrospective review of weight-bearing CT (WBCT) images was conducted for 32 PCFD and 32 controls. A novel measurement, the transverse arch plantar (TAP) angle was designed to directly measure the TA. TA curvature was indirectly measured using the equation described by Venkadesan et al. Uni- and multivariate analyses were performed to compare the TAP angle, Foot and Ankle Offset (FAO), peritalar subluxation, and 5 PCFD classification measurements. Results: The TAP angle was found to be higher in PCFD than controls with a mean angle of 115.24° (SD 10.68) and 100.76° (SD 7.92) (p<0.001) No significant difference was found in the calculated TA curvature between PCFD and controls with mean values of 17.84 (SD 4.41) and 18.18 (SD 3.68) (p=0.741) The univariate analysis showed a moderate positive correlation between the TAP angle and FAO (ρ=0.58;r2=0.34;p <0.001), Multivariate analyses showed Meary’s angle as the only predictive factor of TA collapse (β=0.55,p<0.001). Conclusion: Our direct measurement showed a collapsed TA in PCFD. However, the indirect measure did not show this difference. TA collapse was mainly influenced by Meary’s angle, further supporting the concept of TA and MLA coupling increasing stiffness.

Background: Lapidus arthrodesis is one of the most commonly used techniques in the correction of moderate and severe hallux valgus. We analyzed the clinical and radiological outcomes after using the Phantom® Lapidus intramedullary nail to find an effective technique with fewer complications. Methods: We retrospectively analyzed data of 52 patients who underwent a modified Lapidus arthrodesis with an intramedullary nail at our center from November 2019 to March 2021. The mean follow-up period was 19 (range, 12–26) months. Clinical results were evaluated using the visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society score (AOFAS); three different radiological measures were analyzed. Results: The mean AOFAS score increased from 44.8 to 82 points (P < 0.001). The mean VAS score decreased by 4.7 points (P < 0.001). The intermetatarsal angle decreased from 15° to 6.9° (P < 0.001) and the hallux valgus angle by a mean of 17.9° (P < 0.001). The forefoot width reduced from 93.6 to 84.7 mm (P < 0.001). One case of nonunion was recorded. No implant-related complications were observed. Conclusions: This device shows a great fixation power in the correction of moderate-to-severe hallux valgus. Its complication rate was not higher than that of other fixation devices. Correct compression of the arthrodesis, absence of extraosseous material, and multidirectional stability are important qualities of this implant for the correct treatment of this pathology.

Introduction: Currently, there is no universal method used preoperatively to aide in the correction of Hallux Valgus. The rule of 57 is a novel concept in orthopaedics. Its simplicity has proven valuable preoperatively to calculate the size of osteotomy required to correct bone deformities. We aimed to evaluate the use of the rule of 57 as an effective tool for Hallux Valgus surgery. Method: An in-vitro proof of concept study on models of feet evaluating the use of the rule of 57. Supplemented by a mixed-method questionnaire to gather opinions on the use of the rule of 57 from surgeons who currently perform Hallux Valgus surgeries. Results: The rule of 57 was effective at predicting the translation required to correct Hallux-Valgus in-vitro. The simplicity of the rule of 57 as a preoperative tool was recognised as a strength by the survey participants. However, participants believed that the use of the rule of 57 would not significantly improve patient outcomes. Conclusions: This study has shown that the rule of 57 has the potential to benefit surgeons. Further analysis on its use preoperatively, in-vivo, is required to assess its effectiveness more accurately as a preoperative tool and whether it would improve patient outcomes.

Proximal interphalangeal joint (PIJ) resection with or without temporary K-wire fixation is a common treatment in symptomatic hammertoe deformity. However, scientific support for the use of the K-wire fixation is lacking. In this multicenter randomized controlled trial, we aimed to evaluate the results of PIJ resection with (group A) and without (group B) four weeks of K-wire fixation. The main hypothesis is that both methods for PIJ resection will lead to similar improvement in terms of American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal scale one year postoperatively. Patients older than 18 years, diagnosed with a single hammertoe as a solitary foot problem, who underwent operative treatment between June 2014 and March 2021 were enrolled in this study. Clinical evaluation included AOFAS lesser toe metatarsophalangeal scale, foot function index (FFI) and visual analogue scale satisfaction (VAS) preoperative, 6 weeks and one year postoperative. Furthermore complications during the first postoperative year were assessed. Currently, 41 patients (group A 19 patients, group B 22 patients) completed the study. Data collection of all 42 patients will be completed July 2022. Preliminary results suggest an improvement in AOFAS score six weeks postoperative (group A 51.61 to 81.55 and group B 48.14 to 72.16), FFI (group A 23.02 to 14.46 and group B 23.52 to 17.02), patient satisfaction (group A 3.45 to 7.25 and group B 3.55 to 6.36). Statistical analyses including one year follow up and comparison between the groups will be conducted after data collection is completed (July 2022).

Every year, as many as 2 million patients worldwide present with plantar heel pain with men and women affected equally. This case reports reflects upon a healthy 46 year old female who presented with subtype of true neoplasm called a neural fibro-lipoma arising from the plantar nerve. Referred by her GP for an evaluation of a painful soft tissue mass present in the right plantar aspect of the midfoot. The mass had been present for approximately 2-3 years and had recently increased in size in the last 4 months. This 17x7x11mm painful soft tissue mass was detected by USS and showed this mass extended deep to the plantar fascia not arising from it hence ruling out the common misconception of plantar fibromatosis. It is imperative to rule out any malignancy before excising the mass which is why referring this patient to a Sarcoma MDT was essential. Other infectious differentials including septic arthritis and osteomyelitis were ruled out early since Blood counts showed CRP – 1.2mg/L, White cell count – 5.1 10*9/L, Neutrophils – 3.47 10*9/L. Arthritic differentials such as Gout were also ruled out based on blood parameters which revealed Urate – 287. The patient opted for surgical excision biopsy of the lesion. Post operative period was uneventful with good healing of the wound She was followed up 2 months and at with the histology findings results revealed a rare soft tissue neural neoplasm in keeping of a neuro fibro-lipoma. The patient was happy with the overall outcome and discharged

Introduction Hallux valgus is a common disabling foot condition that causes significant pain and inconvenience. In this study, we investigated the short-term radiological and clinical outcomes between the minimally invasive chevron/akin (MICA) technique and open scarf and akin osteotomy. Methods This is a retrospective study of a prospectively collected hallux valgus database from a tertiary hospital. Forty-three feet that underwent the MICA technique were identified and matched to a control group that underwent the open scarf and akin osteotomy. Data collected include the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal scores, Visual analog scale score, Short Form 36 Health Survey score, patient’s expectation and satisfaction, hallux valgus and intermetatarsal angles. Results Both groups showed a significant improvement at 6 months follow up (p<0.05). Using the general linear model covariance analysis to compare between methods, both groups showed comparable improvement in the clinical outcomes measured. There were significant difference in the change in HVA and IMA between both groups at the 6-months follow up (p<0.05). Conclusion In our short-term comparative study of up to 6 months, we found that the new generation MICA technique has achieved comparable clinical outcomes and significantly better radiological improvement when compared with an open procedure.

