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Purpose: Residual symptoms can be observed after ankle lateral ligament repairs commonly due to hyperlaxity, severe ankle instability or a failed stabilization. In order to increase joint stability, ligament or capsular-ligament plication has been used in other joints. Given that the anterior portion of the deltoid is a stabilizer against anterior talar translation, it could be used as an augmentation to restrict anterior talar translation. The aim of this study was to describe an arthroscopic anterior deltoid plication with a bony anchor as an augmentation to the lateral stabilization. The results in a series of eight patients were presented., Methods: Eight patients (seven males, median age 31 [range, 22-43] years) presented residual instability after arthroscopic all inside lateral collateral ligament repair. Arthroscopic anterior deltoid ligament plication was performed in these patients. Median follow-up was 22 (range, 15-27) months. Using an automatic suture passer and a knotless anchor, the anterior deltoid was arthroscopically plicated to the anterior aspect of the medial malleolus., Results: During the arthroscopic procedure, only an isolated detachment of the anterior talofibular ligament was observed without any deltoid open-book injury in any case. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligament repair and the anterior deltoid plication with a bony anchor. On clinical examination, the anterior drawer test was negative in all patients. The median American Orthopedic Foot and Ankle Society score increased from 68 (range, 64-70) preoperatively to 100 (range, 90-100) at final follow-up., Conclusion: The arthroscopic anterior deltoid plication is a feasible procedure to augment stability and control anterior talar translation when treating chronic ankle instability in cases of residual excessive talar translation., Level of Evidence: Level IV., (© 2024 The Author(s). Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament., Methods: Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken., Results: The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures., Conclusion: The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries., Level of Evidence: Not applicable (cadaveric study)., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: When the intermediate or collicular fascicle of the medial collateral ligament (MCL) is injured, the diagnosis of posttraumatic medial ankle instability (MAI) is supported. The aim of this study was to describe an arthroscopic all-inside MCL repair after posttraumatic MAI secondary to an isolated injury of the MCL deep fascicle with a knotless suture anchor technique., Methods: Seven patients (seven men, median age: 23 [19-28] years) with posttraumatic MAI were treated by arthroscopic means after failing nonoperative management. The median follow-up was 34 (13-75) months. The MCL was repaired with an arthroscopic all-inside technique., Results: A tear affecting the deep and intermediate or collicular fascicle of the MCL was observed in all cases. In addition, five patients were diagnosed with an isolated fibular anterior talofibular ligament (ATFL) detachment, and in two patients, both the ATFL and calcaneofibular ligament were involved. All patients reported subjective improvement after the arthroscopic ligament repair. The median American Orthopedic Foot and Ankle Society score increased from 68 (range: 64-70) preoperatively to 100 (range: 90-100) at final follow-up., Conclusion: Posttraumatic MAI can be successfully treated by an arthroscopic all-inside repair of the MCL. The presence of an MCL tear affecting the tibiotalar ligament fibres attached to the area of the anterior colliculus should be considered a sign of posttraumatic MAI. This partial deltoid injury at the level of the intermediate or collicular fascicle will conduct to a dynamic MAI., Level of Evidence: Level IV., (© 2024 The Authors. Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy., Methods: Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture., Results: In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer., Conclusions: The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy., Level of Evidence: Not applicable., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Rotational ankle instability is a multiligamentous injury defined as an overload injury of the deltoid ligament caused by a long-standing injury of the lateral collateral ligament in patients affected by chronic ankle instability. The purpose of the study was to compare the clinical outcomes of combined arthroscopic repair of lateral and medial ankle ligaments for rotational ankle instability versus isolated arthroscopic lateral ligament repair for lateral ankle instability at 2 years' follow-up., Methods: Between 2019 and 2021, 108 patients with chronic ankle instability were consecutively treated by arthroscopy. Of this group, 83 patients (77%) [median age: 26 (range, 14-77) years] underwent an isolated all-inside lateral ligament repair for lateral ankle instability (group A). In the remaining 25 patients (23%) [median age: 27 (range, 17-58) years], rotational ankle instability was clinically suspected and confirmed during arthroscopy; thus, a combined all-inside repair of lateral and medial ligaments was performed (group B). The same postoperative protocol was utilised for both groups. Patients were prospectively evaluated before surgery, at 3, 6, 12 and 24 months with Foot Functional Index (FFI) score, visual analogue scale (VAS) and Foot and Ankle Ability