Lesser Metatarsophalangeal Joint Instability: Open Surgery Treatment Alternatives.

Lesser metatarsophalangeal joint plantar plate degeneration and tear typically presents as an attritional pattern of capsuloligamentous deficiency in middle-aged patients or sports-related chronic injuries. Knowledge of the anatomy, pathophysiological basis, common patterns, grading and classification of these injuries, and indications for surgery will aid imaging interpretation in the preoperative setting. The acuity and extent of injury, tissue quality, and functional requirements of the patient influence clinical decision-making with respect to surgical management. This article provides an overview of the open surgical treatment alternatives and the most used techniques to solve instability of the metatarsophalangeal joints.

Talus Osteochondral Defect Treatment With Biological Scaffold.

Talus Osteochondral defects (OCDs) are challenging and there is no consensus in literature regarding which is the best method of treatment. New techniques coming from regenerative medicine are being considered good alternatives of treatment and are being used exponentially in orthopaedic surgery. Platelet-rich fibrin (PRF) is the second generation of platelet concentrates. It has a convenient method of acquisition and can be used to create a biological scaffold which is able to seal up cavitary lesions. In this article, the authors describe a talus OCD treated with a biological scaffold, reporting the technique details and its results clinical and radiological results. The case report objective is to portray the use of this kind of biological material, its advantages, and limitations.Level of Evidence: Level 5.

Ankle arthroscopy does not elevate complication rates in ankle fractures.

INTRODUCTION: Ankle fractures rank as the second most common lower limb fractures, and surgical intervention is essential for unstable ankle fractures. The use of ankle arthroscopy in such cases offers several advantages. This study aim is to assess whether arthroscopy influenced on complication rates in 171 ankle fractures treated with arthroscopic assistance. METHODS: This retrospective epidemiological analysis encompassed adult ankle fractures between December 2018 and December 2021. Initially, 173 patients were considered, but two were excluded, leaving a final sample of 171 patients. Postoperative complications were categorized as major or minor. RESULTS: The study included 171 patients with surgically treated ankle fractures assisted by arthroscopy, comprising 76 females and 95 males, with an average age of 41.9 years. Syndesmosis injuries were treated in all diagnosed cases (55.0%), and deltoid ligament injuries received attention when identified (33.7%). Arthroscopic techniques were preferred over open techniques (47.4%). Ten patients experienced complications, consisting of 2 major and 8 minor complications (5.8%). DISCUSSION: Our study's epidemiological findings align with prior literature, demonstrating that intra-articular injuries accompany 63% to 79% of ankle fractures. Arthroscopy allows for both diagnosis and treatment within the same procedure, including joint lavage to reduce inflammation. We diagnosed 57 deltoid injuries and identified a statistical relationship between chondral, syndesmotic, and deltoid ligament injuries. Infection is a common complication in ankle fracture surgery, with rates ranging from 1.44% to 16%. Our study yielded a 5.8% complication rate, comprising 1.2% major and 4.6% minor complications. Patients undergoing ORIF with arthroscopic assistance had a lower prevalence of infection. CONCLUSION: The use of arthroscopic assistance in the surgical treatment of ankle fractures does not increase the overall complication rate. LEVEL OF EVIDENCE: IV.

Venous Thromboembolism Prophylaxis in Foot and Ankle Surgery: A Worldwide Survey.

Current recommendations on thromboprophylaxis for foot and ankle (FA) surgery are often inconsistent and generally based on weak evidence. The aim of this survey study was to evaluate the current practice among orthopedic surgeons regarding venous thromboembolism (VTE) prophylaxis following FA surgery. From February 2019 to March 2020, an online questionnaire was sent by e-mail to orthopedic societies across the world. The questionnaire was hosted by the International Society of Thrombosis and Haemostais RedCAP platform. Topics of interest were VTE rates following FA surgery, duration and type of thromboprophylaxis, bleeding complications, VTE risk factors for prophylaxis and use of risk assessment. A total of 693 FA orthopedic surgeons from all continents completed the survey of whom 392 (57%) performed more than 200 FA procedures per year. A total of 669/693 (97%) respondents stated that thromboprophylaxis is necessary in FA surgeries. When thromboprophylaxis was prescribed, half of surgeons prescribed it for the duration of immobilization. Acetylsalicylic acid, low molecular weight heparin and direct-oral anticoagulants were, in this order, the preferred choice. Acetylsalicylic acid and low molecular weight heparin were predominantly prescribed in North America and Europe, respectively. Previous deep vein thrombosis, immobility, obesity and inherited thrombophilia were considered the main risk factors indicative of thromboprophylaxis use. In this survey, most surgeons agree that thromboprophylaxis is indicated for FA surgery, but the prescription, type and duration of prophylaxis differs greatly with a large intercontinental discrepancy. These survey results could be a foundation for developing uniform guidelines to optimize thromboprophylactic strategies in FA procedures around the world.

