Background: Intramedullary fibular nailing for ankle fracture fixation has gained popularity, particularly in patients at elevated risk of wound complications. Despite its benefits, concerns remain regarding its safety and the quality of fracture reduction achieved through the minimally invasive approach. This anatomical study evaluated the potential risks to adjacent structures during percutaneous retrograde locked intramedullary fibular nail implantation and assessed fracture reduction via radiographic analysis. Methods: Ten cadaveric lower extremities underwent simulated Weber B or C fractures and fixation with a nail. Reduction quality was evaluated fluoroscopically and graded accordingly. Specimens were dissected to assess damage to nearby anatomical structures, and the shortest distances between surgical sites and adjacent structures were measured. Results: Reduction quality was deemed adequate in all specimens. No peroneal tendon injuries were observed. The mean distance between the sural nerve and the distal portal was 14.95 mm (SD 3.99); therefore, this was considered a safe zone. The superficial peroneal nerve (SPN) was identified as the structure at the highest risk of injury, with a mean distance of 4.52 mm (SD 3.27) from the anterior portal and 14.17 mm (SD 5.25) from the lateral portal. The SPN was found in contact with the anterior portal in 3 specimens; however, no structures were injured during instrumentation. Conclusion: In this cadaveric model, the superficial peroneal nerve was the structure at greatest anatomic risk, particularly at the anterior portal, where direct contact was observed in 3 of 10 specimens. All specimens achieved the study-specific reduction threshold. No macroscopic nerve or tendon injury was observed during instrumentation; however, microscopic or functional injury cannot be excluded given the limitations of cadaveric dissection. Clinical Relevance: The current findings support intramedullary nailing as an effective method for achieving adequate fracture reduction while minimizing soft-tissue complications. Nevertheless, strict adherence to the percutaneous technique is essential to minimize iatrogenic injury to neighboring structures. This includes using skin-only incisions, performing blunt dissection down to the bone, and maintaining close approximation of protection sleeves and bone at all times.

Significant progress has been made in understanding the anatomy of the lateral ankle ligaments (LAL) and the arthroscopic techniques used to treat chronic ankle instability (CAI). Although arthroscopic repair techniques are indicated as the first-line surgical treatment, endoscopic reconstruction of the LAL is a validated option in case where repair is contraindicated. The intraoperative arthroscopic assessment of the ligaments plays a significant role in this decision as it allows direct visualization, palpation, and mechanical analysis of the ligament's remnants. This article discusses the indications of the endoscopic reconstruction of the LAL, its advantages and disadvantages, and the main technical steps.

As with all surgical procedures, an adequately performed surgical technique is mandatory to obtain good results and reduce the risk of complications. The surgeon must acquire the necessary skills and expertise to perform these procedures with increasing proficiency. Education, hands-on practice, and mentorship are essential to progress through the learning curve of percutaneous techniques.

Subtalar instability is a complex sequela of lateral ankle sprain, often associated with concomitant CFL and ATFL injuries. The intrinsic subtalar ligaments, particularly the cervical ligament, also contribute to joint stability and are frequently underrecognized due to small size and partial ruptures. Diagnosis requires integration of clinical findings, MRI, and intraoperative assessment. Surgical management should restore anatomy and biomechanics, with a low threshold for addressing CFL pathology. Treatment options include repair, augmented repair, or reconstruction, increasingly performed endoscopically. In advanced cases, intrinsic subtalar ligament reconstruction may be required to achieve durable stabilization.

Percutaneous bunionette correction has demonstrated efficacy and reliability in treating bunionette deformities, positioning itself as a potential new gold standard in this field. By using a long Shannon burr for osteotomy and realignment of the fifth metatarsal, this minimally invasive technique offers significant advantages. The success of the procedure hinges on precise surgical execution, which, when performed correctly, yields excellent outcomes while minimizing the risk of complications. The key benefit of the percutaneous approach lies in its reduced complication rate, which makes it an attractive option for both surgeons and patients. As the medical community continues to embrace less-invasive techniques, the percutaneous bunionette correction stands out as a promising advancement in foot surgery, offering improved patient outcomes and potentially shorter recovery times.