Introduction: Minimally invasive surgery (MIS) presents as an alternative in forefoot surgery, preconizing a faster recovery with less soft tissue aggression. Looked with some skepticism by some surgeons, due to the lack of internal fixation and the absence of long-term outcomes, the last generation techniques addresses this concerns with the use of rigid fixation screws. Minimally invasive chevron osteotomy (MICA) is a metaphyseal osteotomy and theoretically has more potential for correcting the hallux valgus deformity than the classic distal open chevron (OC). Methods: In this retrospective cohort study, the authors report 22 operated feet (20 patients) with MIC, with or without associated Akin osteotomy (AO). As a control group, we selected 22 feet operated with OC, in the same time-frame. The intermetatarsal angle (IMA) and Hallux Valgus Angle were measured pre and post operatively, comparing both groups correction power. Results: Both groups present similar demographic characteristics, normal distribution of the pre-operative deformity and six month follow-up. On the minimally invasive group, the IMA correction was of 9,66º (14,68º to 5,01º) and the HVA correction was of 26,67º (35,26º to 8,59º). On the open surgery group, the IMA correction was of 6,91º (13,18º to 6,27º) and the HVA correction was of 19,06º (34,07º to 15,01º). Both variables presented significant statistical difference between groups (p<0.01). Discussion: Our data confirms the hypothesis that the percutaneous chevron, being a metaphyseal osteotomy, presents a superior correction power than the classic open distal chevron osteotomy. The rigid fixation also offers additional guarantee to avoid deformity recurrence.

Several minimally invasive surgical techniques have been described for the treatment of hallux valgus. These may not include the use of screws or different stabilization methods. The aim of these techniques is to reduce the surgical trauma, complication rate and surgical time and allow a faster recovery. Our aim was to compare the clinical and radiographic results in two groups of patients treated for hallux valgus correction with the percutaneous PBS (Percutaneous Bianchi System) technique with or without a screw. One group of 58 feet treated without screw and the second group of 60 patients stabilized with a screw. The mean follow-up was 36.3 months. All patients were assessed by weight-bearing x-rays, AOFAS, VAS. and patient satisfaction. AOFAS scores improved from the preoperative assessment to the latest follow-up. The VAS score improved from preoperative to the latest follow-up. The mean Hallux valgus angle (HVA), Intermetatarsal angle (IMA) and Distal metatarsal articular angle (DMAA) significatively decreased from the preoperative assessment to the latest follow-up in both groups. The comparisons between the two groups did not showed significant differences. The results of this study show that the PBS technique is effective in the treatment of hallux valgus, even of a severe degree, in terms of symptom relief and functional improvement. Radiographic parameters also showed significant improvements in both groups. Although the results of the group fixed with screws are slightly better, the comparison between the two techniques did not show significant differences in terms of clinical and radiographic outcomes.

Background: Hallux valgus is a debilitating foot deformity that has been treated using various surgical procedures. With benefits such as enhanced cosmesis and less soft tissue traumatization, minimally invasive treatments are becoming more popular. However there is minimal literature evaluating the learning curve of this complex surgical technique. Aim: The objective of the study is to evaluate the learning curve of minimally invasive chevron akin (MICA) osteotomy Methods: 101 consecutive MICA cases performed between 2016-2020 by 2 foot and ankle surgeons at a tertiary institution were studied. Variables studied include operative time, operative blood loss, duration of exposure to image intensifier (II time), length of hospital stay, incidence of complications and radiologic outcomes. Results: 30(29.7%) of the cases were performed by Surgeon A, while 71(70.3%) cases performed by Surgeon B. Surgeons A&B achieved significant improvement (P <0.001) in postoperative mean hallux valgus angle(HVA) / intermetatarsal angle(IMA) to 6.7°(SD= 4.5°) / 6.5°(SD=2.4°) and 6.8°(SD=4.3°) / 5.8°(SD=2.4°) respectively. Surgeons A&B achieved reduction in complication rates in the subsequent half of operations performed; 30% to 13%, 13% to 6% respectively. In both surgeons, the linear regression model also showed a significant negative correlation between increasing case number and operative duration(P <0.001). Conclusion: Both surgeons saw significant improvements in HVA and IMA after MICA. The linear relationship between number of procedures performed and improved operative time underscores the importance of adequate caseload in learning this relatively new procedure.

Background: Little is known about the intersesamoid crista in Hallux Valgus (HV). However, this structure directly interfaces with the sesamoids and surrounding soft tissues and might play an important role in HV deformity. Our primary objective was to compare the angulation between the crista and first metatarsal (M1) longitudinal axis in HV and controls. Our secondary objective was to assess its correlation with the Distal Metatarsal Articular Angle(DMAA). Methods: This IRB approved retrospective case control study evaluated 9 HV and 8 matched controls. The DMAA was measured as initially described on X-Rays, and then on WBCT using a previously validated technique including M1 pronation correction (3d-DMAA). To identify the angle of the inter-sesamoid crista relative to the shaft of the 1st metatarsal, images were semi-automatically segmented to create 3D models. Principal component analysis was used to identify the direction of both the crista and M1 shaft and assess the angle. Results: There was a significant increase in valgus deviation of the crista in HV compared to controls (respectively 14.4+/-8.7° and 5.5+/-3.2°;p=0.017). Mean DMAA were respectively 25.1+/-7.9° in HV and 7.4+/-2.9° in controls(p<0.001). Mean 3d-DMAA were respectively 12.5+/-5.6° in HV and 3.1+/-2.4° in controls(p<0.001).There was a low positive non-significant correlation between the crista deviation and the DMAA(ρ=0.44;p=0.078). There was a moderate positive significant correlation between Crista M1 Angle and 3d-DMAA(ρ=0.57;p=0.017). Conclusion: The longitudinal axis of the crista deviated from M1 in valgus in HV compared to controls. This followed the 3d-DMAA pattern which reflect the valgus deviation of the articular surface.

Pathologies of the first metatarsal joint are a common occurrence, and they might be a source of chronic pain and might impair gait. They could be related to chondral surfaces, osteophytes as well as to the pathology of the sesamoid bones. Arthroscopy of the MTP I is not a routinely carried out procedure, even though there are references in the literature about the indications for such surgical techniques. We present two cases of sesamoid pathologies – stress fractures with subsequent necrosis of the sesamoids. Conservative treatment did not bring any effects , therefore patients were offered surgical treatment. Traditional surgical techniques based on the open approach requires a wide skin incision and soft tissue interference, and all the complications associated with such approach. Patients were therefore offered an arthroscopic surgical treatment. Arthroscopy of the first metatarsal joint was carried out with the concomitant repair of the chondral surface and the resection of the interposing fragment of the sesamoids. After surgery patients followed up physical therapy program and on control examinations presented resolution of pain improvement of function and gait pattern. We conclude that in selected cases arthroscopic treatment of sesamoid pathologies can be mini invasive and effective solution.

The plantar plate is a major stabilizing structure of the MTP joint with instability frequently occurring after a tear or attenuation of this structure. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint during repair. The purpose of this study is to quantify the relative contribution of blood supply to the proximal plantar plate from the metatarsal and plantar fascia. Twelve fresh-frozen human adult cadaver lower extremity specimens were utilized for this study, resulting in 35 lesser MTP joints that were studied. The specimens were prepared as described previously in Finney et al. The second through fourth MTP joints of 12 feet were imaged with nano-computed tomography (nano-CT) at 14-micron resolution. Based on nano-CT imaging, the plantar plate specimen demonstrated microvascular infiltration at the proximal attachments of the metatarsal neck, interosseous muscles, periosteum, and plantar fascia. An average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle. The remaining 36.5% of the vascular supply entered from the plantar fascia. The second toes, third toes, and fourth toes had an average of 64.7%, 59.0%, and 67.1% of vasculature supply from the metatarsal pedicle, respectively. The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. Using the McGlamry elevator for exposure of the MTP joint disrupts the dominant tributary for proximal plantar plate perfusion.

