Background:An isolated posterior malleolar fracture is an uncommon injury and it can mimic simple ankle sprains, however it can be considered as a clue to a significant soft tissue injury which is the same as the when a subtle Segond fracture of the knee can signify a significant ACL injury.This article describes a case report of an isolated subtle posterior malleolar fracture with a significant syndesmotic disruption that was confirmed by examination under anesthesia.Case Presentation:A 28-years-old male patient sustained a twisting injury to his left ankle during a game of football.On examination, there was tenderness over the distal tibia and fibula at the level of the syndesmosis with positive external rotation syndesmosis stress test.An ankle x-ray showed a subtle isolated posterior malleolar fracture and a weight bearing x rays showed decreased tibiofibular overlap and increased tibiofibular clear space.
After a proper surgical consent was taken,Syndesmotic disruption and diastasis were confirmed intra-operatively in different ankle views (AP, Mortise, External rotation stress in mortise view).The syndesmosis was reduced with a clamp and stabilized with two syndesmotic screws. The posterior malleolar fracture was not fixed as it was deemed too small to directly fix.Discussion:An isolated posterior malleolar fracture can easily be missed on plain radiographs and diagnosed as ankle sprain with underestimation of the severity of the associated soft tissue syndesmotic disruption.Conclusions:Our case report highlights that a subtle isolated posterior malleolus fracture should be considered as a part of more complex injury to the ankle till proved otherwise .

Introduction:Dislocations of the mid-tarsal joint (Chopart) are rare. Dorsal displacement is also very rare. This rarity is explained by the stability conferred by the geometry and orientation of the tarsal bones which are firmly united by a solid ligament system. Material and method : 22-year-old patient had suffered trauma to her right foot following a domestic accident. Clinical examination revealed midfoot edema, a deformity of the foot with varus displacement of the forefoot. The vasculo-nervous examination of the foot was without abnormality. The radiological assessment showed a mid-tarsal dislocation of the Chopart. The reduction of the dislocation by external maneuver was performed which was maintained by two pins percutaneously. Additional immobilization with a cast boot was put in place for 8 weeks. The pins are removed as a result. The functional rehabilitation of the foot lasted five weeks. Results:
After 10 months, the functional result was good; walking was painless and the mobility of the foot was satisfactory; the follow-up X-ray does not show any abnormality. Conclusion: Pure dislocation of the tarsal navicular bone is a rare and serious injury. The positive diagnosis is based on standard radiography, the interpretation of which is sometimes difficult, especially for the diagnosis of lesions of the external column. The early management and the perfect anatomical reduction of the lesions are the only guarantees of a good functional result.

Aim- Treatment of posterior malleolus fracture of ankle remains controversial. Although there is evidence that a fracture of the posterior malleolus may result in an increased incidence of osteoarthritis (OA) and therefore worse functional outcome, there is no agreement as to how such fractures should be treated and importance of fragment specific fixation .Methods- We did a retrospective analysis of fixation of posterior malleolus fracture fixation done in our hospital from Jan -Dec 2019 in adults .Results - There were 67 patients with posterior malleolus fracture out of which 15 were treated surgically .Mean age was 52.8 (28-52) . One patient had synostosis and one patient had oa changes with articular step in operated group . Surgically treated patients had better outcome compared to conservatively treated group . Also approach was based on ct configuration of fragments .Conclusion- CT scan should be used for preoperative evaluation for these fractures and approach and fixation should be based on fracture configuration based on ct rather than xrays .

Introduction : The management of tendoachilles (TA) ruptures remains controversial. There is increasing evidence supporting conservative management with functional rehabilitation, with equivalent outcomes and re-ruptures rates when compared to surgery. The role of ultrasound (US) in the diagnosis of TA rupture is also debated. With increasing demands on physiotherapy and rehabilitation services within the National Health Service (NHS) in the UK, the aim of this study was to evaluate outcomes of patients following conservative management in our unit. Methods : All patients who presented to our virtual fracture clinic with TA rupture from January 2019 to January 2020 were included. All patients were allocated to a standardised achilles tendon rupture treatment protocol, including functional rehabilitation in a vacoped boot and physiotherapy supervision. Minimum follow-up was one year. Results : Forty five patients were included in the study. Mean age was 38 years . 38/45 (84.4%) sustained the rupture during sporting activity. 21/45 (46.6%) underwent an US and none of these went onto surgical management. Overall, 3/45 (6.6%) underwent surgical repair of which 2 patients had surgery performed abroad. 14/45 (31.1%) patients received physiotherapy according to the unit’s functional rehabilitation protocol, 21/45 (46.6%) patients had physiotherapy elsewhere and 8/45(17.8%) patients did not have documented physiotherapy. There were no cases of re-rupture at one year follow-up. Patient satisfaction was significantly reduced by inconsistent therapy involvement. Conclusion: Successful outcomes including patient satisfaction with functional rehabilitation relies on the provision of a dedicated functional rehabilitation service but also compliance from patients with local services.

Background: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. Management of this injury can be challenging due to delayed union and refracture. Intramedullary screw fixation rather than conservative management has been recommended in the athletic population.
Methods: Following the PRISMA guidelines, two independent authors searched several databases throughout November 2019 to identify studies reporting on Jones fractures of the 5th metatarsal, exclusively in athletes.
Results: 22 studies where eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4%. The RTP rate in IM screw only was 98.8% in other surgical fixations methods (plate, mini fix) was 98.4% ,whereas in conservative management was 71.6%. RTP in surgical group showed significant superiority over conservative group (OR: 0.033 CI:( 0.005-0.215) P <0.001). The overall time to RTP was 9.6 (8.5-10.7) weeks. The time to RTP in the surgical group (IM screw) was 9.6 (8.3-10.9) weeks, significantly less than conservative groups, which was 13.05 (8.15-17.95) weeks. The pooled union rate in operative group (excluding refracture) was 97.3% (95.1%-99.4%). The pooled union rate in the conservative group was 71.4% (49.1%- 93.7%). Time to union in IM screw group 8.2 (7.5-9) weeks was shorter than conservative group 13.7 (12.7-14.6).The overall refracture rate was 10.2% (5.9%-14.5%).
Conclusion: Return to play following surgical management of Jones fractures in athletes is excellent regardless of the implant used and sport. Intramedullary screw fixation is superior to conservative management. The authors recommend surgical fixation for all Jones fractures in athletes.

Introduction: Triple arthrodesis is considered the gold standard for treating rigid flatfoot deformities with proven long-term reliability of correction and favorable functional outcomes. However, the necessity of fusing an unaffected calcaneocuboid joint has been questioned
Methods: Patients with PTTI stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological deformity correction. Secondary outcomes were operative time, time to union, and complications.
Results: 23 patients matched the inclusion criteria. Thirteen patients underwent double arthrodesis, while ten patients underwent triple arthrodesis. The mean time to union in the double and triple arthrodesis groups was 3.39±0.65 vs. 3.31 ±0.6 months, respectively, with no statistically significant differences (p=0.77). The mean operative time in double and triple arthrodesis groups was, 55.77±15.18 vs. 91.6±24.14 minutes (p<0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score postoperatively (71.46±7.77 vs. 88.38±3.66,p<0.001) and (66.9±7.69 vs. 85±5.83,p<0.001), respectively. Both double and triple arthrodesis groups had statistically significant improvement of preoperative Meary's angle, calcaneal pitch, Cal-MT5 height, calc-MT1 angle, and TN coverage angle postoperatively. There were no statistically significant differences between double vs. triple arthrodesis groups in AOFAS score improvement or deformity correction.
Conclusion: Double arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former.

Background: While there is a large number of studies discussing the high energy Lisfranc injuries, the evidence available on the increasingly reported low-energy injury in active individuals with high demand, including athletes and military personnel, remains scarce and mostly retrospective.

Methods: Following PRISMA guidelines, two independent authors searched several databases through April 2019 to identify studies on low energy Lisfranc injuries in athletes and military personnel. The primary outcomes were RTP/RTD rate and time to RTP/RTD, whereas the secondary outcomes were games missed, time out of practice, time to full recovery, midfoot arthritis, and reoperation.

Results: 15 studies were eligible with a total of 441 subjects. Out of 441 subjects, a total of 380 (86.16%) were able to return to play and duty. There were no statistically significant difference in RTP comparing op vs. non-op [OR=0.714, CI: 0.17-2.88,I2=0%] nor ORIF vs. PA [OR=0.780, CI: 0.310-1.963, I2=0%]. The overall RTP in bony and ligamentous injuries were 82.1% [CI:70.9-93.4%, I2=0%] and 95.8% [CI:92.6-99.1%, I2=0%], respectively with no statistically significant differences [OR=1.909, CI=0.64- 5.64, I2=37%]. The mean time out in non-op and op. groups were 58.01 [CI:13.6-102.4,I2=98.03%] and 116.4 [CI:62.4-170.4; I2=99.45%] days, respectively. The mean time out in bony and ligamentous injury groups were 98.8 [CI:6.1-191.6,I2=99.82%] and 76.4 [CI:37.9-115.02;I2=99.83%] days, respectively with statistically significant differences [SMD:3.621, CI:-5.7-13,I2=83.17%].

Conclusion: Our meta-analysis on low-energy Lisfranc injuries in high demand individuals found an overall excellent RTP/RTD rate. The time out was not affected by the management, bony or ligamentous nature of the injury nor players’ position.

Hallux rigidus is a degenerative arthritis of the first metatarsophalangeal joint. It is a disabling pathology due to pain and stiffness while walking. It is the second most common condition affecting the first metatarsophalangeal joint (MTPJ) after hallux valgus. The first MTPJ arthrodesis is indicated in advanced stages in order to restore correct function of the foot. The purpose of this study was to assess the functional outcome of first MTPJ arthrodesis in hallux rigidus. We conducted a retrospective study of 40 patients over a period of 11 years. We included patients with unilateral hallux rigidus, graded II or III according to the Regnauld radiographic classification. Preparation of the bone ends was achieved using convex and concave reamers and fixation was made by Herbert screws. We assessed the functional outcome based on the American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale. The mean AOFAS functional score was 41/100 preoperatively. The postoperative functional assessment using the AOFAS score was carried out at a mean follow-up of three years and four months. It revealed significant improvement in pain and functional parameters (P <0.01 and P = 0.032 respectively), with an average overall scale after surgery equal to 82 (P = 0.021). We recorded a fusion rate of 97,5 %. Only one patient ended up with pseudarthrosis and required no additional surgery. In conclusion, the present results show that first MTPJ arthrodesis in advanced stages of hallux rigidus allows a fair functional outcome, since the AOFAS scale improved significantly after surgery.

Calcaneum is most common fractured bone of tarsus, resulting in disabling intra-articular fractures. Open fractures represent 10% of calcaneal fractures and their management being tedious and difficult . Calcaneal fractures associated with open wounds, severe blistering, burns , persistent swelling and excessive comminution are very difficult to treat with standard open reduction and internal fixation (ORIF). Treatment with indirect reduction and Iliizarov/ external fixator represents a good promise and solution to frustrating rehabilitation and outcome of such tedious fractures.This was a hospital based prospective study of 30 OPEN displaced intra-articular calcaneal fractures . According to Sanders classification 5 were type II, 14 were type III and 11 were type IV fractures. Functional scoring was done as per American foot and ankle society scale (AOFAS), with 40 % (n=12) as excellent, 53% (n=16) as good and 7 %( n=2) as fair and none poor.12 cases had pin tract infection, Seven patients had heel broadening up to 1cm and Regional sympathetic dystrophy appeared in 3 cases which resolved after frame removal and physiotherapy.Application of Illizarov ring fixator in calcaneum fractures offers unique advantage of being applicable in all circumstances including comminution, open fractures and fractures with poor overlying soft tissue. This procedure is certainly best alternative modality of treatment in difficult calcaneal fractures like soft tissue swelling open fractures.circumstances including comminution, open fractures and fractures with poor overlying soft tissue. This procedure is certainly best alternative modality of treatment in difficult calcaneal fractures like soft tissue swelling open fractures.

