Biomechanical Effects of Hindfoot Alignment in Supination External Rotation Malleolar Fractures: A Human Cadaveric Model.

BACKGROUND: Pressure distribution in the ankle joint is known to be dependent on various factors, including hindfoot alignment. We seek to evaluate how hindfoot alignment affects contact pressures in the ankle joint in the setting of supination external rotation (SER) type ankle fractures. METHODS: SER fractures were created in 10 human cadaver lower extremity specimens, simulating progressive stages of injury: without fracture (step 0), SER fracture and intact deltoid ligament (step 1), superficial deltoid ligament disruption (step 2), and deep deltoid ligament disruption (step 3). At each step, varus and valgus alignment was simulated by displacing the calcaneal tuberosity 7 mm medial or lateral. Each limb was axially loaded following each osteotomy at a static load of 350 N. The center of force (COF), contact area (CA), and peak contact pressure (PP) under load were measured, and radiographs of the ankle mortise were taken to analyze the medial clear space (MCS) and talar tilt (TT). RESULTS: The COF (5.3 mm, P = .030) and the CA (-188.4 mm2, P = .015) changed in step 3 in the valgus hindfoot alignment compared to baseline parameters, indicating the importance of deep deltoid ligament integrity in maintaining normal ankle joint contact stress in the valgus hindfoot. These changes were not seen in the setting of varus alignment (COF: 2.3 mm, P = .059; CA -121 mm2, P = .133). PP were found to not change significantly in either varus or valgus (varus: -4.9 N, P = .132; valgus: -4 N, P = .464).The MCS demonstrated widening in step 3 compared to step 2 (0.7 mm, P = .020) in both varus and valgus hindfoot. The TT increased significantly in step 3 in the valgus hindfoot (2.8 degrees, P = .020) compared to step 0. CONCLUSION: SER-IV fractures with valgus hindfoot alignment showed significant changes in pressure distribution and radiographic parameters when compared to SER-IV fractures with varus hindfoot alignment. CLINICAL RELEVANCE: Based on this cadaver modeling study, patients with SERIV fracture with varus hindfoot alignment and complete deltoid ligament lesion may not need fracture fixation, whereas those with valgus hindfoot alignment likely need fracture fixation.

iNClusive: a database collecting useful information on non-canonical amino acids and their incorporation into proteins for easier genetic code expansion implementation.

The incorporation of non-canonical amino acids (ncAAs) into proteins is a powerful technique used in various research fields. Genetic code expansion (GCE) is the most common way to achieve this: a specific codon is selected to be decoded by a dedicated tRNA orthogonal to the endogenous ones. In the past 30 years, great progress has been made to obtain novel tRNA synthetases (aaRSs) accepting a variety of ncAAs with distinct physicochemical properties, to develop robust in vitro assays or approaches for codon reassignment. This sparked the use of the technique, leading to the accumulation of publications, from which gathering all relevant information can appear daunting. Here we present iNClusive (https://non-canonical-aas.biologie.uni-freiburg.de/), a manually curated, extensive repository using standardized nomenclature that provides organized information on ncAAs successfully incorporated into target proteins as verified by mass spectrometry. Since we focused on tRNA synthetase-based tRNA loading, we provide the sequence of the tRNA and aaRS used for the incorporation. Derived from more than 687 peer-reviewed publications, it currently contains 2432 entries about 466 ncAAs, 569 protein targets, 500 aaRSs and 144 tRNAs. We foresee iNClusive will encourage more researchers to experiment with ncAA incorporation thus contributing to the further development of this exciting technique.

ReverseDock: a web server for blind docking of a single ligand to multiple protein targets using AutoDock Vina.

Several platforms exist to perform molecular docking to computationally predict binders to a specific protein target from a library of ligands. The reverse, that is, docking a single ligand to various protein targets, can currently be done by very few web servers, which limits the search to a small set of pre-selected human proteins. However, the possibility to in silico predict which targets a compound identified in a high-throughput drug screen bind would help optimize and reduce the costs of the experimental workflow needed to reveal the molecular mechanism of action of a ligand. Here, we present ReverseDock, a blind docking web server based on AutoDock Vina specifically designed to allow users with no computational expertise to dock a ligand to 100 protein structures of their choice. ReverseDock increases the number and type of proteins a ligand can be docked to, making the task of in silico docking of a ligand to entire families of proteins straightforward. We envision ReverseDock will support researchers by providing the possibility to apply inverse docking computations using web browser. ReverseDock is available at: https://reversedock.biologie.uni-freiburg.de/.

