Background: This study investigated the footprint of the Achilles insertion in the sagittal orientation to delineate the anatomical landmarks, safe zones for bone resection, and accurate reattachment of the tendon insertion after take-down surgeries in treating insertional Achilles tendinopathies. Methods: Twenty fresh frozen cadavers were selected and the calcanei were dissected maintaining the Achilles tendon insertion intact. Dimensions of the posterior tuberosity were recorded and marked to plan for three sagittal cuts (Fig 1 A). Using an oscillating saw (Fig 1 B.), the posterior tuberosity was cut into four pieces (Fig 1 C,E). A trapezoid shape (Fig 1 D) was reconstructed demonstrating relative location of the footprints of the Achilles insertion compared to the boundaries of the tuberosity on each piece. Results: The calcaneal tuberosity tip to the upper limit of the Achilles insertion was shortest at the medial cut (9.35mm) and longest at the lateral cut (12.15mm). The tendon thickness at the insertion was shortest at the lateral cut (13.19mm) and longest at the middle cut (14.04mm). The distance from the highest to the lowest point of the calcaneal tuberosity, was the longest at the middle cut (41.20mm). Tendon thickness relative to the whole calcaneal tuberosity (BC:CD) was highest at the medial wall. (Table. 1) Conclusion: This study precisely delineated the footprint in each region of the insertion which could lead to future three-dimensional reconstruction of the Achilles insertional footprint and patient-specific instrumentation software directed towards optimizing the management of Insertional Achilles pathology.

Abstract
Introduction: Children and adolescents with symptomatic flexible flatfoot should only undergo surgery if conservative measures fail. This study evaluated the functional and radiological outcomes of tibialis anterior rerouting and calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot. Methods: This prospective study included children and adolescents with symptomatic flexible flatfoot treated by tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was uses to assess the functional results. The measured radiological parameters included the standing AP and lateral talo-first metatarsal, talar head coverage, and calcaneal pitch angles. Results: This study included 28 feet of 16 patients with an average age of 11.6±2.1 years. The mean AOFAS score increased significantly from 51.6±5.5 preoperatively to 85.3±10.2 at the latest follow-up. There was a statistically significant reduction in the mean AP talar head coverage angle from 13.6±4.4º to 3.9±3º, the mean AP talo-first metatarsal angle from 16.9±4.4º to 4.5±3.6º, and the mean lateral talo-first metatarsal angle from 19.2±4.9º to 4.6±3.2º, P<0.001. The mean calcaneal pitch angle increased significantly from 9.6±1.9º to 23.8±4.8º, P<0.001. Three feet had superficial wound infections, which were treated adequately with antibiotics and dressings. Conclusion: Symptomatic flexible flatfoot in children and adolescents can be sufficiently treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory clinical and radiological results.

Introduction Lateral column lengthening (LCL) of the calcaneum is a reliable technique in the management of adult-acquired flatfoot deformity (AAFD). To there remains considerable debate on the optimal graft choice when performing LCL. We aim to compare autograft versus allograft on the impact of time to union and subsequent clinical outcomes. Methods: Retrospective study of thirty-four patients who underwent Evan’s LCL for the correction of Grade IIb AAFD between 2010 to 2018. Patients were divided into 2 groups dependent on the type of graft used when performing Evan’s LCL (Group A – iliac crest autograft and Group B – allograft). Interval radiological analysis was performed preoperatively, 12-weeks, 24-weeks and at 1-year postoperatively. Visual analogue score(VAS), AOFAS-midfoot(AOFAS-Mid), AOFAS-hindfoot(AOFAS-Hind), physical and mental component summary (PCS and MCS respectively) were recorded preoperatively, 6-months and 24-months postoperatively. Results: Group A and B were comparable demographically (gender, side and body mass index) (p >0.05). Time to union was comparable between both groups (Group A – 22.3±7.4 weeks versus Group B – 18.4±7.1 weeks, p=0.174). Both groups demonstrated significant improvement in VAS, AOFAS-Mid and AOFAS-Hind scores at 6 months (p <0.05) and continued experience improvement at 24 months postoperatively (VAS, AOFAS-Mid, AOFAS-Hind, PCS) (p <0.05). No difference in clinical outcomes between both groups at 6-months and 24-months. Both groups did not experience any non-union. Conclusion: Significant improvement in early clinical outcomes were observed in both groups with high union rates. No difference in time to union and clinical outcomes between autograft and allograft when performing LCL.

