Background
various mediators of inflammation are associated for development of osteoarthritis after cartilage trauma. Increasingly recognized is the presence of synovitis in a significant proportion of patients with osteoarthritis.

Objectives
Purpose of the study is to do literature review of bio markers that can help us to guide therapies in future and detect osteoarthritis early.This review will discuss a evolving data leading to our current hypotheses regarding the role of inflammation in OA onset and progression. 

Study Design & Methods
Search was made in Pubmed using key words for biomarkers and post traumatic ankle arthritis. Few human studies and animal studies were selected for the review . 

Results
It was seen that although the inflammation markers were high initially for first few weeks it lowers thereafter .Early therapies targeting the early inflammation seems to give promising results but their effectiveness is questionable due to paucity of evidence. 

Conclusions
In Future more studies are Required to provide high quality evidence for treatment of posttraumatic osteoarthritis.

Background
The purpose of this human specimen experimental study was to compare the fixation stability of clinically used bilayer collagen membrane with fibrin glue (Chondro-Gide, Geistlich Pharma AG, Wollhusen, Switzerland) with trilayer collagen prototype without fibrin glue in chondral defects at the medial or lateral talar shoulder.

Methods
Eleven human specimens were used.  The membranes were implanted in standardized chondral defects at the medial and lateral talar shoulder (randomized).  All tests were performed in load-control (15kg).  Range of motion (ROM) of each ankle was examined individually before testing. The average ROM was 10° dorsalextension (range 0°-20°) and 30° plantarflexion (range 20°-45°).  1,000 testing cycles with the defined ROM were performed.  Two independent investigators, blinded to fixation and membrane type, visually assessed the membrane fixation integrity for peripheral detachment, area of defect uncovered, membrane constitution and delamination.

Results
The clinically used bilayer collagen membrane plus fibrin glue showed higher fixation stability than the trilayer prototype (all p<0.05). No significant differences occurred between medial and lateral talar shoulder location (all p>0.05).

Conclusions
The fixation stability of the trilayer collagen prototype without fibrin glue is lower than of the clinically used bilayer membrane with fibrin glue in chondral defects at the medial and lateral talar shoulder in an experimental human specimen test.  Clinical use of trilayer collagen prototype without fibrin glue has to be validated by clinical testing to evaluate if the lower stability of fixation is still sufficient.

Background
The aim of the study was to compare Matrix-Associated Stem Cell Transplantation (MAST) with Autologous Matrix Induced Chondrogenesis plus Peripheral Blood Concentrate (AMIC+PBC) in chondral lesions at the ankle.

Methods
In a matched-patient clinical follow-up study, patients that were treated with AMIC+PBC from July 17, 2016 to May 31, 2017, and patients that were treated with MAST from April 1, 2009 to July 15, 2016 were included and compared.  Bone Marrow Aspirate Concentrate (BMAC) was used for MAST and Peripheral Blood Concentrate (PBC) for AMIC+PBC to impregnate a collagen matrix (Chondro-Gide, Wollhusen, Switzerland) that was fixed into the chondral lesion with fibrin glue. Size and location of the lesions and Visual-Analogue-Scale Foot and Ankle (VAS FA) before treatment and at follow-up were compared. 

Results
One hundred and twenty-nine patients with 136 chondral lesions were included in both groups.  The lesions were located as follows (MAST/AMIC+PBC, n (%)), medial talar shoulder only, 59 (43)/62 (46); lateral talar shoulder only, 44 (32)/42 (31); medial and lateral talar shoulder, 7 (10)/7 (10); tibia, 19 (14)/18 (13). The lesion size was 1.6/1.8cm2 on average and VAS FA was 46.9/45.7 (MAST/AMIC+PBC).  For MAST/AMIC+PBC groups, 107 (83%)/105 (81%) with 112/110 previous chondral lesions completed the defined 2-year-follow-up after 24.4/23.8  months on average.  VAS FA improved to 82.3/79.8 (MAST/AMIC+PBC).  No parameter significantly differed between MAST and AMIC+PBC.

Conclusions
MAST and AMIC+PBC as part of a complex surgical approach led to improved and high validated outcome scores in 2-year-follow-up.  MAST and AMIC+PBC showed similar results.

Purpose: Systematic review and meta-analysis of outcomes of the AMIC procedure in osteochondral lesions of the ankle, Grade III/IV.

Methods: Studies with a minimum follow-up of 1 year and minimal sample size over 5 that provided clinical results of AMIC repair in the ankle were included based on PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses). The methodological quality of the included studies was assessed by the modified Coleman Methodology Score (mCMS).

Results: 12 studies (454 patients) reporting clinical outcome after AMIC procedure were included. The mCMS was affected by associated surgeries, which are part of the standard of care in osteochondral lesions. Based on the 454 patient population, the mean age was 35 years (12 to 73 years), the mean defect size was 1.51 cm2  (0.2-6 cm2). Significant pain relief was reported in all studies. VAS decreased from 2-10 preoperatively to 0-6 at 5 years postoperatively. AOFAS ankle score improved from 16-79 preoperatively to 28-100 within 5 years postoperatively. MOCART score values increased from 19-66 at the first postoperative year to 20-95 within the 5 postoperative years. The treatment effect was highly significant in FFI, AOFAS, VAS, and MOCART with a 95% confidence interval. Three cases of revision surgery were reported.

Conclusions: In the meta-analysis, the AMIC procedure in the ankle appeared to provide a significant improvement of the clinical status and functional scoring versus preoperative stage. Evidence has generally been obtained in a non-selected patient population, corresponding thus to real-life treatment of ankle OCL.

INTRODUCTION: We used axial loading computed tomography (AL CT) to evaluate preoperative and postoperative talocrural joints of patients who underwent supramalleolar osteotomy (SMO) to treat varus ankle osteoarthritis.

METHODS: We performed retrospective analyses of 16 patients (18 feet) who underwent SMO and fibular osteotomy. Radiographic assessment was performed with weightbearing radiographs and AL CT. Clinical outcomes were assessed based on American Orthopaedic Foot & Ankle Society (AOFAS) scale, visual analog scale (VAS) for pain, and Foot and Ankle Ability Measure (FAAM).