Measure-Sports subscale (FAAM-SS). At the latest follow-up, the satisfaction rate and complications were also recorded., Results: In both groups, FFI, VAS and FAAM-SS scores significantly improved compared to preoperative values (p < 0.001). In addition, according to all the scores evaluated, there was no significative difference (n.s) between groups at the final follow-up or at any of the intermediate follow-up. No major complications were observed in both groups., Conclusions: Arthroscopic ligament repair in case of ankle multiligamentous injuries, such as in rotational ankle instability, provides excellent clinical outcomes and is comparable to isolated lateral ligament repair at 2 years' follow-up. Therefore, when treating ankle instability, arthroscopic repair of each and every ligament that appears injured provides the best potential outcomes and is the recommended treatment., Level of Evidence: Level II, prospective comparative., (© 2024 European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Purpose: Open ligament repair is widely considered the gold standard treatment for chronic ankle instability. Nevertheless, arthroscopic treatment of ankle instability has gained popularity becoming the preferred technique for many surgeons. This study aimed to compare the clinical outcomes of all-inside arthroscopic versus open lateral ligament repair for chronic ankle instability at 5 years follow-up., Methods: Ninety consecutive patients were surgically treated for chronic ankle instability without concomitant intra-articular pathology observed on MRI: 41 patients [median age 28 (range 15-54) years] underwent an open lateral ligament repair (OLR); 49 patients [median age 30 (range 19-47) years] underwent an all-inside arthroscopic ligament repair (ALR). Functional outcomes using the Foot Functional Index (FFI), the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Score, and the Foot and Ankle Ability Measure-Sports Subscale (FAAM-SS) were assessed preoperatively and at the latest follow-up. At the latest follow-up, the satisfaction rate and complications were also recorded., Results: The mean follow-up was 58 ± 17.6 (range 47-81) months. In both groups FFI, AOFAS and FAAM-SS score significantly improved compared to preoperative values (p < 0.001). There was no statistically significant difference in postoperative outcomes between groups in the AOFAS (n.s) and FAAM-SS (n.s), but the FFI results were significantly better in the ALR group (p < 0.05). No major complications were reported in either group., Conclusion: Open and arthroscopic ligament repair to treat chronic ankle instability without concomitant intra-articular pathology produced excellent comparable clinical outcomes at 5 years follow-up. The complications were minimal in both study groups with no significant differences in AOFAS and FAAM-SS scores. However, arthroscopic repair showed significantly better results on the FFI. Therefore, when treating chronic lateral ankle instability, surgeons should consider arthroscopic ligament repair., Level of Evidence: III., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Background: Ankle lateral ligament sprains are common injuries in sports, and some may result in persistent ankle pain and a feeling of instability without clinical evidence of instability. The anterior talofibular ligament (ATFL) has 2 distinct fascicles, and recent publications have suggested that injury isolated to the superior fascicle might be the cause of these chronic symptoms. This study aimed to identify the biomechanical properties conferred by the fascicles in stabilizing the ankle in order to understand potential clinical problems that may follow when the fascicles are injured., Purpose/hypothesis: The aim of this study was to determine the contribution of superior and inferior fascicles of the ATFL in restraining anteroposterior tibiotalar resistance, internal external tibial rotation resistance, and inversion eversion talar rotation resistance. It was hypothesized that an isolated injury of the ATFL superior fascicle would have a measurable effect on ankle stability and that the superior and inferior fascicles would restrain different motions of the ankle., Study Design: Descriptive laboratory study., Methods: A robotic system with 6 degrees of freedom was used to test ankle instability in 10 cadavers. Serial sectioning following the most common injury pattern (from superior to inferior fascicles) was performed on the ATFL while the robot ensured reproducible movement through a physiological range of dorsiflexion and plantarflexion., Results: Sectioning of only the ATFL superior fascicle had a significant and measurable effect on ankle stability, resulting in increased internal rotation and anterior translation of the talus, especially in plantarflexion. Sectioning of the entire ATFL resulted in significantly decreased resistance in anterior translation, internal rotation, and inversion of the talus., Conclusion: Rupture of only the superior fascicle of the ATFL may lead to minor instability or microinstability of the ankle joint, without objective clinical findings of gross clinical laxity., Clinical Relevance: Some patients develop chronic symptoms after an ankle sprain without overt signs of instability. This may be explained by an isolated injury to the ATFL superior fascicle, and diagnosis may require careful clinical evaluation and magnetic resonance imaging examination looking at the individual fascicles. It is possible that such patients may benefit from lateral ligament repair despite having no gross clinical instability.