Introduction Midfoot arthritis (MA) and lesser toe deformities (LTD) are prevalent. However, the epidemiology of these disorders have rarely been reported. Therefore, the aim of this study was to investigate the epidemiology of MA and LTC using Weight-Bearing Computed Tomography (WBCT). Methods WBCT data from September 2014 to April 2022 were retrospectively recruited at a single referral institution. Descriptive analyses were completed to assess prevalence of MA, LTD, and LTD’s subtypes (mallet toe, hammer toe, claw toe, crossover toe, and curly toe). Results 606 cases (247 male, 359 female) among 1316 consecutive cases were selected. 139 male (56.3%) and 210 female cases (58.5%) showed MA. 157 male (63.6%) and 222 female cases (61.6%) showed LTD. 115 male (19.0%) and 157 female cases (25.9%) showed both MA and LTD. The prevalence of MA increased with age in both genders. However, MA in males peaked with BMI between 30 and 40 (28%) contrary to females whose prevalence increased with BMI. LTD had a similar pattern with MA in both genders according to age and BMI. The order of frequency of each LTD subtype is hammer toe (256 cases), claw toe (138 cases), mallet toe (42 cases), curly toe (36 cases) and cross over toe (21 cases). A combination of more than two of the subtypes in LTD was found in 97 cases (25.6%). Conclusion The prevalence of MA and LTD showed a similar pattern with age for both genders but varied for BMI.

Introduction The forefoot and midfoot have a close anatomical and biomechanical relationship. However, related factors of midfoot arthritis (MA) and lesser toe deformities (LTD) have been rarely reported. Therefore, the aim of this study was to investigate risk factors for MA associated with medical history and related factors in LTD by Weight-Bearing Computed Tomography (WBCT). Methods WBCT Data pertaining to foot for from September 2014 to April 2022 were extracted from a single referral hospital. All included cases were divided into two groups based on radiologic evidence from a WBCT scan. LTD were subdivided into mallet toe, hammer toe, claw toe, crossover toe, and curly toe. 24 potential factors including demographics, etiology, and common foot deformities were collected for comparison. Results 606 cases (247 males and 359 females) among consecutive 1316 cases between September 2014 to April 2022 were selected. 139 male cases (56.3%) and 210 female cases (58.5%) showed MA. In stepwise multiple logistic regression analysis, 5 factors remained statistically significant. The multivariate-adjusted odds ratios for age, laterality, BMI, PCFD, and LDT were 1.08, 1.54, 1.05, 6.62, and 3.03 respectively. In bivariable analysis, there was significant difference between MA and all LTD subdivisions. Conclusion Risk and related factors for MA associated with medical history and foot deformities included age, laterality, BMI, PCFD, and LDT.

Introduction Lesser toe deformity (LTD) and its subdivisions are known to be related to inflammatory or neuropathic etiology. However, it is difficult to identify LTD using conventional radiographs. The bony structure and alignment can be more easily detected using Weight-Bearing Computed Tomography (WBCT). Therefore, the aim of this study was to investigate related factors to medical history and foot deformities for LTD and its subdivisions as identified with WBCT. Methods WBCT data from September 2014 to April 2022 were extracted from a single referral hospital. All cases were divided into two groups by the presence of LTD. LTD cases were subdivided into mallet toe, hammer toe, claw toe, crossover toe, and curly toe. 24 potential related factors including demographics, etiology, and common foot deformities were collected for comparison. Results 606 cases (247 males and 359 females) were selected among 1316 consecutive adult cases. 157 male cases (63.6%) and 222 female cases (61.6%) showed LTD. In stepwise multiple logistic regression analysis for LTD, 6 related factors remained statistically significant. The multivariate-adjusted odds ratios for age, body mass index (BMI), hallux valgus (HV), midfoot arthritis (MA), and rheumatoid arthritis (RA) were 1.03, 1.03, 2.5, 3.04, and 8.43 respectively. For hammer and claw toe, 4 and 5 related factors remained statistically significant respectively. Conclusion Related factors for LTD associated with medical history and LTD include age, BMI, HV, MA, and RA.

Background: bioabsorbable magnesium (Mg) screws are new in the field of foot surgery. Their superiority over conventional titanium screw has not been proven. We conducted this retrospective study to compare the clinical and radiological outcomes with either bioabsorbable Mg screws or titanium screws. Methods: a consecutive series of patients (n=60; 11 male, 49 female) underwent hallux valgus corrective surgery. Minimal follow-up period was set for 1 year. Assessment based on patient questionnaire including AOFAS hallux valgus score, visual analogue scale (VAS) patient’s global impression of change (PGIC) and 5th metatarsus circumference. Radiographic assessment included intermetatarsal angle (IMA) and hallux valgus angle (HVA), as well as time to osteotomy union and hardware failure. Results: At one year similar results were obtained radiographically. Healing of osteotomies was significantly faster in the Mg group, hardware failure is estimated to about a fourth. The IF5C was only initially increased, 8±2 millimeters (p<0.05). AOFAS and PGIC scores at 6 months were similar. Conclusions: validated foot scores as well as radiographic analysis indicate that Mg implants are not inferior to conventional titanium screws. Fast achievement of osteotomy union compensates high rate of hardware failure, resulting in patient satisfaction and avoid reoperation for hardware removal.

A camera capable of analysis of photon interference patterns is relevant in medicine as all tissues emit a minute quantity of photons due to biochemical reactions. This create a photo luminescence effect of tissues. The usefulness of this device to detect and quantify foot and ankle pathologies was assessed. Methods: 53 patients with unilateral foot and ankle pain were evaluated. In all patients the cause of pain was not obvious by observation (no outside deformity). Analysis of the images was conducted measuring the interference pattern abnormalities (IPA): Consistent lines of interference pattern flow along the limb, changes in resonant frequency of the photons returned from the tissue , lack of interference pattern in affected area , size of afflicted area. IPA was correlated with results of the Brief Pain Inventory (BPI) and various imaging modalities. Statistical analysis was performed using the Analyze-It software program. Results: In 51 out of 53 patients IPA was observed in the affected limb. The correlation between the size of the IPA and the BPI score was high (R>0.85, p<0.01). Presence of gray areas of tissue was present in 47/53 cases. The correlation between radiological findings and IPA was low (R<0.5, p<0.1) but the correlation between ultrasonographic and MRI findings and interference pattern was high (R>0.9, p<0.001). Conclusion: This method allows quantification of pain in foot and ankle pathologies with a good correlation with the size of IPA. This might reduce the need for imaging and allow quick, cheap, point-of-contact analysis of foot and ankle pathologies.

