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Background: Chronic pain syndrome (CPS) is a common complication after operative procedures, and only a few studies have focused on the evaluation of CPS in foot-forefoot surgery and specifically on HV percutaneous correction. The objective of this study was to compare postoperative pain levels and incidence of CPS in two groups of patients having undergone femoral-sciatic nerve block or ankle block regional anaesthesia before hallux valgus (HV) percutaneous surgery and the association between postoperative pain levels and risk factors between these patient groups., Methods: A consecutive patient series was enrolled and evaluated prospectively at 7 days, 1, 3 and 6 months after surgery. The participants were divided into two groups according to the regional anaesthesia received, femoral-sciatic nerve block or ankle block, and their outcomes were compared. The parameters assessed were postoperative pain at rest and during movement by the numerical rating scale (NRS), patient satisfaction using the Visual Analogue Scale (VAS), quality of life and return to daily activities. Statistical analysis was performed., Results: One hundred fifty-five patients were assessed, 127 females and 28 males. Pain at rest (p < 0.0001) and during movement (p < 0.0001) significantly decreased during the follow-ups; at 6 months, 13 patients suffered from CPS. Over time, satisfaction remained stable (p > 0.05), quality of life significantly increased and patients returned to daily activities and work (p < 0.0001). No significant impact of type of anaesthesia could be detected. ASA 3 (p = 0.043) was associated to higher pain during movement; BMI (p = 0.005) and lumbago (p = 0.004) to lower satisfaction. No operative-anaesthetic complications were recorded. Postoperative pain at rest and during movement improved over time independently of the regional block used, with low incidence of CPS at last follow-up. Among risk factors, only a higher ASA was associated to higher pain during movement, while higher BMI and lumbago to lower satisfaction., Conclusions: Both ultrasound-guided sciatic-femoral and ankle blocks were safe and effective in reducing postoperative pain with low incidence of CPS at last follow-up., Trial Registration: Clinical Trial NCT02886221 . Registered 1 September 2016., (© 2021. The Author(s).)

Osteotomies are commonly used in order to correct hallux valgus deformity. However, soft tissue structures also play an essential role in the etiology, progression, and treatment of hallux valgus (HV). The purpose of the present study was to analyze the correcting power (varus), reduction strength (sesamoid) and rotation of metatarsal and proximal phalanx after percutaneous adductor tendon release (PATR). To date, no study addresses this issue. Eleven cadaveric fresh-frozen below-the-knee cadaveric lower limbs with associated hallux valgus deformity were used. These specimens were subjected to a constant abduction force after PATR. HV and intermetatarsal angles showed statistically significant differences when comparing the preoperative and postoperative periods. PATR showed to be a reliable technique as the adductor tendon was completely released in 9 cases, and 75% released in the remaining 2 feet. The study supports that PATR provides powerful and quantifiable correction of HV deformity and can be accurately performed percutaneously., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Treatment for hallux valgus (HV) remains challenging. Third-generation percutaneous procedures try to reproduce chevron-type osteotomies to replicate their benefits, such as intrinsic stability and reproducibility. We report the first results using a percutaneous, intra-articular, chevron osteotomy (PeICO) technique that mimics the classic intra-articular open chevron procedure, associated with a percutaneous adductor tendon release (PATR) for the treatment of mild-to-moderate HV., Methods: From May 2015 to October 2018, a total of consecutive 114 feet (74 patients) were included. Primary outcome measures included radiographic (hallux valgus and intermetatarsal angles) and clinical parameters such as visual analog scale (VAS), FAAM Activities of Daily Living (ADL), and FAAM Sport, AOFAS Score, and MOXFQ, preoperatively and at final follow-up (Minimum 18 months). A patient satisfaction survey was also performed. Pronation and length of the first metatarsal were also assessed. Secondary outcomes included fluoroscopic time, length of surgery, complications, recurrence, and re-operation rates., Results: At 24.09 months on average, the AOFAS score improved from 52.1 points preoperatively to 91.1 (p < 0.001) at the latest follow-up. VAS decreased from 6.3 to 1. Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (p < 0.001) when comparing pre-operative and post-operative periods. Patients found the procedure to be excellent in 82% and very good in 13.5% of cases. Our global complication and re-operation rates were 5.26% and 3.5% (screw removal), respectively., Conclusion: PeICO combined with PATR proved to be a safe, reliable, and effective technique for the correction of mild-to-moderate HV deformity., (© 2021. SICOT aisbl.)

The state of alarm due to Covid-19 pandemic in Spain stopped all educational and most university research activities. The Spanish Anatomical Society (SAE) Consensus Expert Group on Body Donations piloted a study based on a questionnaire to know the status of body donations and dissection activities during the lockdown, as well as the future implications of Covid-19 pandemic for body donation programs and anatomy teaching. The questionnaire results show that Spanish Universities refused body donations and stopped all dissection research and teaching. The Covid-19 expected influence on anatomy teaching was referred to the increase in teaching workforce and resources required to apply the new safety measures to future practical activities, as well as to prepare and adapt teaching material for online-only programs. The application of reinforced safety measures was expected to be perceived by the respondent's students as a gain in teaching quality, while the transformation of the anatomy courses in online-only programs will be perceived as a quality decrease. The respondent's concerns about future institutional implications of the pandemic were related to increased costs of the adaptation of the facilities and the reinforced preventive measures, as well as the eventual decrease in donations. The complete lockdown applied to dissection rooms was not justified by scientific evidence and represented a break of the confidence deposed in the institutions by the donors. A consensus is required for the adoption of a renewed, comprehensive protocol for present and future body donations including the evidence Covid-19 pandemic has contributed to create., (© 2021 The Authors. Anatomical Sciences Education published by Wiley Periodicals LLC on behalf of American Association for Anatomy.)