Background: No description exists in the literature about the normal evolution of tendon graft after a lateral ankle ligament (LAL) reconstruction. Purpose: To assess the magnetic resonance imaging (MRI) characteristics and the evolution of the tendon graft during different moments in the follow-up after an endoscopic reconstruction of the LAL. Study Design: Cohort study; Level of evidence, 3. Methods: This prospective study included 37 consecutive patients who underwent an endoscopic reconstruction of the LAL with an autograft using the gracilis tendon to treat chronic ankle instability (CAI) resistant to nonoperative treatment (CAI group) and 16 patients without ankle instability (control group). All patients in the CAI group underwent a postoperative assessment at 6, 12, and 24 months using the Karlsson score and MRI examination. Only patients with good and excellent results were included in the study. Graft assessment consisted of qualitative measurements and quantitative evaluations of the reconstructed anterior talofibular ligament (RATFL) and reconstructed calcaneofibular ligament (RCFL), including signal-to-noise quotient (SNQ) and contrast-to-noise quotient (CNQ) measurements in proton density-fat suppressed (PD-FS) and T1-weighted sequences. The analysis of variance test was used to compare the SNQ and the CNQ at different time points for each sequence. Results: The MRI signal at 6 months was increased compared with that of the control group. Next, a significant signal decrease from 6 to 24 months was noted on PD-FS and T1-weighted images. SNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P = .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Similarly, CNQ measurements on PD-FS weighted images for both the RATFL and the RCFL demonstrated a significantly higher signal (P < .01 and P < .01, respectively) at 6 months compared with that of the control group. Subsequently, the signal decreased from 6 to 24 months. Conclusion: The present study demonstrated an evolution of the MRI characteristics, suggesting a process of graft maturation toward ligamentization. This is important for clinical practice, as it suggests an evolution in graft properties and supports the possibility of creating a viable ligament.

Purpose: A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain. Methods: A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test. Results: All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value < .0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value < .01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24. Conclusion: The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies. Level of evidence: Level II (prospective cohort study) (c) 2024 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Subtalar instability (STI) is a disabling complication after an acute lateral ankle sprain and remains a challenging problem. The pathophysiology is difficult to understand. Especially the relative contribution of the intrinsic subtalar ligaments in the stability of the subtalar joint is still controversial. Diagnosis is difficult because of the overlapping clinical signs with talocrural instability and the absence of a reliable diagnostic reference test. This often results in misdiagnosis and inappropriate treatment. Recent research offers new insights in the pathophysiology of subtalar instability and the importance of the intrinsic subtalar ligaments. Recent publications clarify the local anatomical and biomechanical characteristics of the subtalar ligaments. The cervical ligament and interosseous talocalcaneal ligament seem to play an important function in the normal kinematics and stability of the subtalar joint. In addition to the calcaneofibular ligament (CFL), these ligaments seem to have an important role in the pathomechanics of subtalar instability (STI). These new insights have an impact on the approach to STI in clinical practice. Diagnosis of STI can be performed be performed by a step-by-step approach to raise the suspicion to STI. This approach consists of clinical signs, abnormalities of the subtalar ligaments on MRI and intraoperative evaluation. Surgical treatment should address all the aspects of the instability and focus on a restoration of the normal anatomical and biomechanical properties. Besides a low threshold to reconstruct the CFL, a reconstruction of the subtalar ligaments should be considered in complex cases of instability. The purpose of this review is to provide a comprehensive update of the current literature focused on the contribution of the different ligaments in the stability of the subtalar joint. This review aims to introduce the more recent findings in the earlier hypotheses on normal kinesiology, pathophysiology and relation with talocrural instability. The consequences of this improved understanding of pathophysiology on patient identification, treatment and future research are described.

