Purpose Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research. Methods Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used. Inclusion criteria: studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS). Results Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test. Conclusions The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively. Level of evidence IV.

Purpose Our aim is to retrospectively review and evaluate the patterns of affection of Charcot arthropathy of foot and ankle. Methods Two hundred twenty-eight patients (235 feet) with post-acute Charcot were reviewed and classified anatomically through plain radiographs into type I and type II based on single or multiple regions affected, respectively. Type I included ankle, Lisfranc (tarsometatarsal), naviculocuneiform, forefoot, and hindfoot which includes one of the following: talonavicular joint, calcaneocuboid joint, or calcaneus. Type II included peritalar, perinavicular, mid-tarsal Charcot, or any other combination. Both types were further classified into four stages (A, stable with no deformity; B, stable with deformity; C, unstable; and D, deformity/instability with associated mechanical ulcers). ResultsThe most common type was type IIC (27.2%) followed by type IID (18.3%), while types IA and IIA represented the least common types (3.4% and 3.8%, respectively). Types IA and IIA were managed conservatively. All patients in types IC, ID, IIB, IIC, and IID and the majority of type IB received fusion surgery to achieve stability and correction of deformity. Type II D had the highest complication rate (30%). Five patients ended up with amputation, and all were stage IID. Conclusion Affection of single region has better prognosis than affection of two or more regions. Stage A has the best prognosis and can be managed conservatively provided good diabetes control. Surgery is indicated in all cases of types IC, ID, IIB, IIC, and IID to achieve stability and correction of deformity and prevent complications. Mechanical ulcer (stage D) carries the worst prognosis and highest complication rate.

Background Although the precise pathoetiology of Morton’s neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. Materials and methods Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton’s neuroma and who then underwent isolated IML decompression without neuroma resection. Results A total of 12 patients underwent isolated IML decompression for Morton’s neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. Conclusion Isolated IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. Level of Evidence: Level IV: Case series

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Background: End-stage ankle arthritis is frequently treated with either tibiotalar or tibiotalocalcaneal (TTC) arthrodesis, but the inherent loss of accommodative motion increases mechanical load across the distal tibia. Rarely, patients can go on to develop a stress fracture of the distal tibia without any antecedent traumatic event. The purpose of this study was to determine the incidence of tibial stress fracture after ankle arthrodesis, highlight any related risk factors, and identify the effectiveness of treatment strategies and their healing potential. Methods: A retrospective chart review was performed at 2 large academic medical centers to identify patients who had undergone ankle arthrodesis and subsequently developed a stress fracture of the tibia. Any patient with a tibial stress fracture before ankle arthrodesis, or with a nontibial stress fracture, was excluded from the study. Results: A total of 15 out of 1046 ankle fusion patients (1.4%) developed a tibial stress fracture at a mean time of 42 ± 82 months (range, 3-300 months) following the index procedure. The index procedure for these 15 patients who went on to subsequently develop stress fractures included isolated ankle arthrodesis (n = 8), ankle arthrodesis after successful subtalar fusion (n = 2), primary TTC arthrodesis (n = 2), and ankle arthrodesis subsequent to successful subtalar fusion with resultant ankle nonunion requiring revision TTC nailing (n = 3). Four patients had undergone fibular osteotomy with subsequent onlay strut fusion, and 5 had undergone complete resection of the lateral malleolus. Stress fracture location was found to be at the level of the fibular osteotomy in 2 patients and at the proximal end of an existing or removed implant in 9. Fourteen of the 15 patients had a nondisplaced stress fracture and were initially treated with immobilization and activity modification. Of these, 3 failed to improve with nonoperative treatment and subsequently underwent operative fixation (intramedullary nail in 2; plate fixation in 1). Only 1 of the 15 patients presented with a displaced fracture and underwent immediate plate fixation. All patients reported pain improvement and were ultimately healed at final follow-up. Conclusion: In this case series review, we found a 1.4% incidence of tibial stress fracture after ankle arthrodesis, and both hardware transition points and a fibular resection or osteotomy appear to be risk factors. Operative intervention was required in approximately 25% of this population, but the majority of tibial stress fractures following ankle fusion were successfully treated nonoperatively, and ultimately all healed. Level of Evidence: Level IV, retrospective case series.

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Category: Diabetes; Ankle; Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Diabetic Charcot arthropathy of foot and ankle is a devastating, progressive destruction of bone and joint integrity affecting one or more joints. Although several classification systems exist for Charcot arthropathy of foot and ankle depending on developmental stages or anatomic regions affected, the majority of these classifications are mainly descriptive, and none of these classifications specified the management or the outcome with relation to the classification stage. Recently, a new prognostic classification (Mansoura Classification) was published, however the reliability of such classification is still unknown. The aim of this study was to evaluate both interobserver and intra-observer reliability of Mansoura classification for foot and ankle Charcot arthropathy. Methods: Mansoura classification for foot and ankle Charcot arthropathy was presented to participants at an international foot and ankle course, then participants were given colored printed copy of the classification table (table 1) and diagrams. Thereafter, twenty cases of foot and ankle Charcot were presented to participants and they were asked to rate each case according to the classification. The level of experience of all the participants was collected and classified as less than 5 years, 5-10 years, 10-15 years, 15-20 years and more than 20 years. Furthermore, six raters who were specialized in foot and ankle surgery were asked to repeat the classification of the cases after three weeks from the initial evaluation. Kappa statistics was used to evaluate both interobserver and intra-observer reliability using STATA 14.2 program, and results were interpreted as 0.00-0.20 Slight, 0.21-0.40 Fair, 0.41-0.60 Moderate, 0.61-0.80 Substantial; and 0.81-1.00 Excellent. Results: Sixty-one participants with different level of experience completed the evaluation of the twenty cases of foot and ankle Charcot. The interobserver reliability for all participants was moderate (Kappa=0.5). Further analysis according to the level of experience based on the years of practice of orthopedic surgery showed similar moderate reliability (Kappa range 0.4 to 0.57). Intra-observer reliability was excellent for all six participants, Kappa range 0.81 to 0.93. Further analysis of the interobserver reliability of the former six raters who were specialized in foot and ankle surgery showed substantial reliability; Kappa=0.67. Conclusion: Mansoura classification for Charcot arthropathy of foot and ankle has an excellent intra-observer reliability. Although the overall interobserver reliability among orthopedic surgeons was moderate and comparable to other classifications, the interobserver reliability for orthopedic surgeons who were specialized in foot and ankle surgery was substantial. Therefore, Mansoura classification for foot and ankle Charcot has an acceptable reliability and could be promising in the evaluation and guiding the management of such cases.