RESULTS: The mean 2-year follow-up tibial-ankle surface angle, talar tilt angle, Takakura stage, and tibial-lateral surface angle were all significantly different relative to preoperative parameters (P < .05). The mean 6-month follow-up talus rotation ratio was significantly corrected compared to the preoperative value (P = .001). The mean 2-year follow-up AOFAS, VAS at gait, and FAAM scores were all significantly improved relative to preoperative measurements (P = .001).

DISCUSSION & CONCLUSIONS: Abnormal internal rotation of the talus in mild to moderate varus ankle osteoarthritis found on AL CT was significantly corrected after SMO.

Background: In 2018, we started to revise mobile-bearing total ankles with painful instability to a 2-component design. The impact of this novel treatment option on clinical outcomes measures was assessed in the present study.

Methods: Twenty-six patients who underwent a conversion from a mobile-bearing into a fixed-bearing total ankle due to soft tissue overload with concomitant instability were retrospectively analyzed. The mean follow-up time was 1.4 (range 1.0-2.0) years. The clinical outcome was assessed using the Visual Analogue Scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and a 4-point Likert scale (1 = very good, 4 = bad).

Results: VAS for pain improved from mean 6.0 (4-9) before to 3.1 (0-8) after revision surgery (P=<.0001). Similarly, we found evidence for improvement of the AOFAS hindfoot score from mean 53.4 (9-93) before to 68.8 (24-100) after revision surgery (P=.007). Patients were more satisfied after conversion (P=.014). During to follow-up period, one ankle underwent removal of the prosthesis components followed by a hindfoot fusion. Persistent pain was the reason for failure in this case.

Conclusions: Soft tissue overload with concomitant instability is a severe issue when using a 3-component prosthesis design. Increasing the intrinsic stability of the total ankle by converting a 3-component to a 2-component system was found to alleviate pain and improve ankle function.

Background: The purpose of this study was to assess the gained motion after TAA in end-stage ankle OA, and to evaluate whether there is a benefit for patients who underwent an additional heel cord lengthening (HCL).

Methods: Overall, 1074 primary TAA (1006 patients, mean age 62.5 [17-88] years) were performed between May 2003 and December 2017. After prosthesis insertion, the ankle was gradually mobilized into dorsiflexion. If a minimum of 10 degrees of dorsiflexion could not be obtained, an HCL was performed. Ankle range of motion (ROM) was determined with the use of a goniometer preoperatively (PreOP), one year postoperatively (PostOP), and at the last follow-up (LastFU; 5.1 [0.6-15.2] years).

Results: Preoperative ankle ROM increased from mean 30.6° (0-69) to 33.4° (5-65) one year postoperatively, and decreased to 30.9 (0-70) degrees at the LastFU (each P<0.001). Ankle ROM improvement after TAA was higher in ankles with a low preoperative ROM (P<.0001). A higher pain level (P<.0001) and a lower satisfaction score (P<.001) PostOP and at the LastFU were associated with decreased ankle ROM. HCL showed no effect on VAS for pain (P=.090) or patients’ satisfaction (P=.275).

Conclusions: TAA seems to have little potential to increase ankle ROM. The higher pain level and decreased patients’ satisfaction in case of a lower ankle ROM following TAA confirms the importance of preserving ankle motion in patients with end-stage ankle OA. The effect of HCL on ankle ROM is disappointing.

Background: Chronic lateral ankle instability is a common problem following ankle sprains. The modified Brostrom-Gould procedure (MBG) is the gold standard surgical treatment but has a known failure rate of up to 10%, or even more in high-risk groups. Periosteal flap augmentation (PFA) has been proposed to strengthen the repair. This study aims to compare the outcomes of MBG with and without PFA.

Methods: A matched pair study was performed based on prospectively collected registry data for all patients undergoing lateral ankle ligament reconstruction in a tertiary institution. Patients who underwent the MBG with PFA were matched in a 1:1 ratio with patients undergoing MBG alone, based on age, gender, and body mass index (BMI). Clinical outcome scores were compared pre-operatively and at 2 years post-operatively.

Results: 48 patients were included in the study (24 in each group). The mean age was 24.1 years, mean BMI was 23.1, and all patients were male. The baseline demographics and clinical scores in both groups were similar. Both groups demonstrated significantly improved AOFAS Ankle-Hindfoot scores at 2 years post-operatively (p<0.001). At 2 years post-operatively, there was no difference in total AOFAS scores between groups (PFA score 90, MBG score 88, p=0.79), however the PFA group had slightly superior improvement in the “walking surfaces” component of the score (p<0.05). There were no recurrences of instability or revision surgeries.

Conclusion: Compared to the MBG alone, PFA demonstrates a small benefit in terms of negotiating uneven walking surfaces. This may be important in high-demand patients.

The brostrom with the Gould modification operation has been reported to have excellent outcome in chronic ankle instability. In this study, clinical and radiologic outcome was retrospectively compared between the brostrom with the Gould modification operation only and the case with nonabsorbable suture tape.

The research subjects included 77 patients satisfied the condition of weight under BMI 26.61 kg/cm² and follow-up duration over two years (between 48 and 59 months) after the operation. The average age of the subjects was 30.65. For clinical assessment, indicators such as FAOS, AOFAS, FAAM score, Sefton grading system, and the period to return to various activities were used. Talar tilt angle (TTA) and anterior talar translation (ATT) degree was measured using stress radiograph to check the “maintenance” condition of mechanical ankle joint stability.

In a comparison between a group that used internal brace and another group without an internal brace, FAOS, AOFAS, FAAM and VAS score improved at the final follow-up (with : 91.11±5.17, 92.45±2.19, 88.06±4.51, 1.53±0.69 / without : 91.33±5.4, 92.47±2.49, 83.33±4.79, 1.2±0.66) (P = .85, .97, <.001, .04). Sefton grading showed a satisfying functional outcome [with : 43 cases (90.0%) / without : 27 cases (89.3%) ]. TTA and ATT showed a recovery at the final follow-up (with : 13.06±1.55→5.47±0.43, 16.29±2.94→5.82±1.05 / without : 9.27±1.46→4.35±0.35, 10.13±2.23→2.17±0.71) (P < .001).

The patients with an augmentation of nonabsorbable suture tape showed better clinical outcomes and improvement of mechanical stability than the patients who received the brostrom with the Gould modification operation only. 