Background: The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT., Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95 % confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4)., Results: Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia., Conclusions: The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this., Level of Evidence: II., Competing Interests: Declaration of interest None., (Copyright © 2023 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Talus fractures are anatomically complex, high-energy injuries that can be associated with poor outcomes and high complication rates. Complications include non-union, avascular necrosis (AVN) and post-traumatic osteoarthritis (OA). The aim of this study was to analyse the outcomes of these injuries in a large series., Methods: We retrospectively collected data on 100 consecutive patients presenting to a single high volume major trauma centre with a talus fracture between March 2012 and March 2020. All patients were over the age of 18 with a minimum of 12 months follow up post injury. Retrospective review of case notes and imaging was conducted to collate demographic data and to classify fracture morphology. Whether patients were managed non-operatively or operatively was noted and where used, the type of operative fixation, outcomes and complications were recorded., Results: The mean age was 35 years (range: 18-76 years). Open injuries accounted for 22% of patients. An isolated talar body fracture was the most frequent fracture (47%), followed by neck fractures (20%). The overall non-union rate was 2% with both cases occurring in patients with open fractures. The AVN rate was 6%, with the highest prevalence in talar neck fractures. Overall rates of post-traumatic OA of the tibio-talar, sub-talar and talo-navicular joints were 12%, 8%, and 6%, respectively. These were higher after a joint dislocation, and higher in neck or head fractures. The postoperative infection rate was 6%. The overall secondary surgery rate was 9%. There were 2% of patients who subsequently underwent a joint arthrodesis., Conclusion: Our study found that talar body fractures are more common than previously reported; however, talar neck fractures cause the highest rates of AVN and post-traumatic arthritis. Open fractures also carry a greater risk of complications. This information is useful during consenting and preoperatively when planning these cases to ensure adverse outcomes may be anticipated., Competing Interests: Declaration of Competing Interest None., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Objectives: To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed., Design: Large single-center retrospective case series., Setting: Level-1 Trauma Center, London, United Kingdom., Patients: Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019., Intervention: Open reduction and DBP fixation with implants not routinely removed., Main Outcome Measurements: Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes., Results: Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis., Conclusions: This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients., Level of Evidence: Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Malunited comminuted calcaneal fractures result in poor function due subtalar joint arthritis and altered biomechanics. We aimed to assess whether percutaneous subtalar joint screws after fracture reduction provide good outcomes for these difficult injuries., Methods: We retrospectively analysed 15 comminuted calcaneal fractures (in 14 patients) treated with percutaneous subtalar screw fixation. All patients had a minimum of 12 months' follow-up. Six patients had open injuries. On the preoperative and the latest postoperative radiograph, Bohlers angle, Gissane angle, calcaneal inclination, width and length, absolute foot height, and posterior facet height were measured. Preoperative computed tomography scans were used to classify the fractures by Sanders classification. Clinical outcome scores were recorded postoperatively., Results: Mean age was 34.2 ± 14.2 years. Minimum follow-up was 12 months (mean 17.2 ± 4.4 months). Nine patients had a Sanders 4, 3 had a Sanders 3AB, 2 had a Sanders 3BC, and 1 had a Sanders 3AC fracture. Eighty percent of patients had their angle of Gissane, absolute foot height, calcaneal length and inclination restored by this technique. Bohlers angle was restored back into the normal range in 54% of patients. Mean postoperative AOFAS score was 74 ± 11. AOFAS scores positively correlated with postoperative Bohlers angle (Pearson's correlation coefficient 0.85; p = 0.004). One patient (7%) had a wound breakdown postoperatively and three patients (20%) had heel pain from the screws, which improved after removal., Conclusion: Percutaneous subtalar screws offer a reliable option to restore calcaneal anatomy in comminuted calcaneal fractures, with low complication rates. Over 80% of patients had their angle of Gissane, calcaneal length and inclination restored, and over 50% of patients had all radiological parameters