Fracture-dislocations of the talo-navicular joint are rare and usually complex injuries associated with high-energy trauma. Failure to diagnose concomitant lesions can lead to poor functional outcomes and progressive deformities of the foot, as severe capsuloligamentous lesions are often present. Few published data is described in literature as of the current work. We present the case of a 79-year-old male who was referred to our emergency department due to persistent pain and inability to bear weight on his right foot after sustaining a 3-meter fall over two weeks prior. A radiograph and a computed tomography (CT) were promptly performed which revealed a comminuted fracture with dorsal dislocation of the tarsal navicular and a plantar avulsion fragment of the lateral cuneiform. Three weeks after the lesion, the patient underwent primary talo-navicular-cuneiform arthrodesis with cancellous autograft. The posterior tibialis tendon was found to be avulsed and was reinserted into the medial cuneiform with a suture-anchor. At 1-year follow-up the CT revealed successful fusion between the navicular and medial cuneiform, with no fusion however of the talo-navicular joint. The medial longitudinal arch of the foot was maintained. The patient was pain-free with moderate rigidity.

Introduction: The purpose of this study was to compare a Minimally Invasive Chevron Akin (MICA) osteotomy and the well established Open Chevron and Akin osteotomy (OCA).
Methods: The authors retrospectively reviewed the database in a secondary hospital foot and ankle registry from 2019 to 2020. Pre-operatively, and post-operatively the following outcome parameters were determined: Radiographic outcome measures, Visual Analog Score (VAS) of pain, the American Orthopedic Foot and Ankle Society (AOFAS) forefoot score and patient satisfaction.
Results: Thirty cases were analyzed (Sixteen MICA group; Fourteen OCA group). Both operative techniques achieved significant correction of the hallux deformity. The hallux valgus angle (HVA) improved from 32,2 to 7,36 in the MICA and from 31,3 to 12,9 in OCA group, whereas the intermetatarsal angle (IMA) improved from 14,2 to 6,6 in the MICA and from 11,5 to 6,5 in OCA group. No significant differences were observed between the groups by any of the determined outcome parameters.
Conclusion: With the MICA osteotomy, radiological and clinical outcome are comparable to the open technique.

Introduction: In this study, we describe the epidemiology and associated lesions of all calcaneus fractures treated in our institution in a 9-year period and analyze them according to the patients’ characteristics and injury mechanisms. Methods: We retrospectively analyzed clinical records, radiographs and CT scans in order to relate the patients’ characteristics, calcaneus fracture mechanism and pattern and associated lesions. Results: We included 232 patients with calcaneus fractures resulting from 105 falls from height; 58 torsional mechanisms; 48 low-energy falls; 11 direct hits; 10 motor vehicle accidents. Associated injuries occurred in 19,4%, or 25,9% if considering only high-energy mechanism. Foot and ankle lesions accounted for 53% and spinal fractures for 17,7%. Pelvic ring fractures, other lower and upper limb injuries and thoracic or head trauma accounted for the remaining 29,3%. Gender was associated with the type of fracture and lesion mechanism. Concomitant injuries were more common in car and motorcycle accidents (60,0% and 40,0% of patients, respectively), but also falls from height (26,7%). Higher energy resulted in more severe lesions - almost all pelvic ring, spinal fractures and open fractures were caused by falls from height. Conclusion: Particularly when they result from higher energy trauma, calcaneus fractures are often associated with important orthopedic and non-orthopedic injuries. Apart from the classically described lumbar spine fractures, this study helps us keep in mind less obvious lesions including lower limb, upper limb, pelvic and even head or thoracic trauma. It also reinforces the need for a multi-disciplinary approach.

Gesture associated with the different osteotomies of the first metatarsal This osteotomy initially described by Akin in 1925 is well known in Europe. The Akin osteotomy is a medial closing osteotomy of the proximal phalanx described by OF Akin 1 in 1925. It is generally performed for the correction of a hallux valgus deformity in conjunction with a first metatarsal osteotomy,an interphalangeal hallux deformity and a long proximal phalanx.
When the previous times for hallux valgus correction have been met with good MTP 1 congruence,basal osteotomies are very useful and easy to fix. two types of phalangeal osteotomy which have different indications and technique and which we now describe. Those are the basal osteotomies, then diaphyseal.Today, multiple fixation techniques,including suture, thread,screw and staple fixation,have been reported.The authors' preferred technique is staple fixation,which is reported to be safe and effective with a low risk of complications.Diaphyseal osteotomy is more unstable than the basal osteotomy,It requires solid fixation.complications in Akin osteotomies: in the basal osteotomy it may be a rupture of the lateral cortex which gives instability in the osteotomy that is difficult to recover except by the placement of an oblique screw, preferably a screw .in the diaphyseal osteotomy if it is a shortening,displacement of the fragments during the placement of the staples,if a temporary axial wire has not been placed beforehand;excess pinching in the lateral part. In porotic bone and for shortening,it is therefore better to use a screw. In all other cases, the shape memory staple will be used.

Introduction:Achilles tendon rupture is more and more frequent, preferentially affecting young active adults, the victim of a sports accident.Its incidence has increased considerably in the last two decades, linked to the considerable development of sports activities.Material and methods:Our work relates to a prospective study of 160 cases of acute Achilles tendon rupture,over a period of 7 years (minimum 6 months, maximum 7 years),collected between January 2013 and December 2019 in the surgical department. Traumatology Orthopedics at Salim Zemirli Hospital, Algiers.Our patients are divided into 141 men and 19 women, the average age is 39 years old with extreme ages of 16 to 80 years.The maximum number of cases was between 30 and 50 years, with a frequency of 22 cases per year.75% of our patients ruptured the Achilles tendon during a sports accident.Ultrasound was performed on all of our patients confirming the diagnosis.MRI was performed in 5patients, whose clinical diagnosis was difficult.All of our patients underwent open surgery by suturing, lacing or plasty followed by immobilization.Results:Skin infection was observed in three patients.No case of iterative rupture was reported, nor residual pain.Finally,no sural nerve damage or thromboembolic complications were reported.We found in our study a sports recovery at 180 days on average.The functional results at the last follow-up were assessed according to McComis criteria with a mean follow-up of 3 years.Thus, we noted 75% excellent and good results, 25% average results.Conclusion:Achilles tendon ruptures are the preserve of young adult male athletes.Open surgery with early mobilization is probably the method of choice.

In the surgical treatment of flexible flat foott in adults, the calcaneus lengthening osteotomy is aimed at indolence and correction of deformity. The goal of the work was the radio-clinical evaluation of the results of this intervention associated with gestures on the soft parts. The case of a 30-year-old female patient is reported for a soft, symptomatic flexible flat foot. The clinical and radiographic review was performed at an average follow-up of 7 years. On review, Kitaoka's score was excellent at 95 points / 100. Pain and function were significantly improved. The foot was focused. The talian slope and the talo-calcaneal divergence, calcaneal slope, the Méary line were normalized. The calcaneal valgus was reduced by 6.6 ° (16.6 ° to 10 °). The calcaneus lengthening osteotomy associated with movements on the soft parts remains a good indication for flexible flat feet without arthritis degeneration. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus.

New therapeutic approach for idiopathic reducible severe flat foot valgus, symptomatic of children and adolescents, which respects the growth and joint mobility of the foot. Correction extra-articular osteotomies associated with soft tissue gestures are the treatment of choice to restore the morphology and biomechanics of the foot and prevent early joint deterioration
Calcaneo-cuboid-cuneiforme osteotomy, extra-articular osteotomy is the treatment
current ideal for idiopathic reducible severe flat foot valgus in children and
the teenager. The deformation of the foot is corrected while maintaining mobility.
Conceptualized by Rathjen and Mubarak (JPO 1998). This technique is described under the name of 3C osteotomy by Anglo-Saxons: a closing osteotomy (subtraction based on medial) associated with a medial translation of the Calcaneus, a closing osteotomy plantar or medial cuneiform pronation and cuboid opening osteotomy
to restore alignment of the forefoot and midfoot.
For the sake of refinement, efficiency of surgical procedures and improvement of final result both aesthetically and functionally, we propose a strategy less aggressive surgery on still growing immature bones..

Short fibular tendon fissure syndrome is a longitudinal cracking of the tendon that occurs in the retromollar portion. The lesion begins at the tip of the lateral malleolus and can extend up to 5 cm. Cracks most often occur as a result of equine varus trauma and are sometimes associated with chronic ankle laxity. Magnetic resonance imaging (MRI) is the most reliable diagnostic test. We report a case of fissure syndrome of the short fibular tendon in a male patient, aged 52, with a history of Parkinson's, without notion of trauma or chronic ankle laxity, consults for right retromalleolar pain evolving for 2 years. Becoming disabling with lameness. The clinical examination found a painful swelling in the right lateral retromalleolar on palpation. Standard ankle x-rays do not show any bone abnormalities. On the other hand, an MRI shows a flattened aspect of the short fibular tendon in relation to a crack in the tendon. The patient benefits from regularization of the cracked area, followed by immobilization of the ankle for 1 month. The evolution is favorable, with the complete disappearance of the pain. Short fibular tendinopathy associated with Parkinson's disease, no similar case has been found in the literature.

Introduction:Symptomatic synostosis of the tarsus treated by simple resection often presents an unpredictable improvement in symptoms.Frequent recurrence after insufficient resection of the bone bridge which can lead to reossification motivated us to use instead an interposition of the foot muscle or fat.The aim of this study was to describe this surgical technique and to report on our clinical and radiographic results after resection-interposition in the treatment of congenital synostosis isolated from the tarsus.We present the experience of a series of 12 patients observed and followed over a period of 7 years.Material and methods:This prospective study focused on 12 patients (12-18 years old) operated for an isolated tarsal coalition between April 2012 and April 2019.Two patients presented with bilateral involvement.Coalitions of infectious, traumatic or iatrogenic origin have been eliminated.Of the 14 feet identified,8 were calcaneo-navicular coalitions(CNC),and 6 were talo-calcaneal coalitions(TCC); Our preoperative clinical workup focused on the evaluation of the stiffness of the torque, pain,repetitive sprain, flat foot valgus and fibular contracture.The standard radiographic assessment allowed us to study the specific secondary radiographic parameters, we did a CT scan for all our patients. Surgical treatment consisted of resection with interposition (foot muscle or fat).Results: the average follow-up is 3 ½ years.The patients progressed favorably with disappearance of pain,normalization of walking and resumption of sports activity. No recurrence of the coalition at the last follow-up.Conclusion: Resection with muscle or fat interposition is the treatment of choice for isolated coalitions of the tarsus,TCCs remaining accessible for resection if they are not very extensive.

Osteochondral lesion of the talus is a focal injuries to the talar dome with variable involvement of subchondral bone and cartilagem by traumatic event or result of repetitive microtrauma. Treatment of an osteochondral talar lesion remains one of most controversial issues and evidence to support one type of intervention over another is insuficiente There are different options to acute lesions, like as bone immobilization, bone-marrow stimulation and fixation of fragment. Internal fixation is an option for a large fragment and acute injuries. We present a case of a 26-year-old male patient with an acute osteocondral talar fracture after an ankle sprain. Radiography and CT scan were showing an osteocondral talar fracture (zone nine and six) with 11 mm in diameter. The patient was proposed for surgical treatment. The anterior talofibular and anteroinferior tibiofibular ligament were transected to expose the body of talus. Open reduction and internal fixation of fragment was made with bioabsorbable screw and the anterior talofibular ligament was repaired. Patient was kept non–weight-bearing during 6 weeks. At 6 weeks, the patient started a rehabilitation program with partial weight-bearing and full weight bearing was allowed at 8 weeks. According to the literature, clinical outcomes of fixation of the acute osteochondral fragment were good and not influenced by lesion size and many osteochondral fragments can be saved by fixation. In our case, the fixation of fragment with 11 mm in diameter allowed to preserve the native hyaline cartilage and the subchondral bone congruity, with a clinical improvement.

