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Background: This review aimed to critically appraise the most recent orthopedic literature around cone beam weightbearing computed tomography (WBCT), summarizing what evidence has been provided so far and identifying the main research trends in the area. Methods: This scoping review was performed on studies published between January 2013 and December 2023 on the Pubmed database. All studies (both clinical and nonclinical) in which WBCT had been used were critically analyzed to extract the aim (or aims) of the study, and the main findings related to the role of this imaging modality in the diagnostic pathway. Results: Out of 1759 studies, 129 were selected. One hundred five manuscripts (81%) dealt with elective orthopedic conditions. The majority of the analyses (88 studies; 84%) were performed on foot and ankle conditions, while 13 (12%) studies looked at knee pathologies. There was a progressive increase in the number of studies published over the years. Progressive Collapsing Foot Deformity (22 studies; 25%) and Hallux Valgus (19 studies; 21%) were frequent subjects. Twenty-four (19%) manuscripts dealt with traumatic conditions. A particular interest in syndesmotic injuries was documented (12 studies; 60%). Conclusions: In this review, we documented an increasing interest in clinical applications of weightbearing CT in the orthopedic field between 2013 and 2023. The majority of the analyses focused on conditions related to the foot and the ankle; however, we found several works investigating the value of WBCT on other joints (in particular, the knee).

Background: The outcomes of first metatarsal (M1) distal osteotomies in hallux valgus (HV) can be improved, especially for intermetatarsal angle (IMA) correction, which is mainly based on lateral displacement of the M1 head (i.e., translation) through the osteotomy. Conversely, there is a spontaneous reduction in the IMA in first metatarsophalangeal joint (MTP1) arthrodesis. But we do not know whether this can be applied to distal osteotomies. We propose a distal osteotomy, called 3D chevron, which combines supination and varization of the M1 head. This might realign soft tissues around the MTP1, potentially leading to a spontaneous reduction in the IMA by an analogous mechanism to MTP1 fusion. Therefore, our study aimed to assess whether spontaneous reductions in IMAs exist in distal M1 osteotomies in the absence of lateral translations of M1 heads., Methods: A prospective continuous series of 25 3D chevrons was performed. Two groups were formed during surgery. Patients requiring no M1 head lateral displacement were included in the "successful correction without translation" group, and patients requiring M1 head lateral displacement were included in the "failed correction without translation" group. Radiographic analysis was performed preoperatively and at 1 year postoperatively., Results: Twenty-two women and three men, with a mean age of 44.8 ± 14.2 years and a mean body mass index of 22.6 ± 4.1 kg/m 2 , underwent follow-up at one year after surgery. The "successful correction without translation" group was composed of HV with milder deformities (13/25 HVs, median preoperative IMA = 13 (IQR 2)) compared to the "failed correction without translation" group (median IMA = 16 (IQR 2.25) p < 0.001). Spontaneous reductions in IMAs were observed in the "successful correction without translation" group, with a median decrease in the IMA of 6 degrees (CI95%[5.5; 8.0]; p < 0.001) between preoperative and 1-year radiographs., Conclusion: Distal osteotomies allow for spontaneous reduction in the IMA in HV. First metatarsal head translation through an osteotomy should not be considered as the only procedure to correct IMAs in distal osteotomies.

Background: Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals., Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details., Results: Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA., Conclusion: This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2024.)

Background: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high., Methods: We retrospectively assessed weight bearing CT (WBCT) measurements of 32 feet with PCFD diagnosis. The classes and their associated radiographic measurements were defined as follows: class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by Meary's angle, class D (peritalar sub-luxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. A p-value <0.05 was considered significant., Results: Class A showed substantial positive correlation with class C (ρ=0.71; R 2 =0.576; p=0.001). Class B was substantially correlated with class D (ρ=0.74; R 2 =0.613; p=0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R 2 =0.576; p=0.001) and class D (ρ=0.75; R 2 =0.559; p=0.001). Class D showed substantial positive correlation with class B and class C (ρ=0.74; R 2 =0.613; p=0.001), (ρ=0.75; R 2 =0.559; p=0.001) respectively. Class E did not show correlation with class B, C or D (ρ=0.24; R 2 =0.074; p=0.059), (ρ=0.17; R 2 =0.071; p=0.179), and (ρ=0.22; R 2 =0.022; p=0.082) respectively., Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features. Level of Evidence: III ., Competing Interests: Disclosures: CC - Nextremity, CurveBeam: Paragon 28, Zimmer- Paid consultant, Paragon 28 IP Royalties, American Orthopaedic Foot and Ankle Society: Board or committee member, Weightbearing CT International Study Group: Board or committee member, Foot and Ankle International: Editorial or governing board, CurveBeam: Stock or Stock Options; FL – FH Orthopaedics, New Technics: Paid Consultant, Paragon 28, New Clip Technics: IP Royalties, American Orthopaedic Foot and Ankle Society, Weightbearing CT International Study Group, EFAS, AFCP: Board or committee member, CurveBeam, Disior analytics, follow invest, L-innov: stock or stock options; SE – Vilex, Wright Medical Technology, Paragon 38, Stryker: Paid consultant, Paragon 38: IP royalties, American Orthopaedic Foot and Ankle Society, Weightbearing CT International Study Group: Board or Committee member; KCK, AE, KAMC, AF, ML, NSBM, ER, ES, VM - No conflict of interests., (Copyright © The Iowa Orthopaedic Journal 2023.)