In the present study, we examined whether intraoperative ultrasound guidance was effective during repair of Achilles tendon rupture. An internal brace (Achilles Midsubstance SpeedBridge repair, Arthrex Inc.) was used as it facilitates strong internal fixation. A total of 34 patients were included, and the procedure was performed with (group A, n=13) and without (group B, n=21) intraoperative ultrasound guidance. In group A, ultrasound imaging was performed while passing sutures through the proximal Achilles tendon stump using jigs to ensure that each suture was placed in the middle of the tendon stump. Patients started exercising for dorsiflexion one day after the procedure, and were allowed to use loads without orthoses after achieving 0 degrees of dorsiflexion. We reviewed the operative time, Japanese Society for Surgery of the Foot(JSSF) ankle/hindfoot scale, findings on magnetic resonance imaging (MRI) 3 months after the procedure, and occurrence of any complications. Compared with group B, group A had a shorter operative time and less high-signal-intensity areas on T2-weighed MRI. There was no significant difference in the JSSF scale between the groups. There were no cases of re-rupture or surgical site infection. Our findings suggest that the use of ultrasound guidance may improve suturing in terms of accuracy and strength.

Background

Average length of stay after an ankle replacement is 2 to 4 days. Our unit started offering day case ankle replacements to patients in November 2017. The aim of the study was to confirm the safety & cost effectiveness of day case ankle replacement surgery by reviewing the two-year results. Our hypothesis was that the patients undergoing day case ankle arthroplasty would have equivalent short-term outcomes and satisfaction with no readmissions in the first 4 weeks at a significantly lower cost.

Methods

A new day case pathway for ankle arthroplasty was set up in consultation with all stakeholders. Patients were given crutches before surgery. Post-operative pain relief was optimized, and patients were reviewed within 2-5 days.

Results

20 ankle replacements performed as day case over a two-year period from November 2017 were reviewed. No patients required readmission within the first 4 weeks. There were no complications related to day case surgery. All patients except one rated the experience as excellent or good.

Conclusions

Average cost reduction was £880 per case when compared to 20 inpatient procedures from the previous years. With proper patient selection, education and multi-disciplinary protocols ankle arthroplasty can be safely carried out as daycase procedure.We feel that proper patient selection and education, multi-disciplinary protocols and a well-defined clinical pathway are key to successful day case ankle arthroplasty. Learning from successful implementation of this pathway, in our unit we perform all elective foot and ankle procedures (ankle/hindfoot fusions, osteotomies and tendon transfers) as day case whenever feasible.

Background:

Non-insertional achilles tendonitis is prevalent in runners and difficult to treat. Patients who do not respond to conservative treatment are candidates for surgery. There is no consensus in literature regarding the best surgical option for these patients. Aim of our study was to assess early results from a combination of achilles tendoscopy and proximal medial gastrocnemius release (PMGR).

Methods:

We retrospectively reviewed 10 consecutive patients who underwent this combination surgery. Outcome was assessed by visual analogue scores (VAS) for pain and patient satisfaction.

Results:

Mean age of 47.2 years with a mean follow up of 16.2 months. Nine patients were symptom free by 12 weeks. There was no correlation between VAS score improvement and age p=0.6 or follow-up duration p=0.2. Nine out of 10 patients were happy with the outcome. All patients returned to pre-disease level sporting activity by 12 weeks. There were no complications.

Conclusions:

Based on our early results, we feel that this combination surgery is safe and does not cause significant additional morbidity compared to either procedure on its own. We also recommend releasing the plantaris tendon while performing the tendoscopic debridement.

Abstract

Total ankle arthroplasty (TAA) has good clinical outcomes; however, several complications have been reported. Arthrodesis or revision arthroplasty has often been chosen as a salvage operation for failed TAA, but bone defect is a difficult problem in cases of subsidence of the talar component. Here, we have reported an operative method of revision TAA using a custom-made alumina ceramic total talar prosthesis for failed TAA in patients with subsidence of the talar component.

Method

We performed four revision TAAs at 50.0±14.2 months after primary TAA between July 2019 and March 2020. All talar components had subsided severely before revision TAAs. The surgery was performed using an anterior longitudinal incision. After removal of the tibial and talar components and resection of the entire remaining talus bone, a new artificial tibial component was placed on the tibia and an artificial total talus was inserted. The mean follow-up period was 6.0±3.3 months. Clinical outcomes were determined.

Result  

 The mean operation time was 139.8±25.2 minutes. No complications such as infection or prolonged wound healing were reported during the follow-up period. All patients were satisfied with the surgery.

Conclusion

Although careful long-term observation is required, revision TAAs using total talar prosthesis is considered a reliable option for treatment of failed TAA in cases of subsidence of the talar component. 

Background

Chronic lateral ankle instability (CLAI) is treated operatively, while the acute ligament injury, so-called ‘ankle sprain’ is primarily treated nonoperatively with good clinical outcomes. This widely accepted opinion has been proved by clinical scoring, physical examination, stress radiographs, ultrasonography, or magnetic resonance imaging. However, there has been little report of histological biochemical evidence focused on apoptosis that occurred in torn lateral ankle ligament although apoptosis was demonstrated as a considerable cause of ligament degeneration.

Aim

To elucidate the apoptosis occurs within the lateral ligament complex especially anterior talofibular ligament (ATFL) of CLAI.

Method

ATFL tissue was collected prospectively from 15 patients (group C) who underwent modified Broström surgery and 10 patients (group A) who underwent ankle fracture surgery. We assigned ankle fracture patients as alternatives to the acute ankle sprain group to harvest acutely injured ATFL. Immunoassay of caspase 3/7, 8, 9, and cytochrome c activities was performed to determine the intracellular apoptosis pathway. Apoptotic cells were determined by TUNEL (terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling) staining, and immunohistochemistry was performed.

Results

The apoptotic activities of ATFL from group C were significantly higher than those of group A in biochemical and histologic factors of our study.

Conclusion

This study demonstrated that the degenerated ATFL following CLAI showed higher apoptotic activity than acutely sprained ligament. We tried to elucidate the clinical relevance between our laboratory research and previous knowledge. Based on our findings, we could remind previous understandings about surgical indication and timing of lateral ankle ligament injury.