Quo vadis, foot & ankle research? A review.

Over the last two decades, there has been a growing emphasis on the publication quality in Foot & Ankle research. A level-of-evidence rating system for clinical scientific papers has been proposed by the Centre for Evidence-based medicine in Oxford, United Kingdom. As opposed to other subspecialities, foot & ankle surgery deals with a wide variety of clinical problems and surgical solutions, which in turn leads to a generally low number of patients available for study groups. However, level III and IV studies still have a valuable place in orthopaedic research, given the challenges in running high-level studies.The measurement of outcomes in medicine from the patients' perspective (PROMS:(patient reported outcome measures) has grown almost exponentially in all surgical specialties including foot & ankle surgery. There are many PROMs available to foot & ankle surgeons, but there is little consensus on which assessment is most appropriate for a given procedure or diagnosis. Their use in research and clinical practice offers many advantages in clinical practice and research, however, besides the advantages there are also some downsides.

Risk Factors for Failure After Surgery in Patients With Diabetic Foot Syndrome.

Background: In the present study, we aimed to identify risk factors for failure (defined as reoperation within 60 days) after debridement or amputation at the lower extremity in patients with diabetic foot syndrome and to develop a model using the significant risk factors to predict the success rate at different levels of amputation. Methods: Between September 2012 and November 2016, we performed a prospective observational cohort study of 174 surgeries in 105 patients with diabetic foot syndrome. In all patients, debridement or the level of amputation, need for reoperation, time to reoperation, and potential risk factors were assessed. A cox regression analysis, dependent on the level of amputation, with the endpoint reoperation within 60 days defined as failure and a predictive model for the significant risk factors were conducted. Results: We identified the following 5 independent risk factors: More than 1 ulcer (hazard ratio [HR] 3.8), peripheral artery disease (PAD, HR 3.1), C-reactive protein >100 mg/L (HR 2.9), diabetic peripheral neuropathy (HR 2.9), and nonpalpable foot pulses (HR 2.7) are the 5 independent risk factors for failure, which were identified. Patients with no or 1 risk factor have a high success rate independent of the level of amputation. A patient with up to 2 risk factors undergoing debridement will achieve a success rate of <60%. However, a patient with 3 risk factors undergoing debridement will need further surgery in >80%. In patients with 4 risk factors a transmetatarsal amputation and in patients with 5 risk factors a lower leg amputation is needed for a success rate >50%. Conclusion: Reoperation for diabetic foot syndrome occurs in 1 of 4 patients. Risk factors include presence of more than 1 ulcer, PAD, CRP > 100, peripheral neuropathy, and nonpalpable foot pulses. The more risk factors are present, the lower the success rate at a certain level of amputation. Level of Evidence: Level II, prospective observational cohort study.

The tumor core boost study: A feasibility study of radical dose escalation to the central part of large tumors with an integrated boost in the palliative treatment setting.

PURPOSE: For patients with large tumors palliative radiotherapy often is the only local treatment option. To prevent toxicity the administered doses are low. Dose escalation to the tumor could be an option to better smyptom control and prolong local control rates. In this prospective study we used a very pragmatic approach with a simultaneously integrated boost (SIB) to an almost geometrically defined tumor core to achieve this. The primary endpoint was to demonstrate feasibility. METHOD: Patients with solid tumors > 4 cm in diameter of different histologies were eligible in this single arm, prospective, multi-institutional clinical feasibility trial with two treatment concepts: 5â€¯× 5 Gy with an integrated boost to the tumor core of 5â€¯× 10 Gy or 10â€¯× 3 Gy with a boost of 10â€¯× 6 Gy. The objective of dose escalation in this study was to deliver a minimum dose of 150% of the prescribed dose to the gross tumor volume (GTV) tumor core and to reach a maximum of at least 200% in the tumor core. RESULTS: In all, 21 patients at three study sites were recruited between January 2019 and November 2020 and were almost evenly spread (9 to 12) between the two concepts. The treated planning target volumes (PTV) averaged 389.42 cm3 (range 49.4-1179.6 cm3). The corresponding core volumes were 72.85 cm3 on average (range 4.21-338.3 cm3). Dose escalation to the tumor core with mean doses of 167.7-207.7% related to the nonboost prescribed isodose led to PTV mean doses of 120.5-163.3%. Treatment delivery and short-term follow-up was successful in all patients. CONCLUSIONS: Palliative radiotherapy with SIB to the tumor core seems to be a feasible and well-tolerated treatment concept for large tumors. The applied high doses of up to 50 Gy in 5 fractions (or 60 Gy in 10 fractions) did not cause unexpected side effects in the 42 day follow-up period. Further research is needed for more information on efficacy and long-term toxicity.