Background: Lisfranc injuries, if not accurately diagnosed, can result in chronic pain and instability. Previous studies have examined ultrasonographs, radiographs, magnetic resonance imaging (MRI), and conventional computed tomography (CT) scan to differentiate Lisfranc instability, but they focused on a healthy/injured scale without differentiating subtle injury. Weightbearing CT (WBCT) has emerged as a diagnostic tool for detecting subtle Lisfranc injuries. This systematic review aimed to compare WBCT with conventional CT in diagnosing Lisfranc injury, and the ability to differentiate injuries of varying severities., Methods: The review encompassed PubMed, CINAHL, MEDLINE, SPORTDiscus, and Web of Science databases from inception until July 5, 2023. Inclusion criteria involved studies on CT and/or WBCT for Lisfranc injuries and nonoperative studies. Exclusion criteria composed case reports, commentaries, postoperative imaging studies, pediatric patients, studies with nonobjective radiographic measurements, studies exclusively focused on injury classification, and studies with fewer than 5 patients because of poor statistical power. Data extraction focused on radiographic measurements of the Lisfranc complex, categorized into conventional CT, partial WBCT, and total WBCT., Results: Out of the initially retrieved 489 articles, 9 met the inclusion criteria. Several studies consistently demonstrate that WBCT provides a higher level of accuracy in measuring the Lisfranc area, offering enhanced sensitivity to detect subtle alterations in joint structure. Moreover, WBCT exhibits superior sensitivity in distinguishing between healthy Lisfranc joints and those with injuries, particularly when identifying dorsal ligament damage. This imaging modality allows for the detection of significant variations in critical measurements like first-second metatarsal (M1-M2) distance, first cuneiform (C1)-M2 distance, and joint volumes, enabling a more comprehensive assessment of Lisfranc joint health especially with subtle instability., Conclusion: This review evaluates the extant literature on WBCT's utility in diagnosing Lisfranc injuries and compares its effectiveness to CT in distinguishing between injuries of varying severity. WBCT, with reliable measurement techniques, appears more adept at detecting subtle Lisfranc instability compared to CT, likely by allowing the assessment of injury under load., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Cesar de Cesar Netto, MD, PhD, reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events and stock or stock options from CurveBeam, as a paid consultant. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Background: Middle facet subluxation (MFS) has been established as an early indicator of peritalar subluxation. However, when progressive collapsing foot deformity (PCFD) affects the ankle leading to a valgus talar tilt (Class E), structures and anatomic relationships distal to the ankle joint may be affected. Therefore, this study aimed to assess radiographic parameters of peritalar subluxation in patients with PCFD who either did or did not have a valgus ankle. Our hypothesis was that these parameters would differ in Class E patients, upsetting their capability to quantify deformity., Methods: We performed a prospective comparative study utilizing weight-bearing computed tomography (WBCT) images of 21 feet with PCFD and with valgus of the ankle and 64 with flexible PCFD without ankle involvement. Parameters including MFS, the medial cuneiform-to-floor distance, the forefoot arch angle, the talonavicular coverage angle, the hindfoot moment arm (HMA), the foot-ankle offset (FAO), and the talar tilt angle (TTA) were measured and compared. Variables that influence the presence of ankle valgus and overall alignment were assessed by multivariable regression models., Results: Patients with PCFD and ankle valgus demonstrated a higher mean HMA (20.79 mm [95% confidence interval (CI), 17.56 to 24.02 mm] versus 8.94 mm [95% CI, 7.09 to 10.79 mm]), FAO (14.89% [95% CI, 12.51% to 17.26%] versus 6.32% [95% CI, 4.96% to 7.68%]) and TTA (95% CI, 17.10° [14.75° to 19.46°] versus 2.30° [95% CI, 0.94° to 3.65°]) and lower mean MFS (21.84% [95% CI, 15.04% to 28.63%] versus 38.45% [95% CI, 34.55% to 42.34%]) compared with the group without ankle valgus (p < 0.0001 for all). The FAO was influenced by MFS in the group without ankle valgus (p <0.0001) but not in the group with ankle valgus (p = 0.9161). FAO values of ≥12.14% were a strong predictor (79.2%) of ankle valgus deformity., Conclusions: Subluxation of the middle facet was not as severe and did not influence the overall alignment in patients with PCFD who had valgus of the ankle (Class E). These findings suggest a distal peritalar reduction in the presence of a proximal deformity, making MFS an imprecise disease parameter in this scenario. An FAO value of ≥12.14% was a strong indicator of ankle deformity in patients with PCFD., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A565)., (Copyright © 2023 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Foot and ankle disorders are a common reason for orthopedic surgical intervention. After surgery, specific precautions such as partial weight bearing or complete unloading, and the use of walking aids, coupled with a period of rest, are usually implemented to ensure the surgical outcome. However, when these aids are discontinued and the patients resume load increase and normal daily activities, they may enter a transitional phase characterized by inflammation, swelling, and pain. We call this phenomenon the "classic three-month post-operative adaptation phase" (POAP). It is essential to differentiate this physiological transition phase from other conditions, such as from the immediate post-surgical inflammation, complex pain regional syndrome, or an infection. The objective of this expert opinion is to describe and raise medical awareness of this evidence-based phenomenon, which we commonly observe in our daily practice.