Mini Open Fasciotomy for Chronic Exertional Compartment Syndrome: A Prospective Case Series.

Chronic exertional compartment syndrome (CECS) is a challenging pathology that causes pain and physical limitations. Fasciotomy is the gold standard and different techniques have been described. Techniques that allow a fast return to sports and low recurrence rates are of great interest for the athletic population. This is a prospective case series presenting a mini open surgical technique and its results regarding the level of return to sports and quality of life in 13 patients. A specific CECS questionnaire was applied and analyzed concerning the distance patients were able to run before and after treatment, Tegner score, Medical Outcomes Short-Form Health Survey (SF-36), and epidemiological measures. The minimum follow-up was 12 months. The mean distance the patients were able to run per week following the surgical treatment improved from 14.1 to 38.1 km (P = .042) and the mean Tegner score improved from 3.92 to 7.08 (P = .01). Notably, 12 out of 13 patients were satisfied or very satisfied with the outcome. In this sample, the mini open technique improved patients' sports performance and quality of life and minimized pain. Chronic exertional compartment syndrome can be safely approached using a mini open technique with a good rate of satisfaction and return to sport.Levels of Evidence: IV.

Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals.

INTRODUCTION: Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.

Infinity Ankle Arthroplasty Early Latin-America Experience and Patient Outcomes.

INTRODUCTION: The promising data from Ankle Arthroplasty are consequence of the evolution of instruments and implants. Recent studies have shown good results in the short and intermediate follow-up, in addition to high patient satisfaction. The aim of this study is to present the results obtained with 49 cases treated with the Infinity total ankle prosthesis in 2 South America countries. METHODS: This is a case series of 48 patients (27 women and 22 men), treated with 49 Infinity prostheses in Brazil and Colombia. They underwent surgical treatment between April 1, 2016, and January 18, 2020. We used the visual-analogue pain scale (VAS), the AOFAS score for ankle and hindfoot and the measurement of range of motion (ROM) in the pre- and post-surgical period. The radiological evaluation was performed on ankle radiographs in anteroposterior and lateral views, obtained in orthostasis, measuring the parameters suggested by Hintermann. Average follow-up was 4 years. RESULTS: VAS reduced from an average of 7.94 to 1.98; AOFAS increased from 28.02 to 83.16 and ROM increased from 11.45 to 28.08. Distal Tibial Slope is higher for higher improvements in VAS and lower for higher improvements in AOFAS and ROM. We observed 4 wound infections, 1 intra-op medial malleolus fracture. No bone cysts, tibial or talar components subsidence, polyethylene component wear or failure were observed. No salvation procedures were required in this series. DISCUSSION: This study results corroborates literature data showing great improvements in pain, functional pattern, and movement. CONCLUSION: Infinity Ankle Arthroplasty is a safe and reproducible procedure with good outcomes at a short-term follow-up. LEVEL OF EVIDENCES: 4 - Case series.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective.

OBJECTIVE: The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. METHODS: A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings. RESULTS: A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. CONCLUSION: Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.

Minimally Invasive Chevron Akin: Locking The Metatarsal-Cuneiform Joint.

INTRODUCTION: Minimally Invasive Chevron Akin (MICA) can be used to treat hallux valgus (HV) associated with a hypermobility of the first metatarsal-cuneiform joint (1MTCJ). The aim of this study was to perform a radiographic analysis of the MICA, focused on evaluating the 1MTCJ. METHODS: Forty patients (50 feet) with moderate to severe HV underwent a MICA procedure. Radiographic analysis included hallux valgus angle (HVA), intermetatarsal angles between the first and second rays (IMA), the intermetatarsal angle between the proximal fragment of the osteotomy and the second ray (IAPF) and the distance between a point 3 cm distal from the base of the second metatarsal and a point located at the same height for the first metatarsal base (Dist 1-2). The IAPF was compared with the preoperative IMA, and the other parameters were compared preoperatively and postoperatively. The radiographic complications were also recorded. RESULTS: Most patients were female (92%). The mean age was 50.4 years (SD = 16.1) and the mean follow-up was 16.1 months (SD = 3.5). The average HVA improved from 32.5° to 7.3°, and the average IMA from 14.2° to 4.2°. The IAPF and Dist1-2 values showed an increase of 4.8° and 4.0 mm respectively. There were no radiographic complications. Conclusion. Minimally invasive Chevron Akin promotes a great correction of the moderate to severe HV conventional parameters and increase the transversal stability of the 1MTCJ fixing this joint as medial as possible. LEVEL OF EVIDENCE: Level IV, case series.