[Malleolar Fractures - Indication for Nonoperative and Operative Treatment]. / Malleolarfrakturen.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

Evidence for operative treatment of talar osteochondral lesions: a systematic review.

Purpose: Operative treatment of talar osteochondral lesions is challenging with various treatment options. The aims were (i) to compare patient populations between the different treatment options in terms of demographic data and lesion size and (ii) to correlate the outcome with demographic parameters and preoperative scores. Methods: A systemic review was conducted according to the PRISMA guidelines. The electronic databases Pubmed (MEDLINE) and Embase were screened for reports with the following inclusion criteria: minimum 2-year follow-up after operative treatment of a talar osteochondral lesion in at least ten adult patients and published between 2000 and 2020. Results: Forty-five papers were included. Small lesions were treated using BMS, while large lesions with ACI. There was no difference in age between the treatment groups. There was a correlation between preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and change in AOFAS score (R = -0.849, P < 0.001) as well as AOFAS score at follow-up (R = 0.421, P = 0.008). Preoperative size of the cartilage lesion correlates with preoperative AOFAS scores (R= -0.634, P = 0.001) and with change in AOFAS score (R = 0.656, P < 0.001) but not with AOFAS score at follow-up. Due to the heterogeneity of the studies, a comparison of the outcome between the different operative techniques was not possible. Conclusion: Patient groups with bigger lesions and inferior preoperative scores did improve the most after surgery. Level of evidence: IV.

Osteochondral lesion of the talus: still a problem?

Osteochondral lesion of the talus (OLT) often occurs after ankle trauma or repetitive micro-traumata, whereas the actual etiology remains unclear. The most common symptoms are local pain deep in the medial or lateral ankle that increases with weight-bearing and activity, accompanied by tenderness and swelling. Eventually, most patients with symptomatic or unstable OLT require surgery. Many reasonable operative techniques have been described, whereas most lead to similar and satisfactory results. They can be divided into cartilage repair, cartilage regeneration and cartilage replacement techniques. The OLT size and morphology in the first place but also surgeon and individual patient aspects are considered when it comes to surgery. For high postoperative success and low recurrence rates, underlying causes, for example, ligamentous instability and hindfoot malalignment should also be addressed during surgery.

Evaluation of Radiographic Features Including Metatarsus Primus Elevatus in Hallux Rigidus.

The etiology of hallux rigidus remains a controversial issue in foot and ankle surgery, i.e., the relationship between metatarsus primus elevatus (MPE) and hallux rigidus. The purpose of this study was to evaluate several radiographic parameters including first metatarsal elevation in patients with hallux rigidus compared to a matched control group. A retrospective case control study was performed including 50 feet, 25 feet with and 25 feet without hallux rigidus. In the patients with hallux rigidus, the first metatarsal was more elevated than in the control group (8.3 ± 1.7 mm vs 3.0 ± 2.0 mm, p < .001) and in 60% of patients with hallux rigidus MPE was diagnosed, compared to zero patients in the control group (p < .001). The lateral 1 to 2 intermetatarsal angle was higher in patients with hallux rigidus (3.6 ± 2.5 vs -0.7 ± 2.8; p < .001). The first metatarsal declination angle was not different between the 2 groups. Intraclass correlation coefficient between 2 observers for measuring the first metatarsal elevation was 0.929 (p < .001). In the current study, increased elevation of the first metatarsal, a higher incidence of MPE and increased lateral 1 to 2 intermetatarsal angle were found in patients with hallux rigidus compared to the control group. These findings support the theory of an association between MPE and hallux rigidus. Further high reliability of first metatarsal elevation measurement was found in our study.

