Introduction: Triple Arthrodesis has been the preferred surgical treatment of stage III Adult Acquired Flatfoot Deformity. However, studies report subsequent midfoot degenerative arthrosis with medial column instability.
Methods: We carried out a retrospective study based on registry data from a single tertiary institution. Between 2007 to 2014, all patients who had undergone Triple Arthrodesis with percutaneous Tendo-Achilles lengthening were reviewed. All patients were judged to have an Achilles Tendon contracture by the Silfverskiöld test. Patients with previous foot surgery, revision surgeries, and concomitant surgical procedures were excluded. Results: 22 feet from 21 patients met the criteria. Hindfoot and midfoot American Orthopaedic Foot and Ankle Society (AOFAS) scores improved by an average of 34.6 and 36.7 points at 24-months post-surgery, both of which were statistically significant (p<0.001). From 6-months to 2-years post-operatively, there was a significant increase of the Arch by a mean of 5.9 ˚ (P=0.001). A decrease in the Calcaneal Pitch Angle by 3.1 ˚ (p=0.003 was noted). The Cuneiform-Calcaneal angle decreased significantly by 5.6 ˚(p=0.000), with the Navicular Height decreasing significantly by 2.5mm (p=0.011), indicating that there was mid-foot sagging. A total of 18 (85.6%) reported overall satisfaction being met at the time of a phone survey, at an average of 8.3 years (range 5.8 to 12.4) post-surgery.
Conclusion: We conclude that the mid-foot sagging seen radiologically in our series at 2 years may be an early radiological sign of medial column instability, which does correlate with the improved AOFAS mid-foot scores at 2 years.

Introduction: Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus hindfoot and ankle in combination with planovalgus.An important point regarding the successful treatment is careful attention must be paid to determine the precise anatomical location of the deformity. deformity can occur at the subtalar, the ankle or both sites . fibular shortening in the paralytic ankle leading to valgus deformity. The goal of this study is to restore normal ankle alignment with fibular length restoration. Methods:This was a retrospective study reported for (9)ankles in (.9 ) patients were treated by Fibular Lengthening Using Distraction Osteogenesis by ilizarov frame from (2007) to 2017 . Preoperative and post operative, patients were examined clinically and radiographically estimating the talocrural angle.Results:Age at surgery averaged 14 years and mean follow-up was 64 months.All patients had a complete consolidation of the regenerate bone of the fibula with fibular length gain averaged 28 mm.The ilizarov index averaged 63 d/cm . Good alignment of the ankle with marked improvement of the the talocrural angle from 3 to 16 degree achieved. one patient reported residual valgus deformity due to subtalar instability. Conclusions:The fibular lengthening proved to have a good correctional effect on valgus ankle deformity, it is a sufficient method to correct ankle valgus deformity, with a low incidence of complications , but requiring special attention to avoid Too much lengthening would result in talofibular impingement, whereas too small lengthening would not properly stabilize the talus

Background: Triple arthrodesis has stood the test of time as a procedure that can restore a painful, deformed, rigid flat foot into a stable, pain-free one. Since the first descriptions of the triple-arthrodesis procedures, little in the operative technique has changed. Recent studies suggest that some significant alterations in the technique may lead to equally good results. Aim and objectives: to compare functional and radiological outcomes of triple fusion and medial double fusion as a treatment method for neglected cases of rigid flat foot. Methods: The current study is a Randomized controlled trial study conducted in Cairo University Hospital between December 2019 till December 2022.Over 60 feet of 54 patients with rigid flat feet, with the exclusion of patients younger than 14 years old. The patients were classified into two groups; Group (A), 27 patients receiving triple hindfoot fusion, and Group (B), 27 patients receiving medial double fusion. Results: Although There was a high statistically significant difference between AOFAS hindfoot score, calcaneal pitch angle, lat Talo-First metatarsal angle, and Talo-Navicular(TN) coverage angle in the separate comparison regarding pre and postoperative groups A and B. However, There was no statistically significant difference in comparison between the two groups in postoperative AOFAS hindfoot score, calcaneal pitch angle, lateral Talo-first metatarsal angle, and TN coverage angle. Conclusion: The subtalar and the talonavicular joint arthrodesis through a medial approach is reliable for treating rigid flatfoot with deficient lateral skin without calcaneocuboid joint degeneration.