Purpose: The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis., Methods: An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL., Results: A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD ± 0.34)., Conclusion: Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Anterior cruciate ligament (ACL) tears are routinely treated with an ACL reconstruction. This is based on historical literature reporting high failure rates after ACL repairs in addition to the limited healing potential of the ACL. Recently, improved understanding of pathophysiology of ligamentous healing has led to increasing interest in treating proximal avulsions with excellent tissue quality in the acute setting, as this technique allows for ACL healing. Potential advantages of ACL repair include preservation of native proprioceptive and kinematics of the knee, avoidance of graft harvesting morbidity and the possibility to perform a primary ACL reconstruction in case of failure. As a consequence, several techniques for ACL repair have been proposed that can be performed in isolation or with suture augmentation. The primary aim of this technical note is to describe step-by-step the ACL repair technique with and without suture augmentation. The secondary aim of the current study is to review the indications, patient selection and advantages of the technique., Competing Interests: Competing interests: None declared., (© International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A thorough knowledge of the anatomy of the deltoid and spring ligament complex is important for treatment of deformities that impact the foot and ankle. Both ligaments are interconnected, and the study of their anatomic characteristics is better performed together than in isolation. The deltoid ligament is a group of ligaments that derives its origin from the medial malleolus, and the spring ligament complex consist of a group of ligaments that connects the navicular and the sustentaculum tali of the calcaneus. They both play an important role in stabilization of the medial ankle and medial column of the foot., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons., Methods: A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency"., Results: A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm., Conclusion: The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options., Level of Evidence: Level IV.

Purpose: The purpose of the present anatomical study was to define the exact morphology of the posterior fibulotalocalcaneal ligament complex (PFTCLC), both for a better orientation and understanding of the anatomy, especially during hindfoot endoscopy., Methods: Twenty-three fresh frozen specimens were dissected in order to clarify the morphology of the PFTCLC., Results: In all specimens, the ligament originated from the posteromedial border of the lateral malleolus between the posterior tibiofibular ligament (superior border) and the calcaneofibular ligament (CFL), (inferior border). This origin functions as the floor for the peroneal tendon sheath. The origin of the PFTCLC can be subdivided into two parts, a superior and inferior part. The superior part forms an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon. From this structure, two independent laminae can be identified. The inferior part of the origin has no role in the aponeurosis and ligamentous fibres run obliquely to insert in the lateral surface of the calcaneus, in the same orientation as the CFL, but slightly more posterior, which was a consistent finding in all examined specimens. The PFTCLC is maximally tensed with ankle dorsiflexion and is located within the fascia of the deep posterior compartment of the leg., Conclusions: The PFTCLC is part of the normal anatomy of the hindfoot and therefore should be routinely recognized and partly released to achieve access to the posterior ankle anatomical pathology, relevant for hindfoot endoscopy. The origin of the ligament complex forms the floor for the peroneal tendon sheath. The superior part of the origin plays a role in the formation of an aponeurosis with the superior peroneal retinaculum and the lateral septum of the Achilles tendon.

Purpose: ATFL's superior fascicle injury has been considered to be the underlying cause in cases of ankle microinstability. As its clinical diagnosis can be difficult, arthroscopic examination may be the only objective diagnostic tool. The purpose of this study was to determine what types of injuries to the ATFL's superior fascicle are associated with ankle microinstability, and to provide the reader with an arthroscopic classification of the types of microinstability affecting the ankle., Methods: Ankle arthroscopy video records obtained during a four-year period from 232 patients with the diagnosis of ankle microinstability were reviewed. The characteristics of the ATFL's superior fascicle injury were identified, described and recorded along with any concomitant intra-articular pathology., Results: Four different injury patterns were consistently seen affecting the ATFL's superior fascicle. These ranged from ligament attenuation associated with loss of tension (type I), through to partial detachment (type II) or total detachment (type III) from the fibula. Finally, a total or partial resorption of the ATFL's superior fascicle (type IV) was also observed. There was a statistically significant association between the type of injury identified and the rate of intra-articular pathology observed arthroscopically. Equally, the higher the type in the classification, the higher the rate of loose bodies, lateral talar OCD, deltoid "open book" tears, and anterior soft-tissue formation., Conclusion: Different types of ATFL's superior fascicle injury can be observed in patients with ankle microinstability, ranging from ligament attenuation associated with a loss of tension (8.2%) to different degrees of partial (69.1%) and total (16.8%) ligament detachment from the fibula, or ligament remnant resorption (5.9%). As the type of injury progresses along with the proposed classification, the rate of intra-articular injuries also increases. The clinical relevance of this study is that a morphological ATFL's superior fascicle tear is recognized in patients with the diagnosis of ankle microinstability., Level of Evidence: IV.

Background: Both the percutaneous technique with arthroscopic assistance, also known as arthroscopic Broström (AB), and the arthroscopic all-inside ligament repair (AI) are widely used to treat chronic lateral ankle instability. The aim of this study was to compare the clinical outcomes of these 2 arthroscopic stabilizing techniques., Methods: Thirty-nine consecutive patients were arthroscopically treated for chronic ankle instability by 2 different surgeons. The AB group comprised 20 patients with a mean age of 30.2 (range, 18-42) years and a mean follow-up of 19.6 (range, 12-28) months. The AI group comprised 19 patients with a mean age of 30.9 (range, 18-46) years and mean follow-up of 20.7 (range, 13-32) months. Functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog pain scale (VAS) were assessed pre- and postoperatively. Range of motion (ROM) and complications were recorded., Results: In both groups the AOFAS and VAS scores significantly improved compared with preoperative values ( P < .001) with no difference ( P > .1) between groups. In the AB group the mean AOFAS score improved from 67 (range, 44-87) to 92 (range, 76-100) and the mean VAS score from 6.4 (range, 3-10) to 1.2 (range, 0-3). In the AI group the mean AOFAS score changed from 60 (range, 32-87) to 93 (range, 76-100) and the mean VAS score from 6.1 (range, 4-10) to 0.8 (range, 0-3). At the final follow-up 8 complications (40%) were recorded in the AB group. In the AI group 1 complication (5.3%) was observed ( P < .05)., Conclusion: Both the AB and AI techniques are suitable surgical options to treat chronic ankle instability providing excellent clinical results. However, the AB had a higher overall complication rate than the AI group, particularly involving a painful restriction of ankle plantarflexion and neuritis of the superficial peroneal nerve., Level of Evidence: Level III, retrospective comparative study.