Tibial anterior compartment compressibility in healthy subject, measured using compression sonography.

INTRODUCTION: Compression sonography has been introduced for non-invasive measurement of compartment compressibility and possible diagnostic tool for acute or chronic compartment syndrome in studies using human cadavers and animal models. To date, standard values in healthy subjects are not yet defined. The aim was to define standard compartment compressibility values in healthy human subjects and to assess the reliability of this measurement method. METHODS: In 60 healthy volunteers, using ultrasound, the diameter of the tibial anterior compartment was measured while applying no pressure, 10mbar and 80mbar of external pressure. A pressure manometer on the ultrasound head was used to monitor the externally applied pressure. Compartment compressibility ratio (R0-80, respectively R10-80) was calculated as following: The delta of the compartment diameter with high and low external pressure, divided through the diameter with low external pressure. In 10 volunteers, two examinators conducted each two measurements to assess the reliability. RESULTS: Mean compartment compressibility ratio R10-80 was 15.9% ±3.6 (range: 7.2 - 22.2). Mean compartment compressibility ratio R0-80 was 18.2% ±5.0 (3.0 - 32.1). There was no significant correlation with lower leg circumference, height, weight, BMI, gender, hours of sport per week and type of sport (e.g. weightlifting/ cardio). For R10-80, intraobserver ICC 2.1 was 0.89 for an experienced observer and 0.79 for a non-experienced observer. Interobserver ICC 2.1 was 0.78. For R0-80, intraobserver ICC 2.1 was 0.71 for the experienced and 0.56 for the unexperienced observer. Interobserver ICC 2.1 was 0.59. DISCUSSION: In healthy volunteers between 18 and 50 years of age, mean compartment compressibility ratio R10-80 was 15.9% ±3.6, independent of demographic factors and sport activity. Application of 10mbar instead of 0mbar increased image quality. Subsequently, R10-80 showed lower standard deviation and both higher intraobserver and interobserver reliability than R0-80. Using R10-80, this measurement method is reliable with very high intra- and interobserver correlation.

Ankle Joint Pressure in Supination-External Rotation Injuries: A Biomechanical Study in an Unrestrained Cadaver Model.

BACKGROUND: Previous biomechanical studies simulating supination-external rotation (SER) IV injuries revealed different alterations in contact area and peak pressure. We investigated joint reaction forces and radiographic parameters in an unrestrained, more physiological setup. METHODS: Twelve lower leg specimens were destabilized stepwise by osteotomy of the fibula (SER II) and transection of the superficial (SER IVa) and the deep deltoid ligament (SER IVb) according to the Lauge-Hansen classification. Sensors in the ankle joint recorded tibio-talar pressure changes with axial loading at 700 N in neutral position, 10° of dorsiflexion, and 20° of plantarflexion. Radiographs were taken for each step. RESULTS: Three of 12 specimen collapsed during SER IVb. In the neutral position, the peak pressure and contact area changed insignificantly from 2.6 ± 0.5 mPa (baseline) to 3.0 ± 1.4 mPa (SER IVb) (P = .35) and from 810 ± 42 mm2 to 735 ± 27 mm2 (P = .08), respectively. The corresponding medial clear space (MCS) increased significantly from 2.5 ± 0.4 mm (baseline) to 3.9 ± 1.1 mm (SER IVb) (P = .028).The position of the ankle joint had a decisive effect on contact area (P = .00), center of force (P = .00) and MCS (P = .01). CONCLUSION: Simulated SER IVb injuries demonstrated radiological, but no biomechanical changes. This should be considered for surgical decision making based on MCS width on weightbearing radiographs. LEVELS OF EVIDENCE: Not applicable. Biomechanical study.

finDr: A web server for in silico D-peptide ligand identification.