Background

The aim of this study is to describe the early clinical and radiological outcomes of the treatment of patients who underwent an ankle replacement from the lateral transmalleolar approach

Methods

Between 2015 and 2020 a group of 46 patients underwent a lateral approach total ankle replacement. The standard clinical assessment of the AOFAS score, the VAS and FAAM-ADL score were collected pre- and post-operatively, with a minimal follow-up of 12 months. The radiological outcomes were based on standard weightbearing radiographs taken before the surgery, 6 months post-op and during the last visit.

Results

Preoperatively, the means of AOFAS and VAS scores were 40.1 and 7.2 respectively and at the last follow-up visit were 84.5 and 1.7. The mean of the preoperative FAAM-ADL score was 33.1 and at the last follow-up visit was 70.3.  

The radiological assessment showed good positioning of the implants.

In 3 cases early complications occurred -  1 fracture of the medial malleolus, 1 loosening of the tibial component and 1 breakage of the plate used for supramaleolar osteotomy. In 1 case there was a late deep infection.

24 patients (52.2%) had to undergo additional procedures.

All procedures were performed without tourniquet; 1 patient needed a blood transfusion.

 Conclusions

Early results of the lateral approach total ankle replacement show high levels of patient satisfaction and the possibility of anatomical restoration of ankle joint alignment. However, it is necessary to extend the observation period.

[Purpose]

Problems associated with mid- to long-term total ankle arthroplasty (TAA) include loosening and sinking of the talus implant. In Japan, aluminum ceramic talus implants have been developed and are reported to result in good treatment outcomes. Here we investigated and report the treatment outcomes for combined TAA (CTAA), in which TAA is combined with a talus implant during the initial procedure.

[Subjects and Methods]

We assessed 22 cases involving 23 feet that underwent CTAA for which follow-up was available for at least 6 months. The mean follow-up period was 12.4 months. The talus implant was completely customized for all cases, and TNK Ankle tibial components were used. Assessments were performed before and after surgery using JSSF（Japanese Society for Surgery of the Foot） scale for physician-led objective evaluation and SAFE-Q subscales for patient-reported subjective evaluation. Scores were compared using paired t-tests.

[Results]

The mean JSSF score improved significantly from 51.3 points preoperatively to 87.3 points postoperatively. For the SAFE-Q, pain and pain-related scores improved significantly from 41.3 preoperatively to 79.8 postoperatively (p<0.001), physical function and daily lifestyle status improved significantly from 41.6 preoperatively to points postoperatively (p<0.001), social lifestyle function improved significantly from 34.3 preoperatively to 78.2 postoperatively (p<0.001), and overall sense of health improved significantly from 51.3 preoperatively to 82.4 postoperatively (p<0.001).

[Discussion]

Short-term outcomes for CTAA were mostly good in our study population. These findings reveal new possibilities for expanded indications going forward. However, as these were short-term treatment outcomes, further follow-up is required in future studies.

Background: Matrix Induced Autologous Chondrocyte Implantation (MACI) is an established treatment method for larger joints and has shown promising results in the ankle as well. We present a series of post ankle MACI patients with long-term follow-up of clinical and radiological outcomes.  

Methods: Follow-up of 15 patients who underwent MACI grafting from August 2003 to February 2006. Mean follow-up was 12.9 years. Clinical evaluations were conducted using the AOFAS, FAAM and VAS scoring systems and MOCART scoring system for radiological evaluation. 

Results: The mean size of the talar osteochondral defects was 204 mm². We found a significant improvement in mean AOFAS score from 60  preoperatively to a mean of 84 at 12 years  postoperatively The 12 year FAAM score for ADL was 89% (range, 62 to 99). The mean 12 year MOCART score was 65 points (range, 30 to 100) with significant agreement between assessors (P< .001). However, the MOCART scores did not correlate with FAAM scores (P=.86). 

Conclusion: Considering long-term follow-up, we believe MACI is a reliable treatment method for talar osteochondral defects providing lasting pain relief and satisfying clinical results. However, with an equivalent outcome, but at higher costs, and requirement for two operative procedures the results do not seem to be superior to other established methods. The clinical utility of the MOCART score requires further scrutiny since we were not able to show any correlation between the score and clinical outcome. 

Introduction
Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program.

Methods

Retrospective case series of 32 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. 
A standardised postoperative rehabilitation protocol was established. FAAM scores were collected postoperatively. 

Results

The average follow-up was 12 months. Total FAAM score for ADL was 93±10.3% (range, 56 – 100%) and for sport activities 82±21.9% (range, 33 – 100%). The rating of mean postoperativ function for ADL was 91±11.8% (range, 33 – 100%) and 84±23% (range, 1 – 100%) for sport. Twentyseven  patients (90%) rated their overall current level of function as normal or nearly normal.  

Discussion

This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Further follow up will address long term outcomes, requirement for removal of devices and how well the Internal brace is tolerated.

Failure of ankle arthrodesis or total ankle replacement (TAR) results in a challenging clinical situation and may take the form of symptomatic nonunion following arthrodesis and aseptic or infective loosening following TAR. Revision in these scenarios is technically demanding, and if associated with subtalar degeneration, conversion to tibiotalocalcaneal (TTC) arthrodesis may be required, with use of bone grafting to maintain length and reduce disability. Fibular strut grafting in the form of pillars or columns, potentially supplemented by tricortical and iliac graft, may be used in association with intramedullary TTC nailing or lateral plating and has demonstrated encouraging fusion rates. In this technical note, we review the history of this technique and report indications and surgical approach. Furthermore, of 6 cases (mean age 69.8 years) treated at our institution and followed at 13 months (range, 8 to 20 months), 5 (83%) were clinically and radiologically united, and patients were satisfied with the outcome of surgery. One patient with a background of chronic kidney disease remained dissatisfied with no union achieved, persistent pain, and awaiting a below-the-knee amputation. No other complications were observed. TTC fusion augmented with fibular columns and iliac crest autograft is an

option to treat combined ankle and subtalar joint pathologies with significant talar bone loss.

Background: While ankle-foot injuries are ubiquitous and affect ~16% of all military service-members, granularity of the evidence in this population is lacking. Therefore, the purpose of this retrospective cohort study was to characterize ankle sprains in the US military between 2009 and 2013.