Detection of syndesmotic ankle instability remains challenging in clinical practice due to the limitations of two-dimensional (2D) measurements. The transition to automated three-dimensional (3D) measurement techniques is on the verge of a breakthrough but normative and side-to-side comparative data are missing. Therefore, our study aim was two-fold: (1) to establish 3D anatomical reference values of the ankle syndesmosis based on automated measurements and (2) to determine to what extent the ankle syndesmosis is symmetric across all 3D measurements. Patients without syndesmotic pathology with a non-weight-bearing CT scan (NWBCT; N = 38; Age = 51.6 ± 17.43 years) and weight-bearing CT scan (WBCT; N = 43; Age = 48.9 ± 14.3 years) were retrospectively included. After training and validation of a neural network to automate the segmentation of 3D ankle models, an iterative closest point registration was performed to superimpose the left on the right ankle. Subsequently, 3D measurements were manually and automatically computed using a custom-made algorithm and side-to-side comparison of these landmarks allowed one to investigate symmetry. Intra-observer analysis showed excellent agreements for all manual measurements (ICC range 0.85-0.99) and good (i.e. < 2.7° for the angles and < 0.5 mm for the distances) accuracy was found between the automated and manual measurements. A mean Dice coefficient of 0.99 was found for the automated segmentation framework. The established mean, standard deviation and range were provided for each 3D measurement. From these data, reference values were derived to differ physiological from pathological syndesmotic alignment. Furthermore, side-to-side symmetry was revealed when comparing left to right measurements (P > 0.05). In clinical practice, our novel algorithm could surmount the current limitations of manual 2D measurements and distinguish patients with a syndesmotic ankle lesion from normal variance., (© 2023. Springer Nature Limited.)

Artificial intelligence (AI) is looked upon nowadays as the potential major catalyst for the fourth industrial revolution. In the last decade, AI use in Orthopaedics increased approximately tenfold. Artificial intelligence helps with tracking activities, evaluating diagnostic images, predicting injury risk, and several other uses. Chat Generated Pre-trained Transformer (ChatGPT), which is an AI-chatbot, represents an extremely controversial topic in the academic community. The aim of this review article is to simplify the concept of AI and study the extent of AI use in Orthopaedics and sports medicine literature. Additionally, the article will also evaluate the role of ChatGPT in scientific research and publications.Level of evidence: Level V, letter to review., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The early effects of progressive collapsing foot deformity (PCFD) on the ankle and syndesmotic joints have not been three-dimensionally quantified. This case-control study focused on using weight bearing CT (WBCT) distance (DM) and coverage maps (CM) and volumetric measurements as 3D radiological markers to objectively characterize early effects of PCFD on the ankle and syndesmotic joints. Seventeen consecutive patients with symptomatic stage I flexible PCFD and 20 matched controls that underwent foot/ankle WBCT were included. Three-dimensional DM and CM of the ankle and syndesmotic joints, as well volumetric assessment of the distal tibiofibular syndesmosis was performed as possible WBCT markers of early PCFD. Measurements were compared between PCFD and controls. Significant overall reductions in syndesmotic incisura distances were observed in PCFD patients when compared to controls, with no difference in the overall syndesmotic incisura volume at 1, 3, 5 and 10 cm proximally to the ankle joint. CMs showed significantly decreased articular coverage of the anterior regions of the tibiotalar joint as well as medial/lateral ankle joint gutters in PCFD patients. This study showed syndesmotic narrowing and decreased articular coverage of the anterior aspect of the ankle gutters and talar dome in stage I PCFD patients when compared to controls. These findings are consistent with early plantarflexion of the talus within the ankle Mortise, and absence of true syndesmotic overload in early PCFD, and support DM and CM as early 3D PCFD radiological markers., (© 2023. The Author(s).)

Background: Weightbearing computed tomography (WBCT) measurements allow evaluation of several anatomical points for a correct clinical-radiographic diagnosis of pathologies, such as hallux rigidus (HR). In addition, a new semiautomatic segmentation software obtains automated 3D measurements from WBCT scan data sets, minimizing errors in reading angular measurements. The study's objective was (1) to evaluate the reliability of WBCT semiautomatic imaging measures in HR, (2) to evaluate correlation and agreement between manual and semiautomatic measures in the setting of HR, and (3) to compare semiautomatic measurements between pathologic (HR) and standard control groups., Methods: A retrospective study of HR patients was performed including 20 feet with HR. WBCT manual and semiautomatic 3D measurements were performed using the following parameters: (1) first metatarsal-proximal phalanx angle (1stMPP), (2) hallux valgus angle (HVA), (3) first to second intermetatarsal angle (IMA), (4) hallux interphalangeal angle (IPA), (5) first metatarsal length (1stML), (6) second metatarsal length (2ndML), (7) first metatarsal declination angle (1stMD), (8) second metatarsal declination angles (2ndMD), and (9) metatarsus primus elevatus (MPE). The differences between pathologic and control cases were assessed with a Wilcoxon test., Results: Interobserver and intraobserver agreement for manual vs semiautomatic WBCT measurements demonstrated excellent reliability. According to the Pearson coefficient, there was a 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). Comparison between the pathologic group with HR and the control (standard) group allowed for the differentiating of the pathologic (HR) from the non-pathologic conditions for MPE (p < 0.05)., Conclusion: Semiautomatic measurements are reproducible and comparable to measurements performed manually, showing excellent interobserver and intraobserver agreement. The software used differentiated pathologic from nonpathologic conditions when submitted to semiautomatic MPE measurements., Level of Evidence: Level III, retrospective comparative study., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Cesar de Cesar Netto is a paid consultant to Curvebeam and has stock options with Curvebeam. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

A key element of the peritalar subluxation (PTS) seen in progressive collapsing foot deformity (PCFD) occurs through the transverse tarsal joint complex. However, the normal and pathological relations of these joints are not well understood. The objective of this study to compare Chopart articular coverages between PCFD patients and controls using weight-bearing computed tomography (WBCT). In this retrospective case control study, 20 patients with PCFD and 20 matched controls were evaluated. Distance and coverage mapping techniques were used to evaluate the talonavicular and calcaneocuboid interfaces. Principal axes were used to divide the talar head into 6 regions (medial/central/lateral and plantar/dorsal) and the calcaneocuboid interface into 4 regions. Repeated selections were performed to evaluate reliability of joint interface identification. Surface selections had high reliability with an ICC > 0.99. Talar head coverage decreases in plantarmedial and dorsalmedial (- 79%, p = 0.003 and - 77%, p = 0.00004) regions were seen with corresponding increases in plantarlateral and dorsolateral regions (30%, p = 0.0003 and 21%, p = 0.002) in PCFD. Calcaneocuboid coverage decreased in plantar and medial regions (- 12%, p = 0.006 and - 9%, p = 0.037) and increased in the lateral region (13%, p = 0.002). Significant subluxation occurs across the medial regions of the talar head and the plantar medial regions of the calcaneocuboid joint. Coverage and distance mapping provide a baseline for understanding Chopart joint changes in PCFD under full weightbearing conditions., (© 2022. The Author(s).)