Introduction: Tarsal coalition in the adult population is an infrequent yet challenging condition with respect to diagnostic, prognostic and management considerations. Talocalcaneal coalition is the commonest tarsal coalition reported in adulthood, yet is also known to be associated with some of the most significant disease related complications. To the authors knowledge there has not been a comprehensive systematic evaluation of this cohort to date. Methods: We conducted a systematic literature search and evaluated the literature in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary aim of this review was to assess the functional and symptomatic outcomes of different operative approaches with respect to resection of the coalition. Results: The cohort we evaluated is the largest adult tarsal coalition cohort assessed to date. Our results indicate that modifications to the operative approach can have a noteworthy impact on symptom resolution and quality of life. Our results support the hypothesis that interposition of soft tissues may improve symptomatology, but the extent of symptom improvement varies according to the tissue in question. The endoscopic approach to resection of these coalitions shows promise, with on average fewer complications and lower pain scores. Consideration should be given to the location of the coalition and the extent of ossification, as these are important prognostic indicators that can be used in planning future management. Conclusion: Talocalcaneal coalition in adulthood requires meticulous surgical planning to achieve the best overall outcomes. Our review provides a framework for future considerations.

Background: Calcaneonavicular coalitions in adults can be managed conservatively or through operative means involving resection or arthrodesis of the joints. The aim of this systematic review was to compare complication rates and functional outcomes for the different interventions that could be used. Methods: Pubmed, Medline, Embase and the Cochrane library were searched for relevant studies that reported outcomes for the management of calcaneonavicular coalitions in adults. Results: 23 studies met the inclusion criteria, comprising of 118 coalitions. 41 coalitions were managed conservatively and 71 through operative means of which 62 included a resection and 9 had an arthrodesis performed. Patients who were operated upon had a significantly higher complication rate of 23.4% compared to 10.6% for those who were managed conservatively (p=0.048). There was no significant difference in complication rates amongst those who had a resection or an arthrodesis. All studies demonstrated an improvement in functional outcome regardless of intervention used. Conclusion: Conservative management of calcaneonavicular coalitions in adults should continue to be advocated as first line treatment given the lower complication rates compared to operative means.

Background: Foot drop is a very common condition that describes a difficulty in raising the foot upwards voluntarily or involuntarily. It interferes with the patient’s ability to walk and perform daily life activities. The aim of this study is to invent a simple mechanical device that prevent food drops by playing the role of the extensor tendons and as such, allow the patient to walk normally.
Method: The endoprosthesis consists of two Sharpless attachments linked by a Stainless-Steel spring. The design was tested in the mechanical lab, implemented into cadaveric limbs in Charles university FN. Motol cadaveric laboratory and into patients after getting their consent and the approval from the ethical committee.
Results: The endoprosthesis has been tested initially in the mechanical stress machine which showed indefinite tensile strength. the endoprosthesis has been tested in a fresh cadaver where the endoprosthesis idea worked well. The following step was successfully implemented the endoprosthesis in real patients and they did walk properly.
Conclusion: There is no such treatment for foot drop described in the literature as such. This new endoprosthesis is a unique device that allows foot drop patients to walk like any normal individual.

Introduction
Our aim is to assess the clinical outcomes and the number of casts required for correction using Ponseti manipulation technique in two groups. One was performed in the clinic and the second was under mask anesthesia in the operation room (OR).
Methods:
Two groups were treated using Ponseti manipulation technique and plaster casting. Group A (20 cases) was casted at the clinic without any form of anesthesia, and group B (19 cases) was managed under mask anesthesia at the OR.All patients were treated by tendon achilles (TA) tenotomy at OR once the cavovarus has been corrected. Assessment involvedclinical outcomes, Pirani score and Modified Hospital for Joint Disease Functional Rating System (MHJDFR
System),and the number of casts required to achieve the correction.
Results:
The median Pirani score before treatment was 5.5 for both groups. At the final assessment, it was 2 for group A and 0.5 for group B. The median score of MHJDFR System was 10 for group A and 15 for group B before the treatment.At the final assessment, it was 35 for group A and 50 for group B. These changes were statistically significant. The average number of casts applied for cavovarus correction was 7.95 for group A and 2.42 for group B. The differences were statistically significant.
Conclusion:
Ponseti manipulation and plaster casting under mask anesthesia was effective in improving the clinical appearance of the feet and reducing the number of casts needed for correction in comparison to those performed awake at the clinic.

Muller-Weiss Syndrome (SMW) represents a rare and complex entity that results from spontaneous avascular necrosis of the navicular. The authors present a case of a 23-year-old male patient, obese, who was admitted to external consultation in 2015 for midfoot pain with 2 months of evolution. Foot CT showed increased bone density and fragmentation of the navicular, with degenerative talo-navicular changes. MRI confirmed navicular necrosis. The diagnosis of SMW was established. In 2019, it presented clinical and radiological worsening, with progressive talonavicular degenerative changes and loss of the longitudinal arch of the foot. It was proposed for surgical treatment: talo-naviculo-cuneiform arthrodesis (TNCA) was performed with interposition of a homolateral iliac crest tricortical graft and fixation with plate and screws, with reduction of the hindfoot varism enhanced by the percutaneous stretching of the Achilles tendon. SMW represents a rare entity and there is still no consensus on its approach in the literature. In this case, TNCA was chosen instead of triple arthrodesis, since there were no symptoms referred to subastragalin or radiological signs of arthrosis, and it was possible to reduce the hindfoot varus. Graft fixation is not routinely necessary. However, the use of plate eliminates the possibility of graft migration and allows the early removal of the immobilization, with better functional results. In the case presented, the chosen option ensured a good clinical result. This technique shows good results in most studies.

We present a case of a 42 years male phychiatric pacient Who attempted suicide with 8m fall and bilateral open feet fractures. Left foot sustained an open calcaneal fracture and right a 3a gustilo tales fracture dislocation with massive bone loss.
We perform a three-stage surgery with an initial debridementand an external fixator and a second stage with medial malleolus plating and an antibiotic-impregnated customised spacer. He was discharged with a 2months antibiotic treatment, serial inflammatory markers and ambulatory removal of the external fixator. The third stage is amedial plate removal and tibio calcaneal nail previous 3d planification scan.
We used a transfibular external approach. The spacer was retrieved, cartilage was resected and we carved a sferic cavity with a 40mm acetabular reamer. We use a frozed femoral head as massive allograft for the missing talar body that matchs perfect with the acetabular reamer. Posteriorly we insert a tibiocalcaneal phoenix nail with compression system. We use the external portion of the fibula to give strengh and stabilize the graft with a screw and another to the tibia. The ankle was placed in a splint regarding the concerns about weigh bearing of the patient. Postoperative antibiotic was continued until Wound cultures came back negative.

Background
Ankle fractures are one of the most common adult fracture types seen worldwide. Diabetes mellitus (DM) has a prevalence estimated to be 3.9 million in the UK. It is therefore paramount that all general orthopaedic surgeons understand and recognise the effects and sequalae of DM on ankle fractures. Aim: quantify risk of complications associated with diabetic ankle fractures (DAF), summarise ‘usual practice’ and create a protocol for management.

Methods
A systematic literature search was performed in MEDLINE and EMBASE. National guidelines from The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and The Joint British Diabetes Societies (JBDS) were reviewed. Orthopaedic consultant surgeons were sent an online questionnaire to gain a consensus about “usual practice”.

Results
11 studies were identified. The mean rate of complications in DAF was 35.7%. In 6 case-control studies, the OR of complications in DAF ranged from 2.2 – 17.5. Uncomplicated DAF had rates of complications comparable to their matched non-diabetic controls. 80% routinely review HbA1c results and 42.9% new the value in which the risk increased (>69mmol/mol). 93.3% would not use their ‘standard ORIF’ technique when operating on a complicated unstable DAF. 86.7% used an extended period to protect the ankle, 53.3% used a below knee total contact cast. 86.7% thought that complicated DAF should be managed by specialist F&A surgeon.

Conclusions
A protocol was created based on the literature search, pragmatic results from the survey and the important distinction between complicated and uncomplicated DAF. Future validation of protocol driven management is required.

Achilles tendenopathy reported as high as 3.6% , athletes prone group to get this from 7% to 52%. Nearly 25-30% demand surgical interventions, the success rate of traditional open surgery 50-100%, complication 11%. Therefore, minimal invasive techniques reported good results. There were no consensus about dual procedure combining proximal medial gastrocnemius release(PMGR) with distal endoscopic paratenon debridement plus planatris tenotomy. Therefore, results of our case series, could be helpful to build up the continuum process of intervention for non-insertional achilles tendinopathy.
Methods: This was retrospective evaluation 10 consecutive patients with non-insertional achilles tendinitis. Include all adult patients following clinical and MRI evidence of above diagnosis. Excluded, patients who had staged procedures. The procedure, combine PMGR and achilles tendoscopic debridement performed by the senior author. Demographic data, detail of operative interventions, pre- and post-operative visual analogue scores(VAS) and patient satisfaction were retrieved from case notes. Results:We report our results of combined PMGR and achilles tendon debridement, mean age in our population was 47 years (36 – 54) , 7 out of 10 were females, average follow up duration was 16.2 months (8 – 25). Nine out of 10 patients were happy with outcome, mean pre- and post-operative VAS, respectively 8.6 and 1.7, There were no surgical complication and recurrence, during our follow up period. Conclusions:Our cohort, reveal, short and intermediate success rate of combine PMGR and tendoscopic achilles tendon debridement with plantaris resection. This study, brings up the next level of treatment for the recalcitrant cases.

Introduction
Astragalus enucleation is a rare pathology, representing 2% of all talus pathologies and 12% of its dislocations. It is a severe ankle injury due to multiple complications that are produced, such as avascular necrosis and infection.

Goals
Present a case of closed lateral enucleation of the talus, emphasizing the treatment performed on an obese patient and commenting on the results and possible complications.

Material and methods
We present the case of a 31-year-old man who is significantly overweight (BMI 39) and who suffered a forced inversion of the foot when getting out of a van. After the accident (11:15 a.m.) he did not present a neurovascular injury, but he presented with a great deformity and pain. Urgent surgical treatment was indicated (1:45 p.m.): closed reduction was performed with scopic guidance. After evaluating fluoroscopic subtalar instability, open ligamentous reinsertion was performed (reinsertion of the anterior talus and calcaneal peroneal ligament, extensor retinaculum and anterior capsule suture). Stabilization with kw calcaneus-talus and scapho-talar.

Results
96 hours following admission, the patient was discharged with good radiological control, pain and without signs of skin suffering. Kw needles were removed at 6 weeks and a protected load was started. Three months after surgery, he presented a 5º dorsiflexion deficit,no pain and in the podoscope cavus-varus foot grade II. MRI control was performed at 6 months without the presence of complications.