Methods: Healthcare utilization data was derived from the Military Health System Data Repository, which encompasses all in- and out-of-network medical care provided to military members. Diagnosis and procedural codes were used to identify and categorize ankle sprain as being isolated lateral, isolated medial, concurrent medial/lateral, unspecified, or concomitant ankle sprain with malleolar or fibular fracture. Frequency of discrete episodes of care (≥60 days apart), surgical cases, and related healthcare costs were assessed within 1-year following injury.

Results: 30,648 distinct patients were included: 68.2% diagnosed with unspecified ankle sprains, 23.0% with concomitant fracture, 6.9% with isolated lateral sprains, 1.7% with isolated medial sprains and 0.3% with combined medial/lateral sprains.  Pertaining to recurrence, 56.2% had only 1 episode of care, 43.8% with ≥2 episodes, and 2.7% with ≥5 episodes within one-year following the index injury. Sprains with fractures had the highest 1-year median costs (USD $1975); unspecified sprains had the lowest cost (USD $1065). Sprains with fractures were ~2-4 times more likely to have surgery within 1-year following injury (38.7% with fractures; 10.2% with unspecified sprains).

Conclusion:  Ankle sprains were primarily diagnosed using non-specific codes. Fractures were common, which warrants routine clinical examination. Approximately 44% had multiple discrete care-episodes within 1-year following injury, a potential prognostic indicator for chronicity.

Background and objectives

Posterior ankle impingement syndrome is commonly described in athletes, and often diagnosed in a non-athlete population after trauma such as an ankle sprain. Together with clinical examination, magnetic resonance imaging (MRI) is considered the golden standard for diagnosis. As only few data are available, we investigated the prevalence of posterior ankle impingement on MRI in a non-athletic patient population.

Methods 

Data from a cohort study of 194 primary care patients with a recent history (6-12 months) of an ankle sprain were used. All MR images were scored for signs of posterior impingement in a standardized manner. We also developed new measurement methods for investigating a low-lying flexor hallucis longus muscle belly and the posterolateral talar process on MRI, both suggested as causal factors for posterior impingement. 

Results 

The measurements showed a mean posterolateral talar process length of 1.83 mm (SE 0.11 mm).  5% of study patients had a length of 4.16 mm or higher. The mean FHL muscle-tendon transition length was 1.23 mm (SE 0.53 mm) below the distal tibia, with 5% of patients having a length of 10.70 mm or higher. In our study population, 48.5% had MRI features of posterior ankle impingement, 37 (19.1%) patients had an os trigonum/shepherd fracture, 12 (6.2%) accessory muscles, and 44 (22.7%) signs of flexor hallucis longus tenosynovitis. 

Conclusion

Posterior ankle impingement features on MRI were present in almost half of patients a non-athletic patient population. Therefore, clinical correlation is essential to determine their relevance. 

Introduction: It is recommended in patients with syndesmotic ankle injuries to perform a radiographic comparison with the contralateral uninjured ankle. However, to what extend the three-dimensional (3D) congruency in the normal ankle syndesmosis is symmetrical, remains unknown. Therefore, we performed a side-to-side comparison using a non-weightbearing (NWBCT) and weightbearing CT (WBCT).

Methods: In this retrospective comparative cohort study, patients with a NWBCT (N=38; Mean age=51.6 years; SD=17.4) and WBCT (N=43; Mean age=48.9 years; SD=14.3) were analyzed. Inclusion criteria were a bilateral NWBCT and WBCT of the ankle. Exclusion criteria consisted of hindfoot pathology and an age below 18- or above 75years. The left 3D ankle reconstruction was superimposed on top of the right and anatomical landmarks were determined on the fibula using computer-aided software operations (Fig. 1A). The side-to-side differences of these landmarks allowed to establish reference values within two standard deviations. 

Results: Reference values are given for each 3D measurement (Fig 1B). The highest difference in fibular translation was detected anterior-posteriorly (Mean AP_NWBCT=0.2mm; 2SD=3.2/Mean AP_WBCT=-0.1mm; 2SD=2.3). The highest difference in fibular rotation was detected in the external-internal direction (Mean EI_NWBCT=-0.4°; 2SD=8.7/ Mean EI_WBCT=-0,3°;2SD=5.3). No statistical significant difference could be detected in the measurements from the normal ankle syndesmosis in a NWBCT compared to a WBCT scan (P>0.05).

Conclusion: This study provides reference values concerning the three-dimensional configuration in the normal ankle syndesmosis based on side-to-side comparison. In clinical practice, they could aid in distinguishing a patient with a syndesmotic ankle lesion from a normal variance in syndesmotic ankle symmetry. 

 Background: Coronal plane ankle joint alignment is typically assessed using the tibiotalar angle(TTA), which relies on the anatomical axis of the tibia(AAT) and the articular surface of the talus. Often, the AAT differs from the mechanical axis of the lower limb (MAL). We set out to test our hypothesis that the TTA using the MAL would differ from the TTA measured using the AAT in patients with ankle osteoarthritis.

Methods: Standardized standing long leg radiographs of 61 ankles with end-stage osteoarthritis were analyzed. Wemeasured the MAL and the AAT. A line was drawn along the talar articular surface(TA) and the TTA was calculated usingboth the MAL(MAL-TA) and the AAT(AAT-TA). The mechanical axis of the tibia(MAT) was also recorded and the MALMAT angle calculated. The difference between MAL-TA and AAT-TA and its correlation with the MAL-MAT angle were assessed. Intra- and interobserver agreement were measured for MAL-TA and AAT-TA.

Results: The mean MAL-TA was 91.4 degrees (95%CI, 88.5-94.4) and the mean AAT-TA was 91.2 degrees (95%CI,88.6-93.9). The difference ranged from −8.1 to 7.8 degrees, and was greater than 2 and 3 degrees in 42% and 18% of thepatients, respectively. The difference (absolute value) also strongly correlated with the MAL-MAT angle (r=0.91,p<.001). Intra- and interobserver reliability were excellent for both MAL-TA (intraclass correlation coefficient[ICC], 0.93 and 0.91, respectively) and AAT-TA (ICC, 0.91 and 0.89, respectively).

Conclusion: We recommend that surgeons consider using the MAL-TA, which relies on long leg radiographs, especiallywith proximal deformity, to more accurately measure coronal plane ankle joint alignment.