restored by this technique. It offers the benefits of percutaneous reduction and fixation and this procedure may be considered an effective first stage prior to definitive subtalar fusion. Further work is needed to review the longer-term outcomes and the conversion rate to arthrodesis., Level of Evidence: IV (case series), Therapeutic., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Subtalar distraction bone block arthrodesis is a useful technique commonly employed in the management of calcaneal and talar fracture malunion. Traditionally it is performed via a posterolateral or extensile lateral approach, however such approaches have been associated with wound complications, particularly secondary to the added stress caused by the subtalar distraction crucial to this technique. Medial approaches to the subtalar joint have been used in other procedures but have not been reported in subtalar distraction bone block arthrodesis. A novel case and technique illustrating the medial approach for subtalar distraction bone block arthrodesis is discussed. LEVEL OF CLINICAL EVIDENCE: Level 4., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Minimally invasive (MI) surgery is becoming increasingly popular in the treatment of hallux valgus (HV). The scarf osteotomy is an effective procedure with a track record in open HV surgery. We adapted this effective osteotomy to MI surgery as a novel technique never reported before. The aim of this study was to compare the clinical and radiologic outcomes of patients who underwent open or MI scarf., Methods: Between 2017 and 2018, 58 patients were randomized to either open or MI scarf to treat HV deformity. Prospective patient-reported outcome measures and weightbearing radiographs were obtained. Data included the AOFAS score, radiologic angular correction, operative time, fluoroscopy radiation dose, and postoperative pain on visual analog scale (VAS)., Results: The mean follow-up was of 21 (range, 12-38) months. Radiologic measurements (postoperative hallux valgus angle, first-to-second intermetatarsal angle, and distal metaphyseal articular angle) were similar in both groups and showed statistically significant improvement from preoperative measures. The mean operative time for the MI group was 16.7 vs 26.1 minutes in the open group, a statistically significant difference. Radiation exposure was 14 times higher in the MI group when compared to the open group (mean: 34 vs 2.4 mGy/cm 2 , P < .001). There were no major complications in either group., Conclusions: The MI scarf provides a clinically and radiologically equivalent outcome to open scarf for the treatment of HV with reduced operative time and immediate postoperative VAS for pain but is associated with a small increase in radiation exposure., Level of Evidence: Level I, randomized controlled trial.

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.

Aims: Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation in ankle fractures in the setting of a major trauma centre. Our hypothesis is that posterior malleolus fixation leads to improved clinical outcomes., Methods: A total of 320 patients were identified with operatively treated ankle fractures involving a posterior malleolus component, at our institution between January 2012 and January 2018, ensuring a minimum 2 year follow-up. Of these patients, 160 had the posterior malleolus fixed as part of their surgery and 160 did not. Patient demographics, surgical details and complications were assessed. The Manchester-Oxford Foot Questionnaire (MOXFQ) was the primary patient outcome measure., Results: Fixation of the posterior malleolus was associated with a statistically significant improvement in patient outcomes. Mean MOXFQ score in the unfixed posterior malleolus group was 24.03 (0 - 62), compared to 20.10 (0 - 67) in the fixed posterior malleolus group (p = 0.04). Outcomes were worse with increasing size of posterior malleolar fragment. Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%)) and re-operation rate was double., Conclusion: This study demonstrates that in the practical setting of a major trauma unit, fixation of the posterior malleolar fracture leads to improved patient outcomes but with increased metalwork risks and reoperation rates., (Copyright © 2020. Published by Elsevier Ltd.)

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.

Minimally invasive techniques in the treatment of hallux valgus deformity have seen growing popularity since the 1990s. The purpose of this article is to assess the existing body of literature as to the safety and efficacy of minimally invasive techniques and identify areas for further development. The appeal of minimizing soft tissue damage, reducing surgical time, and faster recovery is currently offset by the initial learning curve and a lack of high-quality studies regarding minimally invasive techniques. There is currently insufficient evidence to recommend one minimally invasive technique over another and further high-level evidence studies are warranted., 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.