In the rapidly expanding field of peptide therapeutics, the short in vivo half-life of peptides represents a considerable limitation for drug action. D-peptides, consisting entirely of the dextrorotatory enantiomers of naturally occurring levorotatory amino acids (AAs), do not suffer from these shortcomings as they are intrinsically resistant to proteolytic degradation, resulting in a favourable pharmacokinetic profile. To experimentally identify D-peptide binders to interesting therapeutic targets, so-called mirror-image phage display is typically performed, whereby the target is synthesized in D-form and L-peptide binders are screened as in conventional phage display. This technique is extremely powerful, but it requires the synthesis of the target in D-form, which is challenging for large proteins. Here we present finDr, a novel web server for the computational identification and optimization of D-peptide ligands to any protein structure (https://findr.biologie.uni-freiburg.de/). finDr performs molecular docking to virtually screen a library of helical 12-mer peptides extracted from the RCSB Protein Data Bank (PDB) for their ability to bind to the target. In a separate, heuristic approach to search the chemical space of 12-mer peptides, finDr executes a customizable evolutionary algorithm (EA) for the de novo identification or optimization of D-peptide ligands. As a proof of principle, we demonstrate the validity of our approach to predict optimal binders to the pharmacologically relevant target phenol soluble modulin alpha 3 (PSMα3), a toxin of methicillin-resistant Staphylococcus aureus (MRSA). We validate the predictions using in vitro binding assays, supporting the success of this approach. Compared to conventional methods, finDr provides a low cost and easy-to-use alternative for the identification of D-peptide ligands against protein targets of choice without size limitation. We believe finDr will facilitate D-peptide discovery with implications in biotechnology and biomedicine.

Recurrence Rate After Wide Resection of Plantar Fibromatosis: A Case Series and Systematic Literature Review.

BACKGROUND: The aim was to assess the recurrence rate and clinical outcome after wide resection for plantar fibromatosis. METHODS: A total of 12 patients, 2 to 13 years after wide resection, were assessed for local and magnetic resonance imaging tomographic signs of recurrence at the clinical follow-up. In addition, a systematic review of the literature was conducted. RESULTS: After 7.8 years (2-13), 2 patients (17%) suffered a recurrence. At the last follow-up, median Foot Functional Index was 1 (0-66) and American Orthopaedic Foot and Ankle Society score was 95 (44-100). Six studies with 109 feet (92 patients) were included in the systematic review. The recurrence rate depends on the width of the resection: 67% after local resection, 42% after wide resection, and 27% after fasciectomy. CONCLUSION: In patients with symptomatic plantar fibromatosis, we recommend a wide resection or fasciectomy over a local resection because of the inferior recurrence rate. LEVELS OF EVIDENCE: Level IV: Retrospective case series.

The Effect of the Mobile Subtalar Joint on Calcaneal and Supramalleolar Osteotomies.

BACKGROUND: The mobile subtalar joint (STJ) may compensate for supra- and inframalleolar deformities and counteract the effect of realigning calcaneal or distal tibial osteotomies. The purpose of this study was to evaluate the compensatory effect of the mobile STJ after supramalleolar osteotomy (SMOT) and calcaneus osteotomy (COT) and whether the extent of the compensation correlates with STJ shape and orientation. METHODS: In 10 human lower leg cadavers without evidence of deformity or prior trauma 700 Newton load were applied as a simulated standing pose. The center of force (COF) migration, maximum pressure (Pmax), and the area loaded were measured with high-resolution sensors in the ankle before and after 10-mm varus/valgus sliding COT and 10-degree varus / valgus SMOT. A computed tomographic evaluation of subtalar anatomy was conducted to correlate posterior facet curvature, its varus/valgus orientation in the coronal plane, and the effect on COF, Pmax, and area loaded. RESULTS: The COF migration was significant for both varus and valgus SMOTs (varus SMOT: 1.78 mm, P = .0029; valgus SMOT: 1.85 mm, P = .0018) but not for COT (varus COT: 0.45 mm, P = .85; valgus COT: 1.15 mm, P = .11). Pmax and area loaded changed but not significantly. The radius of the posterior STJ surface showed a moderate correlation (varus SMOT: r = 0.61, P = .063; valgus SMOT: r = 0.28, P = .43, varus COT: r = -0.61, P = .063; valgus COT: r = 0.13, P = .38) and the axis a weak inverse correlation (varus SMOT: r = -0.51, P = .013; valgus SMOT: r = 0.58, P = .079; varus COT: r = -0.51, P = .14; valgus COT: r = 0.38, P = .28) with the COF migration after the osteotomies. CONCLUSION: The compensatory capacity of a mobile STJ is relatively small but appears to limit the effect of COT more than SMOT. The COT is less effective in influencing ankle joint pressure for realignment purposes than SMOT in mobile STJ and clinically more consistent in stiff STJ. Correlations are moderate to weak, whereas the curvature more than orientation of posterior facet inversely correlates with osteotomy's effects. LEVEL OF EVIDENCE: Level IV, biomechanical cadaver study.