Introduction: We set out to conduct a systematic review of the literature comparing the results of percutaneous Hallux Valgus (PHV) surgery with and without lateral soft tissue release (LSTR). Our hypotheses were that LSTR would 1) reduce the risk or recurrence without increasing the risk of complication and 2) lead to an improved clinical outcome with greater radiological correction. Methods: For this PROSPERO-registered PRISMA-compliant systematic review, Pubmed, Embase, Cochrane Library and Scopus were used to identify clinical papers reporting results after PHV surgery. Studies were pooled in two categories: PHV with LSTR (Group1/G1) and without LSTR (Group2/G2). Data (study design, demographics, surgical procedure and clinical and radiological outcome) were extracted and compared. The modified Coleman Methodology Score (mCMS) was used to assess the quality of studies. Results: Sixteen studies were selected (G1:594 feet; G2:553 feet). The pooled proportion of complication in the two groups (27%, 95%CI 17–38 and 25%, 95%CI 12–37, respectively) and the pooled proportion of recurrence at a minimum 18-month follow-up (2%, 95%CI 0-3 and 2%, 95%CI 0-5, respectively) did not differ (p=0.79 and p=0.70). The pre- (51.7±10.6 and 45.8±1.7 points;p=0.23) and post-operative AOFAS scores (89.4±4.3 and 86.9±3.2 points;p=0.16) and the pre-(HVA:29.7±2.9 and 44.1±26.8 degrees,p=0.23)(IMA:12.5±4.2 and 14.1±2.6 degrees;p=0.94) and post-operative radiological angles (HVA:12.1±4.3 and 12.3±2.3;p=0.47)(IMA:9.2±2.2 and 7.9±1.3;p=0.2) did not differ in the two groups. Conclusion: LSTR during percutaneous HV surgery does not seem to improve the clinical and radiological outcome nor reduces the risk of recurrence of the deformity at a mean 4-year follow-up.

INTRODUCTION: The presence of exostoses in the distal phalanx of the hallux is not described in anatomy books and its clinical significance is unknown. The aim of this work is to describe the anatomy of the distal part of the distal phalanx of the hallux. MATERIAL Y METHODS: We compared simple radiographs with computed tomography to study the distal phalanx of the hallux. We analyzed whether there were differences between the two radiological tests to detect dorsal exostoses. Statistical analysis was performed using Stata 12.0 software. RESULT: 27 patients were included. The presence of dorsal subungual exostoses was observed in 16 of the CT scans (59%). In the radiographs, exostosis was visualized in half of the patients. The mean length and height of the exostoses observed on CT was 2.69 ± 0.78mm and 1.57 ± 0.53mm, respectively. Mean distance from the exostoses to the nail was 1.07 ± 0.41mm. On radiographs the mean length was 3.24 ± 0.79mm and the mean height was 1.6 ± 0.35mm. Comparison of mean dorsal exostosis length on CT versus radiographs showed no statistically significant differences (p=0.11). Finally, a classification of the types of dorsal subungual exostoses obtained from CT is proposed. CONCLUSIONS: The presence of dorsal subungual exostoses is frequent in the general population. For its current identification,CT provides more precise information on its size and morphology, allowing us to classify it into six subgroups. However, this additional information is not sufficiently relevant to advise the use of CT instead of radiographs.

INTRODUCTION:. The stress changes that occur under the metatarsal heads when walking in high heels are a determining factor in these pressure changes. However, the use of these shoes is very common. The aim of this study is to observe how plantar pressure varies and its distribution in the forefoot with different heel heights. MATERIAL AND METHODS: We performed a baropodometric study in standing and walking on healthy volunteers in 5 conditions: barefoot, with a 0.5cm, 2.5cm, 4.5cm and 6.5cm rear wedge simulating high heel shoes. RESULTS: 12 people (5 men and 7 women) aged between 25 and 29 years and with a mean BMI of 22 participated in the study. Dynamic baropodometric study showed an increase in peak maximum plantar pressure as the heel height increased (p<0.05). An increase in the percentage of total load transmitted to the forefoot is observed with the progressive increase in heel height (p<0.05). Therefore, the pressure on the heel is lower with high heels. Forefoot loads during walking and with barefoot participants are predominantly distributed in the central forefoot. As heel height increases, metatarsal pressure is deflected medially, thus decreasing pressure on the lateral column. CONCLUSION : The use of heeled shoes produces changes in plantar pressure and its distribution. An increase in the load transmitted to the forefoot and maximum plantar pressure, increase as the heel height increases. Forefoot load distribution shifts toward the internal column.

Background: The peroneus longus (PL) is a primary dynamic stabiliser of the first ray. It attaches to the base of the first metatarsal at the peroneus longus tubercle (PLT). The position and morphology of the PLT may vary according to the direction and strength of pull of the PL, in accordance with Woolf’s law. Differences in morphology of the PLT may therefore reflect changes in the function of the PL, but this has not been well studied. This study defines the normal limits of the PLT position and rotation in patients with normal foot anatomy. Methods: A retrospective analysis of weight bearing CT studies (WBCT) at a single centre was conducted and included 131 feet in 72 patients. The position of the PLT was assessed with novel measurements examining its relation to the floor (tubercle-floor distance) and the metatarsals (tubercle-metatarsal angle). We also measured the angle between the floor and a line bisecting the PLT (bisecting angle), and the metatarsal pronation angle (MPA). Results: Observed mean values were: tubercle-floor distance 28.02mm +/-2.63mm, tubercle-metatarsal angle 32.7 degrees +/-6.32 degrees, bisecting angle 65.58 degrees +/-6.27 degrees, and MPA 6.83 degrees +/-3.19 degrees. Intra- and Inter-observer error were excellent for all measurements. Conclusion: This study reports the position and rotation of the PLT in individuals with normal feet. This normative data may be used in future studies to examine differences between groups of patients with foot pathology, helping us better understand the role of PL in the development and treatment of foot disorders.

At present, there is no consensus on the instrumentation required for taking anamnesis in clinical practice. In recent decades, the use of self-assessment questionnaires by patients has become popular. In a study with a small number of patients, drawing were examined by patients and found to be reliable. Results and discussion: 35 forms were prepared, of which 15 were diagnosed with MORTON’S NEUROMATA. Other types of diseases we have been able to characterize are HALLUX VALGUS, HALLUX RIGIDUS, AVASCULAR NECROSIS OF METATARSOPHALANGEAL JOINT (MPJ), ARTHRITIS OF MPJ, PLANTAR FASCIITIS, PLANTAR PLATE TEAR, SESAMOIDITIES, OSTEOPHYTE. The gestalt of the painting can teach us about the nature of the disease. conclusions: 1. Graphical structure of pain allows optimal diagnosis and understanding of CENTRAL METATARSALGIA 2. Intervals of disease location can be distinguished 3. The patient's explanation is more convincing and gives an advantage to the patient. 4. You can learn about GESTALT of other diseases: Hallux Rigidus Hallux Valgus Plantar Fasciitis Radicular Pain Plantar Plate Tear Achilles Tendinitis 5. Pain caused by nerves damage sometimes goes beyond the limits of the body. 6. Graphic presentation helps in taking anamnesis 7. Graphic image sharpens clinical capability in US and MRI examination 8. New body images should be prepared and divided into areas of the foot (research material below).