Introduction: Müller-Weiss disease is a rare condition that causes degenerative changes in the navicular bone, becoming symptomatic around the fifth decade of life. Objective: To evaluate the functional health status and quality of life of patients diagnosed with Müller-Weiss disease and, secondarily, to determine the influence of factors such as gender, social status, race, body mass index, and surgical and non-surgical treatment in patient outcome. Methods: This study included 30 affected feet (18 patients) with follow-up from 2002 to 2016. Five patients were excluded from reassessment, resulting in 20 feet (13 patients). Questionnaires for functional and quality of life assessment were administered, and statistical analysis was performed. Results: Patients with obesity had poor functional results and low quality of life rates. Regarding quality of life, mainly in the mental health domain, there was a significant difference (p < 0.001) that was not observed in other domains investigated, except for surgical treatment, which was superior to non-surgical treatment in terms of the physical domain (p = 0.024). Bilateral treatment was also superior to unilateral treatment in the Coughlin’s classification (71.4% versus 66.7%). Conclusions: Müller-Weiss disease evolved with poor functional results and low quality of life rates in patients with obesity, with no method of treatment influence on patient outcome, except for the SF-12 physical domain, where surgical treatment showed better results than conservative treatment.

Aim: Ankle arthritis in young adults is both a common and a very challenging problem. Patients who fail conservative treatment and usually offered ankle fusion. The effects of ankle fusion on the gait cycle and the secondary arthritis that develop in neighbouring joints add to the patient dissatisfaction. Ankle distraction offers an alternative in this difficult cohort of patients. Despite promising short-term results, there is a lack of evidence about the long-term outcome of this technique. Material: The study presents prospective data from 40 patients below the age of 45 with advanced ankle arthritis who failed conservative treatment and continued to be symptomatic following arthroscopic ankle debridement. Method: Ankle distraction was done using a dynamic constrained ankle circular frame. All patients were allowed full weight bearing all through the distraction process. The subjective functional evaluation was based on the Manchester Oxford Foot questionnaire (MOXFQ), the Short Form (SF) 12 patient satisfaction questionnaire, and the American Orthopaedic Foot and Ankle Score (AOFAS). Results: At a minimum follow-up of 5 years (5 to 12 years follow-up), 7 patients had failed, demanding a fusion, replacement or below knee amputation. The remaining patients showed a significant improvement (p<0.01) in the MOXFQ score (both the physical and mental components) as well as the SF12 score and the AOFAS score. Conclusion: The medium to long term results of ankle distraction continue to support its use for managing an otherwise difficult presentation of severe ankle arthritis in the young adult.

Introduction: Supramalleolar osteotomy is widely used in treatment of ankle deformities and malunited ankle fusion. Many methods of fixation of supramalleolar osteotomy were described including plates, pins, and Ilizarov. Dome osteotomy is a cylindrical osteotomy with no bone loss in which the axis of the bone is rotated around the center of the circle. We conducted a case series of treatment of ankle deformity due to malunited ankle fusion with supramalleolar dome osteotomy. Methods: Eight poliomyelitis patients with ankle deformity due to malunited ankle fusion underwent supramalleolar dome osteotomy with Ilizarov fixation for deformity correction. Postoperative follow up was done up to 12months postoperatively. We intended to follow up the union of the osteotomy, the axis of the limb, the external clinical appearance, and patient satisfaction. Results: Deformity correction was achieved in all patients as regards the clinical alignment, with no apparent clinical residual deformity in the coronal, sagittal plane or rotational deformity, the limb was clinically sound and ethnically very satisfactory to the patients with correction of the gait. The osteotomy fully united in all patients in a period ranging from 8-11 weeks with average of 9.3 weeks, after which the frame was removed, none of the patients had nonunion or delayed union of the osteotomy. Three patients had pin tract infection during the period of the fixator which was cured by local dressings and antibiotics. Conclusion: Supramalleolar focal dome osteotomy fixed by Ilizarov technique is a good treatment option in treatment of deformities resulting from malunited ankle fusion.

