Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis.

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.

The discrepancy between radiographically-assessed and self-recognized hallux valgus in a large population-based cohort.

BACKGROUND: There has been a paucity of literature revealing the discrepancy between self-recognition about hallux valgus (HV) and radiographically-evaluated foot configuration. Knowing this discrepancy will help to make a comparative review of the findings of previous literatures about epidemiological studies about the prevalence of HV. QUESTIONS/PURPOSES: (1) Is there a discrepancy between radiographically-assessed and self-recognized HV in the general population? (2) What factors affect the self-recognition of HV in the general population? METHODS: The fifth survey of the Research on Osteoarthritis/Osteoporosis against Disability study involved 1996 participants who had undergone anterior-posterior radiography of bilateral feet and answered a simple dichotomous questionnaire on self-recognition of HV. Measurements of the HV angle (HVA), interphalangeal angle of the hallux (IPA), and intermetatarsal angle between 1st and 2nd metatarsals (IMA) were performed using radiographs. Radiographic diagnosis of HV was done using the definition of hallux valgus angle of 20° or more. After univariate comparison of the participant backgrounds and radiographic measurements between participants with or without self-recognition of HV, multivariable logistic regression analysis was conducted in order to reveal independent factors affecting self-recognition. RESULTS: Significant difference was found between the prevalence of radiographically-assessed and self-recognized HV (29.8% vs. 16.5%, p <  0.0001). The prevalence of self-recognized HV increased with the progression of HV severity from a single-digit percentage (normal grade, HVA < 20°) up to 100% (severe grade, HVA ≥ 40°). A multivariable logistic regression analysis demonstrated that HVA, IMA, and female sex were independent positive factors for self-recognition of HV (HVA [per 1° increase]: OR, 1.18; 95% CI, 1.15-1.20; p <  0.0001; IMA [per 1° increase]: OR, 1.15; 95% CI, 1.09-1.20; p <  0.0001; and female sex [vs. male sex]: OR, 3.47; 95% CI, 2.35-5.18; p <  0.0001). CONCLUSIONS: There was a significant discrepancy between radiographically-assessed and self-recognized HV which narrowed with the progressing severity of HV. HVA, IMA, and female sex were independent positive factors for self-recognition of HV. Attention needs to be paid to potentially lowered prevalence of HV in epidemiological studies using self-reporting based on self-recognition.

Clinical Outcomes After First Metatarsophalangeal Joint Arthrodesis by Flat Cut Joint Preparation With Individual Adjustment for Sagittal Alignment.

Sagittal misalignment is a major cause of patient dissatisfaction and re-operation after first metatarsophalangeal (MTP) joint arthrodesis. The stereotypical application of the fixed angle would be undesirable, especially in cases of flat or cavus foot. We retrospectively reviewed 31 cases (27 patients) in which first MTP joint arthrodesis was performed using the flat cut joint preparation technique with reference to the plantar clearance beneath the pulp of the toe while simulating weightbearing by pushing a board against the sole. The most common underlying cause of surgery was rheumatoid arthritis (22 cases [71%]). Clinical outcomes were evaluated by the Japanese of Surgery of the Foot (JSSF) hallux scale and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty-three cases were also examined by pedobarography to evaluate postoperative walking plantar pressure. At the most recent follow-up of a mean 19.6 months, the toe-to-floor distance of the hallux in static standing posture was a mean of 2.5 mm (range, 0-10 mm). All but 1 foot (97%) achieved bone union. There were no complications or revisions due to misalignment of the fused MTP joint. JSSF hallux scales improved significantly from 47 preoperatively to 82 postoperatively. All subscale scores except general health and well-being in the SAFE-Q improved significantly at final follow-up versus preoperative period. Plantar pressure under the hallux was correlated with the toe-to-floor distance but not radiographic parameter. In conclusion, first MTP joint arthrodesis achieved good clinical outcomes when using toe-to-floor distance and Kirschner wire template for flat cut joint preparation.

Effect of gait protocols and postoperative shoes on off-loading of forefoot in preoperative patients for forefoot disorders.