Introduction: Bunion consists of deformities in the axial, coronal, and sagittal planes of the first metatarsal and tarsometatarsal joint. Weightbearing CT allows for evaluation of the components of the first metatarsal along with its proximal articular surface with greater precision. This study aims to observe the effect of the midshaft osteotomy on the tarsometatarsal joint in three dimensions based on WBCT. Methods: 10 subjects underwent midshaft first metatarsal osteotomies with pre and post operative weight-bearing CT scans. Scans were segmented with 3D renderings of the medial cuneiform and the first metatarsal were also generated to evaluate changes in the metatarsal in relationship to the medial cuneiform at the tarsometatarsal joint. Results: The measurements of the rotational parameters showed greater changes in the sagittal plane postoperatively with dorsiflexion of the first metatarsal relative to the medial cuneiform at the first tarsometatarsal joint (p<0.05). Post-operative changes in the coronal plane and axial plane with relationship of the first metatarsal to the medial cuneiform were noted. Distance mapping showed a significant increase in surface-to-surface distance at the dorsal tarsometatarsal joint with a reduced distance at the inferior portion of the tarsometatarsal joint. Discussion: Based on the results of the study, midshaft osteotomies of first metatarsal can cause increased dorsiflexion in the sagittal plane, significant eversion in the coronal plane, and external rotation in the axial plane at the tarsometatarsal joint. Distance mapping analysis on WBCT images identified differences in surface-to-surface interaction of the first metatarsal and the medial cuneiform.

Background: Autologous matrix-induced chondrogenesis (AMIC) has gained popularity in treating osteochondral lesions of the talus and has shown promising short-term results for using the I/III collagen bilayer matrix. We present the first 10-year results of this technique. Methods: All patients underwent an open AMIC procedure for a talar osteochondral lesion ICRS Grade IV. Data analysis included general demographics, preoperative MRI findings, intraoperative details, and Foot-Function-Index (FFI-D) pre-, 1, 5, and 10 years following surgery. At ten years, EFAS-Score was also included. The primary outcome variable was the longitudinal effect of the procedure. Results: 21 consecutive patients were included (8 female and 13 male), 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 FFI-D decreased significantly from pre- to one-year postoperative (56±18 vs. 33±25; p=0.003), with a further, non-significant decrease between one- and five-year follow-up (33±25 vs. 23±20; p=0.457). At ten years, we saw consistent results with an FFI-D of 15±12. The EFAS Score was 17,9 ± 4,18 (max 24), the EFAS Sports Score was 10,6 ± 12,1 (max. 16). BMI and size of the lesion showed a positive correlation to pre- and postoperative scores. The major limitations were persistent moderate pain during activity, especially running. Conclusion: AMIC significantly improves pain and function at the 5- and 10-year follow-up. The most distinct improvement was seen within the first year. We did not see any deterioration of the results from 5 to 10 years.

Background: Malnutrition, or hypoalbuminemia, is defined as a serum albumin level less than 3.5 g/dL. This study aims to investigate the effect of hypoalbuminemia on the rates of complication, readmission, reoperation, and mortality following hindfoot and ankle fusions. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2007-2019 to identify 336 patients (low albumin=32, normal albumin=304) undergoing subtalar (n=167), ankle (n=118), triple (n=76), and/or pantalar (n=18) fusions. Demographics, medical comorbidities, functional dependency, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. As defined by NSQIP, functional dependency is a trichotomous variable (i.e., dependent, partially dependent, independent) that reflects a patient’s ability to engage in activities of daily life. The cohort was predominantly female (51.2%) and mean age was 59.0 (range, 21-89) years. Results: The groups were demographically similar. Hypoalbuminemia patients were significantly more likely to have insulin-dependent diabetes (low=34.4%, normal=7.9%; p<.001), actively be on dialysis (low=12.5%, normal=1.0%; p<.001), and be functionally dependent (low=18.8%, normal=3.6%; p<.001). LOS was significantly greater among the low albumin group (low=5.44 days, normal=2.08 days; p<.001). Complication (low=12.5%, normal=5.6%; p=.125), readmission (low=10.3%, normal=4.8%; p=.427), and reoperation (low=6.3%, normal=2.6%; p=.252) rates did not differ between groups. Conclusion: Malnourished patients are not at an increased risk for 30-day complication, readmission, or reoperation following hindfoot or ankle fusion, despite having a worse preoperative comorbidity profile. However, these patients did have a LOS more than twice as long as the normal albumin cohort.

Background Hindfoot malalignment is a recognized cause of various foot and ankle problems. For more accurate surgical correction of hindfoot malalignment, the reliable intraoperative determination of hindfoot alignment is important. However, there has been no standard method of intraoperative assessment of hindfoot alignment. We devised a modified Méary view to assess intraoperative hindfoot alignment. The purpose of this study was to compare this intraoperative method to other hindfoot alignment measurements. Material and methods Forty-three patients with various foot and ankle conditions who scheduled to get surgery were prospectively recruited. Before the surgery, Saltzman view, Long axial views and Méary PA view were taken in a controlled and standardized fashion. Modified Méary views were obtained on the simulated weight bearing condition using C-arm fluoroscopy in the operation room before surgery. Relationship between three radiographic hindfoot alignments was evaluated by a Pearson’s correlation. Results The mean hindfoot alignment angle was 2.73 degrees(CI,1.29-4.31) on the Saltzman view, 1.36 degrees(CI,0.01-2.72) on the long axial view, -0.47 degrees(CI,-2.01-1.06) on the Méary PA view and 0.85 degrees(CI,-0.47-2.18) on the modified Méary view. The modified Méary view and three other hindfoot alignment views were found to significantly correlate.(r=0.60 for Saltzman view, r=0.34 for Long axial view, r=0.71 for Méary PA view, P <0.05 respectively) Conclusion We found significant correlation between the modified Méary view and three other hindfoot alignment views. The results of our study suggest that the modified Méary view could be used as a reliable intraoperative assessment tool of hindfoot alignment.

Introduction and Aim: The osteochondral lesions of the talus are majorly traumatic and talus is commonly affected, as 60 % of it is covered by cartilage . There is limited potential to heal due to poor regenerative capacity and paucity of blood supply.This study aims to evaluate medium term functional outcome of AMIC procedure for osteochondral lesions of the talus and to correlate the relationship between the size of the lesion,age , functional outcomes and failures.The patients with displaced or partially displaced lesions were included along with those where conservative management failed. Methods: it was a retrospective study from Jan 2015-March 2019. 25 patients were included from a single centre (Single surgeon), standing radiographs and MRI-pre and post operative were taken for all patients. During the procedure micro fracture was combined with application of Chondro-gide, a porcine collagen type I/III matrix & fibrin glue application Pre and post operative American Orthopedic Foot and Ankle Score (AOFAS) and Visual analogue (VAS) score were done for analysis and follow up- 3 months,6 months, 12 months. Results :Mean age was 36 years and etiology was 23 traumatic ,2 non traumatic,mean follow up was 24months (95% CI-19.80-28.28), Mean size of the osteochondral lesion was 1,74 cm2 Mean difference between preoperative and post operative AOFAS score was 49.40(CI-53.21-45.59)(p<.05) ans VAS score was 5.36CI(4.75-5.97) (p<.05 Conclusion: AMIC with Chondro-gide matrix procedure for >1 cm2 osteochondral lesions of talus is a one-step surgical technique with excellent to good results.