Management of gait impairments in people with Charcot-Marie-Tooth disease: A treatment algorithm.

Gait impairments in people with Charcot Marie Tooths disease are the combined result of ankle-foot deformities, muscle weakness, and somatosensory impairments. People with Charcot-Marie-Tooth disease often experience pain and difficulties when walking, especially barefoot. They also trip and fall frequently and have a lower than normal gait speed and distance. Because these gait impairments and related complaints are disabling, clinical management aimed at improving gait is important. Management involves both conservative and surgical treatment options, each with limited scientific evidence. However, a treatment algorithm that describes both conservative and surgical treatment options is currently lacking. This study sets out a step-wise treatment algorithm, based on evidence, if available, and otherwise reflecting practice-based experience. The treatment algorithm will be of value in daily clinical practice, and will serve as a template for future research.

Ligamentous Lisfranc injuries: analysis of CT findings under weightbearing.

PURPOSE: The aim of this study was to investigate the influence of different ligamentous Lisfranc injuries on computed tomography (CT) findings under weight-bearing and to emphasize the indications for surgical treatment of their various types. METHODS: Sixteen human cadaveric lower limbs were placed in weight-bearing radiolucent frame for CT scanning. All intact specimens were initially scanned, and then, dorsal approach was used for sequential ligaments cutting of: (1) the dorsal and the interosseous (Lisfranc) ligaments between medical cuneiform (MC) and metatarsal 2 (MT2); (2) the plantar ligament between the MC and MT3; (3) the plantar ligament between MC and MT2. Based on sequential CT scans, the distances MT1-MT2, MC-T2, as well as the alignment and dorsal displacement of MT2 were measured. RESULTS: Slight increase in the distances MT1-MT2 and MC-MT2 was observed after the disruption of the dorsal and the interosseous ligaments. Further increase in MT1-MT2 and MC-MT2 distances was registered after the disruption of the ligament between MC and MT3. The largest distances MT1-MT2 and MC-MT2 were measured after the final plantar ligament cut between MC and MT2. CONCLUSIONS: Unequivocal instability is observed with simultaneous transection of the Lisfranc ligament with both plantar ligaments. On CT used as diagnostic tool, plantar injuries at the basis of the second and the third metatarsal are indirect signs of violation of the ligaments and represent an indication for surgical treatment. When using magnetic resonance imaging as diagnostic tool, a ruptured Lisfranc ligament alone without dislocation does not necessarily need surgical intervention.

Weightbearing Radiography and MRI Findings in Ankle Fractures.

Background. Static weightbearing radiography can be used to assess stability in ankle fractures by measuring lateral talar shift (medial clear space; MCS). However, the correlation of a stable ankle joint under weightbearing load and the structural integrity of the deltoid ligament has not been shown. In this study, we assessed deltoid ligament integrity on magnetic resonance imaging (MRI) and correlated that with weightbearing and gravity stress test radiography. Methods. Thirty-four patients with supination external rotation II-IV (SER) fractures underwent MRI, weightbearing radiography, and gravity stress test. On MRI, the deep anterior and posterior tibiotalar deltoid, tibionavicular and tibiocalcaneal ligaments, as well as the syndesmosis were assessed as intact, partial rupture, or complete rupture. The MCS was measured as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise view. Results. Twenty-three patients suffered a deep anterior tibiotalar ligament rupture (16 partial; 7 complete) and 2 a deep posterior tibiotalar ligament tear (1 partial; 1 complete). For MCS on weightbearing radiography, no statistically significant differences were identified between any of the individual groups. With gravity stress radiography, only a complete tear of the tibiocalcaneal ligament showed a significantly higher MCS than a partial tear or intact tibiocalcaneal ligament (P < .005). No other ligament disruption showed a significant difference between the complete rupture versus intact or partial tear. Conclusion. Weightbearing radiography does not show much variation in terms of MCS even with ligamentous disruption and fibula fracture. The talus often centers itself underneath the tibia with weightbearing radiography.Levels of Evidence: Level III: Retrospective cohort study.