Adult tendons are highly differentiated. In mature individuals, tendon healing after an injury occurs through fibrotic tissue formation. Understanding the intrinsic reparative properties of fetal tendons would help to understand the maturation tissue process and tendon tissue repair. The present study evaluated the evolution of histoarchitecture, cellularity and the distribution of collagens I, III and V in the posterior tibial tendon in human fetuses at different gestational ages. Morphological profiles were assessed in nine fresh spontaneously aborted fetuses (Group I: five fetuses aged between 22 and 28 weeks of gestation; Group II: four fetuses aged between 32 and 38 weeks of gestation), characterized by a combination of histology, fluorescence and immunohistochemistry. In Group I, the posterior tibial tendon showed statistically significant greater cellularity and presence of collagen III and V than in Group II tendon, which showed a predominance of collagenous I and a better organization of the extracellular matrix compared with Group I tendons. In addition, a statistically significant higher rate of CD90, a marker of mesenchymal cells, was found in Group I tendons. In fetuses with gestational age between 22 and 28 weeks, the posterior tibialis tendons showed a thin and disorganized fibrillar structure, with an increase in collagen III and V fibers and mesenchymal cells. In the posterior tibialis tendons of fetuses with gestational age between 32 and 38 weeks, the fibrillar structure was thicker with a statistically significant increase in type I collagen and decreased cellularity., (© 2022. The Author(s).)

Background: There is increased evidence of first metatarsal hyperpronation in patients with hallux valgus, but its impact on the stability of the first metatarsophalangeal and metatarsosesamoid joints is unknown. A previous biomechanical study showed that an increase in hallucal pronation might lead to medial soft tissue failure of the first metatarsophalangeal joint. Conversely, dynamic studies on hallux valgus have shown that the first tarsometatarsal joint moves in supination during weightbearing, and supination was associated with an increase in the intermetatarsal angle (IMA) and hallux valgus angle (HVA)., Questions/purposes: (1) Does an increase in first metatarsal pronation cause an increase in hallucal pronation? (2) Can an intrinsic increase in first metatarsal pronation lead to first ray supination during weightbearing? (3) Can a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increase supination of the first ray during weightbearing? (4) Is first ray supination during weightbearing associated with an increase in the IMA and HVA?, Methods: Twelve transtibial, nonpaired cadaver specimens without deformities were used. Each specimen underwent six weightbearing CT scans under different conditions. The first three CT examinations were performed without any osteotomy of the first metatarsal. The first was a simulated nonweightbearing condition. The second was a simulated weightbearing condition. The third was a simulated weightbearing condition with medial soft tissue release. Subsequentially, a 30° pronation osteotomy of the first metatarsal was performed, and the same sequence of weightbearing CT images was obtained. On each weightbearing CT image, the HVA, IMA, sesamoid rotation angle, metatarsal pronation angle (MPA), metatarsosesamoid rotation angle, and hallucal pronation (HP) were measured. Motions were calculated based on the differential values of these angular measurements produced by the six different conditions (weightbearing, medial soft tissue release, 30° pronation osteotomy, and combinations of these conditions). We compared means using a t-test for normally distributed variables and the Mann-Whitney U test for nonnormally distributed variables. Correlations were assessed with Pearson product-moment correlation coefficients., Results: We found that 30° pronation osteotomy of the first metatarsal increased the MPA and HP by 28° ± 4° and 26° ± 6°, respectively, in the nonweightbearing condition. No differences between the increase in MPA and the increase in HP were noted (mean difference 2° [95% CI -1° to 5°]; p = 0.20). Therefore, an increase in first metatarsal pronation caused an increase in hallucal pronation. When a 30° pronation osteotomy of the first metatarsal was performed, the first ray motion during weightbearing went from pronation to supination (4° ± 2° in pronation without osteotomy versus 4° ± 2° in supination after the osteotomy, mean difference 8° [95% CI 6° to 9°]; p < 0.001). Therefore, an intrinsic increase in pronation of the first metatarsal led to a first ray supination motion during weightbearing. When a first metatarsophalangeal medial soft tissue release was performed in addition to the 30° osteotomy of the first metatarsal, the supination motion of the first ray increased (4° ± 2° without medial soft tissue release versus 11° ± 7° after the release, mean difference 8° [95% CI 3° to 12°]; p = 0.003). Therefore, a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increased supination of the first ray during weightbearing. Regarding static angular measurements, the HVA and IMA were not correlated with the MPA (ρ = 0.20; p = 0.09 and ρ = 0.22; p = 0.07, respectively). Regarding motions, as the HVA and IMA increased from nonweightbearing to weightbearing the pronation decreased, with strong correlations (ρ = -0.82; p < 0.001 and ρ = -0.77; p < 0.001, respectively). Therefore, a first ray supination during weightbearing was associated with an increase in the HVA and IMA., Conclusion: The combination of first metatarsal intrinsic hyperpronation and first metatarsophalangeal medial soft tissue failure led to a hallux valgus deformity in this cadaveric study. The static measurement of first metatarsal head pronation relative to the ground (MPA) did not reflect the real intrinsic pronation of the first ray, and foot and ankle specialists should be careful when interpreting these measurements. Hallux valgus is a dynamic condition, and the deformity could be more correlated with motions during weightbearing than with plain static measurements., Clinical Relevance: First ray supination compensating for first metatarsal intrinsic hyperpronation might be an important factor in the hallux valgus pathogenesis. Further in vivo studies involving nonweightbearing and weightbearing comparative assessments of hallux valgus and controls should be performed to confirm this pathomechanism., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2022 by the Association of Bone and Joint Surgeons.)