Background: Charcot arthropathy is a neurotraumatic and degenerative foot disorder commonly seen in patients with dense peripheral neuropathy. This study aims to evaluate the outcomes of beaming arthrodesis in a series of patients with midfoot and hindfoot Charcot arthropathy. Methods: We retrospectively identified 12 patients with midfoot (Brodsky I, n=7) or hindfoot (Brodsky II, n=5) Charcot who underwent medial column beaming arthrodesis between 2015 and 2021 by one of two fellowship-trained foot and ankle surgeons at an academic medical center and followed up for at least one year (mean=2.50 years, range=1.04-6.98 years). Six (50.0%) patients presented with preoperative ulceration. Data collected from patient charts included demographics, medical history, postoperative complications, and 90-day reoperation rate. Additionally, Meary’s angle was measured on lateral radiograph preoperatively and at 3-months, 6-months, 1-year (n=11), and 2-years (n=5) postoperatively. Results: Ten (83.3%) patients showed improvement of the Meary’s angle within the two-year follow-up period (preop=19.3degrees, 2-year=10.2degrees). Although insignificant, ulcer patients had greater postoperative alignment at 3-months (ulcer=4.8degrees, no ulcer=3.1degrees; p=.689), 6-months (ulcer=8.8degrees, no ulcer=5.3degrees; p=.551), and 1-year (ulcer=10.4degrees, no ulcer=0.9degrees; p=.099). Overall complication, nonunion, infection, reoperation rates were 50.0% (ulcer=66.7%, no ulcer=33.3%), 25.0% (ulcer=33.3%, no ulcer=16.7%), 41.7% (ulcer=50.0%, no ulcer=33.3%), and 8.3% (ulcer=16.7%, no ulcer=0.0%). Patients with and without ulceration did not differ in any of these measures (p=.567, p=1.000, p=1.000, p=1.000), although the ulcer group fared worse in each. Conclusion: Although the results showed a relatively high complication rate, beaming arthrodesis was able to restore midfoot anatomy and decrease the recurrence of plantar ulceration.

Background: Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet’s (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (β) of the calcaneus (CL angle = α − β). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet’s angle. Methods: The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient—horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and β angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed. Results: The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy. Conclusion: Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning.

Objective: We aimed to evaluate whether addition of early extracorporeal shockwave therapy (ESWT) to physiotherapy improved outcomes in patients with acute plantar fasciitis. Method: We conducted a randomised controlled trial in a tertiary hospital in Singapore. Eligibility criteria were patients ≥21 years old presenting from April 2017 to November 2019 with untreated plantar fasciitis for <1 month with no prior physiotherapy. Exclusion criteria included history of plantar fasciitis, calcaneal fractures, chronic steroid use, pregnancy, chronic limb injuries and risks for venous thromboembolism. Patients were randomized using a random number generator into either Group A (ESWT + physiotherapy) or Group B (physiotherapy only). Visual Analogue Scale (VAS), SF-36 and AOFAS scores were measured at baseline and 3-months. T-tests were performed for statistical significance. Result: 46 patients were eligible for the trial. 10 were lost to follow up. 15 in Group A and 21 in Group B were treated and assessed. Mean age was 51.6. Baseline VAS scores were Group A (5.5±2.3) and Group B (6.1±2.1) (p=0.451). There was no significant difference in 3-month VAS scores between Group A (4.7±2.2) and Group B (5.2±2.6) (p=0.543). Baseline AOFAS scores were Group A (72.7±12.8) and Group B (73.9±14.2) (p=0.801). There was also no significant difference in 3-month AOFAS scores between Group A (76.7±5.1) and Group B (77.2±13.4) (p=0.876). No significance difference in SF-36 scores were seen at 3-months between the two groups. Conclusion: The addition of early ESWT to physiotherapy did not result in better outcomes compared to physiotherapy alone for acute plantar fasciitis.

Subtalar arthrodesis is used in the treatment of painful and/or deforming conditions of the hindfoot. The goal is to obtain a rigid, painless, normal-aligned hindfoot. Traditionally, the open approach was the most common, however, the advancement of arthroscopy has boosted arthroscopic subtalar arthrodesis, which has proven to obtain at least the same results, but with series showing less complications. We performed a retrospective review of all patients who underwent arthroscopic subtalar arthrodesis between June 2018 and December 2021. 17 patients (9 females and 8 males) with a mean age of 58 years (ranging from 41 to 71 years) underwent arthroscopic subtalar arthrodesis with 2-cannulated screw fixation. 4 of these patients underwent combined talonavicular arthrodesis, 1 of them arthroscopic. After surgery, they followed a rehabilitation protocol. The mean follow-up time was 12 months (ranging from 8 to 16 months). There was a clinical improvement in the scores evaluated (VAS, AOFAS, SF-36). A subjective assessment of patient satisfaction was also made, 8 being “very satisfied” and 9 “satisfied”. We had a rate of 100% of union in the control radiographs at 12 weeks. In one of the cases we had a case of nonunion of the talonavicular arthrodesis. We had no complications of the operative wound. We had a case of transitory paresthesias of tibial nerve and a casa of peroneal tenosynovitis that resolved. Over the past few years, arthroscopic subtalar arthrodesis has proven to provide at least similar results to the open technique, with even better fusion rates and lower complications.

Background: Up to 25% of Achilles tendon ruptures are initially missed, leading to poor clinical outcomes. We have observed that many patients describe this injury as ‘someone kicked me from the back but when turned around to look, nobody was there’ (the phantom!). We wanted to test whether this ‘phantom kick’ description is unique to this particular injury and therefore could aid in improving its earlier diagnosis. Methods: A retrospective study of all patients who attended the Glasgow Royal Infirmary Emergency Department with lower limb soft tissue injuries in 2020 and 2021 was done. Eligible patients were asked to complete a questionnaire. One of the questions asked them about the sensation they experienced following the injury, with the ‘phantom kick’ symptom being one of the options. The sensitivity and specificity of the ‘phantom kick’ was then calculated in relation to Achilles tendon ruptures. Results: 280 patients in total were contacted to complete the questionnaire. The response rate ranged from 43% to 51%. The sensitivity and specificity rates calculated were 75% (Confidence Interval: 62-88%) and 94% (CI: 89-99%) respectively. The odds of selecting the ‘phantom kick’ option were 45 times greater in patients with Achilles tendon ruptures compared to patients with soft tissue knee injuries and ankle sprains (p<0.001). Conclusion: The ‘phantom kick’ has a high specificity score comparable to other diagnostic tests for Achilles tendon ruptures and can therefore be used as an effective screening tool and a pointer to the diagnosis of this injury.

Chronic Achilles tendon ruptures, defined as a rupture for more than 4 to 6 weeks, remain a challenging condition to diagnose and treat. The palpable tendon gap or a positive Thompson test that is usually present in an acute setting is often absent in a chronic rupture, since scar tissue fulfills the gap between tendon ends, thus falsely suggesting an uninterrupted tendon. Patients reports pain in the calf and limping after a trauma There are currently no clear evidence-based guidelines on the optimal treatment for these patients. Flexor hallucis longus (FHL) has been advocated as the ideal candidate for tendon transfer, used in reconstruction and augmentation techniques, as it provides both mechanical and biological advantages. This procedure can be performed with the classic open procedures with an extensive surgical approach in a relative hypovascularized zone, which was susceptible to wound complications. Endoscopic transfer of flexor hallucis longus reduced wound complications and has shown good to excellent outcomes. In fact, after transferring the FHL, the patients have been showing the ability to wear regular shoes wear and recover the ability to do a single-heel rise. In this article, we describe a successful treatment of 11 patients with FHL endoscopic transfer to treat chronic achilles tendon rupture and a review of the current evidence an outcome of this treatment, as well as a description of the surgical technique. This minimally invasive procedure has been offering an exceptional functional improvement, benefiting the reduced complications from this approach.

Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The pre-injury median TAS score was 4 point and unchanged at the last follow-up. The mean ATRSs and AOFAS Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score one point lower than that at pre-injury and with less favorable clinical outcomes.

Objective: To assess the agreement between semi-automatic 3D measurements and manual measurements derived from WBCT images in patients with end-stage AO who underwent TAR. Methods: In this retrospective IRB (ID #201904825) approved study, we evaluated patients who underwent a lateral trans-fibular approach for TAR for end-stage ankle OA. The study included 14 ankles from 14 patients. Raw multiplanar data was analyzed using the CubeVue® software. Lateral talar station (LTS) was obtained in the sagittal plane and Hindfoot Moment Arm (HMA) and Talar Tilt Angle (TTA) were calculated in the coronal view. Semi-automatic 3D measurements were performed using the Disior® software. Intra-rater reliabilities were analyzed using ICC. Agreement between methods was tested utilizing Bland-Altman plots. Each measurement was assessed using the Wilcoxon signed-rank test. Alpha risk was set to 5% (α = 0.05). P-values of ≤ 0.05 were considered significant. Results: Reliabilities using ICC ranged from moderate to almost perfect for manual and semiautomatic WBCT measurements in the preoperative and postoperative groups for HMA and LTS. There was high correlation between parameters calculated from manual and semi-automatic measurements and strong agreement between the readers and software in both groups. Conclusions: Manual (M) and semiautomatic (SA) 3D measurements expressed excellent agreement for pre and postoperative groups, indicating a high correlation between the parameters calculated, and a strong agreement between the readers and the software in both groups.

Lesion size in Osteochondral lesions of the talus (OLTs) is to be considered while choosing a treatment, as clinical outcome decreases after microfractures at mid-term, in larger lesions. Regenerative techniques, such as autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), bone marrow–derived cell transplantation (BMDCT) and autologous matrix-induced chondrogenesis (AMIC), are higher quality treatments and the results may be less impacted by the size of lesion. Purpose of this study is to systematically review clinical studies reporting the impact of size on clinical outcome, following regenerative treatment for OLTs. Sixteen studies (471 ankles) were identified. The mean follow-up was 51,5 ± 7,2 months; the lesion area was 192 ± 139 mm2. AOFAS score improved from 58.6 ± 7.7 pre-op to 88.5 ± 9.4 at final follow-up. Five studies (follow up 34.5±5.9 months) found significative inverse correlation between lesion size and clinical outcome. Mean lesion area was 188±63 mm2 in 4 studies and volume 2400 mm3 in one. No correlation was evident in the remaining studies. The studies with no correlation had a significatively longer follow up with respect to the others. The lesions treated with regenerative techniques are larger than those treated by microfractures, still it was not possible to detect a cut off size after what the use of a regenerative technique is discouraged. Higher level clinical evidence is necessary to further investigate this topic and give a more detailed algorithm treatment.

Background: Double arthrodesis of the subtalar (ST) and talonavicular (TN) joints, along with isolated TN arthrodesis, are commonly performed for hindfoot osteoarthritis and rigid hindfoot deformity. This study evaluates the effect of surgical construct on outcomes of double or isolated TN arthrodesis. Methods: We identified 64 patients (64 feet) who underwent double (n=52) or isolated TN (n=12) arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon at an academic medical center with at least three months of follow-up (mean=1.48 years, range=0.27-4.39 years). ST constructs included one (n=4) or two (n=48) cannulated screws, while TN constructs included a dorsal plate (n=2), dorsal plate and screw (n=12), isolated screws (n=4), screw and staple (n=32), or isolated staples (n=14). Given the few cases in which TN constructs included solely plates or screws, these constructs were excluded from comparative analysis. Weightbearing radiographs were obtained preoperatively, at first weightbearing follow-up, and at final follow-up. Results: Among TN constructs, the time to ST (plate+screw=0.54 years, screw+staple=0.27 years, staple=0.28 years; p=.018) and TN (plate+screw=0.48 years, screw+staple=0.27 years, staple=0.29 years; p=.034) fusion was significantly quickest among patients receiving a screw and staple or isolated staple construct. Postoperative complication and reoperation rates did not differ by ST or TN construct. Overall cohort rates of complication, 90-day readmission, and reoperation were 25.0%, 4.7%, and 10.9%, respectively. Conclusion: These results demonstrate utilization of a screw and staple or isolated staple construct have a quicker time to fusion than plate and screw constructs for the TN joint.

Autologous chondrocyte implantation (ACI) is an established procedure in the ankle providing satisfactory results. The development of a completely arthroscopic ACI procedure in the ankle joint made the technique easier and reduced the morbidity. The purpose of this investigation was to report the clinical results of a series of patients who underwent arthroscopic ACI of the talus at long term follow-up. Forty-six patients (mean age 31.4 ± 7.6) affected by osteochondral lesions of the talar dome (OLT) received arthroscopic ACI between 2001 and 2006. Patients were clinically evaluated using AOFAS score pre-operatively and at 12, 36, 87 months and at final follow-up at 198±11,56 months. The mean pre-operative AOFAS score was 57.2 ± 14.3. At the 12-month follow-up, the mean AOFAS score was 86.8 ± 13.4 (p = 0.0005); at 36 months after surgery, the mean score was 89.5 ± 13.4 (p = 0.0005); at 87 months of follow-up the score was 92.0 ± 11.2 (p = 0.0005) whereas at the final follow up it was 78,6 ± 20,4. Nine patients failed (31%) and underwent a new surgery. This study confirmed the ability of arthroscopic ACI to repair osteochondral lesions in the ankle joint with satisfactory and durable clinical results after long-term follow-up.

Purpose: The Hindfoot Moment Arm (HMA) was developed to evaluate the hindfoot alignment on X rays, and was recently introduced into the field of WBCT by Saltzman et al. The authors of this study have noticed that it is very difficult to determine the long axis of the tibia using the Saltzman WBCT HMA technique. This study was to introduce a modified technique and compare the inter and intra-observer reliabilities between the modified and the Saltzman WBCT HMA techniques. Methods: HMA was evaluated on WBCT scans of 10 healthy foot and ankles using both techniques. In the modified technique, the sagittal plane thickness of one scan cut was increased to include the full width and length of the tibia and the axis of the distal tibia. Results: Both techniques had excellent intra- and interobserver reliability (Saltzman WBCT HMA intra-observer ICC=0.97, inter-observer ICC=0.94; the modified WBCT HMA intra-observer ICC=0.99, inter-observer ICC=0.91). Conclusions: The modified WBCT HMA was equivalent to the Saltzman technique in both inter and intra-observer reliabilities. The authors found that the modified technique was easier and less time consuming to perform in identifying the axis of the tibia since the modified technique uses multiple cuts to restore the full thickness of tibia, which not only reduces potential error, but also saves time during measurements. Compared with a relatively shorter tibia in one cut, the reconstructed tibia provides a longer and clearer shaft to work with, which allows both proximal and distal circles to be drawn with higher precision.