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Lateral release (LR) for the treatment of hallux valgus is a routinely performed technique, either by means of open or minimally invasive (MI) surgery. Despite this, there is no available evidence of the efficacy and safety of MI lateral release. Our aim was to study 2 popular techniques for MI LR in cadavers by subsequently dissecting the released anatomical structures., Methods: Twenty-two cadaveric feet were included in the study and allocated into 2 groups, 1 for each procedure: 1 group underwent a MI adductor tendon release (AR), and in the other group, an extensive percutaneous lateral release (EPLR) (adductor tendon, suspensory ligament, phalanx-sesamoid ligament, lateral head of flexor hallucis brevis, and deep transverse metatarsal ligament) was performed. Anatomical dissection was performed to identify neurovascular injuries and to verify the released structures., Results: Both techniques demonstrated to be effective in reproducing a MI LR. A satisfactory release of the adductor tendon was achieved equally in both techniques ( P = .85), being partial in most EPLR cases and full in the majority of AR cases. The EPLR was successful in releasing the intended additional structures ( P < .05). One case of inadvertent complete section of the flexor hallucis longus was identified in the percutaneous adductor tendon release group. No cases of dorsolateral nerve injury were seen with either of the techniques., Conclusion: Percutaneous lateral release was a reliable and accurate technique in this cadaveric model. The MI AR proved to be more effective in fully releasing the adductor tendon while the ER was intended and able to release a number of other structures., Clinical Relevance: MI LR is a safe procedure that could obviate the need for open surgery to achieve the same surgical goal. It can be associated to either open or MI osteotomies in the correction of hallux valgus.

Purpose: Neurovascular structures around the ankle are at risk of injury during arthroscopic all-inside lateral collateral ligament repair for the treatment of chronic ankle instability. This study aimed to evaluate the risk of damage to anatomical structures and reproducibility of the technique amongst surgeons with different levels of expertise in the arthroscopic all-inside ligament repair., Methods: Twelve fresh-frozen ankle specimens were used for the study. Two foot and ankle surgeons with different level of experience in the technique performed the procedure on 6 specimens each. The repair was performed following a standardized procedure as originally described. Then, an experienced anatomist dissected all the specimens to evaluate the outcome of the ligament repair, any injuries to anatomical structures and the distance between arthroscopic portals and the superficial peroneal nerve (SPN) and sural nerve., Results: Dissections revealed no injury to the nerves assessed. Mean distance from the anterolateral portal and the SPN was of 4.8 (range 0.0-10.4) mm. The mean distance from the accessory anterolateral portal to the SPN and sural nerve was of 14.2 (range 7.1-32.9) mm and 28.1 (range 2.8-39.6) mm, respectively. The difference between the 2 surgeons' groups was non-statistically significant for any measurement (mm). In all specimens both fascicles of the anterior talofibular ligament were reattached onto its original fibular footprint. The calcaneofibular ligament was not penetrated in any specimen., Conclusions: The all-inside arthroscopic lateral collateral ligament repair is a safe and reproducible technique. The clinical relevance of this study is that this technique provides a safe and anatomic reattachment of the anterior talofibular ligament, with minimal risk of injury to surrounding anatomical structures regardless of the level of experience with the technique.

Purpose: Ankle lateral collateral ligament complex has been the focus of multiple studies. However, there are no specific descriptions of how these ligaments are connected to each other as part of the same complex. The aim of this study was to describe in detail the components of the lateral collateral ligament complex-ATFL and CFL-and determine its anatomical relationships., Methods: An anatomical study was performed in 32 fresh-frozen below-the-knee ankle specimens. A plane-per-plane anatomical dissection was performed. Overdissecting the area just distal to the inferior ATFL fascicle was avoided to not alter the original morphology of the ligaments and the connecting fibers between them. The characteristics of the ATFL and CFL, as well as any connecting fibers between them were recorded. Measures were obtained in plantar and dorsal flexion, and by two different observers., Results: The ATFL was observed as a two-fascicle ligament in all the specimens. The superior ATFL fascicle was observed intra-articular in the ankle, in contrast to the inferior fascicle. The mean distance measured between superior ATFL fascicle insertions increases in plantar flexion (median 19.2 mm in plantar flexion, and 12.6 mm in dorsal flexion, p < 0.001), while the same measures observed in the inferior ATFL fascicle does not vary (median 10.6 mm in plantar flexion, and 10.6 mm in dorsal flexion, n.s.). The inferior ATFL fascicle was observed with a common fibular origin with the CFL. The CFL distance between insertions does not vary with ankle movement (median 20.1 mm in plantar flexion, and 19.9 mm in dorsal flexion, n.s.). The inferior ATFL fascicle and the CFL were connected by arciform fibers, that were observed as an intrinsic reinforcement of the subtalar joint capsule., Conclusion: The superior fascicle of the ATFL is a distinct anatomical structure, whereas the inferior ATFL fascicle and the CFL share some features being both isometric ligaments, having a common fibular insertion, and being connected by arciform fibers, and forming a functional and anatomical entity, that has been named the lateral fibulotalocalcaneal ligament (LFTCL) complex. The clinical relevance of this study is that the superior fascicle of the ATFL is anatomical and functionally a distinct structure from the inferior ATFL fascicle. The superior ATFL fascicle is an intra-articular ligament, that will most probably not be able to heal after a rupture, and a microinstability of the ankle is developed. However, when the LFTCL complex is injured, classical ankle instability resulted. In addition, because of the presence of LFTCL complex, excellent results are observed when an isolated repair of the ATFL is performed even when an injury of both the ATFL and CFL exists.

Purpose: When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability., Methods: Thirteen patients [12 men and 1 woman, median age 32 (15-54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18-42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique., Results: During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an "open book" tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44-77) preoperatively to 100 (77-100) at final follow-up., Conclusion: Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle., Level of Evidence: Level IV, retrospective case series.