Pes planovalgus is one of the most common pediatric foot deformities. Surgery is only indicated for symptomatic flexible flatfoot with failed conservative treatment. In children, lateral column lengthening surgery is advantageous as it preserves the growth and development of the foot without fusing the joints.

Four electronic databases were searched for relevant articles reporting the outcomes of lateral column lengthening surgery in idiopathic flexible flatfeet of children with a minimum 1-year follow-up. Pre and postoperative radiological outcomes were recorded using talometatarsal angles, talonavicular coverage, calcaneal pitch, and talocalcaneal angle. The functional results were recorded. Rehabilitation protocol and complications were noted.
Results: A total of 16 studies were included for the final review, with a total of 336 patients (468 feet) with a mean age of 11.65 years.There was a statistically significant improvement in the postoperative radiological parameters like anteroposterior (AP) talocalcaneal angle, AP talometatarsal angle, AP talonavicular angle, and in lateral views talocalcaneal angle, talometatarsal angle, and calcaneal pitch in comparison to preoperative values (p < 0.00001). The mean postoperative AOFAS scores had a standard mean difference of −5.24 [95% confidence interval (CI); −6.39, −4.09] from the mean preoperative AOFAS scores, and this difference is statistically significant (p < 0.00001). Complications like pain in the foot, infection, under-correction, graft displacement, and calcaneocuboid or talonavicular joint subluxation were noted.
Lateral column lengthening surgery is promising with good midterm clinical and radiological outcomes with acceptable complications for treating symptomatic flexible flatfeet in pediatric and adolescent populations.

Introduction: Plantar fasciitis is the most common cause of foot pain and is usually respond to conservative treatment. However, a minority of patients fails non-operative management and requests surgical intervention.Though, there is no consensus as to the best surgical management. The aim of this study was to compare results of proximal medial gastrocnemius release(PMGR) and open medial plantar fasciotomy(OMPF) in the treatment of plantar fasciitis. Methods: This retrospective study compared 25 patients with plantar fasciitis that underwent PMGR with 25 that underwent OMPF. Both groups were compared regarding age, sex, BMI, laterality, duration of symptoms and Silfverskiold's test. Different standardized evaluation scales were used to evaluate results 6 months postoperatively including American Orthopaedic Foot& Ankle Society (AOFAS) score and visual analogue scale(VAS) for pain. Results: No significant difference were found in terms of the AOFAS, 88.1 +/- 10.2 for PMGR and 82.3+/- 14.9 for OMPF and regarding pain evaluation by VAS, the results were 25.8+/- 18.3 for PMGR and 30.6+/- 28.6 for OMPF. Relatively, faster recovery was observed in the PMGR group. Conclusion: There were no major preference for one technique over the other, regarding pain, AOFAS score. However, we recommend PMGR for treating this condition because it avoids the biomechanical complications potentiually encountered in the OMPF. Keywords: plantar fasciitis, proximal medial gastrocnemius release, open plantar fasciotomy.