OBJECTIVES: The purpose of this study was to clarify the effect of gait protocols and postoperative shoes on forefoot load in preoperative patients for forefoot disorders and compare footwear comfort between different types of postoperative shoes. METHODS: Fourteen subjects scheduled to undergo forefoot surgeries were recruited. The maximum force under the forefoot region was measured during 10 m straight walking in two gait patterns with six different shoe types. Visual analogue scale (VAS) scores for footwear comfort, subjective lower thigh pain, and electrical activities of lower thigh muscles were also evaluated. RESULTS: The body weight-normalized maximum force under the forefoot region significantly decreased in step-to gait compared to normal gait regardless of the shoe types used. Under the same gait condition, no significant difference was observed in the forefoot off-loading effect between the different shoe types used. Significantly worse VAS scores, significantly higher tibialis anterior muscle activities, and complaints of lower thigh pain were demonstrated in the gait with the reverse camber shoe. CONCLUSIONS: Gait protocol of step-to gait had more forefoot off-loading effect than postoperative shoes. The forefoot off-loading effect did not differ among the postoperative shoes, suggesting that postoperative shoes can be selected with an emphasis on footwear comfort.

Comparison between suture and staple fixations as internal fixation techniques for Akin osteotomy.

BACKGROUND: Suture and staple fixations are commonly used methods for Akin osteotomy; however, there has been a paucity of studies comparing these methods without bias. PATIENTS AND METHODS: We retrospectively compared the outcomes of 58 Akin osteotomies performed by a single surgeon using suture fixation and 39 Akin osteotomies performed by the same surgeon using staple fixation during the same period. RESULTS: Bone union at the osteotomy site was achieved in all cases with no cases of complications related to the materials used. Occurrence of breakage of the lateral cortex of the proximal phalanx showed no significant difference between the suture and staple groups. The lateral cortex breakage produced greater instability at the osteotomy site with the staple fixation compared to the suture fixation. CONCLUSIONS: Comparison of suture and staple fixations of Akin osteotomy demonstrated the superiority of suture fixation against staple fixation in terms of stability and cost-efficiency.

Association between fall history and performance-based physical function and postural sway in patients with rheumatoid arthritis.

OBJECTIVES: Patients with rheumatoid arthritis (RA) are at increased risk of falling; therefore, fall prevision and prevention are critical. The present study aimed to evaluate the ability of physical performance assessments to discriminate between RA patients with and without a history of falling. METHODS: Fifty patients with RA were divided into two groups according to the presence or absence of a history of falls within the previous 1 year. Physical performance was assessed using the short physical performance battery (SPPB), which consists of the timed standing balance, gait speed, and chair stand tests. Standing balance was also assessed as postural sway using a force platform in several positions including standing with both feet together, semitandem, and tandem. Backgrounds, SPPB, and postural sway were compared between the two groups. RESULTS: Fourteen patients (28%) reported one or more falls within the previous year. There were no significant intergroup differences in baseline characteristics or SPPB score. The group with a history of falls had significantly longer measured time for the 5-repetition chair stand test and significantly longer postural sway in the semitandem position. The discriminate analysis revealed that 5-repetition chair stand test or its combination with postural sway in the semitandem position significantly discriminated between fallers and non-fallers. CONCLUSION: Numerical evaluation of the chair stand test and postural sway in the semitandem position seems more appropriate than SPPB for assessing the fall risk of patients with RA.

The Effect of Gastrocnemius Recession and Tendo-Achilles Lengthening on Adult Acquired Flatfoot Deformity Surgery: A Systematic Review.

The purpose of this study was to evaluate the available clinical and radiographic evidence for incorporation of a gastrocnemius recession or tendo-Achilles lengthening into the surgical correction of adult acquired flatfoot deformity. A systematic review of the literature was performed using PubMed, Embase, Cochrane, CINAHL, and Google Scholar. Among the relevant articles, the level of evidence and quality was identified using the Methodological Index for Non-Randomized Studies tool. No study explicitly examined whether clinical or radiographic outcomes after adult acquired flatfoot deformity correction are improved when incorporating a gastrocnemius recession or tendo-Achilles lengthening compared with when no such procedure is performed, nor have they directly compared outcomes between 2 procedures. Studies demonstrated an overall improvement in postoperative range of motion and plantar flexion power after gastrocnemius recession, but such findings are hard to separate from the clinical contribution of concomitant corrective procedures to the foot itself. All studies that analyzed anteroposterior talo-calcaneal angle, anteroposterior lateral talo-first metatarsal angle and calcaneal inclination angle revealed improvement of each parameter postoperatively. There were no high-level evidence studies in the literature explicitly quantifying ankle range of motion, plantar flexion power, or radiographic impact of gastrocnemius recession or tendo-Achilles lengthening on adult acquired flatfoot deformity correction. Although gastrocnemius-soleus complex contractures have certainly been demonstrated to coexist with adult acquired flatfoot deformity, support for lengthening procedures is largely based on expert opinion or case series and is difficult to distinguish from the clinical contribution of associated corrective procedures.