Purpose: Tendon grafts are often utilized for reconstruction of the lateral ligaments unamenable to primary repair. However, tendon and ligaments have different biological roles. The anterior tibiofibular ligament's (ATiFL) distal fascicle may be resected without compromising the stability of the ankle joint. The aim of this study is to describe an all-arthroscopic and intra-articular surgical technique of ATiFL's distal fascicle transfer for the treatment of chronic ankle instability., Methods: Five unpaired cadaver ankles underwent arthroscopic ATiFL's distal fascicle transfer using a non-absorbable suture and a knotless anchor. Injured or absent ATiFL's distal fascicle were excluded from the study. Following arthroscopy, the ankles were dissected and evaluated for entrapment of nearby adjacent anatomical structures. The ligament transfer was also assessed. The distance between the anterolateral (AL) portals and the superficial peroneal nerve (SPN) was measured and the shortest distance was reported., Results: All specimens revealed successful transfer of the tibial origin of the ATiFL's distal fascicle onto the talar insertion of anterior talofibular ligament's (ATFL) superior fascicle. The fibular origin of the ATiFL's distal fascicle remained intact. There were no specimens with SPN or extensor tendon entrapment. The median distance between the proximal AL portal and SPN was 3.8 mm. The median distance between the distal AL portal and SPN was 3.9 mm., Conclusion: An all-arthroscopic approach to an ATiFL's distal fascicle transfer is a reliable method to reconstruct the ATFL's superior fascicle. Transfer of ATiFL's distal fascicle avoids the need for tendon harvest or allograft. The lack of injury to nearby adjacent structures suggests that it is a safe procedure. The clinical relevance of the study is that ATiFL's distal fascicle can be arthroscopically transferred to be used as a biological reinforcement of the ATFL repair, or as an ATFL reconstruction.

Purpose: An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic ATFL all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality., Methods: Fifteen patients [9 men and 6 women, median age 30 (19-47) years] with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing non-operative management. Median follow-up was 18 (12-23) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut, but were recycled and used for augmentation of the ligament repair., Results: Arthroscopic examination demonstrated an isolated anterior talofibular ligament (ATFL) injury with poor remnant ligament tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median AOFAS score increased from 66 (44-87) preoperatively to 100 (85-100) at the final follow-up., Conclusion: Chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality., Level of Evidence: IV, retrospective case series.

Purpose: Anatomic reconstruction of the anterior talofibular ligament and calcaneofibular ligament is a valid treatment of chronic hindfoot instability. The purpose of this study was to investigate the outcomes of this procedure performed by an all-inside endoscopic technique., Methods: This study is a retrospective evaluation of a prospective database. Subjects were all patients who underwent an endoscopic lateral ligament reconstruction between 2013 and 2016. All patients had symptoms of ankle instability with positive manual stress testing and failed nonoperative treatment during at least 6 months. At final follow-up the outcome was assessed using the visual analogue score (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and Karlsson-Peterson scores., Results: After an average follow-up of 31.5 ± 6.9 months, all patients reported significant improvement compared to their preoperative status. The preoperative AOFAS score improved from 76.4 ± 15 to 94.7 ± 11.7 postoperatively (p = 0.0001). The preoperative Karlsson-Peterson score increased from 73.0 ± 16.0 to 93.7 ± 10.6 postoperatively (p = 0.0001). The VAS score improved from 1.9 ± 2.5 to 0.8 ± 1.7 (p < 0.001). Two patients had complaints of recurrent instability., Conclusion: Endoscopic ligament reconstruction for chronic lateral ankle instability is a safe procedure and produces good clinical results with minimal complications. In addition, the endoscopic approach allows an assessment of the ankle joint and treatment of associated intra-articular lesions., Level of Evidence: II.

Purpose: A thorough understanding of the arthroscopic anatomy is important to recognise pathological conditions. Although some ankle ligaments have been described as intra-articular structures, no studies have assessed the full visibility of these structures. The purpose of this study was to assess arthroscopic visibility of medial and lateral ankle collateral ligaments., Methods: Arthroscopy was performed in 20 fresh frozen ankles. The arthroscope was introduced through the anteromedial portal and the anterior compartment was explored in ankle dorsiflexion without distraction. Intra-articular structures were tagged using a suture-passer introduced percutaneously and they were listed in a table according to the surgeon's identification. After the arthroscopic procedure, the ankles were dissected to identify the suture-tagged structures., Results: According to the suture-tagged structures, 100% correlation was found between arthroscopy and dissection. In the anterior compartment, the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament on the medial side were observed. The deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament were tagged at the posterior compartment., Conclusion: Ankle dorsiflexion and non-distraction arthroscopic technique allows full visualisation of the medial and lateral ankle collateral ligaments: the superior fascicle of the anterior talofibular ligament, the distal fascicle of the anterior tibiofibular ligament and the anterior tibiotalar ligament. When using distraction, posterior structures as the deep fascicle of the posterior tibiofibular ligament and the intermalleolar ligament can be observed with anterior arthroscopy.

Purpose: The open "Broström-Gould" procedure has become the gold standard technique for the treatment of chronic ankle instability. Although arthroscopic techniques treating ankle instability have significantly evolved in the last years, no all arthroscopic Broström-Gould has been described. The aim of the study was to describe the all-arthroscopic Broström-Gould technique [anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER)], and to evaluate the clinical results in a group of patients., Methods: Fifty-five patients with isolated lateral ankle instability were arthroscopically treated. Arthroscopic ATFL repair with biological augmentation was performed through a two-step procedure. First, the ligament is reattached through an arthroscopic procedure. Next, the ligament is augmented with the IER that is endoscopically grasped. Both the ligament repair and its augmentation with IER were performed with the help of an automatic suture passer and two soft anchors. Characteristics of the patients, and pre- and postoperatively AOFAS and Karlsson scores were recorded., Results: The median preoperative AOFAS score increased from 74 (range 48-84) to 90 (range 63-100). According to the Karlsson score, the median preoperative average increased from 65 (range 42-82) to 95 (range 65-100). No major complications were reported. Only one case (1.8%) required a revision surgery at 23 months of follow-up., Conclusion: The arthroscopic all-inside ATFL repair with biological augmentation using the IER is a reproducible technique. Excellent clinical results were obtained. The technique has the advantage of its minimally invasive approach and the potential to treat concomitant ankle intra-articular pathology., Level of Evidence: Retrospective case series, Level IV.