Introduction: Tarsometatarsal (TMT) fusion is the commonly performed surgical procedure for end-stage midfoot arthritis. To date, there is no consensus on the best fixation technique for TMT arthrodesis using combinations of screws, plates and staples. There are limited data to demonstrate either superiority of a given fixation method. In this article, we present our early results and experience using continuous compression implants CCI. Method: All patients older than 18 years undergoing TMT fusion for midfoot arthritis between January 2017 and September 2022 identified retrospectively with minimum follow-up of 6 months. All procedures performed using thigh tourniquet and all patients received local anesthetic ankle block prior to skin incision. Data collected to assess tourniquet time, PROMS (MOXFQ scores) and pain scores as well as post-operative complication. Fifty-eight patients divided into one group (21 patients) in which TMT were fused using lag screws and/or locking plates and a second group (37 feet) in which fusion was achieved with CCI. Results: Tourniquet times were significantly shorter in the CCI group (P < .005). Post-op complications were less in the CCI group compared the control group. Post-op pain scores and PROMS were significantly lower in the CCI group (P < .005). Conclusion: In our study, we believe that the early results from using CCI for midfoot fusion are promising and offers safer and better outcomes in comparison to standard fixation using combination of screws and plates fixation.

Aim: This is a multi-centre, prospective, observational study, of the INFINITY fixed bearing total ankle arthroplasties. The aim is to report the medium-term results of a large cohort. We report the minimum two-year results of this prosthesis which is currently the most used ankle arthroplasty in the National Joint Registry of England and Wales. Material: 503 patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. 65% of patients were degenerative, 27.4% were post-traumatic and 7.6% had inflammatory arthritis. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). Method: All patients had an ankle replacement with the INFINITY fixed bearing total ankle arthroplasty. 99 (19.7%) implantations utilised patient specific instrumentation. Radiographic, and functional outcome data were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results: At a mean follow up of 36 months, 21 patients have died, 10 withdrew and 4 lost to follow up. 9 implants (1.8%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%.
There was a significant (p<0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Conclusion: The INFINITY fixed bearing total ankle arthroplasty has shown a low revision rate and a high functional outcome at a minimum of 2 years postoperative.

Introduction: Hallux valgus is one of the most common surgically corrected forefoot deformities. Studies evaluating clinical outcomes of minimally invasive chevron and akin (MICA) procedure have shown shorter operation time, faster recovery, and smaller scars compared to the open approach. Biomechanical cadaveric studies have focused on the open approach with minimal on MICA. To our knowledge, no studies have compared different proximal screw placements in MICA which can either be three-point fixation or intramedullary. This study aims to compare the biomechanical properties of fixation between these two techniques in MICA. Methods: Six matched pairs of human fresh frozen cadaveric feet were randomized to either three-point fixation or intramedullary groups. Both procedures were performed by a single fellowship-trained orthopaedic foot and ankle surgeon. Using a material testing machine, each specimen underwent 1000 cycles of plantar-to-dorsal uniaxial loads from 0 to 31 N in cantilever configuration while monitoring bending stiffness and distal fragment dorsal angulation. They were then subjected to load until failure at a compression rate of 10mm/min. Results: Specimens from both groups tolerated the walking fatigue test. Mean bending stiffness of three-point fixation was 84% higher than intramedullary constructs (P=.002). Mean dorsal angulation of intramedullary was thrice that of three-point fixation constructs (P=.008). Mean load to failure of three-point fixation was 30% higher than intramedullary constructs (P=.001). Conclusion: Three-point fixation provide superior biomechanical stability compared to intramedullary proximal screw placement. The surgical technique using three-point proximal screw fixation can offer robust fixation and may lead to better clinical outcomes.

Background: Osteochondral lesions (OCL) of the talar dome are difficult to treat. Bone marrow stimulation despite promising results, results in fibrocartilage that incurs different mechanical and biological properties to normal cartilage. Newer modalities such as concentrated bone marrow aspirate and particulate juvenile cartilage have been devised. However, these newer modalities might not be available and if present are extremely expensive.
Methods: Twenty-three patients with OCL on the medial talar dome were included in the present study. Patients underwent open medial malleolar osteotomy, autologous bone grafting from the osteotomy site in addition to a reversed periosteal patch flap that was also obtained from the surgical incision site. This latter biological membrane was attached to the grafted site by fibrin-glue. Patients were clinically evaluated using AOFAS Ankle-hindfoot score and radiological follow-up, Tegner activity levels and return to previous levels of activity were also documented for all patients. All patients were followed up for a minimum of two years.
Results: There was a documented statistical improvement in the AOFAS Ankle hindfoot scores (p <0.01). Radiological evidence of successful bony incorporation was present in all patients except two (91.3%). One patient had a recurrence with cystic formation, while the other still had partial filling of the graft site. No major neurovascular or skin complications were encountered.
Conclusion: The current study demonstrated satisfactory and comparable results using the described technique as a viable alternative to the recent yet more expensive biological methods in management of OCL of the talar dome specifically on the medial side.