Transcription factor Hes1 modulates osteoarthritis development in cooperation with calcium/calmodulin-dependent protein kinase 2.

Notch signaling modulates skeletal formation and pathogenesis of osteoarthritis (OA) through induction of catabolic factors. Here we examined roles of Hes1, a transcription factor and important target of Notch signaling, in these processes. SRY-box containing gene 9 (Sox9)-Cre mice were mated with Hes1(fl/fl) mice to generate tissue-specific deletion of Hes1 from chondroprogenitor cells; this deletion caused no obvious abnormality in the perinatal period. Notably, OA development was suppressed when Hes1 was deleted from articular cartilage after skeletal growth in type II collagen (Col2a1)-Cre(ERT);Hes1(fl/fl) mice. In cultured chondrocytes, Hes1 induced metallopeptidase with thrombospondin type 1 motif, 5 (Adamts5) and matrix metalloproteinase-13 (Mmp13), which are catabolic enzymes that break down cartilage matrix. ChIP-seq and luciferase assays identified Hes1-responsive regions in intronic sites of both genes; the region in the ADAMTS5 gene contained a typical consensus sequence for Hes1 binding, whereas that in the MMP13 gene did not. Additionally, microarray analysis, together with the ChIP-seq, revealed novel Hes1 target genes, including Il6 and Il1rl1, coding a receptor for IL-33. We further identified calcium/calmodulin-dependent protein kinase 2δ (CaMK2δ) as a cofactor of Hes1; CaMK2δ was activated during OA development, formed a protein complex with Hes1, and switched it from a transcriptional repressor to a transcriptional activator to induce cartilage catabolic factors. Therefore, Hes1 cooperated with CaMK2δ to modulate OA pathogenesis through induction of catabolic factors, including Adamts5, Mmp13, Il6, and Il1rl1. Our findings have contributed to further understanding of the molecular pathophysiology of OA, and may provide the basis for development of novel treatments for joint disorders.

Lateral collapse of the tarsal navicular in patients with rheumatoid arthritis: Implications for pes planovarus deformity.

OBJECTIVES: In patients with rheumatoid arthritis (RA), the talonavicular joint is commonly involved and midfoot collapse can lead to progressive flattening of the arch. Despite a general awareness of the important structural role of the talonavicular joint in rheumatoid foot disease, details of its destructive pattern have not been elucidated. METHODS: We cross-sectionally investigated 176 RA patients (342 feet) and classified their feet into the following five groups according to radiographic findings: arthritis (RA changes with normal navicular shape), Müller-Weiss Disease (MWD) (collapse of the lateral aspect of the tarsal navicular), flat (flattened navicular), ankylosis (ankylosis of the talonavicular joint), and normal. We compared medical histories and radiographic measurements among all five groups. RESULTS: The arthritis group comprised 91 feet, 36 in the MWD group, nine in the flat group, 12 in the ankylosis group, and 194 classified as normal. The MWD group demonstrated a trend towards pes planovarus deformity in contrast to pes planovalgus deformity in the arthritis group. Corticosteroid use and the mean daily dosage were the highest in the MWD group. CONCLUSIONS: This report revealed a high prevalence of MWD-like changes to the navicular in RA patients and its association with pes planovarus deformity and corticosteroid usage.

Comparison of mouse and human ankles and establishment of mouse ankle osteoarthritis models by surgically-induced instability.

OBJECTIVE: Prevalence of ankle osteoarthritis (OA) is lower than that of knee OA, however, the molecular mechanisms underlying the difference remain unrevealed. In the present study, we developed mouse ankle OA models for use as tools to investigate pathophysiology of ankle OA and molecular characteristics of ankle cartilage. DESIGN: We anatomically and histologically examined ankle and knee joints of C57BL/6 mice, and compared them with human samples. We examined joints of 8-week-old and 25-month-old mice. For experimental models, we developed three different ankle OA models: a medial model, a lateral model, and a bilateral model, by resection of respective structures. OA severity was evaluated 8 weeks after the surgery by safranin O staining, and cartilage degradation in the medial model was sequentially examined. RESULTS: Anatomical and histological features of human and mouse ankle joints were comparable. Additionally, the mouse ankle joint was more resistant to cartilage degeneration with aging than the mouse knee joint. In the medial model, the tibiotalar joint was markedly affected while the subtalar joint was less degenerated. In the lateral model, the subtalar joint was mainly affected while the tibiotalar joint was less altered. In the bilateral model, both joints were markedly degenerated. In the time course of the medial model, TdT-mediated dUTP nick end labeling (TUNEL) staining and Adamts5 expression were enhanced at early and middle stages, while Mmp13 expression was gradually increased during the OA development. CONCLUSION: Since human and mouse ankles are comparable, the present models will contribute to ankle OA pathophysiology and general cartilage research in future.

