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Ten percent of all ankle fractures sustain an associated syndesmotic injury. Syndesmosis injuries have been reported in conjunction with ankle sprains to ankle fractures, with an incidence between 1% and 18%. Isolated ligamentous syndesmosis sprains are rare and consequently are often undiagnosed, progressing to chronic ankle symptoms such as pain and disability, until arthritic joint changes indicate the original pathology. Syndesmotic injuries, even isolated, are not always easy to diagnose because they range from a simple sprain to frank diastasis. Among the most important predictors of functional results, on treatment of syndesmotic injuries, is the accurate restoration of the syndesmotic space. The suspension technique can achieve flexible fixation of the syndesmosis and permit full range of motion of the tibiofibular joint, thanks to starting rehabilitation exercise at an early stage after surgery.

Plantar fasciitis is one of the most common pathologies treated by a foot and ankle surgeon, being the most common cause of heel pain, affecting up to 10% of the population. Nonoperative therapy is the first choice and can have good stable results over time: when this fails, surgical treatment should be indicated and is warranted. Most patients are treated conservatively with physiotherapy, medications, ice, orthotics, and local injections, but about 10% of patients undergo surgical therapy to resolve recurrent symptoms. Various surgical procedures are available for the treatment of recalcitrant plantar fasciitis. The most common surgical management typically consists of open versus endoscopic plantar fascia release. Comorbidities at the foot or lower limb are documented in association with plantar fasciitis, although these do not represent the main cause of the disorder. The endoscopic resection of the plantar fascia, with or without heel spur removal, allows good visualization of the entire plantar fascia and allows a minimally invasive technique that provides patient satisfaction and stable and acceptable outcomes.

Chronic ankle instability is a joint disorder that is managed by different surgical treatments. In the literature, some advocate primary repair of remaining ligament portions, and others espouse ligament reconstruction with tendon transfers, grafting, or synthetic materials. Several techniques have been proposed with the traditional open approach anatomic reconstruction with or without the use of anchors. Further ankle disorders caused by and associated with joint instability frequently present in any articular compartment and are preferably treated with arthroscopy. Therefore, this procedure assumes a main role in the care of secondary symptomatic pathologies. The modified Brostrom repair is the method of choice for primary open operative treatment for chronic ankle instability. Recently, it has been proposed that this procedure be performed by arthroscopic technique, using dedicated portals to complete all the modified steps.

Open procedures to manage the surgical treatment of ankle arthritis have been considered the gold standard, limiting ankle arthroscopic procedures to providing articular disorders balance and to debriding the joint. Gradually, different surgical techniques have appeared in several studies trying to realize techniques less invasive and less invalidating for the joint. Therefore, the past two decades have shown a great increase of popularity and utilization of ankle fusion performed by arthroscopic procedures, with many studies aiming to demonstrate its advantages compared with open surgery, indications, and contraindications. Thus, arthroscopy has been confirmed as a reliable procedure: the analysis between arthroscopic and open ankle fusion has even revealed a statistically significant reduction of cost differences for total charges, reimbursement to the surgeon, and reimbursement to the hospital in cases of outpatient procedures.

Purpose In chronic lateral ankle instability, primary ligament repair is not always possible because of poor quality of the local tissues. A free autologous or allograft tendon graft or synthetic grafts are suitable alternative. We describe middle term results of arthroscopic reconstruction of the anterior talofibular ligament (ATFL) using a free autologous ipsilateral gracilis graft in patients with chronic ankle instability. Methods Eleven patients with chronic lateral ankle instability with imaging evidence of isolated ATFL tear underwent arthroscopic reconstruction of the ATFL using a free ipsilateral gracilis graft. Functional and subjective assessment were performed after an average of 24 months following the index procedure. Results At 24 months, all patients showed objective improvements. One patient reported transient dysaesthesiae on the dorsolateral aspect of the foot and heel. Conclusions Arthroscopic isolated reconstruction of the ATFL with a free ipsilateral gracilis grafts is safe, allowing restoration of joint stability and low surgical morbidity. Study design Case series

Posterior and anterior arthroscopy of the ankle and hindfoot may have to be undertaken at the same surgical sitting. Standard arthroscopic practice does not allow to approach both compartments without changing the position of the patient. In the supine position, most intra-articular structures of posterior portion of the ankle joint can be accessed from anterior portals with judicious traction, but visualization of posterior extra-articular compartment and hindfoot are not possible. To avoid repositioning of the patient, we have developed a procedure that allows access to the posterior compartment of the ankle with the patient supine. We describe a 2 posteromedial ankle portals procedure, which allows to reach both the posterior side of the ankle joint and the hindfoot extra-articular compartments keeping the patient supine throughout the procedure. After treatment of anterior compartment disorders using standard anterior portals, 2 posteromedial entry portals permit to visualize and treat pathologies of the posterior ankle and of the hindfoot, without prolonging surgery.

Both posterior and anterior arthroscopy of the ankle may be indicated in the same patient. With the patient supine, it is possible to reach most intraarticular structures of the ankle through the standard anterior portals, but difficult to examine the posterior compartments and to perform hindfoot endoscopy. In most patients following the anterior procedure the patient is positioned prone to operate on the posterior compartment. We describe a two-portal posteromedial hindfoot procedure that allows the surgeon to reach both the posterior joint space and the extraarticular compartment of the hindfoot with the scope and instruments, regardless of diagnosis, with the patient supine. After arthroscopy on the anterior portion of the foot using standard anterior portals, the two posteromedial portals allow endoscopic inspection and management of abnormalities in this region without repositioning the patient and without any remarkable local complication.Level IV. See Guidelines for Authors for a complete description of levels of evidence.