Purpose: The anterior tibiofibular ligament (ATiFL) and its distal fascicle have been the subject of numerous studies, mainly due to the involvement of this ligament in anterolateral soft-tissue impingement of the ankle. There is currently no firm evidence related to the incidence of the distal fascicle or the frequency with which it is in contact with the talus, or whether this is a constant anatomic finding. In addition, the terminology used to refer to this structure is not accurate and varies widely in previous studies. The purpose of this study was to perform an anatomic study on a large number of specimens to clarify the anatomy of the anterior tibiofibular ligament, and specifically its distal fascicle, and its possible role in anterior ankle impingement syndrome., Methods: During a 7-year period (2010-2016), cadaveric ankle specimens dissected at our Anatomy Department were included in this study, accounting for a total of 154 ankles. The incidence of the distal fascicle and its contact with the talus were documented., Results: One hundred and seventeen ankles were included [78 men, 39 women, with a median age of 79.3 years (range 51-100 years)]. The ATiFL was found to have a distal fascicle in 100% of ankles, contacting the anterolateral part of the talus in all cases. The contact was increased in plantarflexion and reduced in dorsiflexion and finally disappeared completely in maximum dorsiflexion., Conclusions: The ATiFL has a constant distal fascicle that is in contact with the talus in the neutral position and in plantar flexion. Contact disappears in maximum dorsiflexion.

Purpose: Chronic ankle instability has been described as presenting with complete tears of both the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in 20% of cases. Arthroscopic techniques to treat chronic ankle instability are increasingly being reported and in some instances they can be technically demanding. The aim of this study was to describe an arthroscopic all-inside repair of both the ATFL and CFL, and to report the outcomes of a group of patients with chronic ankle instability that underwent the technique., Methods: Twenty-four patients [22 male and 2 female, median age 41 (range 22-56) years] with chronic ankle instability and torn ATFL and CFL were treated arthroscopically after failing non-operative management. Median follow-up was 35 (mean 34.7, and range 18-55) months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, both fascicles of the ATFL and the CFL were repaired., Results: Arthroscopic examination demonstrated ATFL and CFL injuries in all patients. Subjective improvement in their ankle instability was observed postoperatively. The anterior drawer and the talar tilt tests were negative at follow-up. The median AOFAS score increased from 65 (mean 65, range 52-85) preoperatively to 97 (mean 97, range 85-100) at final follow-up., Conclusion: Chronic ankle instability with concomitant injury of both the ATFL and CFL, can be successfully treated by an arthroscopic all-inside repair. The clinical relevance of the study is the description of the first arthroscopic all-inside ATFL and CFL anatomic repair technique, which offers excellent clinical results and the inherent benefits from minimally invasive surgery., Level of Evidence: IV, retrospective case series.

Ankle dorsiflexion arthroscopic technique with distraction at a surgeon's discretion is the current standard for ankle arthroscopy in most parts of the world. Reasons favoring the use of dorsiflexion during anterior ankle arthroscopy are based on the insertion of the anterior ankle joint capsule, which happens at a distance from the articular surfaces: this allows a large and safe anterior working area during dorsiflexion; ankle dorsiflexion also reduces the tension of anterior neurovascular structures and moves them away from the anterior aspect of the ankle, which protects them from damage during performance of the arthroscopic procedure; in addition, a lower rate of complications has been reported when dorsiflexion without distraction is being used for ankle arthroscopy. Nevertheless, intermittent ankle distraction can still be used during ankle arthroscopic procedures, but with just a few indications. In this infographic, authors explore and present the current indications for distraction in ankle arthroscopy as well as the broader indications for performing ankle dorsiflexion arthroscopic technique., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Access to the talar dome for the treatment of osteochondral lesions (OCLs) can be achieved via several different approaches to the ankle joint. The recent description of an anatomical nine-grid scheme of the talus has proven useful to localise OCLs but no studies have demonstrated which approaches are indicated to access each of these zones. The aim of this study is to demonstrate the access afforded to each zone by each approach., Methods: Four standard soft tissue ankle approaches were performed simultaneously in ten fresh-frozen cadavers (anterolateral - AL, anteromedial - AM, posterolateral - PL, posteromedial - PM). The area of the talus, which was accessible with an instrument perpendicular to the surface was documented for each of the approaches. Using ImageJ software the surface area exposed with each approach was calculated. The talar dome was then divided using a nine-grid scheme and exposure to each zone was documented., Results: The AL, AM, PL and PM approaches allow for exposure of 24%, 25%, 5%, 7% of the talar dome respectively. The AL gives access to zones 3 (completely) and 2, 5, 6 (partially); the AM to zones 1 (completely) and 2, 4, 5 (partially); the PL to zones 9 and 8 (partially); and the PM to zones 7 and 8 (partially)., Conclusions: A large area of the talar dome cannot be easily accessed with the use of standard soft tissue approaches (39%). Minimal or no access is achieved for grid zones 4-6 and 8. In those instances careful preoperative planning is necessary and extended exposure can be achieved with the use of osteotomies, section of the ATFL or through modified approaches., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Percutaneous surgery is experiencing sustained growth based on third-generation techniques. This cadaveric study was designed with the main goal of exploring the risk of iatrogenic tendon and neurovascular lesions and defining the safe zones in a percutaneous, intra-articular, chevron osteotomy (PeICO) procedure, as well as assessing the accuracy of the osteotomy itself., Methods: Eight feet from below-knee fresh-frozen specimens were selected. After the procedure, the specimens were dissected, and structures were inspected for damage., Results: The results of the safety measurements were as follows: (1) distance between portal 1 (P1) and the lateral border of the extensor hallucis longus (EHL) tendon: average 17.6 mm (range 12.7-21.3); (2) distance between P1 and the dorsomedial digital nerve (DMDN): average 7.2 mm (range 1.6-10.4); (3) distance between P1 and the metatarsophalangeal joint: average 15.7 mm (range 9.4-20.5); distance between portal 2 (P2), or the osteosynthesis portal, and the metatarsophalangeal joint: average 25.5 mm (range 22-30.4); distance between P2 and the lateral border of the EHL tendon: average 12.7 mm (range 8-16.7); and distance between P2 and the DMDN: average 4.1 mm (range 1.7-8.2). There were no iatrogenic injuries. The osteotomy angulation in the sagittal plane (reproducibility) average was 85.6 degrees., Conclusion: There were no iatrogenic injuries on this cadaveric study of PeICO., Clinical Relevance: This study will help orthopedic surgeons understand the risks of performing percutaneous surgery by mimicking an accepted open technique (chevron).