Background: The treatment of ankle osteoarthritis (OA) varies depending on the severity and distribution of the associated joint degeneration. Disease staging is typically based on subjective grading of appearance on conventional plain radiographs, with reported subpar reproducibility and reliability. The purpose of this study was to develop and describe computational methods to objectively quantify radiographic changes associated with ankle OA apparent on low-dose weightbearing CT (WBCT)., Methods: Two patients with ankle OA and 1 healthy control who had all undergone WBCT of the foot and ankle were analyzed. The severity of OA in the ankle of each patient was scored using the Kellgren-Lawrence (KL) classification using plain radiographs. For each ankle, a volume of interest (VOI) was centered on the tibiotalar joint. Initial computation analysis used WBCT image intensity (Hounsfield units [HU]) profiles along lines perpendicular to the subchondral bone/cartilage interface of the distal tibia extending across the entire VOI. Graphical plots of the HU distributions were generated and recorded for each line. These plots were then used to calculate the joint space width (JSW) and HU contrast., Results: The average JSW was 3.89 mm for the control ankle, 3.06 mm for mild arthritis (KL 2), and 1.57 mm for severe arthritis (KL 4). The average HU contrast was 72.31 for control, 62.69 for mild arthritis, and 33.98 for severe arthritis. The use of 4 projections at different locations throughout the joint allowed us to visualize specifically which quadrants have reduced joint space width and contrast., Conclusion: In this technique report, we describe a novel methodology for objective quantitative assessment of OA using JSW and HU contrast., Clinical Relevance: Objective, software-based measurements are generally more reliable than subjective qualitative evaluations. This method may offer a starting point for the development of a more robust OA classification system or deeper understanding of the pathogenesis and response to ankle OA treatment., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Background : Previous literature suggests that patients treated with total ankle arthroplasty (TAA) versus ankle arthrodesis (AA) may have better function and lower risk for adjacent joint arthritis in the foot. Little is known on how these interventions affect proximal joints such as the knee. Questions : We sought to assess whether patients with TAA and AA exhibited altered biomechanics linked to the onset and progression of knee osteoarthritis (KOA). We used the knee adduction moment (KAM), a surrogate measure for the mechanical load experienced at the medial tibiofemoral compartment, because it is linked with the onset and progression of KOA. Methods : At a minimum of 2 years postoperatively, instrumented 3-dimensional walking gait was recorded in 10 TAA and 10 AA patients at self-selected walking speeds. TAA patients had either a Salto Talaris or INBONE prosthesis. Average first and second peak KAMs (Nm/kg), KAM impulse (Nm-s/kg), and range-of-motion (ROM, °) were calculated on both the affected and unaffected limbs for each patient. Results : There were no significant differences in the KAM's first and second peaks, impulse, or knee ROM in any plane between the unaffected and affected limbs, or between TAA and AA. Conclusion : TAA and AA may not meaningfully affect ipsilateral knee kinetics and KAMs in short-term follow-up. This study highlights the importance of continuing to study these parameters in larger cohorts of patients with longer follow-up to determine how our treatment of end-stage ankle arthritis may affect the incidence or progression of ipsilateral KOA., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Constantine A. Demetracopoulos, MD, reports relationships with Wright Medical, Integra LifeSciences, Stryker, and RTI Surgical. Jonathan T. Deland, MD, reports relationships with Arthrex and Zimmer. Cesar de Cesar Netto, MD, reports relationships with Curvebeam and Ossio. Guilherme H. Saito, MD, reports relationships with Wright Medical. Scott J. Ellis, MD, reports relationships with Wright Medical and Paragon 28. The other authors report no potential conflicts of interest., (© The Author(s) 2021.)

Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Background: Ankle osteoarthritis (AO) is often secondary to prior trauma and frequently presents with joint deformity. Total ankle replacement (TAR) has been shown as a viable surgical option to reduce pain, improve function, and preserve ankle joint range of motion. The standard TAR uses an anterior approach, but recently a lateral trans-fibular approach has been developed. Our aim was to determine if the lateral TAR was able to correct alignment and improve patient reported outcomes (PROs) in patients with end-stage AO., Methods: This IRB-approved, retrospective comparative study included 14 consecutive patients that underwent lateral trans-fibular approach TAR for end-stage AO. All patients had received pre-and post-operative WBCT imaging on the affected foot and ankle. Using multiplanar reconstruction of WBCT images, measures of coronal and sagittal plane ankle alignment: 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 postoperatively at the latest clinical follow-up., Results: All patients demonstrated a significant deformity correction in all 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 PROs measured exhibited significant improvement postoperatively, the Tampa Scale for Kinesiophobia (TSK) (42.7-34.5, p=0.012), PRO-MIS Global Physical Health (46.1-54.5, p=0.011), EFAS (5-10.3, p=0.004), and FAAM Daily Living (60.5-79.7, p=0.04). Multivariate analysis assessing the influence of deformity correction in the improvements of PROs found that PROMIS Global Physical Health was significantly associated with improvements in FAO and LTS, TSK associated with HMA, and FAAM Daily Living with FAO and TTA (p<0.05)., Conclusion: The results of this retrospective comparative cohort study suggest that the lateral trans-fibular TAR can correct different aspects of AO deformity. The method also impacted PROs, particularly TSK, PROMIS Global Physical Health, EFAS, and FAAM Daily Living. Direct correlation between some of the deformity correction measurements and the significantly improved PROs was found. The obtained data could help surgeons when making treatment decisions and be the base for comparative prospective studies. Level of Evidence: III ., (Copyright © The Iowa Orthopaedic Journal 2022.)