Purpose: Range of motion (ROM) of the 1st metatarsophalangeal (1st MTP) joint is impacted by the function of the gastrocnemius-Soleus-Plantar fascia (GSP) complex. This study investigated the function of GSP complex and its impact on ROM of the 1st MTP joint in a group of patients with a variety of foot and ankle disorders (study group), and normal controls. Methods: Thirty-four feet in the study group) and 27 normal control feet were included in this prospective study. ROM of the 1st MTP joint was measured in both groups when different segments of the GSP complex was tightened and relaxed during the Barouk, Silverskiold, and Jack tests. Results: From the GSP complex being fully tight (Jack test) to partially relaxed (Knee extended, neutral ankle, & Barouk test 2), to fully relaxing (Barouk test 1), average dorsiflexion of the 1st MTP was larger in the controls than in the study group, with significant difference between the two groups in the full ROM of the 1ST MTP and plantarflexion of the IP joint when the knee was straight and ankle was in neutral. Conclusions: Change of the difference in ROM of the 1st MTP joint between the two groups with the GSP complex being tightened and relaxed, might be due to GSP contracture being more common in in the study group than the controls. The findings of this study gives us insight into the presence of asymptomatic functional hallux rigidus in both patients with symptomatic foot and ankle disorders and controls.

Objective: To analyze the clinical results of the arthroscopic modified Broström operation (MBO) combined with internal-brace augmentation in patients with chronic lateral ankle instability (CLAI) and generalized joint laxity (GJL). Methods: 111 patients were treated with MBO combined with internal-brace augmentation. The patients were divided into a GJL group (29), and a those with CLAI (82 patients). Mechanical stability of the affected ankle joint was examined radiographically preoperatively, at 6 months, and at the last follow-up. Visual analogue score (VAS), the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were recorded pre and postoperatively as well to reflect clinical outcomes. All statistical analyses were completed using SPSS 20.0. Results: The average follow-up time was 21.7±5.2 months for the GJL group, and 20.9±5.3 months for the CLAI group. FAAM and Karlsson scores improved at 6 months after operation and at the final follow-up (P<0.05). Preoperative talar tilt angle and anterior talar translation in the GJL group were significantly greater than that in the CLAI group (P<0.05). Postoperatively, both talar tilt angle and anterior talar translation decreased in both groups at 6 months and at the last follow-up with no differences between the two groups (P<0.05) (Tables 1-4, Figure 1). Conclusion: Arthroscopic MBO combined with internal-brace augmentation is a good therapeutic choice for treating CLAI with GJL. It can effectively restore the anatomy of the anterior talofibular ligament with sufficient stability as well as keeping all the advantages of the minimally invasive arthroscopic MBO.

Intro
Adult acquired flatfoot deformity (AAFD) is a progressive, degenerative condition that affects approximately 3% of the female population over 40 years old. Evidence has shown that the medial displacement calcaneal osteotomy (MDCO) is an effective treatment option, for advanced flexible flat foot deformities Recent surgical advances have explored minimally invasive (MI) options for MDCO, aiming to reduce soft tissue trauma(10). To our knowledge no systematic review has compared MI surgery to the traditional open approach for MDCO.

Methods
A search of Pubmed, Embase and Cochrane was conducted in-line with PRISMA Guidelines. Inclusion criteria; Study must include intra-opeartive or post operative outcomes following open or MI MDCO, >10 patients in study, Adult patients only.

Results
24 papers with 1,163 cases were included. There were comparable AOFAS scores between both MI and open MDCO. Degree of correction between the two methods was similar also. Three papers directly compared the two techniques, with two reporting favourable outcomes in the MIS groups in terms of wound infection, wound healing, post-operative stay and reduced operating time. One paper reported higher wound dehiscence in MI MDCO.

Conclusion
Early evidence supports MI MDCO as a viable alternative to open MDCO with potentially favourable patient and radiological outcomes achieved. Further RCT’s directly comparing the two surgical techniques would be beneficial. Work needs to investigate why one source reported a significantly higher wound dehiscence rate in MI MDCO, to fully understand the risk this poses.

Stainsby procedure and Hansens procedure have been originally described for the correcting the clawed lesser toes and clawed hallux respectively secondary to rheumatoid arthritis.The same principles can be used for clawed toes secondary to any condition.We describe a case who developed fixed clawing secondary to diabetes mellitus. A 52yr old female patient developed clawing in the toes of left foot since 3yrs.She also had 5th metatarsophalangeal Joint dislocation about 2 yrs ago secondary to trauma.She had developed callosities in the sole of the foot followed by ulceration under the 5th metatarsal (MT) head. She had radiographs and MRI scan showed chronic osteomyelitis in the distal aspect of 5th MT. Clinically, there was fixed clawing all the toes.Stainsby procedure was done for all the lesser toes.It involves returning the plantar plate and fat pad back to their normal anatomical position underneath the metatarsal heads.Extensor tenotomy was done followed by excision of the proximal 1/3rdof the proximal phalanx.Extensor tenodesis was done. For the 5th toe, we also excised the deformed 5th metatarsal head, neck and distal shaft. The toe was shortened.Hansen’s procedure was done for the clawed Hallux.FHL was detached at its insertion into the distal phalanx through a medial incision.FHL was then passed through a tunnel in the proximal part of the proximal phalanx. These procedures correct the clawing deformity of the toes and help in the resolution of the associated metatarsalgia and callosities. Thereby, reducing the chances of infection & chronic ulcers in the toes.