Purpose: The aim of this study was to systematically evaluate the available literature on minimally invasive surgical (MIS) treatment for hallux valgus and to provide an overview of the different surgical techniques., Methods: A systematic review of the literature available in MEDLINE, EMBASE, and the Cochrane database was performed including studies from January 2001 to 1 January 2018. The radiological outcomes (hallux valgus angle (HVA), intermetatarsal angle (IMA)), complication rates, and clinical outcome scores were evaluated. The MINORS scale was used to assess the methodological quality of included articles., Results: Of 278 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 2279 procedures in 1762 patients. The surgical techniques were divided into five categories: the Bosch technique, MIS Chevron-Akin, Reverdin-Isham procedure, Endolog system, and techniques involving distal soft tissue release and fixation. Results regarding radiological correction, clinical outcomes, and complication rate varied widely., Conclusions: The studies included were of too little level of evidence to allow for data pooling or meta-analysis. There were too few studies on each surgical technique category to assess whether one is more effective than the rest. However, there is some evidence that the Chevron and Akin showed the most potential for improvement of the HVA and the Endolog for the IMA. An overall complication rate of 13% was obtained among all included studies. Appropriately powered randomized controlled trials, utilizing validated outcome measures, blinded assessors, and long-term follow up are needed to assess the efficacy of MIS techniques.

The crucial role of the spring ligament complex within the pathologic process that leads to flatfoot deformity has evolved recently. There has been improvement in the anatomic knowledge of the spring ligament and understanding of its complex relationship to the deltoid complex and outstanding advances in biomechanics concepts related to the spring ligament. Optimization of flatfoot treatment strategies are focused on a renewed interest in the spring ligament and medial soft tissue reconstruction in concert with bony correction to obtain an adequate reduction of the talonavicular deformity and restoration of the medial longitudinal arch., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background:: Operative management of chronic Achilles tendon ruptures is challenging, and numerous techniques have been described. Risk of infection and wound breakdown have been described after open techniques, and minimally invasive methods have been proposed to avoid them. The aim of this study was to describe the clinical and radiological results obtained after endoscopic flexor hallucis longus (FHL) tendon transfer in patients with chronic Achilles tendon rupture., Methods:: Between 2012 and 2015, a total of 22 patients were endoscopically treated for chronic Achilles tendon rupture. Mean age was 69 years (range, 59-84 years). Mean follow-up was 30.5 months (range, 18-46 months). Preoperative magnetic resonance imaging (MRI) was obtained and tendon gap measured. An MRI was obtained at 9 to 12 months following surgery to evaluate Achilles tendon changes., Results:: Preoperative MRI examination showed a mean tendon gap of 6.3 cm (range, 3-10.7 cm). The MRI control was obtained only in 12 patients, and a normal or close to normal Achilles tendon was observed in all but 1 patient. The mean American Orthopaedic Foot & Ankle Society score increased from 55 preoperatively (range, 26-75) to 91 (range, 74-100) at final follow-up. All patients returned to their daily activities without difficulties. No patients reported complaints or symptomatic deficits of great toe flexion strength. No major complications were encountered., Conclusion:: Chronic Achilles tendon ruptures were successfully treated by an all-endoscopic procedure. The endoscopically assisted FHL transfer provided excellent results while benefiting from the minimally invasive procedure advantages. However, it entailed some technical challenges and may not be suitable for less experienced surgeons., Level of Evidence:: Level IV, retrospective case series.

Background: The purpose of this prospective study was first to evaluate the safety and effectiveness of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) in treating central metatarsalgia, identifying possible contraindications. The second objective was to verify the potential of DMMO to restore a harmonious forefoot morphotype according to Maestro criteria., Methods: A consecutive series of patients with metatarsalgia was consecutively enrolled and treated by DMMO. According to Maestro criteria, preoperative planning was carried out by both clinical and radiological assessment. Patient demographic data, AOFAS scores, 17-FFI, MOXFQ, SF-36, VAS, and complications were recorded. Maestro parameters, relative morphotypes, and bone callus formation were assessed. Statistical analysis was carried out ( p < 0.05)., Results: Ninety-three patients (93 feet) with a mean age of 62.4 (31-87) years were evaluated. At mean follow-up of 58.7 (36-96) months, all of the clinical scores improved significantly ( p < 0.0001). Most of the osteotomies (76.3%) had healed by 3-month follow-up, while ideal harmonious morphotype was restored only in a few feet (3.2%). Clinical and radiological outcomes were not different based on principal demographic parameters. Long-term complications were recorded in 12 cases (12.9%)., Conclusion: DMMO is a safe and effective method for the treatment of metatarsalgia. Although Maestro criteria were useful to calculate the metatarsal bones to be shortened and a significant clinical improvement of all scores was achieved, the ideal harmonious morphotype was restored only in a few feet. Hence, our data show that Maestro criteria did not have a predictive value in clinical outcomes of DMMO.

Background: Ankle instability is a common consequence of ankle sprains. Injury of the anterior talofibular ligament (ATFL) is the most common cause of ankle instability 1 . Arthroscopic treatment of ankle instability is an emerging field attracting increased interest among surgeons 2-10 . The arthroscopic all-inside ATFL repair allows the surgeon to explore the ankle joint, treat concomitant pathology when encountered, and reattach the injured ATFL to its fibular anatomical location. The aim of this article is to describe the arthroscopic all-inside ATFL repair through a 3-portal no-ankle-distraction technique., Description: After patient positioning, anteromedial and anterolateral portals are created. An accessory anterolateral portal is created just anterior to the fibula and about 1 cm proximal to the tip of the lateral malleolus. The arthroscope is introduced through the anteromedial portal, and the instruments are introduced through the anterolateral portal. Recognition of the ligament and evaluation of the ligament tear with a probe are required. The footprint for the fibular attachment of the ATFL is debrided. The ligament is penetrated with a suture passer. A nitinol loop is pushed and then is pulled out through the accessory portal. The nitinol wire is replaced by a double high-resistance suture. The limbs of the suture located in the accessory portal are passed through the anterolateral portal. Next, one or both limbs of the suture are passed through the loop suture. Pulling of the suture limbs introduces the loop into the joint and the ligament is grasped by the suture. The tunnel for the anchor is drilled. The knotless anchor is loaded with the suture, and the anchor and suture are introduced with the ankle in dorsiflexion and valgus. Postoperatively, the ankle is immobilized with a removable walking boot for 4 weeks. Once use of the walking boot is discontinued, physical therapy is started., Alternatives: Nonoperative treatment with physiotherapy or sports restriction can be an alternative for patients with surgical contraindications or as a first step of treatment. Open techniques (repair or reconstruction) or other arthroscopic-assisted techniques (arthroscopic introduction of anchors and percutaneous passage of sutures, or arthroscopic-assisted reconstruction) are possible surgical alternatives to the described technique to treat ankle instability., Rationale: The described technique has the advantage of being done with a minimally invasive approach and providing an anatomical repair of the ligament. Concomitant intra-articular pathology can be addressed during the procedure through the same arthroscopic approaches. Early rehabilitation and the lack of intra-articular knots are additional benefits of the technique.