Conclusions
Urgent reduction and open ligamentous stabilization in obese patients avoids short-term (skin suffering), medium-term (ankle-instability) and long-term (talus necrosis) complications

Introduction
The treatment of calcaneal fractures represents an important therapeutic challenge, especially in the lateral approach, due to a rate of complications(infection or wound dehiscence)
Goals:
Evaluate the sinus tarsal approach and show how to solve the technical difficulties to achieve a reduction of the joint anatomy with this approach.
Material and methods.
Three clinical cases of patients aged 71, 46 and 62 years with Sanders type III and two IV fractures, respectively, are presented. Two of them, the mechanism was a fall from a height of one meter and one patient had a multiple trauma. All of them underwent radiography and CT for preoperative assessment and measurement of the Böehler and Guissane angle.
Results
Surgical intervention was performed at 16 days on average (min.9;max.20).Approach to the sinus tarsi in lateral decubitus with good visualization of the lateral and axial radiographs.Tips and Tricks:Use of the calcaneal distractor(give length to the external column)/Steiman in posterior tuberosity(correct varus)/fracturoscopy(visualize joint reduction)/Joint reduction and provisional fixation with Kw/Stabilization with specific plate of the sinus tarsi/supplementation of the set with two 4.5 cannulated percutaneous posterior tuberosity screws / fracture site filling with bone substitutes. Intradermal suture and 24-hour drainage. Immobilization 15 days and discharge at 8 weeks with active and passive mobilization.
Evolution
Rx Böehler study (preop.10º±2/postop.28±4).Rx Guissane(preop.125º±3postop.105±4).None of the patients had skin problems or infection.
conclusion
The sinus tarsi approach in complex intra-articular fractures (Sanders III and IV) of the calcaneus allows minimizing postoperative soft tissue complications, achieving adequate joint reduction and stabilization.

Introduction
A hindfoot nail is an alternative fixation for complex ankle and distal tibial fractures in patients with instability and poor skin condition.
The aim was to evaluate hindfoot nails for unstable ankle fractures with regards union rates, further surgery and complications
Methods
A retrospective review between 2013 and 2020 at a single centre. All patients that underwent a hindfoot nail for ankle fractures were included with at least 6 months follow-up.
Results
There were 25 patients with 26 fractures. The mean age was 73.6 (32-92). 8 males and 18 females. The mean charlson co-morbidty score was 4.6 (2-7). 3 patients were diabetic, 6 had chronic venous insufficiency.
The mechanism of injury was 1 RTA and 25 low energy injury
The indications for surgery were co-morbidities in 18, poor skin condition in 9, fracture complexity in 2 and delayed presentation in 1
The nail used was 23 Stryker T2 Hindfoot Nails and 3 Valor Wright Medical Hindfoot Nail.
There were 7 tibial pillon fractures, 13 bimaleolar and 6 trimalleolar fractures.
Union was achieved on 24 cases (1 nonunion and 1 pt died before F/U). 6 patients died within 1 year.
5 reoperations were performed, 3 metalwork removal, 1 below knee amputation and 1 skin graft. There were 7 complications with 4 prominent metalwork, 1 DVT, 1 deep infection and 1 HAP.
Conclusion
Hindfoot nail has a low rate of complications and high union rates. In a select subset of patients with an unstable ankle fracture is a viable surgical treatment

Introduction
Prosthetic joint infections are a devastating complication and occur in upto 4.6% of ankle replacements. The most common surgical treatment is conversion to fusion. The primary outcome of this systematic review was union, secondary outcomes included re-operation, treatment techniques and complications.

Methodology
A systematic review was conducted using PRISMA guidelines analysing conversion to fusion for infected ankle replacements. Initially 467 papers were identified and 13 papers met the inclusion criteria to be included in the final analysis.

Results
36 patients in 13 papers were included. The mean age was 60.8.
There were 2 revisions and 1 below knee amputation.
A two stage procedure was undertaken in 17 ankles and a one stage procedure in 19 ankles. Of those that underwent a 1 stage procedure union occurred in 18 of the 19 (94.7%) ankles and 13 of 17 (76.5%) ankles that underwent a 2 stage revision (p=0.27158).
The surgical technique varied in all papers. Overall the surgical technique was screw fixation in 10 patients of which 9 united, 9 external fixator (8 united), 12 intramedullary nail (9 united), 2 plating (all united), 3 unknown.

Discussion
This systematic review analyses all papers that included ankle arthrodesis for the management of an infected total ankle replacement. This review demonstrates that there is currently limited data for analysis to draw solid conclusions.

Introduction
The 5-year revision rates for ankle replacements are currently 6.9%. When an ankle replacement fails it can either undergo revision ankle replacement or conversion to fusion. Currently there is a paucity of literature on the outcomes of these.
The aim of this meta-analysis is to assess the outcomes of revision ankle replacement with respect to further revision surgery, fusion, complications and functional outcomes
Methods
A systematic review was conducted using PRISMA guidelines. Papers analysing revision ankle replacements were included. All papers were reviewed by two authors. 15 studies met the inclusion criteria. A meta-analysis of proportions was performed
Results
The pooled percentage where the revision ankle replacement failed was 14% (95% CI 8%-21%) For non-revision re-operations 12% (95% CI 5%-22%) of revision ankle replacements underwent further surgery. Five studies with a total of 16 scores reported pre and post-operative outcome scores for revision ankle replacement. Of these 16, 12 demonstrated significant improvement, and 4 demonstrated a non-significant improvement
Conclusions
Revision ankle arthroplasty for failed total ankle replacements has considerable risks of failure and re-operations, especially in those with prosthetic joint infection. All studies though demonstrated improved functional outcomes following surgery.

Introduction : Ongoing controversy exists over the indications and benefits of posterior malleolar fixation in ankle fractures. The theoretical benefits of posterior malleolar fixation now widely accepted as restoration of articular congruity, restoration of fibular length and stabilisation of the syndesmosis. The aim of this pragmatic study was to evaluate the outcomes of posterior malleolar fracture fixation 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, between January 2012 and January 2018, with minimum 2 year follow-up. The Manchester-Oxford Foot Questionnaire (MOXFQ) at final follow-up, 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). Metalwork-related issues were higher in the posterior malleolus fixed group (24/160 (15%) versus 10/160 (6.2%), p=0.03). Re-operation rate was double (34/160 (21.2%) vs 16/160 (10%), p = 0.03). Conclusion : This pragmatic study is one of the largest published series that assesses patient reported outcomes in posterior malleolar fixation. 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.

Introduction: Non-union of zone 2 and 3 little metatarsal base fractures cause persistent pain and discomfort. Such painful non-unions can be managed surgically with percutaneous screw fixation. We report the result of 9 consecutive patients with such fracture who were treated with this method. Methods and materials: Patients with non-union of Zone 2 and 3 metatarsal base were offered surgery. Fracture site was not opened in any case. Guide wire was inserted under image intensifier guidance from base of metatarsal across the fracture site in the medullary canal. It was subsequently drilled and replaced with partially cannulated screw. Patients were followed at 2/52, 6/52, 3/12 and then every 3/12 until fracture healed. Radiological healing was considered when bridging callus was seen in 3 or more cortex on two different orthogonal views. Results: The mean age of patient was 40.7 years (range 21 to 56 years). None of them were diabetic and one was smoker and one had rheumatoid arthritis. Four were stress fractures and rest were traumatic injuries. The average duration from injury to surgery was 7 months (range 2 to 15 months). The average duration of fracture healing was 4.5 months (6 weeks to 11 months), however all of them were pain free at 6 weeks following surgery. Conclusion: Our results shows that all fracture healed irrespective of duration of injury with closed percutaneous methods. The screw fixation results in improved stability for fixation by reducing the strain across fracture site and drilling caused biological stimulus for fracture healing.

Background: The objective of this study was to report the results of a new minimally invasive Achilles reconstruction technique and to assess the perioperative morbidity and functional outcomes. Methods: Our case series included had 14 patients (M:F=11:3), with a mean age of 45.6 years. Each patient had a chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (range 2-10). The mean total follow-up was 30.1 months (range, 12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion. Results: The mean length of the defect was 5.1cm (ranged from 3 to 8 cm), while the length of the turndown flap ranged from 8 to 13 cm (mean, 10.1). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at the last follow-up. The mean ATRS score improved from preoperatively 49.4 to 91.4. None of the patients developed a wound complication. No patient had a re-rupture or sural nerve damage. Conclusion: We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.

Background: Hallux valgus is one of the most common deformity of toes seen in out patient clinic. There are hundreds of procedures described for correction of this deformity. We evaluated correction of deformity by distal soft tissue release and restoring intermetatarsal angulation using adjustable suture buttons (Mini Tight Rope; Arthrex, Inc, Naples, FL).Materials and methods:Total 16 patients, 5 males and 11 females, with mean age of 48 years, were operated with mean follow up of 16.34 months .Patients with symptomatic hallux valgus with intermetatarsal angle (IMA) 9-18 degrees were selected for surgery. In each case,pre and postoperative hallux valgus angle (HVA), IMA was calculated at preoperative ,immediately post operative (non wight bearing ) , 3 and 12 months(weight bearing) . Results: Pre-operative mean HVA was 30.77±5.23 degrees and IMA was 16.24±4.73 degrees. Post-operative HVA was 17.27±4.51 degree and IMA was 8.32±1.7 degree at 1 year (weight bearing x ray). The mean decrease in HVA from preoperative to final follow-up was 15.4± 1.3 degrees (p<0.01) and the average change in IMA from preoperative to final follow-up was 8.2 ±1.8 (p<0.01) degrees. No recurrence was seen at final follow up. Discussion: Hallux valgus correction with osteotomy has its demerits like mal or non union,transfer metatarsalgia, shortening of metatarsals or avascular necrosis of metatarsal head.Suture button technique alleviate these compications,addresses the dynamic instability between first and second metatarsal. Conclusion: Short-term results demonstrated excellent clinical and radiological outcome of suture button fixation of hallux valgus.

Background: Reconstruction of Tendoachilles (TA) tendon using speedbridge technique following excision of Haglund deformity under WALANT(wide awake local anaesthesia without tourniquet) is relatively newer technique.The present study evaluate long term outcome of speed bridge technique under WALANT. Materal and Methods: Patients who failed to respond to conservative management at least after 6 months, were selected for surgery. All the patients underwent open excision of Haglund deformity after detachment of TA tendon and achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision was performed. Reconstruction of TA tendon was done using fibretape and 4.75 mm biocompositeSwivelock [ArthrexAchilles SpeedBridge Convenience Pack (AR-8928 BC-CP)].Clinical evaluation was done using AOFAS Hind Foot Score (HFS) at pre-operatively,6 weeks,3 months ,6 months and 12 months. Results: 11 female and 2 male patients (16 feet)with mean age of 53.00±4.93 years were analysed. Mean follow up period were 2.1±0.32 years.The mean postoperative HFS, at 16 months of postoperative period, was 87.61±4.69 compared to mean preoperative HFS of 53.07±5.93 (p value <0.01) with full weight bearing on an average of 15.2±2.7 days postoperatively. Discussion: The hourglass type of fixation construct definitely confers to increased surface area of tendon compression, better healing of tendon and early weight bearing. Conclusion: Haglund deformity excision and reconstruction of tendoachilles using double row technique under WALANT is agile yet cost effective construct for early mobilization with an excellent clinical outcome.

Background: WALANT is the new and safe anesthetic technique to perform the surgery in the extremities, especially in the wrist and hand surgeries.Purpose of this study was to evaluate effectiveness of WALANT for Tendoachilles Z lengthening .Methods: 30 patients were operated under WALANT, out of which there were18 male and 12 female. WALANT mixture was prepared using Lignocaine mixed with Adrenaline (1:200000) and sodium bicarbonate which was diluted with normal saline.After Tendoachilles lengthening procedure, postoperative pain assessment was done immediately, followed by functional assessment at 6 months postsurgery.Results: Mean age was 19.08±4.78 years. Mean duration of onset of anesthesia was 8.11±3.10 minutes. Mean duration of surgery was 15.87±3.08 minutes.Mean post operative VAS score after 6 hours of surgery was 3.23±1.03.Mean AOFAS hind foot score (HFS) was found to be improved from 52.07±9.56 to 88.10±3.35(p <0.01).Conclusion: WALANT is an effective method of anesthesia for Tendoachilles lengthening. Indication for WALANT can be extended to other ankle and foot procedures.