Introduction: Insertional Achilles Tendinopathy (IAT) is a common condition characterized by pain, swelling, and stiffness and can lead to rupture of the tendon and hence significant disability. Among the operative management options, dorsal closing wedge calcaneal osteotomy (DCWO) first introduced by Zadek is a globally adapted and safer treatment paradigm. It intends to lessen the impingement between the Achilles tendon enthesis and the posterosuperior angle of calcaneum by creating an osteotomy that shortens the anatomical length of calcaneum, thereby elevating the insertion of Achilles tendon. Very limited literature is found globally and is still an evolving entity. Methodology: This is a retrospective chart review. A total of 10 patients (11 DCWOs), were included in the analysis. After approval from the Ethical Review Committee, the medical records of all the patients were reviewed for patient demographics and surgery characteristics. The functional outcome was evaluated using European Foot and Ankle Society (EFAS) score and postoperative complications if any were noted on follow-ups. Results: The mean age of the patients was 49.10 years (SD ± 12.93). Six patients were males and 4 were females. The mean duration of surgery was 69 minutes. The mean follow-up time at which the EFAS score was calculated was 4 months. The mean EFAS score was found to be 19 points (SD ± 6.55). Only one patient, experienced calcaneal non-union at 3 months due to thermal necrosis. Conclusion: Zadek osteotomy yields promising results for recalcitrant IAT in terms of pain relief, range of motion, and functional outcomes.

Introduction: Fibular shortening with a medial and syndesmotic ligament instability causes lateral translation of the talus. We hypothesise that the interaction of the anterior inferior tibiofibular ligament (AITFL) tubercle of the fibular with the anterior tibial incisura would precipitate lateral translation due to the size differential.
Methods: Twelve cadaveric ankle specimens were dissected, removing all soft tissue except for ligaments. They were fixed onto a bespoke jig allowing tibial fixation and free movement of the talus and fibula. The fibula was progressively shortened in 5mm increments until complete ankle dislocation, measuring the medial clear space with each increment.
Results: The larger AITFL tubercle interaction with the smaller tibial incisura caused a significant increase in lateral translation of the talus. This occurred in most ankles between 5-10mm of fibular shortening. The medial clear space widened following 5mm of shortening in 5 specimens (mean: 2.07, s.d: 2.53). All 12 specimens experienced widening by 10mm fibular shortening (Mean: 7.21mm, s.d: 2.21) and reached complete dislocation by 35mm fibular shortening.
Conclusion: This study shows, that with fibular shortening, the interaction between the distal fibular AITFL tubercle and the anterior tibial incisura precipitates a lateral translation of the talus in an ankle fracture model where the medial and syndesmotic ligaments have been transected and the lateral ligaments remain intact. The interaction occurred between 5 and 10mm of fibular shortening. Beyond this point there was a near linear correlation between fibular shortening and medial clear space widening

Introduction ; Mini invasive techniques for hallux valgus are less damaging to soft tissues and 1st MP, it carry a lower risk of complications. We use percutaneous technique to correct the deformity with one percutanous k-wire. Methods: Twenty two patients with hallux vulgus were treated using a percutaneous technique over the period March 2020 –Sept. 2022, Under Fluoroscopy One k-wire 2.5mm inserted adjacent to the medial side of the nail of the big toe down to the proximal 1cm of the first MT , osteotomy of the first MT at proximal 2CM , pushing the k-wire through the medulla of the first MT to navicular , bandage and foot splint were applied. With a mean follow-up of 6 months. Radiographic pre- and postoperative assessment of the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle position with standing x-rays. Results: According to the AOFAS score, the patients improved from a preoperative median of 49 to 69. At 6monthes follow-up. Patients were satisfied 84% . A mean radiographic correction of the HVA of 13.2 degrees, of the IMA of 5 degrees, and of the DMAA of 5. degrees was achieved. The AOFAS global score and every individual parameter improved significantly between pretreatment and latest follow-up (P > .01). A total of 4 (.88%) complications were reported. Conclusion: This percutaneous technique, which use single K-wire as internal fixation described, produced durable results for the correction of HV, reliably correcting the deformity and resulting in significant improvement in function and decrease of pain.