Over the last two decades, there has been a growing emphasis on the publication quality in Foot & Ankle research. A level-of-evidence rating system for clinical scientific papers has been proposed by the Centre for Evidence-based medicine in Oxford, United Kingdom. As opposed to other subspecialities, foot & ankle surgery deals with a wide variety of clinical problems and surgical solutions, which in turn leads to a generally low number of patients available for study groups. However, level III and IV studies still have a valuable place in orthopaedic research, given the challenges in running high-level studies.The measurement of outcomes in medicine from the patients' perspective (PROMS:(patient reported outcome measures) has grown almost exponentially in all surgical specialties including foot & ankle surgery. There are many PROMs available to foot & ankle surgeons, but there is little consensus on which assessment is most appropriate for a given procedure or diagnosis. Their use in research and clinical practice offers many advantages in clinical practice and research, however, besides the advantages there are also some downsides.

PurposeKnowledge of the complex anatomy of the lateral ankle ligaments is essential to understand its function, pathophysiology and treatment options. This study aimed to assess the lateral ligaments and their relationships through a 3D view achieved by digitally marking their footprints.MethodsEleven fresh-frozen ankle specimens were dissected. The calcaneus, talus and fibula were separated, maintaining the lateral ligament footprints. Subsequently, each bone was assessed by a light scanner machine. Finally, all the scans were converted to 3D polygonal models. The footprint areas of the talus, calcaneus and fibula were selected, analysed and the surface area was quantified in cm2.ResultsAfter scanning the bones, the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL) footprints were continuous at the medial side of the fibula, corresponding to a continuous footprint with a mean area of 4.8 cm2 (+/- 0.7). The anterior talofibular ligament (ATFL) footprint on the talus consisted of 2 parts in 9 of the 11 feet, whilst there was a continuous insertion in the other 2 feet. The CFL insertion on the calcaneus was one single footprint in all cases.ConclusionThe tridimensional analysis of the lateral ligaments of the ankle demonstrates that the ATFLif, CFL and PTFL have a continuous footprint at the medial side of the fibula in all analysed specimens. These data can assist the surgeon in interpreting the ligament injuries, improving the imaging assessment and guiding the surgeon to repair and reconstruct the ligaments in an anatomical position.