Standard arthroscopy of the ankle does not allow to approach at the same time the anterior and posterior compartments. Keeping the patient supine and with the application of judicious traction, anterior ankle arthroscopy allows to examine the various intra-articular structures, but treat is limited only to anterior pathology. Also, it is not possible to explore posterior compartment and posterior hindfoot through an anterior approach. Normally, for those patients in whom both the anterior and posterior compartments were to be operated upon, surgery is stopped, and the patient has to be re-positioned. We describe a 2 postero-medial hindfoot portals procedure, which allows to reach both the posterior aspect of the ankle joint and the extra-articular compartment of the hindfoot keeping the patient supine throughout the procedure. After arthroscopy of the anterior compartment using standard anterior portals, 2 postero-medial endoscopic approaches make it possible to visualize and treat pathologies of the posterior ankle and of the hindfoot, without prolonging the operation through the need to reposition the patient in the prone position.

The purpose of this study was to compare outcomes of chondroplasty versus microfracture versus osteochondral autologous transplantation (OAT) in patients with osteochondral lesions of the talus (OLT).After prospective sample size analysis, patients with symptomatic, recalcitrant Ferkel class 2b, 3, and 4 OLT were randomized to chondroplasty, microfracture, or OAT treatment groups. Outcomes were measured with use of the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHS), the Subjective Assessment Numeric Evaluation (SANE) rating, Numeric Pain Intensity (NPI), and magnetic resonance imaging (MRI).Eleven patients had chondroplasty, 10 ankles (9 patients) had microfracture, and 12 patients had OAT. Mean time to follow-up was 53 months (range, 24 to 119 months). AHS scores showed no differences at 12 and 24 months, and SANE ratings showed no differences at final follow-up. NPI was significantly lower (P.001) in chondroplasty and microfracture cases as compared with OAT at 24 hours postoperatively. Pearson's correlation analysis demonstrated an inverse relation between microfracture and OAT groups in that better outcome was associated with smaller lesions, compared with the chondroplasty group, which revealed mixed results with no particular trend. MRI revealed incomplete fill and edema after chondroplasty or microfracture and chondral gaps after OAT.Our results demonstrate no difference between chondroplasty, microfracture, and OAT with regard to AHS and SANE ratings in patients with OLT. However, NPI at 24 hours postoperatively was significantly lower in patients who had chondroplasty and microfracture.Level I, Therapeutic study, high-quality randomized controlled trial with no statistically significant differences but narrow confidence interval.

Introduction Over the past two decades arthroscopy of the ankle joint has been considered a procedure well and widely accepted by orthopaedic surgeons, forming their opinion as an easy tool and an easy-to-use technique. Advancing technology, equipment, and instrumentation improved, and new and advanced techniques has been developed for those joints considered small in dimension but not in importance. Increasing novel procedures lead out in time the opportunity for significant complications to develop. Many studies described by more than twenty years ago the involvement of vascular and nervous structures, addressing various rates of overall complications between 0.7% to 33% and focusing different problems related to the procedure and to the surgical technique itself. Because their position close to the areas of portal placement and to deep instruments direction, many of them has been considered at risk. Nevertheless they lie very superficial, making it easy to feel artery pulse and making it easy to palpate tendons and bony edges which are in their strict proximity. Despite neurovascular structures can present anatomic variations widely described in origin and in course, the risk of their lesion still remain low. Methods Authors present a long-term retrospective follow-up on ankle arthroscopy. From January 1999 to February 2009, 542 patients were submitted to ankle arthroscopy addressed both to anterior and posterior compartment. Only 485 have been enrolled and 57 have been lost to the survey. All the patients were evaluated with AOFAS score scale for the final results of the different surgical procedures. Results The overall complication rate was 8.6% for a total of 37 complications. The neurovascular ones were 20, twelve related to vascular problems and 8 to neurological ones. Specifically in 4 cases anteromedial portal placement was too close to saphenous vein origin, in 5 posteromedial approach was too close to posterior tibial artery branches, in 1 lateral portal was opened on a branch of peroneal artery, 2 had persistent wound bleeding for three days after surgery because of a too aggressive procedure. The peroneal nerve was involved in six cases, proximally for the compression of distraction and distally because the placement of the portal too medial, the saphenous nerve appeared compressed in two cases. All these complications were recovered in a few days, except three cases of high peroneal compression which needed a long period of rehabilitation. In five patients was recorded superficial ankle pain because non-invasive joint distraction at the heel and dorsal foot. Despite the tourniquet has been always used, only four patients referred pain at calf because long time use. Three cases were affected with a reflex sympathetic dystrophy totally recovered after four months of therapy. Two patients had a delay in wound healing because of diabetes. In one patient an instrument that broke was promptly removed by the surgeon during surgery, one presented with a superficial infection, and one was submitted to a subsequent procedure. Conclusion Understanding the anatomy of ankle compartments helps in avoiding injuries to neurovascular structures. Following step by step the correct anterior and posterior surgical procedures permits to respect vessels and nerves along their paths, limiting problems and complications.