Background: With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision., Methods: Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions., Results: A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%)., Conclusion: COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic., Level of Evidence: Level III., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2021.)

Cone-beam computed tomography (CBCT) has been applied in dentistry and medicine for nearly two decades. Its application in the foot and ankle specialty has grown exponentially in recent years. Weight-bearing CBCT allows clinicians to obtain weight-bearing images that can be viewed in all three planes and to construct three-dimensional models, similar to those constructed from traditional CT scans, as well as exposing patients to less radiation than do traditional CT scans. This technology has revolutionized diagnoses, improving the understanding of various lesions and surgical planning in the foot and ankle specialty. Ongoing studies of the use of weight-bearing CBCT in foot and ankle surgery are focused on fully automated and semi-automated three-dimensional measurements, as well as bone segmentation, mapping of the distances/orientation of the joints, and the production of customized implants. The aims of this review article are to show the evolution of this emerging tool in the foot and ankle specialty, to update those in related specialties on its use in current clinical practice, and to indicate where the research community is heading.

Background: Weightbearing computed tomography (WBCT) is a reliable and precise modality for the measurement and analysis of bone position in the foot and ankle, as well as associated deformities. WBCT to assess three dimensional relationships among bones allowed the development of new measurements, as the Foot and Ankle Offset (FAO), which has high inter and intra-rater reliability. This study reports the University of Iowa's experience utilizing WBCT for the care of foot and ankle patients by describing its utility across different orthopedic diseases in improving diagnostic assessment, aiding surgical planning, and expanding the use for objective clinical follow-up., Methods: The medical records of consecutive patients with various foot and ankle disorders that underwent WBCT examination as part of the standard of care at a single institution between November 2014 and August 2020 were retrospectively reviewed. Patient factors, including body mass index (BMI), sex, and patient comorbidities were collected. 3D coordinates for calculation of FAO were harvested using the Multiplanar Reconstruction (MPR) views were calculated from the obtained exams. Descriptive statistics were performed with Shapiro-Wilk test and the Anderson-Darling tests., Results: 1175 feet and ankles (820 patients) had a WBCT performed over the studied 68 months. 53% of the subjects were male and 47% female. 588 of the acquisitions were from the right side (50.04%) and 587 from the left side (49.96%). Diabetes was present in 15.47% of, Rheumatic diagnoses in 4.52% and smoking habits in 44.10% of patients. Mean BMI of the sample was found to be 32.47 (32.03-32.90, 95% CI). The mean Foot and Ankle Offset (FAO) encountered in the study's population was 2.43 (2.05-2.82, 95% CI; min -30.8, max 37.65; median 2.39)., Conclusion: This study contains the largest cohort of WBCTs with accompanied FAO measurements to date, which can aid with establishing a new baseline FAO measurement for multiple pathological conditions. Acquiring WBCTs resulted in a variety of more specific diagnoses for patient with foot and ankle complaints. The ability to utilize WBCT for presurgical planning, the capability to provide a 3D reconstruction of patient anatomy, and its use for assessment of advanced relational foot and ankle measurements, such as FAO, demonstrate how WBCT may serve as a remarkable utility in clinical practice and has become a standard of care in our practice at the University of Iowa. Level of Evidence: IV ., Competing Interests: Disclosures: JF-Arthrex, Inc: Research support, Integra: Paid consultant, OnconRegen: Unpaid consultant. CDCN-CurveBeam:Paid consultant; Stock or stock Options, Nextremity: Paid consultant, Ossio: Paid consultant, Paragon 28: IP royalties; Paid consultant, Zimmer: Paid consultant; PP-Arthrex, Inc: IP royalties, Crossroads: Paid consultant; Stock or stock Options, Novastep: Paid consultant, Smith & Nephew: Paid consultant. SL-Foot and Ankle Clinics of North America: Editorial or governing board, Foot and Ankle Orthopedics: Editorial or governing board. NSBM-Brazilian Foot and Ankle Society: Board or committee member. The other authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: Malrotation of medial column bones of the foot has been advocated as an important factor in foot conditions such as hallux valgus and progressive collapsing foot deformity. Although stated as a deformity component, variances of normality in the general population are not completely understood. This study intended to describe the rotational profile of all medial column bones using weightbearing computed tomography (WBCT) images in a cohort of patients with different foot and ankle problems., Methods: In this retrospective study, 110 feet of 95 consecutive patients that received a WBCT for assessment of different foot and ankle pathologies were included. Measurements were performed by a blinded fellowship-trained orthopedic foot and ankle surgeon. Rotation of the navicular, medial cuneiform, proximal and distal first metatarsal as well as proximal phalanx of the first toe were recorded. Positive values were considered pronation and negative values were considered supination. Rotational profile of each bone/ segment was assessed by ANOVA and comparison between each segment was performed using Wilcoxon Each-Pair analysis. P-values of less than 0.05 were considered significant., Results: On average, a rotational positioning in pronation (internal rotation) was observed for all medial column bones. The navicular (43.2°, CI 41.1°-45.3°) and the proximal metatarsal (33.9°, CI 31.8°-36.0°) showed the highest mean rotation values. The medial cuneiform presented the lowest mean pronation (6.1°, CI 4.0°-8.3°). Comparison between each bone segment demonstrated statistically significant differences of rotational alignment for the different bones (p<0.0001), with the exception of the distal metatarsal and proximal phalanx, that had similar amounts of pronation. A zig-zag rotational pattern of alignment was observed from proximal to distal, with relative supination/pronation of adjacent medial column bones., Conclusion: The overall rotational profile of medial column bones was found to be in absolute pronation, most pronounced at the navicular and proximal first metatarsal, with significant differences in the amount of pronation when comparing most of the medial column bones. The presented data may be utilized as reference/ baseline values of medial column rotation, supporting future prospective, comparative and controlled studies. Level of Evidence: IV ., Competing Interests: Disclosures: Cesar de Cesar Netto-CurveBeam: Paid consultant; Stock or stock Options, Foot and Ankle International: Editorial or governing board, Nextremity: Paid consultant, Ossio: Paid consultant, Paragon 28: IP royalties; Paid consultant, Weightbearing CT International Study Group: Board or committee member, Zimmer: Paid consultant. Daniel Soares Baumfeld-Arthrex, Inc: Paid presenter or speaker, Merck: Paid presenter or speaker. John E. Femino Arthrex, Inc: Research support, Integra: Paid consultant, OnconRegen: Unpaid consultant. The other authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT., Objective: This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program., Methods: A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system-Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility., Results: Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022., Conclusions: The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes., International Registered Report Identifier (irrid): DERR1-10.2196/19111., (©Andrew A Post, Ebonie K Rio, Kathleen A Sluka, G Lorimer Moseley, Emine O Bayman, Mederic M Hall, Cesar de Cesar Netto, Jason M Wilken, Jessica F Danielson, Ruth Chimenti. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 03.11.2020.)

Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing post-traumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: The infrapatellar branch of the saphenous nerve (IPBSN) is a purely sensory nerve innervating the anteromedial aspect of the knee and anteroinferior knee joint capsule. Total knee arthroplasty (TKA) is commonly used to treat end-stage arthritis, but the IPBSN is often injured and results in numbness around the anteromedial knee. The aim of this cadaveric study was to describe the course and variability of the IPBSN and to assess whether it is possible to preserve during a standard midline surgical approach in TKA., Methods: Ten fresh-frozen cadaver legs were dissected using a midline approach to the knee. Skin and subcutaneous flap were reflected to expose both the saphenous nerve and its branches. The branches of the IPBSN were identified, and their vertical distances above the tibial tuberosity (TB) were recorded: TB to inferior branch, to middle branch, and to superior branch., Results: There were 10 left-sided specimens (6 female, 4 male) with a mean age of 79.9 ± 9.8 years. 8 (80%) specimens had 2 branches of IPBSN while 2 (20%) specimens had 3 branches. The average distance from TB to the inferior branch was 16.8 ± 8.3 mm (3.0-28.0); middle branch, 24.0 ± 1.4 mm (23.0-24.9); and superior, 45.9 ± 7.7 mm (32.0-54.5)., Conclusion: Our cadaveric study found no consistent way to preserve the IPBSN using a standard midline approach in TKA. It is important to provide proper patient education on this complication, and surgeons should be aware of approximate locations and variations of IPBSN while performing other knee procedures.

Background: Weightbearing cone beam computed tomography (WB CBCT) allows detailed 3-dimensional imaging of the foot and ankle in a weightbearing state and provides improved accuracy and reliability of foot alignment measures, especially when compared with conventional radiographic views., Purpose: To describe the foot alignment in National Basketball Association (NBA) players with different symptomatic foot and ankle injuries using WB CBCT and to determine if any predominant morphotype would be identified., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 45 active NBA players (mean age, 24.4 years [range, 20-34 years]; N = 54 feet [29 right, 25 left]) were assessed using WB CBCT. Measurements included the following: (1) foot and ankle offset (FAO), (2) calcaneal offset (CO), (3) hindfoot alignment angle (HAA), (4) angle between the inferior and superior facets of the talus (Inftal-Suptal), (5) angle between the inferior facet of the talus and the horizontal floor line (Inftal-Hor), (6) forefoot arch angle (FAA), (7) navicular-to-floor distance, and (8) medial cuneiform-to-floor distance. Measurements were then compared with values available in the literature for a "normal" foot morphotype., Results: Among the 54 feet, the mean FAO was 0.48% (95% CI, -0.25% to 1.21%), the mean CO was 1.18 mm (95% CI, -0.50 to 2.87 mm), and the mean HAA was 1.42° (95% CI, -0.80° to 3.65°). The mean Inftal-Suptal angle was 5.31° (95% CI, 3.50°-7.12°), while the mean Inftal-Hor angle was 4.04° (95% CI, 2.56°-5.51°). The mean FAA was 15.84° (95% CI, 14.73°-16.92°), the mean navicular-to-floor distance was 38.30 mm (95% CI, 36.19-40.42 mm), and the mean medial cuneiform-to-floor distance was 26.79 mm (95% CI, 25.30-28.28 mm). None of these values were found to be significantly different when comparing forwards, guards, and centers., Conclusion: NBA players presenting with symptomatic foot and ankle injuries had a fairly "normal" foot morphology, with a tendency toward a varus hindfoot and a high-arched morphotype. No significant differences were found between players based on their position on the court. WB CBCT may help to shed light on anatomic risk factors for common injuries in professional players and may aid in the planning of specific prevention programs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: C.C.N. is a paid consultant for CurveBeam and Ossio, has stock/stock options in CurveBeam, and has received hospitality payments from Stryker and Zimmer Biomet. F.L. is a paid consultant for CurveBeam and Newclip and has stock/stock options in CurveBeam. A.E. has stock/stock options in Bacterin, has received educational support from Arthrex and Gotham Surgical Solutions & Devices, and has received hospitality payments from Arthrex and Gotham Surgical Solutions & Devices. M.O. has stock/stock options in CurveBeam. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Introduction: Lateral release to improve patellar tracking is commonly performed during total knee arthroplasty. Blood is supplied to the lateral patella by two main arteries: the superior and inferior lateral genicular arteries. The transverse infrapatellar artery also branches off the lateral inferior genicular artery to supply the inferior half of the patella. Severance of any of these arteries during lateral release can lead to avascular necrosis of the patella. This cadaveric study investigates the lateral vasculature to the patella and whether it can be visualized and preserved during lateral release of the patella., Materials and Methods: This study involved ten cadavers, each of which underwent lateral release of the patella. One senior joint surgeon performed and supervised the incisions and attempted to locate and preserve these vessels. We then quantified the number of cadavers with visualized blood vessels and analysed their location and course to determine whether they could be preserved during lateral release of the patella., Results: In our study, three of the ten cadavers had an artery that was visible within the incisional plane and preserved. Two were the inferior lateral genicular artery, and one was the superior lateral genicular artery. In the other seven cadavers, no vessels were visualized during the lateral dissection., Conclusions: These results demonstrate that it is difficult to visualize blood supply to the patella during lateral release. Every attempt should be made to preserve these blood vessels to avoid devascularization to patella in the setting of an already severed medial vascularity due to standard approach to knee replacement.