Background: A lateral ankle sprain (LAS) is the most common musculoskeletal injury in the physically active population. It is uncertain what percentage of these patients develop persisting symptoms including pain, recurrent sprains and subjective instability. This systematic review was conducted to assess the presence and duration of persistent symptoms after a first LAS. Methods: A systematic review of the Medline, Web of Sciences, Embase, CINAHL and Pedro databases was performed to identify peer-reviewed articles concerning the occurrence and duration of remaining symp-toms after a first LAS. Inclusion criteria focused on selection of patients without previous ankle injuries and study quality. One of the following outcomes had to be described: subjective instability, resprains, re-maining symptoms.Results: In total, 15 studies were included. The occurrence of patients with subjective instability decreased from 37.9% (95%CI [6.0-69.7]) at 3 months to 16.1% (95%CI [7.8-24.3]) at 6 months and 8.1% (95%CI [3.3-13.3]) at 12 months. The occurrence of patients with a recurrent LAS was 15.8% (95%CI [6.3-25.3]) at 12 months. The occurrence of patients with residual pain decreased from 48.6% (95%CI [23.6-73.5]) at 3 months, to 21.5% (95%CI [2.8-40.2]) at 6 months and 6.7% (95%CI [3.2-10.1]) at 12 months.Conclusion: This study offers new insights in the presence of remaining symptoms after a first LAS and the development of chronic ankle instability. Twelve months following an initial LAS, a significant number of patients may still have symptoms. The incidence of subjective instability, and pain, continues to decrease until 12 months post-injury. This new information may suggest that a longer period of non-operative treatment may be warranted before recommending surgical intervention in patients with a first LAS.(c) 2021 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Background: Today, the relative contribution of each ligamentous structure in the stability of the subtalar joint is still unclear. The purpose of this study is to assess the material properties of the different ligamentous structures of the subtalar joint. Methods: Eighteen paired fresh-frozen cadaveric feet were used to obtain bone-ligament-bone complexes of the calcaneofibular ligament (CFL), the cervical ligament (CL) and the anterior capsular ligament-inter-osseous talocalcaneal ligament complex (ACaL-ITCL). The samples were subjected to uniaxial testing to calculate their respective stiffness and failure load. Results: The stiffness of ACaL-ITCL complex (mean: 150 +/- 51 N/mm, 95% confidence interval (CI): 125.0-176.6 N/mm) was significantly higher than both CFL (mean: 55.8 +/- 23.0 N/mm, CI: 43.8-67.7 N/mm) and CL (mean: 63.9 +/- 38.0 N/mm, CI: 44.4-83.3 N/mm). The failure load of both the ACaL-ITCL complex (mean:382.5 +/- 158 N, CI: 304.1-460.8 N) and the CFL (mean:320.4 +/- 122.0 N, CI: 257.5-383.2 N) were significantly higher than that of the CL (mean:163.5 +/- 58.0 N, CI: 131.3-195.7 N). The injury pattern demonstrated a partial rupture in all CFL and ACaL-ITCL specimens and in 60% of the CL specimens. Conclusion: The CFL, CL and ACaL-ITCL show significant differences in their intrinsic mechanical properties. Both the CFL and CL are more compliant ligaments and seem to be involved in the development of subtalar instability. Based on the material properties, a gracilis tendon graft seems more appropriate than a synthetic ligament to reconstruct a CL or CFL. A partial rupture was the most commonly seen injury pattern in all ligaments. A fibular avulsion of the CFL was only rarely seen. The injury patterns need further investigation as they are important to optimize diagnosis and treatment. (C) 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Percutaneous techniques are becoming increasingly popular in forefoot surgery. In percutaneous toe corrections, usually, no hardware is used. The hardware-free technique avoids any hardware-related complications, but relies highly on the effect of the dressing to keep the foot in the desirable corrected position while healing occurs. The first postoperative dressing is applied by the surgeon. A combination of adhesive taping, sterile gauzes, and an elastic cohesive bandage is used for the first 10 to 14 days. The technique is tailored to the surgical procedure performed and aimed at correcting the preoperative deformity. For the next phase of healing, different bandage techniques can be used. Customized elastic taping is helpful to guide toe position. Alternatively, orthodigital splints can be used. Surgeons should master several bandage techniques. This allows them to choose the best technique depending on the situation. Often, the bandage techniques should be modified to the preoperative situation, the surgical technique, the deformity, and the correction achieved. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE:Diagnosis and treatment of subtalar instability (STI) remains complicated and challenging. The purpose of this study was to investigate the outcome of an anatomical reconstruction of the cervical ligament in patients with suspected chronic STI. METHODS:This prospective study assessed the results of a surgical reconstruction of the cervical ligament using a gracilis tendon graft in a group of 14 patients (16 feet). Diagnosis of STI was performed using a predefined algorithm including clinical signs, MRI and peroperative evaluation. All patients had symptoms of chronic hindfoot instability despite prolonged non-surgical treatment. At final follow-up the outcome was assessed using the Karlsson score, the Foot and Ankle Outcome Score and the American Orthopaedic Foot and Ankle Society score. RESULTS:After an average follow up of 22.6 months (range, 15-36), all patients reported significant improvement compared to their preoperative symptoms. The mean preoperative Karlsson score improved from 36.4 ± 13.5 (median 37, range 10-55) to a mean postoperative Karlsson score was 89.6 ± 8.5 (median 90, range 72-100) (P < 0.0001). The cervical ligament reconstruction was combined with other procedures in 13 cases: calcaneofibular ligament (CFL) reconstruction (3), CFL and anterior talofibular ligament reconstruction (7), bifurcate ligament reconstruction (3). CONCLUSION:Anatomical reconstruction of the cervical ligament is a valid technique to treat patients with STI. It is a safe procedure and produces good clinical results with minimal complications. This technique can be considered in more complex cases and can be combined with other procedures according to the specific location of the instability. LEVEL OF EVIDENCE:Level III.