Percutaneous Bunionette Correction: Retrospective Case Series.

Introduction. Bunionette is a deformity of the fifth metatarsal in which there is a painful lateral bony prominence of the distal region of this bone caused by various anatomical and biomechanical changes. The aim of this study is to report on a minimally invasive technique without the use of hardware to treat these deformities. Methods. This is a case series of 18 patients, 25 feet, who underwent bunionette percutaneous surgical treatment. All patients answered the American Orthopaedic Foot and Ankle Society (AOFAS) scale and the visual analogue pain scale (VAS) preoperatively and at the last follow-up. Standard radiological evaluation included measurement of intermetatarsal (4-5 IMA) and fifth toe metatarsophalangeal (5-MTTP) angles. Time to radiographic consolidation, complications, and satisfaction rate were also documented. Results. The average follow-up was 15.9 months, the AOFAS increased from 49.6 to 92.4 and the VAS decreased from 7.7 to 1.2. It was observed that average 5-MTTP decreased from 15° to 2.7° and that 4-5-IMA decreased from 9.1° to 3.3°. These outcomes showed a statistically significant difference (P < .001). The most common observed complication was the formation of a hypertrophic bone callus in the third postoperative month in three operated feet (12%). One patient had algodystrophy, which improved after conservative treatment. There were no cases of infection, neuropraxis, or recurrences. Fifteen patients rated the result as excellent, 2 as good, and 2 as regular. Conclusion. Percutaneous osteotomy of the fifth metatarsal without the use of hardware is a safe, reproducible technique and presents good clinical and radiographic results for the treatment of bunionette.Levels of Evidence: Therapeutic studies, Level IV: Case series.

Corin ankle arthroplasty: Case-series.

BACKGROUND: Total Ankle Arthroplasty (TAA) is complex and can bring a wide variety of complications. Implant revision rates can vary from 4% to 8% in 5 years. Recent publications have shown good results in the short and intermediate follow-up and high patient satisfaction. The pre- and postoperative evaluation of these patients should include physical examination and objective radiographic measurements, which may have predictive value for implant failures and survivorship. In this paper we will present the results obtained with 29 patients treated with the Zennith (Corin Group, UK) total ankle prosthesis in Brazil. METHODS: This paper presents the results obtained with 29 patients treated with the Corin-Zennith prosthesis in three tertiary hospitals in Brazil, with an average follow-up of 5 years. The patients were submitted to clinical and radiographic evaluation. There were seventeen women and twelve men, ranging in age from 35 to 76 years, who were submitted to surgical treatment between January 16, 2013 and May 5, 2017. RESULTS: Seven patients (24%) presented cysts, being 4 (13.7%) tibial cysts and 3 (10.3%) tibial and talar cysts. Six patients (20.6%) presented talar subsidence and 3 (10.3%) presented tibial subsidence. Three patients (10.3%) presented component wear. VAS reduced and AOFAS and ROM increased in the post-operative period. The development of Cysts was associated with the theta angle and the difference in LTS (between the post and preoperative period) was associated with tibial subsidence. The complications rate was 44.8%, the revision rate was 6.9% and the survivorship rate was 93.1%. CONCLUSION: The Corin-Zennith prosthesis demonstrated to be a safe implant for improving functional parameters. Functional outcomes were not influenced for most commonly measured radiographic parameters. Further studies are needed to better understand these associations.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective

ABSTRACT Objective The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. Methods A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings. Results A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. Conclusion Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.

Planejamento pré-operatório de correção de deformidades supramaleolares através de impressão 3D / Preoperative planning of supramaleolar deformities correction through 3D printing

Planejamento pré-operatório de correção de deformidades supramaleolares através de impressão 3DRELATO DE CASOModelos impressos em 3D têm sido explorados profundamente no campo médico, destacando-se como importante ferramenta de auxílio para planejamento cirúrgico. Os autores apresentam relato de caso de um paciente, com artrose pós-traumática do tornozelo direito, submetido a osteotomia supramaleolar, em cunha de fechamento medial. Esta cirurgia foi realizada após planejamento operatório por impressão 3D, o que pode demonstrar reprodutibilidade deste método. (AU)

3D printed models have been explored deeply in the medical field, standing out as an important aid tool for surgical planning. The authors present a case report of a patient with post-traumatic arthrosis of the right ankle, who underwent supramaleolar osteotomy, using a medial closure wedge. This surgery was performed after operative planning by 3D printing, which can demonstrate the reproducibility of this method. (AU)

The Rotational Positioning of the Bones in the Medial Column of the Foot: A Weightbearing CT Analysis.