[Cartilage metabolism and mechanobioscience.]

Joint cartilage is under exposure to repetitive mechanical stress. It is well known fact that the mechanical stress is a major cause of joint disorders such as osteoarthritis. However the molecular mechanisms of cartilage under mechanical stress remain unclear. In recent years, some notable mechanosensor or signal cascades relating to mechanotransduction had been identified, which might be promising targets for treatment of joint disorders.

Identification of fibroblast growth factor-18 as a molecule to protect adult articular cartilage by gene expression profiling.

To identify genes that maintain the homeostasis of adult articular cartilage and regenerate its lesions, we initially compared four types of chondrocytes: articular (AA) versus growth plate (AG) cartilage chondrocytes in adult rats, and superficial layer (IS) versus deep layer (ID) chondrocytes of epiphyseal cartilage in infant rats. Microarray analyses revealed that 40 and 186 genes had ≥10-fold higher expression ratios of AA/AG and IS/ID, respectively, and 16 genes showed ≥10-fold of both AA/AG and IS/ID ratios. The results were validated by real-time RT-PCR analysis. Among them, Hoxd1, Fgf18, and Esm1 were expressed more strongly in AA than in IS. Fgf18 was the extracellular and secreted factor that decreased glycosaminoglycan release and depletion from the cartilage, and enhanced proliferation of articular chondrocytes. Fgf18 was strongly expressed in the articular cartilage chondrocytes of adult rats. In a surgical rat osteoarthritis model, a once-weekly injection of recombinant human FGF18 (rhFGF18) given 3 weeks after surgery prevented cartilage degeneration in a dose-dependent manner at 6 and 9 weeks after surgery, with significant effect at 10 µg/week of rhFGF18. As the underlying mechanism, rhFGF18 strongly up-regulated Timp1 expression in the cell and organ cultures, and inhibition of aggrecan release by rhFGF18 was restored by addition of an antibody to Timp1. In conclusion, we have identified Fgf18 as a molecule that protects articular cartilage by gene expression profiling, and the anticatabolic effects may at least partially be mediated by the Timp1 expression.

Histopathological Confirmation of Axonal Sprouting in Regenerative Peripheral Nerve Interface.

Symptomatic neuroma represents a debilitating complication after major limb amputation. The regenerative peripheral nerve interface (RPNI) has emerged as a reproducible and practical surgery aimed at mitigating the formation of painful neuroma. Although previous animal studies revealed axonal sprouting, elongation, and synaptogenesis of proximal nerve stump within the muscle graft in RPNI, there is a lack of reports confirming these physiological reactions at the histopathological level in human samples. This report presents a case of below-knee amputation with RPNI due to foot gangrene resulting from polyarteritis nodosa. Subsequently, an above-knee amputation was necessitated due to the exacerbation of polyarteritis nodosa, providing the opportunity for histopathological examination of the RPNI site. The examination revealed sprouting, elongation, and existence of neuromuscular junction of the tibial nerve within the grafted muscle. To the best of our knowledge, this is the first report demonstrating axonal sprouting, elongation, and possibility of synaptogenesis of the nerve stump within the grafted muscle in a human sample.

Runx2 and Runx3 differentially regulate articular chondrocytes during surgically induced osteoarthritis development.

The Runt-related transcription factor (Runx) family plays various roles in the homeostasis of cartilage. Here, we examined the role of Runx2 and Runx3 for osteoarthritis development in vivo and in vitro. Runx3-knockout mice exhibited accelerated osteoarthritis following surgical induction, accompanied by decreased expression of lubricin and aggrecan. Meanwhile, Runx2 conditional knockout mice showed biphasic phenotypes: heterozygous knockout inhibited osteoarthritis and decreased matrix metallopeptidase 13 (Mmp13) expression, while homozygous knockout of Runx2 accelerated osteoarthritis and reduced type II collagen (Col2a1) expression. Comprehensive transcriptional analyses revealed lubricin and aggrecan as transcriptional target genes of Runx3, and indicated that Runx2 sustained Col2a1 expression through an intron 6 enhancer when Sox9 was decreased. Intra-articular administration of Runx3 adenovirus ameliorated development of surgically induced osteoarthritis. Runx3 protects adult articular cartilage through extracellular matrix protein production under normal conditions, while Runx2 exerts both catabolic and anabolic effects under the inflammatory condition.