La reconstruction des ligaments latéraux (LAL) est une option pour traiter chirurgicalement les instabilités chroniques de cheville (CAI) résistantes au traitement conservateur. Cette technique utilise une greffe tendineuse. Le propos de cette étude est de décrire les caractéristiques IRM de la greffe tendineuse et son évolution durant le suivi postopératoire. Cette étude prospective a inclus 37 patients consécutifs qui ont bénéficié d’une reconstruction du LAL endoscopique (groupe CAI) et 37 patients sans instabilité de cheville (groupe contrôle). Tous les patients du groupe CAI ont eu un examen clinique à 6, 12 et 24 mois et ont été évalués par le score de Karlsson. Les patients du groupe CAI avec un résultat bon ou excellent et du groupe contrôle ont eu une IRM suivant le même protocole. L’évaluation de la greffe a consisté en une mesure qualitative (impression générale du signal de la greffe) et une mesure quantitative par étude du SNR (Signal-to-Noise Ratio) et du CNR (Contrast-to-Noise Ratio) du ligament talo-fibulaire reconstruit (RATFL) et du ligament calcanéo-fibulaire reconstruit (RCFL) dans les séquences pondérées T1, T2 et DP-FS. L’analyse IRM a été réalisée en consensus par un radiologue ostéoarticulaire et un chirurgien de la cheville indépendant en aveugle des résultats cliniques. Au total, 33 patients du groupe CAI ont été retenus au recul de 6 mois, 29 à 12 mois et 20 à 24 mois. L’analyse qualitative des ligaments reconstruits (RATFL et RCFL) a montré un signal élevé par rapport au groupe contrôle. Le signal a ensuite diminué du 6 e au 24 e mois sur les images en séquences pondérées T1, T2 et DP-FS. Pour l’analyse quantitative, un test ANOVA a été utilisé pour comparer les SNR et CNR aux différents temps pour chaque séquence. Les mesures en séquences pondérées T2 et DP-FS du SNR et du CNR ont également montré pour le RATFL et le RCFL à 6 mois un signal élevé par rapport au groupe contrôle. Le signal a ensuite diminué du 6 e au 24 e mois ( p < 0,04). L’analyse IRM retrouve une évolution des signaux sur la greffe tendineuse au niveau des 2 ligaments reconstruits similaire à celui des greffes tendineuses de reconstructions du ligament croisé antérieur du genou. Cette évolution est en faveur d’un phénomène de ligamentisation de la greffe tendineuse.

Purpose: The percutaneous treatment of bunionette deformity has been demonstrated as a reliable and satisfying technique with low risk of complications. However, there are some obvious variations in the surgical technique and perioperative protocol. The purpose of this study is to analyze the currently used techniques and to look for some agreements. Hypothesis: There are some points of agreement in surgical technique and perioperative protocol when using a percutaneous technique to treat bunionette deformity. Methods: A survey was sent to 50 orthopedic surgeons with specific experience in percutaneous tech-niques. The questions were related to different aspects of the surgical bunionette procedure and the perioperative protocol. Results: A response rate of 92.0% was obtained. Several points of agreement were found. A condylectomy is rarely used while an osteotomy is performed in almost all procedures. This osteotomy is single (95.7%), complete (66.2-72.7%) and performed with a Shannon long burr (73.9%). The location of the osteotomy depends of the deformity (63.0%). Discussion: This study demonstrates some consensus in the use of the surgical technique and the periop-erative protocol. The percutaneous oblique osteotomy is the preferred technique while a condylectomy is only rarely used. Level of evidence: V, Survey study. (c) 2020 Elsevier Masson SAS. All rights reserved.

This review describes a case of atraumatic avascular necrosis in the foot and ankle in a patient with systemic sclerosis who did not receive corticosteroid therapy. Both avascular necrosis and systemic sclerosis are uncommon disease entities. This case demonstrates that vasculitis and secondary vasoconstriction in the pathogenesis of systemic sclerosis are important risk factors for the development of avascular necrosis of the foot and ankle. Therefore, if these patients develop chronic foot and ankle pain, avascular necrosis should be included in the differential diagnosis, even if they do not receive corticosteroids. For the diagnosis and follow-up of avascular necrosis MRI remains the gold standard. Thus, MRI should be used to diagnose avascular necrosis in an early stage. Level of Clinical Evidence: 4.