Background: This study used the technique of distance mapping to measure the space of the “peri-navicular” joints in a group of controls and Muller Weiss Disease (MWD) feet, to prove the key pathologic changes of MWD.  Methods:   Weight bearing CT Scans of 55 controls, and 69 MWD feet were used for 3D segmentation. Distance mapping was applied to compare the space of the perinavicular joints between the two groups. Morphology of the navicular bone and the talonavicular articulation in the two groups were also studied.  Results:   MWD feet had significant narrowing of the lateral and dorsal sides of the navicular compared with the controls. The bony articular surfaces of the talonavicular joint on the navicular of the two groups matched well, meaning that the deformity changes occurred predominantly to the shape of the navicular but not the contour of the articular surface. The joint space was significantly greater in the talonavicular, middle and lateral naviculocuneiform, and the calcaneocuboid joints in MWD feet than in normal controls.  Conclusions:  The change in the shape of navicular causes the development of the cascade of MWD deformities. The sequalae includes increased joint space on both sides of navicular tail, and in the calcaneocuboid joint, lateral subluxation of the talus head, relative medial subluxation of the navicular, a varus heel, proximal shift of the calcaneal tuberosity, a flat arch with subsidence at the talonavicular joint, decreased adduction of the forefoot, medial translation of the cuboid at the calcaneocuboid articulation, and a shortened 1st metatarsal. 

Introduction: Studies of peritalar joint congruence have been performed using either XR, WBCT, or 3D segmentation and analysis. However, none of these techniques can demonstrate the cartilage nor the location of the articulation on the bone surface. This study used 3D surface mapping to assess morphometrics of the cartilage surfaces of the peritalar joints. Methods: 10 fresh-frozen cadaveric feet were dissected to expose the calcaneus, cuboid, talus, and navicular, and their articular surfaces. Surface mapping of the articular surfaces and the bones was completed using an Artec Space Spider 3D scanner and Mmics. Further digital analysis was completed using GeoMagic Studio 10. Results: Detailed information of the articular surfaces is summarized in Table 1. The average articular area on both sides of the joint matched each other well in the posterior facet of the subtalar joint (4% difference), and calcaneocuboid joint (3% difference). However in the anterior & middle facets of the subtalar joint, the cartilage articular area on the talar side was 129% of that on the calcaneus (p<0.05), and in the talonavicular joint the cartilage articular area on the navicular was 142% of that on the talus (p<0.05). Conclusion: The cartilage articular surfaces in certain peritalar joints do not match its opposing surface in size. In the talonavicular joint, it is easy to understand since area of the socket must be much smaller than that of the ball in order for the joint to glide and rotate and this needs further investigation.