Introduction: Operative correction of symptomatic bunionette by means of minimally invasive (MI) osteotomies of the 5th metatarsal (M5) has gained popularity. This study aims to investigate the safe zones of commonly used techniques and the risk of injury to neurological structures., Materials and Methods: Ten human fresh frozen cadaveric feet were dissected and branches of the sural nerve were identified. A frontal section of the feet was performed at the site of the skin incision described for M5 MI osteotomies (corresponding to distal and mid diaphyseal osteotomies). The location of the lateral dorsal cutaneous nerve (LDCN) of the sural nerve or its branches was documented using a goniometer and o'clock references placed on the frontal section of the M5., Results: The LDCN showed variations in the distribution of its branches, forming the dorsolateral branch - a single terminal branch for the 5th toe - in 6/10 cases or two terminal branches - the dorsolateral and dorsomedial - in 4/10. At the point of osteotomies, the dorsolateral branch was identified at a mean of 22.7° from the extensor tendon around the M5 circumference and in all cases between 12 and 2 o'clock in a right foot or 10 o'clock to 12 o'clock in a left., Conclusion: The studied M5 osteotomies can place the dorsolateral branch of the fifth toe at risk and safe zones lie between 10 o'clock to 2 o'clock in any foot laterality. If these landmarks are considered, the risk of nerve damage is minimized when performing MI osteotomies of the M5., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Snapping peroneal tendons is a rare cause of lateral ankle pain. Two subgroups have been described: chronic subluxation with superior peroneal retinaculum (SPR) injury and intrasheath subluxation with SPR intact. The aim of the study was to report the tendoscopic findings and results in patients affected by snapping peroneal tendons without evident dislocation., Methods: Between 2010 and 2015, a total of 18 patients with a retromalleolar "click" sensation and no clinical signs of peroneal tendon dislocation underwent tendoscopy. Mean age was 29 years (range, 18-47). Mean follow-up was 45 months (range, 18-72)., Results: Tendoscopic examination revealed an intact SPR in 12 patients. Of these 12, a space-occupying lesion was present in 7, a superficial tear of peroneus brevis in 4, and a shallow fibular groove in 7. An SPR injury without peroneal tendon dislocation was observed in the remaining 6 patients. All these 6 patients presented a shallow fibular groove. Although the SPR was injured, they had been diagnosed as intrasheath subluxation. Patients with intrasheath subluxation and intact SPR underwent debridement of a space-occupying lesion in 11 cases and fibular groove deepening in 5 cases. Patients with intrasheath subluxation and SPR injury underwent fibular groove deepening without addressing the SPR. At follow-up, the mean American Orthopaedic Foot & Ankle Society score increased from 76 (range, 69-85) preoperatively to 97 (range, 84-100). No recurrence or major complications were reported. Conclusion Intrasheath subluxation of peroneal tendons was successfully treated tendoscopically. A new subgroup of intrasheath subluxation with SPR injury but no clinically evident peroneal tendon dislocation is reported., Level of Evidence: Level IV, case series.

Background: Haglund syndrome is a common cause of heel pain. Risk for tendon detachment after calcaneoplasty can exist. Open Achilles tendon detachment, calcaneoplasty, bursectomy, pathologic tendon-tissue debridement, and tendon reattachment of the Achilles tendon is a common surgical management of Haglund syndrome combined with insertional Achilles tendinopathy. The aim of this study was to describe the endoscopic calcaneoplasty and anchor suture augmentation of the Achilles insertional area, and the results obtained in patients with an increased risk of Achilles tendon rupture after calcaneoplasty., Methods: Between 2012 and 2015, endoscopic calcaneal ostectomy and suture anchor augmentation was performed in 12 patients. Mean age was 44.8 years (range, 35-52 years), and mean follow-up was of 33.5 months (range, 21-46 months)., Results: The mean AOFAS score increased from 70 preoperatively (range, 55-85) to 92 (range, 63-100) at final follow-up. The mean VISA-A questionnaire increased from 34 preoperatively (range, 15-63) to 92 (range, 30-100) at follow-up. No major complications were reported. All patients returned to their daily activities without limitations, but 2 described complaints with sports activity., Conclusion: Endoscopic calcaneoplasty and tendon augmentation with suture anchor for the treatment of Haglund syndrome was a reproducible and safe technique that offered the advantages of the endoscopic technique., Level of Evidence: Level IV, retrospective case series.

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.

Background: The purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures., Methods: Ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section RESULTS: The DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5-45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5-40)., Conclusions: Using the clock method the DMDN and DLDN were found consistently between 10 o'clock and 2 o'clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery., (Copyright © 2016 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this non-randomized retrospective study was to investigate outcomes of minimally displaced, proximal 5MTB fractures, treated by a below-knee walking cast or a functional elasticated bandage with a support of a flat hard-soled shoe., Methods: A consecutive patient series was divided into two groups: the cast group (CG) and the functional group (FG). The subjects were radiologically and clinically evaluated according to Mehlhorn and Lawrence-Botte classification, and AOFAS Midfoot score, respectively., Results: 154 patients were followed up for a median of 15 months (range 12-24). There was no significant difference (p > 0.05) among the outcomes of each fracture pattern regarding the treatment choice. However, an earlier return to sports was noted in the FG, while Type-3 fractures achieved the worst results., Conclusion: Type-1 and 2 minimally displaced 5MTB proximal fractures can be successfully treated conservatively without weight-bearing restriction and without benefit of a cast with respect to a functional elasticated bandage., Level of Clinical Evidence: level III retrospective comparative study., Competing Interests: Conflict of interest statement The Authors declare that they have no conflict of interest related to the publication of this manuscript, and they have not received benefits or financial funds in support of this study.

