Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity.

BACKGROUND: To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL). METHODS: From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. 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 control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up. CONCLUSION: Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Talocalcaneal coalition classifications: A critical analysis review and suggested new classification system with implications for treatment.

Talocalcaneal coalitions (TCC) is the second most frequent tarsal coalition reported. Our aim was to review talocalcaneal coalition classifications and to propose a new classification emphasizing a therapeutic approach. None of the classifications described for TCC mention the presence of flatfoot or valgus hindfoot, which are the key elements when defining the optimal treatment of this disease. We defined five clinical and radiological factors that would guide the choice of surgical treatment and based on these, we proposed a new classification system.

Managing the Severe Cavus Foot Deformity in Global Humanitarian Programs.

The cavus foot represents a complex spectrum of deformity ranging from the subtle idiopathic to the severe sensorimotor neuropathy and other neuromuscular deformities. The successful surgical treatment of the cavus foot depends on a fundamental understanding of the underlying multiplanar deformity, inherent muscle balance, and the rigidity of the hindfoot. The location of the deformity is described and understood according to its multiple apices. These deformities are addressed with osteotomies or arthrodesis directed at the apices of deformity. Simultaneously, correction of muscular imbalances with appropriate tendon transfers must also be performed to prevent recurrent deformity. With these principles in mind, the surgical correction of the cavus foot becomes simplified and algorithmically driven.

Morphological and evolutionary insights into the keystone element of the human foot's medial longitudinal arch.

The evolution of the medial longitudinal arch (MLA) is one of the most impactful adaptations in the hominin foot that emerged with bipedalism. When and how it evolved in the human lineage is still unresolved. Complicating the issue, clinical definitions of flatfoot in living Homo sapiens have not reached a consensus. Here we digitally investigate the navicular morphology of H. sapiens (living, archaeological, and fossil), great apes, and fossil hominins and its correlation with the MLA. A distinctive navicular shape characterises living H. sapiens with adult acquired flexible flatfoot, while the congenital flexible flatfoot exhibits a 'normal' navicular shape. All H. sapiens groups differentiate from great apes independently from variations in the MLA, likely because of bipedalism. Most australopith, H. naledi, and H. floresiensis navicular shapes are closer to those of great apes, which is inconsistent with a human-like MLA and instead might suggest a certain degree of arboreality. Navicular shape of OH 8 and fossil H. sapiens falls within the normal living H. sapiens spectrum of variation of the MLA (including congenital flexible flatfoot and individuals with a well-developed MLA). At the same time, H. neanderthalensis seem to be characterised by a different expression of the MLA.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons.

OBJECTIVES: To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS: We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS: Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p â€‹= â€‹0.005). CONCLUSION: LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE: Level V.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. PURPOSE: The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. RESULTS: There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). CONCLUSION: Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Management of the Subtalar Joint Following Calcaneal Fracture Malunion.

Subtalar joint arthrosis is common following intra-articular calcaneus fractures. The appropriate management of pain secondary to posttraumatic arthritis depends on the status of the remaining posterior facet articular cartilage, the magnitude of any residual joint displacement and distortions in the overall morphology of the calcaneus. In select circumstances, joint-preserving surgical techniques may be considered including lateral wall exostectomy, far lateral posterior facet joint debridement, and intra-articular osteotomies. When the subtalar joint is not salvageable, some form of arthrodesis procedure is pursued. Occasionally, an extra-articular osteotomy may be necessary in combination with arthrodesis to correct deformity.

A multi-jurisdictional outbreak of Salmonella Typhimurium infections linked to backyard poultry-Australia, 2020.

Zoonotic salmonellosis can occur either through direct contact with an infected animal or through indirect contact, such as exposure to an infected animal's contaminated environment. Between May and August 2020, a multi-jurisdictional outbreak of Salmonella Typhimurium (STm) infection due to zoonotic transmission was investigated in Australia. In total, 38 outbreak cases of STm with a median age of 5 years were reported. Epidemiological investigation showed contact with live poultry to be a common risk factor with most cases recently purchasing one-week old chicks from produce/pet stores. Traceback investigation of cases identified 25 product/pet stores of which 18 were linked to a single poultry breeder farm. On farm environmental sampling identified the same STm genotype as identified in cases. Whole genome sequencing of both environmental and human outbreak isolates found them to be highly related by phylogenetic analysis. This investigation describes the first documented widespread zoonotic salmonellosis outbreak in Australia attributed to backyard poultry exposure and identified potential risk factors and prevention and control measures for future outbreaks. Prevention of future outbreaks will require an integrated One Health approach involving the poultry industry, produce/pet store owners, animal healthcare providers, public health and veterinary health agencies and the public.

Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity.

Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.

Diagnostic Accuracy of the Progressive Collapsing Foot Deformity (PCFD) Classification.

BACKGROUND: A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification. METHODS: This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant. RESULTS: For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively. CONCLUSION: The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation."Level of Evidence: Level II, prospective comparative study.

Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity.

BACKGROUND: Historical concept of flatfoot as posterior tibial tendon dysfunction (PTTD) has been questioned. Recently, the consensus group published a new classification system and recommended renaming PTTD to Progressive Collapsing Foot Deformity (PCFD). The new PCFD classification could be effective in providing comprehensive information on the deformity. To date, there has been no study reporting intra- and interobserver reliability and the frequency of each class in PCFD classification. METHODS: This was a single-center, retrospective study conducted from prospectively collected registry data. A consecutive cohort of PCFD patients evaluated from February 2015 to October 2020 was included, consisting of 92 feet in 84 patients. Classification of each patient was made using characteristic clinical and radiographic findings by 3 independent observers. Frequencies of each class and subclass were assessed. Intraobserver and inteobserver reliabilities were analyzed with Cohen kappa and Fleiss kappa, respectively. RESULTS: Mean sample age was 54.4, 38% was male and 62% were female. 1ABC (25.4%) was the most common subclass, followed by 1AC (8.7%) and 1ABCD (6.9%). Only a small percentage of patients had isolated deformity. Class A was the most frequent component (89.5%), followed by C in 86.2% of the cases. Moderate interobserver reliability (Fleiss kappa = 0.561, P < .001, 95% CI 0.528-0.594) was found for overall classification. Very good intraobserver reliability was found (Cohen kappa = 0.851, P < .001, 95% CI 0.777-0.926). CONCLUSION: Almost half (49.3%) of patients had a presentation dominantly involving the hindfoot (A) with various combinations of midfoot and/or forefoot deformity (B), (C) with or without subtalar joint involvement (D). The new system may cover all possible combinations of the PCFD, providing a comprehensive description and guiding treatment in a systematic and individualized manner, but this initial study suggests an opportunity to improve overall interobserver reliability. LEVEL OF EVIDENCE: Level III, retrospective diagnostic study.

An Approach to the Management of Severe Clubfoot Deformities on Global Humanitarian Programs: The Role of Talectomy.

The approach to treatment of severe untreated or recurrent congenital talipes equinovarus deformities is very different in the world where patients are mobile, have access to repeated return visits for follow-up treatment, and where more sophisticated options for gradual correction with external fixation are available. For treatment, talectomy may be the only option to treat certain neglected clubfoot deformities during humanitarian programs and it may still have to be used as a salvage procedure used in modern foot surgery. Our extensive experience with these deformities has been on global humanitarian programs.

Management of Complex Tarsal Coalition in Children.

Complex tarsal coalition includes extensive talocalcaneal coalition, double or triple coalition, coalition with severe hindfoot deformities, or coalition with a ball-and-socket ankle deformity. Careful preoperative physical examination including diagnostic injection is important in treatment planning. Both radiographic examination and computed tomographic scan that involve not only the foot but also the ankle are necessary to analyze the location and size of the coalitions, determining the presence of arthritis in the involved or adjacent joints, and if there are any deformities including a ball-and-socket ankle, which is frequently associated with complex tarsal coalitions.

Return to Play and Fracture Union After the Surgical Management of Jones Fractures in Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population. PURPOSE: To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures. STUDY DESIGN: Meta-analysis. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures. RESULTS: Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%). CONCLUSION: The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Titrating the Amount of Bony Correction in Progressive Collapsing Foot Deformity.

RECOMMENDATION: There is evidence indicating that the amount of bony correction performed in the setting of progressive collapsing foot deformity reconstructive surgery can be titrated within a recommended range for a variety of procedures. The typical range when performing a medial displacement calcaneal osteotomy should be 7 to 15 mm of medialization of the tuberosity. The typical range when performing an Evans lateral column lengthening should be 5 to 10 mm of a laterally based wedge in the anterior calcaneus. The typical range when performing a plantarflexion opening wedge osteotomy of the medial cuneiform (Cotton) osteotomy should be 5 to 10 mm of a dorsal wedge. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Progressive Collapsing Foot Deformity: Consensus on Goals for Operative Correction.

RECOMMENDATION: In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient's age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.

Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity.

RECOMMENDATION: Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. LEVEL OF EVIDENCE: Level V, consensus, expert opinion.