The 3D anatomical complexity of the foot and ankle and the importance of weight-bearing in diagnosis have required the combination of conventional radiographs and medical CT.Conventional plain radiographs (XR) have demonstrated substantial limitations such as perspective, rotational and fan distortion, as well as poor reproducibility of radiographic installations. Conventional CT produces high levels of radiation exposure and does not offer weight-bearing capabilities.The literature investigating biometrics based on 2D XR has inherent limitations due to the technology itself and thereby can focus only on whether measurements are reproducible, when the real question is whether the radiographs are.Low dose weight-bearing cone beam CT (WBCT) combines 3D and weight-bearing as well as 'built in' reliability validated through industry-standardized processes during production and clinical use (quality assurance testing).Research is accumulating to validate measurements based on traditional 2D techniques, and new 3D biometrics are being described and tested.Time- and cost-efficient use in medical imaging will require the use of automatic measurements. Merging WBCT and clinical data will offer new perspectives in terms of research with the help of modern data analysis techniques. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170066., Competing Interests: ICMJE Conflict of interest statement: F. Lintz declares consultancy for Curvebeam LLC, activity relating to the submitted work. C. de Cesar Netto declares consulting fees or honoraria for Curvebeam LLC, activity relating to the submitted work; consultancy for Ossio; stocks/stock options and travel/accommodation/meeting expenses from Curvebeam LLC, activities outside the submitted work. A. Burssens declares a clinical research grant from the University Hospital of Ghent, activity relating to the submitted work; consultancy, payment for lectures, and travel/meeting/accommodation expenses from Curvebeam LLC, activities outside the submitted work. Alexeij Barg declares consultancy for Medartis, activity outside the submitted work. Martinus Richter declares consultancy for Curvebeam LLC, activity relating to the submitted work.

Ankle arthrodesis has been widely reported as an effective solution in treating tibiotalar joint osteoarthritis. The arthroscopic tibiotalar approach for arthrodesis has also been proven to give excellent results in terms of bone fusion rates and reduction of wound-related pain and complications. Historically, ankle malalignment has represented one of the main contraindications for the arthroscopic procedure, but interestingly some investigators have shown that the coronal joint deformity may be addressed arthroscopically as well. Other investigators have also demonstrated that part of the valgus/varus is due to malrotation of the talus within the mortise; therefore, controlling the talar position becomes crucial for correcting more severe deformities. We present here a technique for correcting tibiotalar malalignment during arthroscopic arthrodesis in varus or valgus ankles, performed through a K-wire used as a joystick to manage the talar position on both the coronal and axial planes.

Our goal was to develop a novel technique for inducing Achilles tendinopathy in animal models which more accurately represents the progressive histological and biomechanical characteristic of chronic Achilles tendinopathy in humans. In this animal research study, forty-five rabbits were randomly assigned to three groups and given bilateral Achilles injections. Low dose (LD group) (n = 18) underwent a novel technique with three low-dose (0.1mg) injections of collagenase that were separated by two weeks, the high dose group (HD) (n = 18) underwent traditional single high-dose (0.3mg) injections, and the third group were controls (n = 9). Six rabbits were sacrificed from each experimental group (LD and HD) at 10, 12 and 16 weeks. Control animals were sacrificed after 16 weeks. Histological and biomechanical properties were then compared in all three groups. At 10 weeks, Bonar score and tendon cross sectional area was highest in HD group, with impaired biomechanical properties compared to LD group. At 12 weeks, Bonar score was higher in LD group, with similar biomechanical findings when compared to HD group. After 16 weeks, Bonar score was significantly increased for both LD group (11,8±2,28) and HD group (5,6±2,51), when compared to controls (2±0,76). LD group showed more pronounced histological and biomechanical findings, including cross sectional area of the tendon, Young's modulus, yield stress and ultimate tensile strength. In conclusion, Achilles tendinopathy in animal models that were induced by serial injections of low-dose collagenase showed more pronounced histological and biomechanical findings after 16 weeks than traditional techniques, mimicking better the progressive and chronic characteristic of the tendinopathy in humans.

The aim of this case report was to describe a successful diabetic limb salvage procedure in the treatment of an infected diabetic foot ulcer through a multidisciplinary team approach and complex surgical reconstruction involving a femoral head bone allograft and musculocutaneous latissimus dorsi free flap. The decision to proceed with aggressive staged efforts at diabetic limb salvage should be made only after careful consultation with the patient, his or her family, and the rest of the multidisciplinary healthcare team.