Purpose: This study was to evaluate extent of the calcified enlargement of the Achilles insertion using a newly developed angular measurement pathologic Achilles insertion angle (PAIA), and compare it among groups with different hindfoot and arch height alignments. Methods: Weightbearing lateral Xrays of 85 patients with symptomatic Insertional Achilles Tendinopath (IAT) were reviewed. PAIA, a lateral view of subtalar joint alignment (LVSJA), calcaneal Pitch angle, ratio of the Medial Cuneiform Base Height/Cuboid Height, ratio of the Medial Cuneiform Base Height/Fifth Metatarsal Height were evaluated. Results: The average PAIA was 12.56°(2.45-29.79), with 69.41% neutral, 16.47% varus and 14.12% valgus hindfeet. There were significant differences in Pitch angle, the Medial Cuneiform Base Height/Cuboid Height between the valgus and varus, the valgus and neutral, but not the varus and neutral hindfoot groups. The PAIA difference between the neutral and varus groups was significantly larger than the others. There was no significant correlation between PAIA and the calcaneal Pitch angle, and the two arch height indexes. Conclusion：This is the first to include the morphology of the calcaneus, the hindfoot and arch height features in assessing IAT. It has found that patients with a varus hindfoot had a much smaller Achilles insertion calcification than those with a neutral hindfoot. Further investigation with a larger sample size to study possible correlations among clinical symptoms, calcaneus morphology, and alignment of the feet will be helpful to guide both diagnosis and treatment of IAT in particular when combined malalignment in the hindfoot and midfoot is presented.

Between 2014 and 2021, 22 patients (16 male) with acute Achilles tendon rupture underwent an endoscopic assisted Flexor Hallucis Longus (FHL) tendon transfer. Their mean age was 56 years, and their mean BMI was 28.9. The left foot was involved in 12 cases. A magnetic resonance imaging (MRI) was performed on all patients to confirm the diagnosis, and all patients were operated on within seven days post-injury. The patient was lying in a prone position with a thigh tourniquet. Access to the hindfoot area was achieved through standard posterolateral and posteromedial portals. After meticulous debridement, the FHL tendon was identified, mobilized, and harvested. Under fluoroscopy, a calcaneal tunnel was established with a cannulated drill (usually no more than 7 mm in width). The tendon stump was fixed with an interference screw with the ankle in full plantar flexion. A below-knee cast in full equinus was applied for two weeks, and then it was changed to a walking boot for one month. A physiotherapy protocol focused on early weight-bearing with functional rehabilitation was suggested for all patients. Patient satisfaction was assessed with The Achilles tendon Total Rupture Score with a mean value of 86,8±17,4. Complications were reported in 2 patients (one stiffness and one intraoperative screw breakage). Passive and active range of motion and calf and ankle circumference have also been recorded and assessed. An MRI was obtained at six months postoperatively, showing Achilles tendon continuity (integrity) in all patients. All the patients return to their pre-traumatic level of activity.

Objective To use 3D distance maps(DMs) and coverage maps (CMs) from weight-bearing-CT (WBCT) images to assess subluxation across the Chopart joint in PCFD patients. We hypothesized that CMs would show decreased coverage indicative of subluxation through regions of the Chopartjoint in PCFD patients when compared to controls. Methods Retrospective-study, we analyzed WBCT of 20-consecutive-patients with flexible-PCFD and 20-controls. Coverage-area was divided into six-regions on the talar-head and 4 on the calcaneal-cuboid-articular-surface. Novel 3D-distance-mapping (DM) technique was used to objectively characterize joint-coverage across the entire Chopart-surface on both talus-and-calcaneus. Distance-maps were measured in millimeters and colored-to-highlight-covered-areas. Distances-less-than 4mm were defined to be covered, while areas with distances-greater-than 4mm uncovered. Joint-coverage was defined as percentage-of-articular-area with DMs lower than 4 mm. Coverage-Maps (CM) were built highlighting areas-of-coverage (teal) versus non-coverage (pink). Foot-and-Ankle-Offset-(FAO) was used as a reference semi-automatic three-dimensional-measurement. Results The superomedial and the inferomedial regions of the talar-head were found to have 75% and 79% decrease in coverage in PCFD-cases relative to the controls (ps<0.003). Medial side of the head had an overall-increase in coverage (ps<0.002). Calcaneal-cuboid-joint plantar-region was found to have a significant coverage-decrease of 12% relative to the controls (p=0.037), while the lateral-quadrant observed a 13% increase (p=0.002). Conclusions Our results support the hypothesis that significant-changes occur at the Chopart-joint in early-flexible-PCFD-cases. Increased-coverage in the lateral-region of the talar-head and decreased-coverage in the medial and plantar regions point to internal-rotation of the talus indicating subluxation through the entire joint. Coverage-3D-mapping enabled objective subluxation quantification through the Chopart-joint in early-stage-PCFD.

Objective To evaluate improvements of PTS, subtalar-joint articular-coverage, and extra-articular impingement following PCFD joint-sparing surgical-treatment, as well as the influence of these improvements in patient-reported outcomes. Methods Prospective-comparative-study. Adult-PCFD patients that failed conservative-treatment for three-months and underwent hindfoot-joint-sparing surgical-procedures by a single-surgeon. Realignment soft-tissue and bony-procedures performed were recorded. All-patients underwent Weight-Bearing-CT-(WBCT) preoperatively, and at 3-and-12-months follow-up. Two-observers performed traditional WBCT PCFD-measurements. The-foot-bones were segmented, and distance-measurements were performed along-the-entire 3D-superior-surface of the calcaneus, including subtalar-joint (SJ) articular-facets (anterior, middle, and posterior), sinus-tarsi and subfibular-area. Color-coded coverage-maps (CM) were calculated to grade the amount-of-articular-joint-coverage and extra-articular-impingement. Patient-Reported-Outcomes-(PROs) were recorded at all follow-up time-points. Results Twenty-patients (15F/5M), mean-age, BMI, and follow-up of respectively 48.1-years, 33.88-kg/m2, and 13.2-months. Significant-improvements in all traditional PCFD WBCT-measurements were noted postoperatively. Articular-coverage (CM) of the SJ middle-and-anterior-facets improved postoperatively by respectively 13.5%-(p=0.02) and 78%-(p=0.001). Similarly, improvement in sinus-tarsi-impingement, with a 69% decrease in sinus-tarsi-coverage was observed-(p<0.001). Significant PROs improvements were-also-noted, with Pain-Catastrophizing-Score (PCS) improving from 13.4 to 5.2 (p=0.0032) and European-Foot-and-Ankle-Score-(EFAS) from 6 to 8.5 (p=0.036). Improvements in PROs for PCS and EFAS were explained its majority-by-improvement in SJ articular-coverage and sinus-tarsi-impingement, with R2 values of respectively 84% and 92% for PCS and EFAS. Conclusions We found significant improvements in the subtalar-joint (SJ) anterior-and-middle-facet articular coverage as well as significantly decreased sinus-tarsi and subfibular-impingement. Most importantly, we found that PTS and SJ articular coverage improvements were the most important variables to influence Patient-Reported-Outcomes. Three-dimensional-evaluation of PTS and joint-coverage can hopefully optimize treatment and improve-outcomes in PCFD.