Introduction:

Adult acquired flatfoot deformity (AAFD) is a complex three-dimensional (3D) pathology primarily affecting the hindfoot. Understanding of AAFD progression and severity in the hindfoot have seen significant advances, but its effects on the ankle are not well characterized under loading. This study sought to use 3D distance maps (3DDMs) to objectively characterize the effects of AAFD on the tibiotalar joint under normal weightbearing conditions.

Methods:

With IRB-approval, 15 AAFD and 9 control patients who underwent weightbearing CT (WBCT) were evaluated retrospectively. 3DDMs were generated from WBCT data across the entire tibiotalar interface. Each DM consisted of thousands of individual measurements across the talar dome, which was divided into a 3-by-3 grid to evaluate coverage and distances in each region.

Results:

In AAFD feet, talar dome coverage was lower in anteromedial (57.3%, p<0.003), anterior middle (43.4%, p<0.006), and anterolateral (35.5%, p<0.02) regions and higher in posteromedial (51.2%, p<0.005), posterior middle (50.4%, p<0.0002), and posterolateral (69.3%, p<0.001) regions. Similarly, the anteromedial (50.4%, p<0.0003) and anterior middle (34.3%, p<0.004) regions had significantly higher average 3D distances (joint space widening) while medial (25.0%, p=0.14) and lateral (18.4%, p=0.17) gutter increases were non-significant.  

Conclusion:

Our 3D distance maps findings are consistent with increased plantarflexion, anterior translation, eversion and possible external rotation of the talus underneath the mortise in patients with AAFD, when compared to controls. Decreased anteromedial and increased posterolateral talar dome coverage as well as widening of the anteromedial aspect of the ankle joint were hallmarks of our results.  Further studies are needed.

Introduction:

Compression sonography has been introduced for non-invasive measurement of compartment elasticity and possible diagnostic tool for acute or chronic compartment syndrome in studies using human cadaver and animal models.

To date, standard values in healthy subjects are not available. The aim was to define the standard compartment elasticity in healthy human subjects and to assess the reliability of this measurement method.

Methods: In 60 healthy subjects, using ultrasound, depth of the tibialis anterior compartment was measured while applicating 10mmHG and 80mmHG of external pressure. A pressure manometer on the ultrasound head was used to monitor the externally applied pressure. The ratio of the two values defined the elasticity. In 10 subjects, two examinators conducted each two measurements to assess the reliability.

Results: Mean elasticity of the tibialis anterior compartment was 15.9% (standard deviation: 3.7; range: 5.0 – 22.2). There was no significant correlation with lower leg circumference, height, weight, BMI, gender, hours of sport per week and type of sport (e.g. weightlifting/ cardio). Intraobserver reliability showed an interclass correlation (ICC) of 0.89 for the more experienced and 0.79 for the less experienced observer. Interobserver reliability showed an ICC of 0.78.

Discussion: Mean elasticity of the tibialis anterior compartment in healthy subjects was 15.9%. The elasticity did not show a dependence on demographic parameters or amount or type of sport conducted. This measurement method is reliable with very high intra- and interobserver correlation.

Chronic ankle instability is due to the tear of the lateral ligament complex mainly Anterior Talo-Fibular Ligament(ATFL). Main mechanism of injury is ankle plantar flexion and inversion and 20% associated with symptomatic  ATFL +/- Calcaneo-Fibular Ligament(CFL) injury.  Isolated CFL injury  is uncommon and is due to dorsiflexion and inversion. Aim of this study is to assess the efficacy of symptom control mainly ankle pain and instability with ATFL repair and augmentation with InternalBrace. We included all the patients who had double suture anchor ATFL repair and augmentation from 2016 to 2019. All patients had non weight bearing cast for two weeks followed by Weight bearing and physiotherapy. Patient were assessed 2wks, 6wks ,3 months, 6 months and +/- in 1 year following surgery. All had preoperative MRI scan those who did not have positive MRI scan had positive examination under anaesthesia(5/42). There were 42 patients, 24 male and 18 females. The mean age is 39.8 years. Mean follow up is 8 months. Three had underline generalised ligamental laxity.
Five patients continued to have lateral ankle pain 6 months after the surgery. One patient(2.38%) with a Beighton’s score of 6, developed recurrent instability confirmed to have re rupture and had to undergo revision surgery. The Sefton grade was measured post-operatively in follow up visits, at the final follow up 95.2% of patients rated good to excellent outcome. ATFL repair and augmentation is a reliable technique which allowed early weight bearing and return to activity, higher patient satisfaction and lower re-rupture rate.

Introduction

Muscle tightness is a common form of soft tissue dysfunction, with various established contributing factors. The gastrocnemius is one of the most commonly tightened muscles of the lower limb, and has a fundamental role in the mechanics of the knee and ankle joint. The purpose of this study was to describe the “Hands to Knee” sign for the first time and its association with isolated gastrocnemius tightness (IGT). The “Hands to knee” sign is observed when the sitting patient involuntarily reaches for the affected knee with their hands when lifting up the foot for examination. 

Methods

This was an observational study conducted over a 6 month period in an outpatient setting, within a regional orthopaedic unit. 30 patients were identified – all were referred to a specialised foot and ankle clinic. All patients with a positive “Hands to Knee” sign were assessed by senior author TB using the modified Silfverskioeld test. 100% of our cohort was female, average age was 55.7 with a range of 20-77 years.

Results

There was a statistically significant association between a positive “Hands to knee” sign and IGT (p-value <0.001). 

All patients demonstrating a positive “Hands to Knee” sign were shown to have IGT, using the modified Silfverskioeld test.

Conclusion

There are limited clinical signs described in the context of IGT. We describe the “Hands to Knee” sign as a simple and reproducible clinical test. The authors of this paper have observed a statistically significant association between IGT and the “Hands to Knee” sign.

Posterior ankle impingement syndrome (PAIS) is commonly described in athletes, yet often diagnosed in a non-athlete population after trauma such as ankle sprain. Together with clinical examination, magnetic resonance imaging (MRI) is considered the golden standard for diagnosis. However, little data is available on the prevalence of MRI findings of PAIS in these patients. Therefore, we investigated the prevalence and relevance of MRI findings of PAIS in this population. 