The bibliometric studies in the field of orthopedics have increased due to the large volume of available literature which prevents understanding the exact direction of the related field. This study aimed to identify and analyze the 100 most-cited articles related to flat-foot disorder to reveal their characteristics and research trends. All available literature on Web of Science database until 2020 were analyzed and 100 most-cited articles were determined. The characteristics of the articles were analyzed for any association with total citation number and citation density (citation per year). The highest citation number was 278 and the average citation density was 3.4. Twenty-two of the articles were case-series, 15 were reviews and 14 were cadaver studies. 26 of studies had Level 3 and 36 of studies had Level 4 evidence. The study number with Level 1 and 2 evidence was only 3 for each. Author number was positively correlated with publication year, indicating increased collaborations of different institutions in recent years. Citation density was positively correlated with publication year and reference number, indicating higher citation density in more recent papers and in papers that used more citations from other studies. No significant difference in citation numbers was detected according to parameters including institution number, study design, level of evidence, etc. The available data provides the general characteristics of 100 most-influential papers about flat-foot. The results of this study can guide the researchers about the trends of the most-cited articles and help to recognize the areas lacking a high level of evidence.

achilles tendon is the largest tendon in body,weakest point is present around 2.16cm from insertion.factors such as age, diabetes mellitus, steroid use, direct trauma by sharp object causes tear. tendon has very less blood supply in the mid substance. tendon ruptures are common in individuals with high intensity training without preconditioning .Use of corticosteroids and antibiotics can cause atypical tear .surgical management depends on following parameters like level of injury, gap between edges amount of retraction and patient factors. options includes primary repair using krackows/Kessler's/bunnells suturing technique ,repair using FHL tendon graft, gastrocnemius turned down the fascial flap and v-y advancements plasty. We present a series of 4 cases of tendoachilles tear managed surgically in elderly patients.materials and method management depends on the location of the tear and availabiLe tendon stalk at insertion. Only repair using krackows suture tech or use of FHL graft and interference screw is decided on pre op local ultrasound or mri and intraop scenario.
Here 2 cases are managed with krackows suturing using ethibond and 2 are with FHL graft and interference screw.results and conclusion 
 final functional outcome depends on intraoperative stability of the repair, ankle physiotherapy and on wisely selection of the method depends on the location of the tear. Reconstruction with FHL tendon using interference screw in calcaneum helps to repair insertional tears in elderly patients. Even Elderly patients with diabetes can be managed well with good functional outcome without complication using above-mentioned methods.all patients gained functional recovery at 3 month post op.

 

Introduction: Injuries around the ankle are often associated with extensive soft tissue involvement. Two important components of soft tissue management for these fractures are lower limb elevation and fracture site distraction. Currently, no single method is found to be effective in providing both simultaneously. Thus, we propose a novel Triangular Elevation and Distraction (TED) frame design of tubular external fixator for soft tissue management in the pilon fractures. Methods: The data of patients admitted with pilon fracture (AO/OTA-43 B/C) from January 2017 to December 2019 were retrospectively reviewed from the hospital records. All these patients were given either TED frame or Bohler Braun Splint along with Calcaneum Pin Traction (BBSCPT) for the initial management of soft tissue injury and fracture stabilization. Results: 30 patients were managed with TED frame application and 33 with BBSCPT for pre-operative management of the soft-tissue condition. Time required for soft-tissue resolution in AO/OTA 43-B fractures was significantly less in TED frame group 137.4 + 26.4 hrs., compared to the BBSCPT group 204.8 + 30.8 hrs. (p-value <0.001). Swelling subsidence was also noted significantly earlier in AO/OTA 43-C fractures managed with TED frame 168.4 + 24 hrs. compared to 271.4 + 48.6 hrs. with BBSCPT. Conclusion: The novel TED frame design is economical, effective, easy to apply, and convenient for the management of soft tissue components in pilon fractures. With a simple design and readily available components, this frame can be applied quickly in any emergency department under local anesthesia.

Introduction: The study aimed to establish and subsequently improve the rate of stability assessments of ankle fractures where there is uncertainty of fracture stability and the impact this has had on the avoidance of potentially unnecessary surgery. Methods:
Two independent audit cycles from October 2019 to May 2020, each covered a period of sixteen weeks. All patients had closed isolated lateral malleolar fractures at the level of the syndesmosis involving skeletally mature bone. Other fractures were excluded. After local presentation of the first audit cycle, a stability-based management protocol was introduced, incorporating an education programme and management guideline. The same criteria applied for the closure of the audit loop of data. Results: A total of 75 ankle fractures were included. In the initial audit cycle, 17.5% of patients did not undergo weight-bearing X-rays within two weeks of injury to determine stability. Compliance was improved to 94.3% in the second cycle. Interestingly, we found that only one stability assessment was performed for the five operated ankles in the first audit, versus a 100% compliance rate in the second cycle. There was a significantly higher complication rate in operated versus conservatively managed ankles. We also observed more accurate documentation, specifically regarding the stability of the fracture, following education and awareness of their clinical importance. Conclusion: By implementing a stability-based management guideline, there was an improvement in compliance with guidance towards stability assessments of ankle fractures. This potentially led to the avoidance of unnecessary surgery on fractures where stability assessments supported non-operative management.

Calcaneus fracture makes up to 2% of all fractures. Treatment of calcaneus fracture is contraversal. In most of the departments the ORIF technique is beign used. In Hungary almost all departments use minimal invasive technique. The developing of this technique has been started by a hungarian surgeon, Mihály Forgon in early 1980. Which have further been developed by another hungarian traumatologist, György Zadravecz in 1989. This method is done by the use of distractors and with the help of ligamentotaxis to reduce the fracture and percutan fixation with screws. Advantages of this method compared to ORIF are, early operation and shorter hospitalization, shorter operation time, less risk of infection, less subtalar joint stiffness, no scar and nevertheless cheaper. I had the possibility to work for 8 years in the Middle East in the orthopedics department in the State of Qatar. Overthere due to huge number of constructions this type of fracture is not rare among the labour, who have been operated with ORIF method, with use of different type of plates. I had the possibilty to introduce minimal invasive operation with the help of Zadravecz distractor technique. Since we started to do operation with this technique and the comparison between the two methods it showed advantages toward the minimal invasive operation technique.

Charcot neuropathy is a syndrome characterized by fractures and luxations with non or minor trauma. It affects patients with peripheric neuropathy resulting from different conditions, the most common being diabetes.
We present the case of a male patient, 62 years old, with arterial hypertension, that comes to an appointment at our Hospital with the previous diagnosis of Charcot arthropathy (etiology still unclear) with years of evolution, that had been proposed to a foot amputation because of a severe structural deformity of the foot and recurrent plantar ulceration.
The objective of any reconstructive procedure is to achieve a stable plantigrade foot, to allow ulcers to heal and to allow a load compatible with activities of daily living independently, avoiding amputation.
Arthrodesis, despite the high rate of incomplete union in these patients, can be useful in cases of instability, pain or recurrent ulceration in which conservative treatment fails.
The bone healing time after surgical reconstruction is often prolonged, and therefore, the durability of the fixation is crucial.
Given the advanced stage, we proposed an arthrodesis of the medial and lateral columns of the foot (with intramedullary Bolt nails) and autologous bone graft form the iliac crest.
With this surgical approach, it was possible to correct the foot deformity in “rocker bottom foot”, and a stable plantigrade foot was obtained. There was scarring of the plantar ulcer and consequent preservation of the affected limb. Functionally, there was a return to independence in activities of daily living, and all the objectives proposed were achieved.

introduction: Avulsion fractures of the posterior calcaneal tuberosity are rare injuries, account for only 1% to 3% of all calcaneus fractures. The thin, soft tissue envelope and poor vascular supply at this area predispose complications. Emergency reduction to relieve skin has been recommended. Often occurs in osteoporotic patients; therefore, fixation of the displaced fragment is difficult. We detail a technique using high resistance suture. Case presentation: 77-year-old woman. Physical examination revealed good skin condition with subcutaneous palpation of bone fragment, plantar flexion inability and positive thompson's sign. X – rays demonstrated Type II Avulsion Fracture of Posterior Calcaneal Tuberosity. Urgent surgery was performed. A posterolateral incision was made on the lateral side of Achilles insertion with careful dissection avoiding damage to the sural nerve. The bone fragment was found subcutaneous and small, after the fracture was exposed, a high resistance suture was passed through the Achilles tendon with the attached bony fragment using the bunnel technique. The suture threads were pulled and sutured through calcaneus, the displaced fragment moved distally, and anatomical reduction was achieved with the ankle in plantar flexion. Results: X Rays showed good reduction of the fracture. The patient was put on equinus short leg cast for 6 weeks. The patient was advised on non-weight bearing for 6 weeks. Discussion: A firm fixation can be achieved even if the bony fragment is thin and small using this technique. Urgent reduction and stabilization in the first 6 hours after the trauma are essential to avoid skin necrosis.

Introduction:Fracture about the ankle may result in widening of the medial part of the ankle mortise as seen on the X-ray. Some cases repaired syndesmosis injury in the ankle malleolar fracture with screw or knotless suture system in spite of malreduction of the fibula. The purpose of this study is the significance of the reduction of the fibula in the ankle fracture.
Materials:The study population are 219 cases treated in surgical for the AO classification type B and C ankle malleolar fractures. The average of follow up time is 18 months (over 6 months). The average of age is 57.5 years (from 15 to 89). Examination items are the Japanese Society for Surgery of the Foot (JSSF) standard rating system, range of motion in ankle, state of reduction of the fibula and complications. Only eighteen cases treated the tibio-fibular screw fixation(only 8 %).
Results:In all cases fracture united without infection and any other complications. The average of JSSF scale were 93.5 (from 74 to 100) points. In fifty-five cases, the incongruity of the articular surfaces of the fibula and talus remained. motion in ankle joint, state of reduction of the fibula and complications in eighteen cases One case occurred osteochondral lesion of the talus and osteophyte of the ankle joint in 1 year after operation.
Discussion & Conclusion:The unsatisfactory clinical results associated with slight widening of the ankle mortise. The congruity of talo-fibular joint is the important to get the stability in the ankle joint.

Objectives: Medial malleolar stress fractures are uncommon, even in the sporting population. The purpose of this study is to examine the morphological findings of the ankle X-ray image in the stress fracture of the medial malleolus.
Materials: The study population comprised eight patients that received surgery. The age of average age is 15.3 years (from 14 to 20). Surgical procedure used cancellous screw fixation and plate fixation procedure. One case was treated screw fixation with osteotomy of the fibula.
Results: All fractures united without further intervention. The average of healing time was 7 months (range of 5 to 21 months). All patients had resumed sporting activity to their previous level. The case of the screw fixation with osteotomy of the fibula acquired ankle joint stability after the surgery.
Discussion: All fractures were the same pattern of the fracture line, and X-rays showed shortening of distal fibula. One patient had delayed healing, with symptoms persisting for twenty-one months. In this case, valgus instability of the ankle joint existed under the fluoroscopic examination. Another case had a distal fibular stress fracture six months after the surgery.
Conclusion: We have concluded that shortening of the distal fibula can cause stress fractures of the medial malleolus.

Aim of the study: to evaluate the efficacy of the 1st MTP joint chondroplasty in hallux rigidus (HR) and the necessity of the metatarsal bone shortening osteotomy.
Materials and methods: the 1st MTP joint chondroplasty was performed in 29 patients with HR. The operation technique includes cheilectomy, clearing of the cartilage defect, microfracturing and covering of the defect by collagen matrix. 11 patients underwent a shortening metatarsal osteotomy. To assess the results we used VAS of pain, Foot Function Index (FFI) and range of motion (ROM) in 1st MTP joint.
Results: in patients with osteotomies, ROM before the surgery was 20°, VAS of pain – 70, FFI – 5.8. In patients without osteotomies, ROM was 20°, VAS of pain – 67.5, FFI – 6.3.
In patients with osteotomies, after 3 months VAS of pain was 32.5, FFI – 3.4, ROM – 52.5°. After 6 months VAS of pain was 22.5, FFI – 1.5, ROM – 56.5°. After one year VAS of pain was 10, FFI – 0.8, ROM – 75°. In patients without osteotomies, after 3 months VAS of pain was 22.5, FFI – 2.2, ROM – 56.5°. After 6 months VAS of pain was 10, FFI – 0.7, ROM – 65°. After 12 months VAS of pain was 2.5, FFI - 0.5, ROM – to 77°.
Conclusion: chondroplasty is effective surgical method; the results in patients with osteotomies were inferior to the results without osteotomies, therefore, in most cases we don’t recommend to do the shortening metatarsal osteotomy.