Background: The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes., Methods: A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out ( P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%)., Results: All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points ( P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time., Conclusion: Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications., Level of Evidence: IV, case series.

Purpose: The flexor hallucis longus (FHL) tendon is the main anatomical landmark during hindfoot endoscopy, and anatomical variations related to the FHL can pose a risk to the tibial nerve and posterior tibial vessels during hindfoot endoscopy. The aim of this study was to determine the distance between the FHL tendon and the tibial neurovascular bundle in the posterior ankle joint when an anatomical variant of the FHL is present. The hypothesis was that the shortest distance between the tibial neurovascular bundle and the FHL tendon in the working area of the hindfoot endoscopy is increased when an anatomical variant of the FHL is present., Methods: A retrospective review was performed using consecutive ankle magnetic resonance imaging (MRI) scans obtained during 1 year. All scans with anatomical variations related to the FHL were included in the study. A control group including scans without anatomical variations was obtained for comparison. The shortest distance between the FHL tendon and the neurovascular tibial bundle was measured in both groups., Results: Three-hundred and fifty-five ankle MRIs were reviewed. 35 scans with anatomical variants of the FHL (9.8%) were found and comprised the study group that was compared to 35 scans without variants (control group). The mean distance from FHL to the neurovascular tibial bundle in the control group was 0.9 mm. The study group consisted of 18 cases with distal muscle belly insertion (5.1%), and 17 cases with an accessory tendon corresponding to a flexor digitorum accessorius longus (4.5%). In these subgroups, the mean distance from FHL to the neurovascular tibial bundle was 1.1 and 1.5 mm respectively. Overall this distance was found to be higher in the group with anatomical variants (1.3 mm) when compared to the control group (0.9 mm) (p < 0.05)., Conclusion: During hindfoot endoscopy, the presence of an anatomical variant related to the FHL tendon has proven safer anatomically than in its absence, due to the increased distance between the FHL tendon and the tibial neurovascular bundle in the working area. However, the minimal difference observed in safety distances still poses a major risk of injury during hindfoot endoscopic procedures in all cases.

Objective: Our objective is to review the anatomy and exposure of the posterior column and posterior tibial malleolus (the posterior tibial plafond) by defining the access corridors through 3 different approaches-posteromedial, posterolateral, and modified posteromedial., Methods: Cadaveric dissection with percentage of posterior tibial malleolus exposed, and strain gauge measurements to evaluate traction on the neurovascular bundle., Results: The 3 different approaches are applicable for exposure of different portions of the distal posterior tibial malleolus. Strain gauge measurements reveal the least traction on the flap containing the neurovascular bundle with the modified posteromedial approach (7.0 N) compared with the posteromedial (21.5 N) and posterolateral (16.8 N) approaches. Exposure of the posterior tibial malleolus was greater with the modified posteromedial approach (91%) compared with the other 2 approaches (posteromedial = 64%, posterolateral = 40%)., Conclusions: Depending on the location of the principal fracture fragments, particularly in high energy ankle and pilon fractures, each of the posterior approaches has its indication, with the modified posteromedial approach revealing more of the posterior anatomy than the other 2 approaches. The latter approach places the least traction on the flap containing the neurovascular bundle.

Background: Minimally invasive surgery (MIS) represents one of the most innovative surgical treatments of hallux valgus (HV). However, long-term outcomes still remain a matter of discussion within the orthopaedic community. The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy, following exostosectomy and lateral release., Methods: Eighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed preoperatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Patient satisfaction and complications were recorded. Computer-assisted measurement of antero-posterior radiographs was taken preoperatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA) and the tibial sesamoid position. Also, the bridging bone/callus formation was evaluated at the different radiographic follow-ups, while the articular surface congruency and the metatarsal index were calculated only preoperatively and at the last follow-up. Patient satisfaction was assessed using the visual analogue score (VAS). Statistical analysis was carried out using the paired t test. Statistical significance was set at p < 0.05., Results: The mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The post-operative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°, HVA 12.50°, DMAA 4.72° and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3 (3.75%). The complete healing of the osteotomies was achieved in all series at 3-month follow-up. However, the results obtained in the correction of the severe HV deformities were less encouraging., Conclusions: Minimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy, in combination with previous exostosectomy and subsequent lateral soft-tissue release, is a safe, effective and reliable procedure for correction of mild-to-moderate HV. However, it requires a long learning curve because of the inherent difficulty of the mixed different surgical procedures., Trial Registration: ClinicalTrials.gov PRS Protocol Registration and Results System: NCT02886221.

Gastrocnemius contracture has recently gained relevance owing to its suggested relationship with foot disorders such as metatarsalgia, plantar fasciopathy, hallux valgus, and others. Consequently this has induced a renewed interest in surgical lengthening techniques, including proximal gastrocnemius release, to resolve gastrocnemius contracture in patients with foot disorders. This article describes and discusses the general anatomy of the triceps surae and the surgical anatomy of the gastrocnemius., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Unlabelled: Lesser toe deformities are one of the most common conditions faced by orthopedic surgeons. Knowledge of the anatomy of the lesser toes is important for ensuring correct diagnosis and treatment of deformities, which are caused by factors such as muscle imbalance between the extensor apparatus and flexor tendons. However, this apparatus has not received sufficient attention in the literature. In addition, the large number of inaccurate and erroneous descriptions means that gaining an understanding of these structures is problematic. The objective of the present article is to clarify the anatomy of the extensor apparatus by means of a pictorial essay, in which the structures involved will be grouped and discussed in detail. The most relevant clinical implications will be addressed., Level of Evidence: Level V, expert opinion., (© The Author(s) 2014.)