BACKGROUND: Malrotation of medial column bones of the foot has been advocated as an important factor in foot conditions such as hallux valgus and progressive collapsing foot deformity. Although stated as a deformity component, variances of normality in the general population are not completely understood. This study intended to describe the rotational profile of all medial column bones using weightbearing computed tomography (WBCT) images in a cohort of patients with different foot and ankle problems. METHODS: In this retrospective study, 110 feet of 95 consecutive patients that received a WBCT for assessment of different foot and ankle pathologies were included. Measurements were performed by a blinded fellowship-trained orthopedic foot and ankle surgeon. Rotation of the navicular, medial cuneiform, proximal and distal first metatarsal as well as proximal phalanx of the first toe were recorded. Positive values were considered pronation and negative values were considered supination. Rotational profile of each bone/ segment was assessed by ANOVA and comparison between each segment was performed using Wilcoxon Each-Pair analysis. P-values of less than 0.05 were considered significant. RESULTS: On average, a rotational positioning in pronation (internal rotation) was observed for all medial column bones. The navicular (43.2°, CI 41.1°-45.3°) and the proximal metatarsal (33.9°, CI 31.8°-36.0°) showed the highest mean rotation values. The medial cuneiform presented the lowest mean pronation (6.1°, CI 4.0°-8.3°). Comparison between each bone segment demonstrated statistically significant differences of rotational alignment for the different bones (p<0.0001), with the exception of the distal metatarsal and proximal phalanx, that had similar amounts of pronation. A zig-zag rotational pattern of alignment was observed from proximal to distal, with relative supination/pronation of adjacent medial column bones. CONCLUSION: The overall rotational profile of medial column bones was found to be in absolute pronation, most pronounced at the navicular and proximal first metatarsal, with significant differences in the amount of pronation when comparing most of the medial column bones. The presented data may be utilized as reference/ baseline values of medial column rotation, supporting future prospective, comparative and controlled studies.Level of Evidence: IV.

Deltoid ligament arthroscopic repair in ankle fractures: Case series.

INTRODUCTION: Diagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid repair through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications. OBJECTIVE: Demonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair. METHODS: This is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to open malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and functionality according to the Visual Analogue Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) at a minimum of 6 months follow-up. RESULTS: From January 2016 to January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed. DISCUSSION: The repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal. DESIGN: Level IV. Retrospective case series.

Current Trends in Treatment of Injuries to Spring Ligament.

The spring ligament is the main static supporter of the medial longitudinal arch. Identifying every detail of the pathophysiology of each condition in which these structures are involved is the key to an appropriate approach and treatment. Isolated reconstruction of the posterior tibial tendon present long-term results with a high failure rate. It is important to diagnose spring ligament injuries because of the probable consequences if not treated, such as acquired flatfoot deformity and loss of correction of treated flatfoot. The option of surgical treatment is discussed in this article.

Anterior and Posterior Ankle Impingement Syndromes: Arthroscopic and Endoscopic Anatomy and Approaches to Treatment.

Ankle impingement refers to a chronic painful mechanical limitation of ankle motion caused by soft tissue or osseous abnormality affecting the anterior or posterior tibiotalar joint. Impingement can be associated with a single traumatic event or repetitive microtrauma. These syndromes are a possible etiology of persistent ankle pain. An arthroscopic approach to this pathology, when indicated, is considered as ideal treatment with its high safety and low complication rate. We describe the clinical and potential imaging features, and the arthroscopic/endoscopic management strategies, for the 4 main impingement syndromes of the ankle: anterolateral, anterior, antero-medial, and posterior.

Distal Tibiofibular Syndesmotic Widening in Progressive Collapsing Foot Deformity.