Background: Arthrodesis is the current gold standard for treatment of hallux rigidus (HR). Few studies have assessed the efficacy of cheilectomy in severe HR. Here we aimed to assess if cheilectomy alone is an effective surgical treatment for the management of severe HR.
Methods: Retrospective analysis of patients who underwent cheilectomy over a 15-year period. Severity of first MTPJ arthritis was graded radiologically using the Coughlin and Shurnas classification. In patients with a pre-operative grade 3 or 4 we assessed their functional status using the Foot and Ankle Outcome Score (FAOS) with a minimum of 6 month follow up. We compared our results with pre-published scores for arthrodesis.
Results: A total of 22 patients underwent cheilectomy for severe HR. 13 (65%) completed the FAOS and hence were included in the full analysis. Median follow up was 24 months and mean age was 57 years. Mean FAOS score post-operatively was 60.0 compared to a mean published FAOS score post-arthrodesis of 80.2. Across all 5 domains of the FAOS, average scores were above 50 for cheilectomy however all were below published breakdown scores for the FAOS when compared to arthrodesis.
Conclusion: Cheilectomy provides a potential alternative to arthrodesis in severe HR. In appropriately selected patients, functional outcomes are acceptable, even many years post operatively. Published outcomes for FAOS are better for arthrodesis although larger comparative studies are required to determine whether this is statistically and clinically relevant. This study suggests that cheilectomy should not necessarily be excluded on HR grade alone.

Introduction: Chronic Exertional Compartment Syndrome (CECS) of the lower limb responds well to fasciotomies. A history and compartment pressure testing are both required in order to diagnose CECS. We evaluated a cohort of post-fasciotomy patients for proposed predictive criteria of a good outcome. Methods: 27 post-fasciotomy patients were reviewed retrospectively. Subjective pre- and post-operative pain scores were gained via questionnaire. All patients underwent pre-operative dynamic compartment pressure monitoring. Point-Biserial and Pearson Correlation coefficients were used to calculate correlation between multiple diagnostic criteria and pain score reduction following fasciotomies. Results: Peak compartment pressure over 40mmHg (p=0.0007) and an Area Under the Curve (AUC) of over 22,000mmHgSec2 (p=0.0002) were found to strongly correlate (r >0.7) with a positive surgical outcome. A moderate correlation (r >0.5, <0.7) existed between a classical history (p=0.006), symptoms lasting less than 1 hour after rest (p=0.006), and a gradient of over 10 (p=0.006). No correlation was found with other criteria. When combined into a scoring system (2 points if correlation >0.7, 1 point if >0.5 and <0.7) a score of 4 points or more (out of 7) had a correlation coefficient of r=0.82 (p=0.0001) with improvement in pain scores. There was no significant correlation with improved outcome if the score was under 4. Conclusion: We have identified diagnostic criteria that can be used to help predict a positive outcomes following fasciotomies. We propose a score to aid the management of such patients. We recommend taking these results to prospective trials to test the efficacy of predictive scoring.

Introduction: Osteoid osteoma is a benign bone tumour rare in the astragalus (2%) - higher prevalence in adolescents and young adult males. Its nidus is difficult to detect in initial imaging. Delay in diagnosis and treatment can be caused by atypical symptoms, presence of trauma and high-performance sports practice. The case of a 16-year-old with diagnosis delay is described. Case report: 16-year-old, high-performance canoeing athlete, with pain in the back of the ankle and right hindfoot, no history of trauma and normal x-ray. CT revealed changes in the cortex compatible with evolving stress injury. MRI showed bone oedema on the medial dorsal aspect, corroborating the diagnosis. Subjected to intra-articular infiltrations with PRP, load management and physical therapy, with transitory improvement. Complaints worsened 18 months after symptom onset, predominantly nocturnal, responding to anti-inflammatories. Higher-resolution CT (64 sections) revealed: subchondral lucent lesion (3.6mm/diameter) on the anterior margin of the astragalin trochlea cartilage, intra-articular, compatible with osteoid osteoma nidus. Underwent arthroscopy excision and filling of the defect with autologous graft of iliac crest and collagen matrix. Histology confirmed diagnosis. Without complaints three months after resuming sports practice. Asymptomatic at one-year follow-up. Conclusion: Osteoid osteoma of ankle joint is progressive and difficult to diagnose in initial stages. Adequate imaging with better acuity may prove necessary for a correct diagnosis, shortening treatment cycle, and improving QoL. Osteoid osteoma is included in differential diagnosis of chronic ankle pain in young patients due to its rare nature, difficulties in clinical diagnosis and unusual radiographic presentation.

Introduction: The peroneal tendons dislocation is a rare condition mainly affect young adults and athletes. It results from a dorsiflexion and eversion of the foot associated with a sudden contraction of the peroneal muscles. The tendons traverse the lateral malleolus posteriorly through a groove covered by retinaculum and the integrity of this tunnel is essential for its stability. Any injury directed at these structures may cause a recurrent dislocation. Case Presentation: Three male soccer players, mean age of 23 years, observed by recurrent ankle sprain with instability. They presented a peroneal tendons dislocation with pain, swelling and functional limitation. They were submitted to surgical repair according to the bone block technique. The postoperative period included an immobilization with cast during 4 weeks, followed by partial weight bearing and physiotherapy for progressive rehabilitation. The athletes resumed sports practice without restrictions after 7 months. Discussion: Different treatments for peroneal tendons dislocation were reported by Van Dijk et al in ESSKA-AFAS International Consensus (2018). Surgery should be used in cases of chronic dislocation and acute cases in active patients. The three most used procedures are retinaculum suture, groove reconstruction and bone block technique. The lack of randomized studies makes difficult to compare the superiority of the different techniques, so the final decision should take in account the patient´s status, retinaculum integrity and surgeon experience. Conclusion: The bone block technique proved to be an effective procedure, allowing a fast recovery with complete remission of the complaints and no more functional limitation.

Introduction: The chronic Achilles tendon rupture is defined by an injury more than 4 to 6 weeks, related to failure of the diagnosis or an ineffective treatment. Reconstruction is often complex and currently there is no standard treatment, particularly for large tendon defects. Case presentation: 41-year-old male patient, observed due to pain in the right Achilles tendon with 6 months of evolution. He presented local pain with a palpable tendon defect and difficulty on walking with forefoot support. MRI showed a complete tear of 3cm. Surgical debridement and excision of scar tissue were performed resulting in a defect of 5cm between the tops of the tendon. He underwent V-Y advancement repair associated with flexor hallucis longus tendon transfer and immobilized the foot in equinus. Four weeks later he started physiotherapy for functional rehabilitation. After 6 months he presented full range of motion, total weight-bearing and no limitation for daily activities (AOFAScore 98). Discussion: The V-Y advancement repair should be used in defects between 2 to 5cm. Some advantages are the use in young patients and greater vascularization of the tendon due to its closely to the soleus muscle. In cases with a defect equal to or greater than 5cm, the association with flexor hallucis longus tendon transfer presents better functional results, increasing plantar flexion strength and ankle mobility. Conclusion: The V-Y advancement repair reinforced by flexor hallucis longus tendon transfer has good clinical and functional outcomes in the treatment of chronic Achilles tendon rupture with defects greater than 5cm.

Introduction: Bimalleolar fractures are common. The incidence varies between 223 and 248/100000 persons/year. Both genders are equally affected and, generally, these fractures are due to low energy mechanisms. The anatomic joint reconstruction is the key for a successful treatment. Methods: Retrospective study of 45 patients, submitted to surgical treatment of Weber type B or equivalent bimalleolar fracture, between June 2018 and May 2019. The average follow-up was 9,6 months. All patients were subjected to a clinical, radiologic and functional evaluation. Fracture type, age, gender, BMI, waiting time to surgery and hospitalization time were assessed and the AOFAScore was measured for functional assessment. Results: 71,11% of patients were female. The average age was 50,51 years and the average BMI was 26,97 kg/m2. 60% of the patients had a Weber B type fracture and 40% had a Weber B equivalent fracture. Worse AOFAScore was associated to Weber B equivalent fracture (p=0,005). In patients with a BMI >= 30 kg/m2 the score was lower when compared to patients with a BMI <25 kg/m2 (p<0,01), but not when compared to the group of >=25 and <30 kg/m2. Conclusions: Despite the good results associated to the surgical treatment of Weber type B and equivalent bimalleolar fractures, factors such as BMI >=30 mg/m2 and injury of the deltoid ligament leads to a worse prognosis. This result seems to be associated to the loss of joint stabilization by the deltoid ligament and mechanical overload in obese individuals.

The Achilles tendon is one of the most commonly ruptured tendons; acute Achilles tendon rupture can be easily diagnosed and treated. However; a marked number of cases are still missed and not treated appropriately. Chronic Achilles tendon rupture is defined when the diagnosis is done 4 to 6 weeks post injury. In this study, our aim was to assess the functional results following the reconstruction of chronic Achilles tendon rupture. Data was collected retrospectively and prospectively for 21 patients diagnosed with chronic Achilles tendon rupture who later underwent surgical reconstruction between 2010 and 2018. All patients were clinically assessed and underwent MRI scans to confirm the diagnosis and to plan the reconstruction procedure. The reconstruction was performed by using Flexor hallucis longus Tendon or Gastrocnemius flap. The primary outcome measured was the AOFAS score, other data included patient demographics, length of follow up, re-rupture rate and surgical complications. The Mean pre-operative AOFAS score was 43 and increasing to 73 post-operatively, with an average follow up of 8 months. One patient had superficial wound infection and no re-ruptures were recorded. This does show that the use of an FHL or Gastrocnemius flap seems to yield satisfactory functional results, and thus can be used in treatment of Achilles tendon rupture with delayed diagnosis or presentation.

Background: Various treatment options including operative procedures are described for painful foot conditions. Traditionally gastrocnemius recession is performed for the correction of gastrocnemius equinus contracture of the ankle, but it has also been described in the management of patients who suffer from plantar fasciitis and/or Achilles tendinitis. Objectives: In this study we aimed to review the outcome of medial gastrocnemius recession in improving pain and symptoms for patients who are suffering from plantar fasciitis and Achilles tendinitis and have failed conservative management. Methods: We conducted a retrospective review of patients who underwent gastrocnemius recession procedure for plantar fasciitis or Achilles tendinitis from 2011 to 2020 at our centre. Patients who had a structural foot or ankle deformity were excluded. Primary outcomes recorded were the Visual Analogue Score (VAS) and Patient satisfaction; other data collected included patient demographics, postoperative complications and follow up length. Results: The study identified 35 patients who underwent 40 medial gastrocnemius recession procedures. Of these patients 21 had Achilles tendinitis and 14 had a diagnosis of plantar fasciitis. Follow up was 22 weeks on average (6 - 56). The average preoperative VAS score was 8 reducing to an average of 2.2 postoperatively and 30 patients reported they were satisfied with the procedure. Conclusions: Provided appropriate patient selection secondary to individual patient examination and assessment, our study shows that Gastrocnemius recession appears to be an effective treatment for plantar fasciitis and Achilles tendinitis.