We re-analyzed the data from Van Ochten et al., a cohort study of 194 primary care patients with a recent history (6-12 months) of an acute ankle sprain. MR images were scored in a standardized manner for anatomical risk factors of PAIS. Since no clear definitions exist in the literature, we developed new measurement methods for investigating a low-lying flexor hallucis longus muscle belly and the posterolateral talar process on MRI and set up a standard for normal versus abnormal anatomy. 

Measurements showed a mean posterolateral talar process length of 5.23 mm (+/- 0.28 mm) with a 95th percentile of 9.99 mm and a mean FHL muscle-tendon transition length of 0.79 mm (+/- 0.50 mm) below the distal tibia, with a 95th percentile of 11.00 mm. 48.5% had MRI findings of PAIS, in which 37 (19.1%) patients had an os trigonum/shepherd fracture, 12 (6.2%) had accessory muscles, 44 (22.7%) showed signs of FHL tenosynovitis and 1 patient had a loose body.

PAIS signs and risk factors are highly prevalent on MRI. Therefore, clinical correlation is essential to set the diagnosis.  

Introduction :  National cohorts give valuable insights about total ankle replacements (TARs) outcomes.  While survivorship beyond 5 years are uncertain, little is known about the revision rates of these replacements in France. This study aimed to investigate the surgical trends, implants survivorships and risk factors of TARs in France using our national database. 

Methods : We included patients hospitalized from 2010 to 2019 who underwent TARs and identified from our national exhaustive database.  Demographics, discharges, procedures and implants were extracted.  Kaplan Meier estimations and Cox’s proportional hazards regression models were performed to modelize time to revision, evaluating the survivorship free of mechanical revision and the overall survivorship free of any revision.  Adjusted hazard ratios were reported.  

Results: A cohort of 4,748 patients was extracted, with a mean age of 63 years.  The mean follow-up was 5 years (range, 1 – 10 years).  Revisions were noted in 817 cases, including 734 cases for mechanical revision and 83 cases for infection.  The 1-year, 2-year, 5-year and 10-year survivorship free of any revision was 94%, 89%, 83% and 76%, respectively.  Younger age, implants design, simultaneous osteotomies and/or fusion, and an institutional volume ≤ 15 procedures per year were found independent predictors of mechanical revision and revision for any cause.

Discussion: In the largest series to date from France, the 10-year survivorship free of any revision was 76% and consistent with registries from other countries.  Patients’ selection seems mandatory to mitigate risk factors for revision, namely the youngest patients and those with malalignment.

Background

This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst areas of future research and prognostic factors.

Methods

A scoping review was performed according to the frameworks of Arksey and O’Malley, Levac and Peters. An electronic search was completed in PubMed, Embase, Emcare, Cinahl, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria.

Results

In total, 747 unique articles were identified, of which 73 (9.8%) met all selection criteria criteria. A variety of treatment methods are described in the literature, with flexor hallucis longus tendon transfer being the most common.  The American Orthopaedic Foot and Ankle Society (AOFAS) score was the most commonly reported outcome emasures, although 16 other measures were reported in the literature. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%).

Discussion

Although beneficial results were reported following a variety of techniques, comparison is challenging due to low-level study design and confounding factors such as tendon gap size and treatment delay. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient.

Purpose

This study aims to assess the short term outcomes of non-operative treatment in the management of chronic Achilles tendon ruptures.

Methods

A retrospective review of all patients receiving non-operative treatment for chronic Achilles rupture (>28 days between injury and treatment), in the senior author's clinic between December 2014 and May 2019 was performed. All patients were managed according to the described Leicester Achilles Management Protocol, an eight-week functional dynamic regime.

Results

A total of 17 consecutive patients with a minimum follow up of 6 months were managed non-operatively. The cohort included eight males and nine females with a mean age of 63.4 14.3 years. The mean time from injury to start of treatment was 43.9 days (range 30 - 102 days). The mean ATRS at 6 months post treatment was 53±17.8. A total of 10 patients were also available for 12 month follow up. The mean ATRS in these patients at 12 months was 73 ±15.2. 

Discussion

Although operative treatment appears to show superior outcomes, our results indicate that good outcomes may be achieved using a non-operative protocol in patients who decline or are unfit for surgery. Recent research shows the mean age of Achilles rupture has increased by 0.721 years every five years, since 1953. It could therefore be likely that an increasing number of patients suffering chronic Achilles ruptures may be unfit for operative treatment. It is important that further research into the non-operative treatment of these patients is conducted.

Introduction:

Arthrodesis is still a widely used option for treating osteoarthritis of the ankle. Dreaded complications remain wound healing disorders, infections and pseudarthrosis. These complications can be influenced by the surgeon with the chosen approach, joint preparation and stable fixation. Modern implants were developed which combine stability and flexibility for an individual surgical approach, i.e. anterior, posterior, or anterolateral). According to the authors' knowledge, the anterolateral approach is primarily used for ankle trauma, but has not been described for ankle arthrodesis.

Aim of the presentation:

The aim of this presentation is to describe the anterolateral approach with the use of an anatomical plate for ankle arthrodesis and to show the first midterm results with this technique in a high risk population.

Material and methods:

Patients with a high risk for complications treated between 2019 and 2021 were included. High-risk-patients are defined as having two or more of the following concomitant diseases: diabetes, polyneuropathy, rheumatism, osteonecrosis, severe obesity (>120 kg), age >65. 11 patients were included in the study. The follow-up period was 27 to 8 (average 14) months.

Results:

There were no complications. For the patients currently under investigation, the EFAS score improved significantly from 3.3 to 17.8 points. All patients were subjectively satisfied with the result and would have surgery again.

Conclusion:

The described technique is well suited for ankle arthrodesis, especially in high-risk-patinents where complications are expected.

Background: Tibio-talo-calcaneal fusion after removal of alloplasty is a difficult procedure with a high risk of non-union. We wanted to review our results after using a novel method for this procedure, combining retrograde nailing with a trabecular metal implant and bone marrow aspirate concentration in addition to autologous bone grafting. 

Materials and methods: This was a retrospective review of a patient series, where some of the patients also had prospectively registered data. 31 ankles in 30 patients were operated from January 2016 to February 2019. In the same period, we did no revision arthroplasties due to unavailability of our previous revision implant.