BACKGROUND: Lateral overload in progressive collapsing foot deformity (PCFD) takes place as hindfoot valgus, peritalar subluxation, and valgus instability of the ankle increase. Fibular strain due to chronic lateral impingement may lead to distraction forces over the distal tibiofibular syndesmosis (DTFS). This study aimed to assess and correlate the severity of the foot and ankle offset (FAO) as a marker of progressive PCFD with the amount of DTFS widening and to compare it to controls. METHODS: In this case-control study, 62 symptomatic patients with PCFD and 29 controls who underwent standing weightbearing computed tomography (WBCT) examination were included. Two fellowship-trained blinded orthopedic foot and ankle surgeons performed FAO (%) and DTFS area measurements (mm2). DTFS was assessed semiautomatically on axial-plane WBCT images, 1 cm proximal to the apex of the tibial plafond. Values were compared between patients with PCFD and controls, and Spearman correlation between FAO and DTFS area measurements was assessed. P values of less than .05 were considered significant. RESULTS: Patients with PCFD demonstrated significantly increased FAO and DTFS measurements in comparison to controls. A mean difference of 6.9% (P < .001) in FAO and 10.4 mm2 (P = .026) in DTFS was observed. A significant but weak correlation was identified between the variables, with a Þ of 0.22 (P = .03). A partition predictive model demonstrated that DTFS area measurements were highest when FAO values were between 7% and 9.3%, with mean (SD) values of 92.7 (22.4) mm2. CONCLUSION: To our knowledge, this was the first study to assess syndesmotic widening in patients with PCFD. We found patients with PCFD to demonstrate increased DTFS area measurements compared to controls, with a mean difference of approximately 10 mm2. A significantly weak positive correlation was found between FAO and DTFS area measurements, with the highest syndesmotic widening occurring when FAO values were between 7% and 9.3%. Our study findings suggest that chronic lateral impingement in patients with PCFD can result in a negative biomechanical impact on syndesmotic alignment, with increased DTFS stress and subsequent widening. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Medial and Lateral Combined Ligament Arthroscopic Repair for Multidirectional Ankle Instability.

BACKGROUND: The high prevalence of ankle sprains in the population produces a significant number of patients with lateral instability. Persistence of this condition may lead to the progressive involvement of medial structures, causing a multidirectional rotational instability. METHODS: This is a retrospective study with patients diagnosed with multidirectional instability who underwent ankle arthroscopy with medial (arthroscopic tensioning) and lateral repair (arthroscopic Bröstrom) between January 2018 and January 2020. All patients were evaluated for pain and function according to the visual analog scale (VAS) score and the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score at a mean of 14.8 months (5-27 months) in follow-up. A total of 30 ankles (29 patients) were included in the study. RESULTS: The AOFAS score increase from a 49.7 (CI 5.8) to a 91.9 (CI 2.4) mean (P = .001) and was followed by significant improvement in the mean VAS score (6.8, CI 0.37-0.95, CI 0.31). The majority of patients had associated procedures (53.3%), and a low complication rate was found (16.6%). CONCLUSION: Combined medial and lateral arthroscopic repair might be an effective and safe alternative in the treatment of multidirectional instability. Inclusion of the deltoid ligament complex and the low invasiveness of the arthroscopic technique may improve the clinical outcomes of these patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Fifth Metatarsal Fractures in Professional Soccer Players: Case Series.

OBJECTIVE: Fifth metatarsal fractures occur mainly in young athletes, with an estimated incidence of 1.8 per 1000 individuals per year. This study aims to evaluate the functional outcome of professional soccer players undergoing surgical treatment of fifth metatarsal base fractures. METHODS: We appraised 34 soccer players operated on from July 2001 to June 2016. All individuals were assessed by the American Orthopedic Foot and Ankle Score (AOFAS) and Visual Analog Scale (VAS) before and after surgery, with a mean 23-month follow-up. The need for grafting, fracture healing, Torg classification, and return to sports were also evaluated. RESULTS: There were 10 attackers, 7 offensive-defensive midfielders, 6 side defenders, 5 central defensive midfielders, 3 defenders, 2 goalkeepers, and 1 defensive midfielder, at an average age of 19 years. Preoperative and postoperative AOFAS averaged 42 and 99 points, respectively, whereas VAS scores were 6 and 0. The longer the time to get operated on, the greater was the need for grafting (P = .011). In our study, all fractures have consolidated. Return to sports occurred, on average, 73 days after surgical treatment, and it was not influenced by the time to get operated on, fracture healing, Torg classification, and grafting. CONCLUSION: Surgical treatment of the fifth metatarsal base fracture in professional soccer players presents good clinical results. Getting back to activities after surgery is not influenced by surgery time, fracture healing, Torg classification, and grafting.Levels of Evidence: Level IV: Therapeutic studies, Case series.