Symptomatic Medial Bone Excrescence in the Distal Phalanx of the Hallux after the First Metatarsophalangeal Joint Arthrodesis: A Case Report and Radiographic Reviews.

Medial bone excrescence at the base of the distal phalanx of the hallux is a common manifestation which is rarely painful. In this case report, we described the first case of the excrescence becoming symptomatic one year after a metatarsophalangeal (MTP) joint arthrodesis of the great toe in a 74-year-old female. The medial bony excrescence which was obscure preoperatively became obvious postoperatively in the anteroposterior foot radiographs. The patient was successfully treated by an excision of the excrescence. In order to clarify the pathology of the excrescence, we reviewed the radiographs with respect to the excrescence before and after hallux surgeries including 97 metatarsal osteotomies and 33 MTP joint arthrodesis. The width of the excrescence measured in the anteroposterior foot radiographs displayed substantial increment one month after the hallux surgeries (osteotomy group: 0.9 ± 0.7 vs. 1.5 ± 0.7 mm, p < 0.01; arthrodesis group: 1.3 ± 0.8 vs. 1.8 ± 1.0 mm, p < 0.01). However, there was no significant difference in the width of the excrescence between one month after surgery and at the most recent follow-up of around 20 months in average after the surgery (osteotomy group: 1.5 ± 0.7 vs. 1.4 ± 0.7 mm, p = 0.62; arthrodesis group: 1.8 ± 1.0 vs. 1.8 ± 0.7 mm, p = 0.37). The present case and our radiographic review suggested that the postoperative medial bony excrescence was not the result of change of position of the preexisting excrescence. The correction of pronation deformity through hallux surgeries could emphasize the medial bony excrescence and cause symptomatic irritation upon shoe contact.

Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis.

BACKGROUND: The effectiveness of scarf and Akin osteotomy with intra-articular lateral soft tissue release for the correction of hallux valgus (HV) in patients with rheumatoid arthritis (RA) has not been elucidated. METHODS: A total of 36 feet in 28 patients with RA who had scarf and Akin osteotomy with intra-articular stepwise lateral soft tissue release between 2015 and 2020 at a single institute were investigated retrospectively, with a mean follow-up period of 32.0 ± 16.9 months. Radiographic evaluations including the HV angle, intermetatarsal angle, and sesamoid position were performed preoperatively and postoperatively. Clinical outcomes were assessed using the Japanese Society of Surgery of the Foot (JSSF) hallux scale and self-administered foot evaluation questionnaire (SAFE-Q). RESULTS: The procedure resulted in significant HV correction, with a recurrence rate of 13.9%. The JSSF scale and all five SAFE-Q subscale scores significantly improved (p < 0.05), with no major complications. More than 90% of cases achieved adequate lateral soft tissue release without sacrificing the adductor tendon of the hallux. CONCLUSIONS: Intra-articular stepwise lateral soft tissue release in combination with scarf and Akin osteotomy provided satisfactory radiographic and patient-reported outcomes for the correction of HV in patients with RA with minimum lateral soft tissue release.

Juvenile Dysplasia Epiphysealis Hemimelica with Multiple Ankle Free Body.

Dysplasia epiphysealis hemimelica (DEH), also known as Trevor's disease, is a rare overgrowth of cartilage that commonly arises in the epiphyseal bone of children. We report a rare case of DEH originating from a talus accompanied by multiple intra-articular free bodies in a 7-year-old patient with ankle instability. After the primary surgery for free body removal and microfracture technique for the cartilage defects in the ankle joint, the free body recurred. Secondary surgery of arthroscopic free body removal with lateral ankle ligament repair succeeded in treating the patient, without further recurrence of the free body.

Lateral Heel Pain Caused by Impingement of Hypertrophic Peroneal Tubercle and Os Peroneum.

Hypertrophic peroneal tubercle (HPT) is an overgrowth of the peroneal tubercle located on the lateral aspect of the hindfoot, which could cause tenosynovitis of the peroneus longus tendon. Os peroneum (OP) is an accessory ossicle that exists in the peroneus longus tendon at the lateral aspect of the calcaneocuboid joint. Both HPT and OP can cause lateral foot pain and occasionally require surgical treatment. We encountered a case of lateral foot pain of HPT coexisting with OP. Careful preoperative magnetic resonance imaging, dynamic ultrasonographic image, and block injection suggested an impingement of HPT and OP as a cause of lateral foot pain. Surgical resection of HPT, while retaining OP, successfully achieved pain relief in the patient. To the best of our knowledge, this is the first report presenting a case of HPT coexisting with OP successfully treated without OP resection.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence.

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.