Introduction: A combination of the geometry of the tarsal bones, ligaments, plantar aponeurosis, and muscle-tendon complexes contributes to the medial longitudinal arch structure. It was hypothesized in this study that there might be morphological abnormalities in the bone and joint surfaces of the navicular, the keystone of the medial longitudinal arch, in healthy controls and patients with symptomatic congenital flatfoot deformities. Methods: Weightbearing CT scans of 8 controls and 8 symptomatic congenital flatfeet were used for 3D segmentation of the navicular bones using Mimics. The morphology of the bone was compared between the two groups using the methods described in Figures 1 and 2. The articular surface of the talonavicular joint was mapped and separated from the rest of the navicular using GeoMagic Studio 10. Each articular surface was oriented to a rectangular shape to measure the length and width and the depth calculated by Pythagorean theorem. Results There was no statistically significant difference between the congenital flatfoot group and controls in the morphology of the navicular bone and metrics of the talonavicular articulation). Conclusion: In this pilot study with a small sample size, there was no significant difference observed in morphology of the navicular bone and its talonavicular articular surface between the congenital flatfoot group and the controls. Further study with a larger sample size and more detailed information of the articulation contours under investigation by our research group.

Background: Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of Acute Achilles tendon ruptures (AATR). The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted Flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures.
Methods: One hundred and seventeen patients were included in the current study including two groups: 59 patients who underwent percutaneous Achilles repair (PAR Group), and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared . Patients were clinically evaluated using AOFAS Ankle-hindfoot score, ATRS, and ATRA measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels and return to previous levels of activity were also documented for all patients.
Results: Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs. 73%, p <0.01 ). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered.
Conclusion: The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures.

Syndesmotic injuries are complex ankle injuries. PITFL provides most of the strength of the syndesmosis. Some anatomists consider the transverse tibiofibular ligament independent from the posterior inferior tibiofibular ligament. The location of the transverse ligament below the posterior tibial margin helps it prevent posterior talar translation.
We present a case of PITFL injury with two posterior fragments of the fibula suggesting the hypothesis that the superficial and deep ligaments are of separate identities.

A case of 41-year-old patient with complex ankle fracture. Initially, closed reduction and an external fixator was positioned. Then, open reduction and osteosynthesis was

The medial malleolus was stabilized with two screws, the posterior malleolus with an antiglide plate, and superficial posterior inferior ligament with an anchor.
Due to persistence of pain and discomfort after 1 year, a comparative CT scan of both ankles showed instability of the fibula in the fibular notch.
Intraoperatively, instability of the syndesmosis was confirmed. We performed an osteotomy of the posterior fragment of the fibula, recentered the fibula in its notch and fixed it temporarily by two K wires. An intraoperative 3D imaging confirmed the correct reduction of the syndesmosis. We then fixed the syndesmosis by a TightRope®. For stabilization of the PITFL, we utilized the InternalBraceTM ligament augmentation repair system.

This report sustains that the transverse tibiofibular ligament is a separate identity from the PITFL. We believe that the technique described offers a stable construct for revision surgeries of the PITFL.

Injuries of the first metatarsophalangeal joint are common among athletes. However, injuries involving the sesamoid complex are rare.
In this case report, a female gymnast presented with a history of pain and instability of the first metatarsophalangeal (MTF) joint of the right foot.
She denied any recent trauma or injury.
She had pain at single-limb heel rise at MTF joint and reduced agility. The patient had tenderness under the fibular sesamoid.
Radiographic and magnetic resonance imaging revealed proximal retraction of the fibular sesamoid with signs of tear of the fibular sesamoid phalangeal ligament and intersesamoid ligament.
We decided to surgically repair the fibular sesamoid ligament and use a tape for augmentation. We used a dorsal approach of the MTF joint and a small medial and plantar approach for passage of the tape through the sesamoids bones. Sutures and tape were anchored in the proximal phalanx through a bone tunnel and interference screw. Estability was tested intra-operatively and fluoroscopy was used to verify normal alignment of the fibular sesamoid. A proper dressing was used to maintain plantarflexion. In addition to ROM activities, the patient underwent weight-bearing exercises and strength training exercises progressivelly.
At 3 months, the patient returned to moderate sports activity and at 6 months she reported minimal to no pain and fully return sports activity.
Although our patient displayed some characteristics associated with a turf-toe injury, the distinguishing trait of this case was the isolated fibular sesamoid retraction injury with a history of chronic micro trauma secondary to overuse.