Abstract
Introduction:
The weekend warrior has long been prey to musculoskeletal injuries as a result of intermittent, high intensity activity. The Achilles tendon is known to be particularly vulnerable in this population cohort. During the COVID-19 lockdowns in Ireland and all over the world, viral challenges and dances have encapsulated the spirit of a global community with the ‘Jerusalema’ dance being no exception. The rise of this particular viral sensation was at the detriment of the Achilles tendons of three middle aged gentlemen on who we base our case series. Through these cases however, we highlight one centres approach to operative management and accelerated functional rehabilitation programme.

Methods:
A case series on the impact of the ‘Jerusalema Dance’ on presentations of Achilles tendon rupture to the ED in a single regional hospital was carried out in from February -March 2021 to highlight the use of an integrated Achilles tendon rehabilitation programme implemented in the Orthopaedic department, and its potential use in this at-risk patient cohort.

Results:
Over the space of ten days three cases of Achilles tendon rupture presented to the emergency department in Midlands Regional Hospital Tullamore (MRHT). Each of them had the same mechanism of injury while dancing the 'Jerusalema'. These patients were surgically managed and were initiated on an accelerated rehabilitation programme in line with local institution practice. Postoperative outcomes were good with no complications noted. Follow up is ongoing.

Introduction: Subtalar joint dislocations are rare, 1% of all dislocations. They are classified by Broca, according to the position of the foot in relation to the talus, as medial (65%), lateral and posterior. The objective is to present a rare case of medial fracture-dislocation of the subtalar joint and to describe its treatment. Methods: Presentation of the case of a 65-year-old man who came to the emergency room due to a traffic accident with direct trauma to the right foot, resulting in marked deformity and edema of the foot, without neurovascular compromise. Imagiologically, a medial subtalar fracture-dislocation was diagnosed. Initially, he underwent closed reduction and percutaneous Kirschner wire fixation, but a good result was not achieved and loss of reduction was observed. Subsequently, he underwent open reduction and internal fixation using two Steinmann pins. Results: Follow-up at 3 weeks, 6 weeks, 3 months and 6 months. Subsequently, a plaster splint was placed for 3 weeks. The Steinmann pins were removed at 6 weeks. At 6 months, he was walking without a walker, but with occasional limp and residual pain. Conclusion: This case presents a rare entity with an unpredictable prognosis. It depends on the variety of the dislocation, severity of the trauma, whether the dislocation is open or closed, the immobilization time and others. Treatment of dislocations with closed reduction is associated with superior results, but generally difficult to achieve.

Talar fractures usually result from high-energy trauma. Complications may include nonunion, avascular necrosis, osteoarthritis, and infection when associated with open fracture. This case is about a 38-year-old man with a motorcycle accident resulting in an open fracture-dislocation (Gustilo IIIB) of the left talus neck (Hawkins IV). Urgent surgery was performed with debridement, lavage and open reduction assisted with an external fixator. The external fixator was removed at the 5th week. After four months, he developed a fistula with seropurulent exudate, caused by Escherichia Coli. X-ray showed bone sequestration in the talus. He underwent new debridement and regional flap after antibiotic therapy. After 1 year, radiographically, posttraumatic ankle osteoarthrosis was observed. He hadn’t had new signs of infection and wished to undergo an ankle replacement. However, scintigraphy was suggestive of infection. The severity of the fracture is directly proportional to an increased risk of chronic pain and posttraumatic osteoarthritis. In active patients, the functional compromise resulting from these complications usually requires changes in lifestyle. Joint replacement would allow reaching the pre-traumatic level. Nevertheless, infectious complications contraindicate this treatment and arthrodesis was suggested. Pantalar arthrodesis is the usual management in terminal cases of hindfoot/ankle neuropathy and osteoarthrosis. In this case, ankle arthrodesis by Ilizarov external fixator was proposed to prevent the spread of the infection. The possibility of chronic osteomyelitis and risks/failure inherent to perform an arthroplasty under such conditions were discussed. The patient accepted salvage arthrodesis. The choice of technique aims to minimize the risk of new complications.

Introduction: Spontaneous avascular osteonecrosis of the navicular in adults is a rare bone dysplasia, known as Müller-Weiss syndrome, and it’s etiology remains unclear. This syndrome is distinct from Köhler disease, which is a childhood osteochondrosis of the tarsal navicular. It occurs in adults between 40 and 60 years of age and is more common in females. Our aim is to present a brief review of this disease and report a difficult case that required revision surgery to achieve optimal results. Methods: Presentation of the case of a 66-year-old woman with classic radiographic findings consistent with Müller-Weissdisease. The patient was treated initially with a triple arthrodesis of her right foot. At 6 months, postoperatively radiographs demonstrated a successful medial arch fusion but the patient presented ankle instability with a varus axis. External ligament repair surgery was refused by the patient, at this time. The following months several consultations were missed and the patient returned only at 2 years post-op. The disease had progressed, with evident osteoarthritis, an important varus deformity and instability. Ankle fusion was performed. Results: At 2 years’ follow-up, the patient was asymptomatic. The American Academy of Orthopaedic Surgeons Ankle Hindfoot (AOFAS) score was 87, compared with a preoperative score of 36. Conclusion: This complex case, with an evolution not as linear as expected, may raise awareness, provide a better understanding of how to manage this type of deformities and be helpful for surgeons when choosing the most appropriate operative procedure.

Introduction: Understanding the three-dimensional anatomy of the talar neck is essential to assess reduction of talar neck fractures, as well as in planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. This study aimed to identify from the existing literature, those geometrical parameters that describe the three-dimensional anatomy of the talar neck and determine their reference values. Methods: A scoping literature review was conducted in accordance with a published protocol. Geometrical parameters that describe the three-dimensional anatomy of the talar neck were identified. Pooled estimates of these parameters were determined by a random-effects meta-analysis model. Results: The combined searches yielded 4626 results, of which 21 studies were included in the review and 15 in 6 different sets of metanalysis. A total of 8 different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Conclusions: Although the literature reports parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

Introduction: No consensus has been obtained for the selection of joint preservation surgery for hallux valgus deformity in patients with rheumatoid arthritis (RA). We compared radiographic changes of DLMO (distal lineal metatarsal osteotomy) and Scarf (modified Scarf osteotomy).
Methods: 66 feet in 43 cases who underwent the joint preservation surgery for forefoot deformity of RA with minimum follow-up period of one year were included (DLMO; 36 feet in 25 cases, Scarf; 30 feet in 18 cases). The hallux valgus angle (HVA), sesamoid displacement by Hardy’s classification and postoperative complications (infection, non-union and recurrence of the painful callus) were analyzed and compared between two groups.
Results: The HVA (mean ± SE) for DLMO and Scarf was 43.9°±9.3 and 48.2°±9.8 preoperatively (n.s.), -7.2°±4.8 and 14.7°±7.4 immediately after surgery, and 3.4°±13.4 and 21.9°±12.7 at one year after surgery. The HVA was significantly improved at immediate after surgery and was maintained to one year in both groups. The HVA was significantly improved in DLMO than in Scarf. The results of Hardy’s classification showed significant improvement in DLMO. The incidence rates of postoperative complications showed no difference between two groups.
Discussion and Conclusion: Although, both DLMO and Scarf surgery showed good post-operative HVA and maintenance of improvement of HVA, the better improvement of HVA and sesamoid displacement are observed in DLMO group.

Introduction: Displaced intra-articular calcaneus fractures (DIACF’s) account for 75% of all the calcaneus fractures and have been associated with poor functional outcomes regardless of the treatment provided. The purpose of our study was to compare the results of operative vs non-operative treatment of DIACF’s in terms of functional outcome and complications. Methods: 71 patients with DIACF's (7- bilateral) were enrolled, making the total number of calcaneus fractures understudy 78. 40 calcaneum was treated conservatively and 38 operatively with open reduction and internal fixation with plate and screws. The patients were followed up and assessed using the Functional outcome assessment score and The American Orthopaedic Foot and Ankle Score (AOFAS). Results: 78 calcaneus fractures in the study were followed up for a minimum period of 2 years and a maximum period of 4 years. The functional outcome assessment score and AOFAS revealed no statistically significant difference between the two groups. Return to pre-injury work was delayed in conserved patients. However, complications were significantly higher in patients who were operated on. The ability to wear a shoe, and perform high-impact activities were found to be similar between the two groups. Conclusion: The optimal treatment for DIACF’s remains an ongoing debate. As no statistically significant difference was found regarding the functional outcome of the two groups, the authors conclude that conservative treatment is better for DIACF’s due to low complication rate and no added surgical morbidity to the patient who is already suffering from a highly morbid condition.

Introduction: Bone wax has been used for years by surgeons as a hemostatic agent to prevent bleeding from bone surfaces. Despite being extremely rare, it has been documented that bone wax may remain in the body for many years as a foreign body. Case presentation/evolution: 20-year-old male, student, bilateral talocalcaneal tarsal coalition. Submitted to arthroscopic coalition resection to the right foot. Bone wax was used to achieve local hemostasis. 1 week post-op, he is admitted to the ER because of progressive foot oedema, redness and local haematoma infection. He was consequently hospitalized for two weeks for IV antibiotics. 10 weeks post-op, after several episodes of persistent local active drainage, local compression was performed with extrusion of several medium-large bone wax fragments with no sign of absorption. Another similar episode occurred at 16 weeks post-op with extrusion of remaining medium bone wax fragments. The wound closed and the patient no longer had any subsequent local symptoms following this event. Discussion: Review of the literature found only a few articles concerning bone wax complications in foot surgery, despite its wide usage in this area. Adverse reactions include only mild inflammatory reactions in tissues “adjacent” to the site of application. Only a few reports included the formation of foreign body giant cell reaction and local inflammation at the site of bone wax application, an evolution which the present case resembles. Conclusion: Despite its rarity, the possibility of adverse events using bone wax in foot and ankle surgery should be taken into account.

Background: Subtalar joint dislocation is a rare entity. Usually related to high energy trauma can be exposed in 25%. Classification is based on the direction of dislocation. The rate of undiagnosed dislocations varies from 64-88%. Methods and Results: Retrospective analysis of patients admitted with subtalar joint dislocation in the last 7 years was performed. 4 cases were identified (2 women, 2 men). Average age was 49.25. 3 dislocations were closed, 1 exposed, and they were all lateral. 3 of the patients were submitted to a closed reduction, the exposed one to an open reduction. 1 of the patients had a fracture of the base of the 5th-metatarsal, 1 had an aligned fracture of the cuboid and talus, 1 (exposed dislocation) lesion of posterior tibial artery. All were immobilized 6 weeks with a splint. 3 of the patients, at 3-month follow-up, were walking without external support, without limitation of mobility. The patient with the exposed dislocation was walking with crutches and had a slight limitation on the dorsiflexion of the ankle, but no pain on a daily basis. The mean AOFAS score was 89. Discussion: Given the rarity of this lesion and the high rate of non-diagnosis, a high index of suspicion is required. Immediate reduction is essential for reducing the risk of soft tissue complications and avascular necrosis. Immobilization should be maintained 4-6 weeks. A shorter period may predispose to recurrent dislocation, too prolonged, increases joint stiffness and loss of function. Good results are expected in 70% of the cases.

Complete traumatic dislocations of the first metatarsophalangeal (MTP) joint are rare traumatic injuries, typically classified based on the x-ray appearance of the sesamoids. We present the case of a 19-year-old male patient from Guinea Bissau who was admitted to the Orthopaedics Emergency Service in Portugal, due to pain and functional limitation of the first right toe after trauma six months before playing football, without medical observation at the time in his country of origin. Clinically, he presented a varus hallux deformity with reduced local mobility and radiologically, dorsal MTP dislocation. At seven months of evolution, he underwent surgery to open reduction by medial approach. Intraoperatively, extensive intra-articular fibrosis and cartilage loss were found, with the immobility of the first metatarsal head and first phalanx base. We proceed with the release of both extremities and subsequent internal fixation with two Kirschner wires. After eight weeks the Kirschner wires were removed, and five months after surgery articular congruence was maintained associated with good mobility however, he presented with plantar pain at the level of MTP suggesting sesamoiditis and joint space narrowing on the radiograph which suggests that he may evolve into a hallux ridigus. This case corresponds to type IIA (Jahss’s classification) because there is a widening of the inter-sesamoid interval, in which usually closed reduction is possible however, after seven months the resulting fibrosis made it impossible. Considering the time of evolution, the patient presented a good functional result, having returned to play football however, early degenerative changes are expected.