Results: Mean follow-up time from surgery to data collection was 23 months (range 6–46). There were two non-unions (6.5%), and one delayed union, none of these has been reoperated. The mean postoperative Manchester-Oxford Foot and Ankle Questionnaire score (MOxFQ) was 33.6 points. 9 patients scored an average MOxFQ at 72.9 immediately before surgery, while at follow-up this had decreased to 36.2, an improvement of 36.7 points (95% CI 18.3–54.9). There were 5 possible nerve injuries and 1 minor infection.One patient had the leg amputated 1 year after the surgery due to a non-related necrotizing fasciitis. 

Conclusion: The short to medium term patient satisfaction and fusion rates are reasonably good with this novel combination of techniques. 

Introduction: Auto-generated 3-dimensional (3D) measurements based on weightbearing cone-beam computedtomography (CT) scan technology may allow for a more accurate hind- and midfoot assessment. The current study evaluated the reliability and clinical relevance of such measurements in patients with posttraumatic end-stage ankle osteoarthritis.

Methods: Seventy-two patients treated at our institution for posttraumatic end-stage ankle osteoarthritis, with available weightbearing conventional radiographs and a cone-beam CT scan, were analyzed. Twenty healthy individuals aged between 40 and 70 years served as controls. Seven variables were measured on the conventional radiographs (2D) and compared to 3D measurements that were based on reconstructions from cone-beam CT scans. The reliability of each measurement was calculated and subgroups formed according to commonly observed deformities.

Results: Inter- and intraobserver reliability was superior for 3D compared to 2D measurements. The accuracy of 3D measurements performed on osteoarthritic ankles was similar to 3D measurements performed on healthy individuals. Thirty-three of the 72 included patients (46%) evidenced an inframalleolar compensation of a supramalleolar/intra-articular ankle deformity (78% = varus compensation; 22% = valgus compensation), whereas 24 of those 72 patients (33%) showed no compensation or a further increase of a supramalleolar/intra-articular ankle deformity (67% = varus deformity; 33% = valgus deformity).

Conclusion: Auto-generated 3D measurements of the hind- and midfoot are reliable in both healthy individuals and patients with posttraumatic end-stage ankle osteoarthritis. Such measurements may be crucial for a detailed understanding of the location and extent of hindfoot deformities, possibly impacting decision making in the treatment of end-stage ankle osteoarthritis.

Introduction: Total ankle replacement(TAR) is an established surgical solution for end-stage ankle osteoarthritis. It has become the backbone of the treatment of end-stage ankle arthritis. Newer implants achieve better results than previous designs. The aim of this study was to present long-term survivorship of the HINTEGRA TAR in a large cohort.

Methods: A retrospective cohort study including 683 patients (722 ankles) was conducted. All patients were treated for end-stage ankle arthritis and received HINTEGRA TAR. Revision was defined as exchange/removal of the talar and/or tibial component, conversion to ankle fusion, or amputation. A survivorship analysis was performed and potential risk factors assessed using Cox regression. Clinical outcomes including visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot score and patient`s satisfaction were assessed preoperatively and at the last follow-up. 

Results: The mean follow-up time of the 683 patients was 11.7±4.6 years (range 0.5 – 20.0). The cumulative overall survival after 5, 10 and 15 years was 93% (95% CI 91 – 95), 86% (83 - 88) and 82% (78 - 85) respectively. Aseptic loosening and instability were the most common reasons for revision. The majority of revisions was exchange of both tibial and talar components.  

Conclusion: Total ankle replacement is a reliable surgical method in the treatment of end-stage ankle osteoarthritis. The HINTEGRA TAR showed desirable long-term implant survivorship with acceptable revision rate. Instability as the most common reason for revision has to be evaluated and addressed at the index surgery. 

Total ankle replacement (TAR) is performed for inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1998. In this study, we look at trends in the use and outcomes of TAR in Scotland.

We identified patients from the SAP who underwent TAR between 1998 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and examined trends in implant type over the following time periods: 1998-2005; 2006-2010 and 2011-2015. Age, gender, indication, outcomes and trends in implants used for each time period were examined.

There were 499 primary TAR procedures with an overall incidence of 0.5/10⁵ population per year. Eight implants were identified with significant changes in the numbers of each type used over time. The peak incidence of TAR was in the 6th decade and mean age of patients increased from 59 years in 1998–2005, to 65 years in 2011–15 (p<0.0001). The percentage of patients with inflammatory arthropathy was 49% in 1998-2005, compared with 10% in 2011-2015. Arthrodesis and infection rates appeared to be higher during the middle time period. The male to female ratio changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=<0.0001).

This study examines a large number of TARs from an established arthroplasty registry. The rate of TAR has increased significantly in Scotland from 1998 to 2015. Indications and patient age have changed over time and could impact outcomes after ankle replacement.

Background:

Numerous methods have been described for the surgical management of Chronic Achilles insertional tendinopathy. The Arthrex Speed Bridge is a novel 4-anchor double row fixation technique. We aim to study our results and experience of the Arthrex Speed Bridge technique in Insertional Achilles Tendinopathy (IAT).

Methods:

Patients with a diagnosis of IAT managed via the Arthrex Speed Bridge between January 2014 to January 2020 were included. Retrospective data was collected, including any complications. All included patients had both pre-and post-operative Manchester-Oxford Foot Questionnaire (MOXFQ) scores. Normality testing was conducted on the mean MOXFQ score change (pre and post operatively), with the Paired sample t-test analysing parametric data and Wilcoxon signed-rank non-parametric.

Results:

A total of eight patients met the study inclusion criteria. A posterior medial incision was most favoured (n=5), whilst no concomitant procedures took place. There were no cases of re-rupture and four reports of complications (Surgical Site Infection: n=2, Haematoma: n=1, Sural nerve injury: n=1), though, conservatively managed. All three parameters measured by the MOXFQ indicated improvement post-operatively compared to pre-operatively (Walking Standing: 14.2 ± 34.7; p = 0.314, Pain: 30 ± 30.0; p = 0.089, Social Interaction: 47.7 ± 25.7; p = 0.039) Statistically significant (p<0.05) improvements were seen in social interaction amongst patients.

Conclusion:

Our study reported significant improvements in patient symptoms, satisfaction, and improved PROM scores following operative management of IAT. Post-operative complications were easily manageable, and there was no reported failure of fixation, further re-in forcing the safety of this technique for IAT.