Introduction: A rare causes of chronic ankle pain is longitudinal tear of peroneus brevis tendon. Peroneus Brevis (PB) tears are thought to occur from both trauma and chronic instability. We report a case of chronic lateral ankle pain due to longitudinal tear of the peroneus brevis tendon. Case report: A 51 years female, presented with pain and swelling behind the lateral malleolus on the left side. She had a twisting injury of ankle before six months. The patient had pain on eversion and single- legged standing. Magnetic Resonance image(MRI) showed irregularity at PB tendon and excessive fluid inside the synovial sheath. Surgical exploration of the peroneal tendon showed longitudinal split of the peroneus brevis tendon about 3 cm long at the level of retrofibular groove. The peroneus longus was intact and neither of the tendons was subluxated. The one part of the torn PB tendon which was frayed was trimmed distally and sutured to the main tendon using an absorbable suture. The lax superior peroneal retinaculum was plicated and fixed to the fibula using a suture anchor. The bony irregularitiesof lateral malleolus were smoothened. At one year follow up, the patient had no residual symptoms. Conclusion: Injury to the peroneal tendons is a frequently overlooked cause of persistent lateral ankle pain after trauma. High degree of clinical suspicion is important to diagnose the injuries. MRI serves as the key diagnostic tool. These tendon injuries need to be managed based on the extent and quality of the tears.

Background
Minimally invasive surgery of the toes was popularised in the united kingdom by Mr Redfern. Many surgeons have adopted this technique due to its quicker recovery time and better patient rehabilitation. This study looks into the outcome of Minimally Invasive procedure for lesser toe deformity correction at a district general hospital.
Objectives
1. To determine the complications and functional outcome in patients who have had a minimally invasive lesser toe surgery
Methods
This is a retrospective study of 30 patients and 46 toes. Patients who had minimally invasive lesser toe deformity correction surgery such as for claw toe and hammertoe were included. Patients were followed up to a year to check for recurrence or any complications.
Results
Our study showed promising results from the minimally invasive procedure. Only two patient had a complication, one being a superficial infection and the other temporary paraesthesia of the toe which recovered after six months. All patients reported good functional outcome. Patients who had a previous open procedure for other toes reported quicker rehabilitation after the minimally invasive procedure. The average length of hospital stay was also reduced in these patients when compared to other elective foot and ankle procedures

Conclusion
We conclude that a Minimally invasive procedure for lesser toe deformity correction is associated with good patient satisfaction and function with low complication rates compared to open surgical technique.

Objectives
The study aims to determine whether an arthroscopic ligament reconstruction is necessary to relieve clinical ankle instability symptoms in patients with an MRI scan showing medial or lateral ligament tear.
Methods
This was a single centre retrospective case series study of 25 patients with ankle instability and ligament tear on MRI scan who had undergone arthroscopic procedures from January 2015 to December 2018. Patients were followed up for an average period of 3 years postoperatively to check for any recurrence of symptoms
Results
Of the 25 patients, 23 had ATFL tear on MRI scan, and 2 had deltoid ligament tear. Examination under anaesthesia was stable in 13 patients and unstable in 12 patients. The majority of the patients (76%) had a simple arthroscopic ankle debridement and no ligament repair. Six patients needed Brostrom repair.
Conclusions
Our study has shown that in patients with MRI proven ligament tear and clinical instability, a ligament reconstruction was unnecessary in most patients. The instability symptoms of patients were relieved by simple ankle arthroscopic debridement.

Background: Plantar fibromatosis (PF) or Ledderhose disease is an uncommon benign, hyperproliferative disease of the plantar aponeurosis of unknown etiology. Case Presentation: We describe a clinical case of a 63-year-old woman that presented with pain on the first ray while walking and loss of motion of the first MTP joint of the left foot.At physical examination, it was noted thickening of the plantar fascia on the medial side of the foot. The patient had a previous scarf’s osteotomy for correction of hallux valgus and had bilateral palmar fibromatosis. The MRI demonstrated degenerative arthritis of the first MTP joint and thickening of the plantar aponeurosis. She was proposed to MTP joint arthrodesis and sub-total fasciectomy . Four weeks after surgery the patient was walking without crutches, with good skin healing. Over the 2 year follow up period, there wasn’t recurrence of the symptoms. Discussion:
For treating Ledderhose, conservative treatment is usually the first approach. Local steroid injection is a valid conservative method used in most cases. Since the FP is benign and radiotherapy may lead in long term to secondary malignancies, it may be appropriated to use in patients with recurrence after surgery.
Extracorporeal shockwave showed promising outcome, but further studies on more patients are necessary. Operative treatment is reserved for debilitating cases. PF is locally very aggressive and local excision of PF lesions results in a high rate of recurrence. For this reason, subtotal fasciectomy and wide excision is recommended.

Objectives: To assess the outcome of the sinus tarsi approach and C-Nail fixation of displaced intra-articular calcaneal fractures (DIACFs). Methods: Ninety-seven patients (mean age 44.3 years, 71 men and 26 women) with 114 DIACFs were treated between October 1, 2016 and December 31, 2019. In all cases, the posterior facet was reduced through the sinus tarsi approach and fixed with one or 2 screws. After reducing all fragments to the articular block, the final fixation was performed percutaneously with C-Nail, locked with 6 screws. Patients were assessed for restoration of the Böhler angle, complications, and overall fracture reduction. To assess the functional outcome, we used the Mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score and Maryland Foot Score after 12 months. Results: The Böhler angle improved from 22.5 degrees preoperatively to 29.6 degrees postoperatively. The articular step-off was reduced from 5.1 mm preoperatively to 0.6 mm postoperatively. The postoperative radiologic calcaneal score was 2.9, on average. Superficial wound edge necrosis was seen in 3 patients (3%) and superficial infection was observed in one (1%). After a 1-year follow-up, we recorded a mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score of 89.6 and a mean Maryland Foot Score of 92.6. Conclusions: After obtaining an anatomic reduction of the articular surface of the posterior facet with lag screws, the C-Nail represented a viable alternative to plate stabilization in the treatment of DIACFs, combining primary stability with low soft tissue complications.

Chronic ankle instability is due to the tear of the lateral ligament complex mainly Anterior Talo-Fibular Ligament(ATFL). Main mechanism of injury is ankle plantar flexion and inversion and 20% associated with symptomatic ATFL +/- Calcaneo-Fibular Ligament(CFL) injury. Isolated CFL injury is uncommon and is due to dorsiflexion and inversion. Aim of this study is to assess the efficacy of symptom control mainly ankle pain and instability with ATFL repair and augmentation with InternalBrace. We included all the patients who had double suture anchor ATFL repair and augmentation from 2016 to 2019. All patients had non weight bearing cast for two weeks followed by Weight bearing and physiotherapy. Patient were assessed 2wks, 6wks ,3 months, 6 months and +/- in 1 year following surgery. All had preoperative MRI scan those who did not have positive MRI scan had positive examination under anaesthesia(5/42). There were 42 patients, 24 male and 18 females. The mean age is 39.8 years. Mean follow up is 8 months. Three had underline generalised ligamental laxity.
Five patients continued to have lateral ankle pain 6 months after the surgery. One patient(2.38%) with a Beighton’s score of 6, developed recurrent instability confirmed to have re rupture and had to undergo revision surgery. The Sefton grade was measured post-operatively in follow up visits, at the final follow up 95.2% of patients rated good to excellent outcome. ATFL repair and augmentation is a reliable technique which allowed early weight bearing and return to activity, higher patient satisfaction and lower re-rupture rate.

Background: To explore the application and clinical efficacy of surgical approach strategies in open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans.
Methods: This retrospective cohort study included data of 25 patients with closed complex tibial Pilon fractures treated from October 2011 to March 2014, Surgical approaches were selected based on fracture line distribution and bone displacement revealed by axial CT scans, and an open reduction method was adopted for internal fixation of the bone plates. Postoperatively, Burwell-Charnley radiographic criteria were used to determine fracture reduction quality. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Complications, fracture union time, and the AOFAS scores at last follow-up were recorded.
Results: The 25 included patients were followed for 22-60 months postoperatively (average follow-up 33.9 months). Of these, 19 patients achieved anatomical reduction of the articular surface, 5 achieved good reduction, and one achieved fair reduction. No fracture malunion or internal fixation failures were found at last follow-up. All 25 patients had AOFAS scores ranging from 80 to 100 at last follow-up (average 88.4). Overall, 15 patients were excellent, 10 good, and 0 fair or poor, with excellent and good rates of 100%.
Conclusions: Surgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications.

Background: There are several studies about arthroscopic repair techniques for the avulsion of the anterior talofibular ligament (ATFL). However, the research concentrated on the lesion of the talar insertion of ATFL is very rare.
Methods: Among 122 patients who suffered from recurrent ankle sprain and underwent arthroscopic ATFL repair from October 2016 to January 2019 in our hospital, 11 patients with an avulsion of the talar insertion of the ATFL were diagnosed and treated with the arthroscopic suture-bridge repair technique in the present study. The clinical outcomes were assessed using the Karlsson-Peterson score, American Orthopedic of Foot and Ankle Society (AOFAS) ankle and hindfoot score, Sefton articular stability scale and Visual Analogue Scale (VAS). The complications were recorded at the time of observation.
Results: The mean follow-up time was 28.18±6.90 (range 18 to 36) months. At the final follow-up, the average of Karlsson-Peterson score, AOFAS ankle-hindfoot score, and VAS score was 91.82±6.81, 93.64±5.05, and 0.82±0.87, respectively. Based on the Sefton stability scale, thus 90% of cases were in the excellent or good category. No wound infection and neurovascular injury were encountered. At the last follow-up, no case required revision surgery. Only one case suffered from local irritation at the knotless anchor site.
Conclusions: The arthroscopic suture-bridge technique could be suitable for treatment of an avulsion of the talar insertion of the ATFL due to quick activity recovery and few complications.

Fifth metatarsal fractures are associated with high rates of nonunion. We compared the 9-month nonunion incidence in fifth metatarsal fracture patients using EXOGEN (Bioventus LLC), low-intensity pulsed ultrasound, versus control (standard of care) patients. Adults with acute/delayed fifth metatarsal fractures who initiated EXOGEN treatment within 91 days of the fracture were enrolled. Control patients with the same eligible fractures were extracted from MarketScan™ administrative claims database (IBM Watson Health). Propensity score modeling accounting for demographics, comorbidities, concomitant medication, and type of fracture/fracture treatment was used to address potential selection bias. Effectiveness was compared for 1,943 EXOGEN and 10,259 controls. Study endpoint was based on presence/absence of an ICD-10-CM nonunion diagnosis code in medical billing records/claims. Matched controls had a significant increase in nonunion risk compared to patients who used EXOGEN for at least 90 total once-daily treatments (OR = 1.67; p=0.048). EXOGEN group’s results improved with more treatments. EXOGEN was also found to attenuate the effect of many of nonunion risk factors on nonunion rates. EXOGEN treatment delay was associated with increased nonunion risk of ~20% for every 15 days of latency 45 days post-fracture. In this large external comparator study, EXOGEN was found to be effective in mitigating the risk of nonunion in fifth metatarsal fracture patients when used for a minimum of 90 total treatments, even in the presence of many nonunion risk factors. Treatment should be initiated as soon as possible following fracture (at least by 45 days post-fracture) to further reduce the risk of nonunion.