• The aim of this study was to determine whether all-arthroscopic repair would lead to improved clinical outcomes, lower complication rates, shorter postoperative immobilization and earlier return to activity compared to open Broström repair in the surgical treatment of chronic lateral ankle instability (CLAI).

• A systematic literature search was conducted using Pubmed and Embase to identify studies dealing with a comparison of outcomes between all-arthroscopic and open Broström repair for CLAI. The search algorithm was ‘ankle instability’ AND ‘Brostrom’ AND ‘arthroscopic’ AND ‘open’. The study had to be written in English language, include a direct comparison of all-arthroscopic and open Broström repair to treat CLAI and have full text available. Exclusion criteria were former systematic reviews, biomechanical studies and case reports.

• Overall, eight studies met the inclusion criteria and were included in the analysis. Clinical outcomes did not differ substantially between patients treated with either arthroscopic or open Broström repair. Studies that reported on return to activity and sports following surgery suggested that patients that had all-arthroscopic Broström repair returned at a quicker rate. Overall complication rate tended to be lower after arthroscopic Broström repair.

• Similar to open repair, all-arthroscopic ligament repair for CLAI is a safe treatment option that yields excellent clinical outcomes.

• Level of Evidence: Level III evidence (systematic review of level I, II and III studies).

• Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term ‘Jones’ fracture has been used inconsistently in the literature.

• In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes.

• Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient’s needs and the ‘personality’ of the fracture.

• If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the ‘gold standard’ of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems.

• Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain.

• Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.

• Overuse injuries imply the occurrence of a repetitive or an increased load on a specific anatomical segment which is unable to recover from this redundant microtrauma, thus leading to an inflammatory process of tendons, physis, bursa, or bone.

• Even if the aetiology is controversial, the most accepted is the traumatic one.

• Limb malalignment has been cited as one of the major risk factors implicated in the development of overuse injuries.

• Many authors investigated correlations between anatomical deviations and overuse injuries, but results appear mainly inconclusive.

• Establishing a causal relationship between mechanical stimuli and symptoms will remain a challenge, but 3D motion analysis, musculoskeletal, and finite element modelling may help in clarifying which are the major risk factors for overuse injuries.

• Bioabsorbable and biodegradable implants offer new possibilities in orthopaedic and trauma surgery. As soon as the initial stability of the degradable implants has reached the qualities of conventional materials, new devices may find usage in younger and more demanding patients. Residual conventional osteosynthetic material or the necessity to remove metal increasingly seems to be more of an adverse event than daily practice in forefoot surgery. Nevertheless, some drawbacks need to be discussed.

• Recent literature screened for the use of bioabsorbable and biodegradable materials in forefoot surgery, available implants and indications in forefoot surgery were analysed and summarized. Apart from common indications in forefoot surgery, points of interest were the type of biomaterial, the process of biodegradation and biointegration, and possible adverse events. Materials were comprehensively discussed for each indication based on the available literature.

• Polylactide, polyglycoside and polydioxanone are considered safe and sufficiently stable for use in forefoot surgery. Low complication rates (e.g. 0.7% for pin fixation in hallux deformities) are given.

• Magnesium implants suffered from an extensive corrosive process in the first generation but now seem to be safe in forefoot surgery and offer good options compared with conventional titanium screws, especially in procedures of the first ray.

• Allograft bone has proven feasibility in small case series, but still lacks larger or randomized clinical trials. The first results are promising.

• Bioresorbable and osseointegrating devices offer attractive new possibilities for surgeons and patients. Despite all the known advantages, the difficulties and possible complications must not be forgotten, such as soft tissue reactions, unwanted osteolysis and a lower primary mechanical load capacity.

Cite this article: EFORT Open Rev 2021;6:1132-1139. DOI: 10.1302/2058-5241.6.200157

• Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches.

• It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic.

• There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG).

• A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma.

• Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema).

• Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment.

• Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%.

• Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible.

• A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression.

• Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology.

Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031

• Computer-assisted orthopaedic surgery (CAOS) is a real-time navigation guidance system that supports surgeons intraoperatively.

• Its use is reported to increase precision and facilitate less-invasive surgery.

• Advanced intraoperative imaging helps confirm that the initial aim of surgery has been achieved and allows for immediate adjustment when required.

• The complex anatomy of the foot and ankle, and the associated wide range of challenging procedures should benefit from the use of CAOS; however, reports on the topic are scarce.

• This article explores the fields of applications of real-time navigation and CAOS in foot and ankle surgery.

Cite this article: EFORT Open Rev 2021;6:531-538. DOI: 10.1302/2058-5241.6.200024

• Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.

• In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.

• Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.

• Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.

• Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.

• Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging.

Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017

• There is some confusion in the terminology used when referring to MIS (Minimal invasive surgery) or percutaneous surgery. The correct term to describe these procedures should be percutaneous (made through the skin) and MIS should be reserved for procedures whose extent is between percutaneous and open surgery (e.g. osteosynthesis). Minimal incision surgery may be distinguished in first, second and third generation minimal incision surgery techniques.

• First generation MIS hallux valgus surgery is mainly connected with the Isham procedure; an intraarticular oblique and incomplete osteotomy of the head of the first metatarsal without fixation.

• The Bösch osteotomy and the SERI are classified as second generation MIS hallux surgery. They are both transverse subcapital osteotomies fixed with a percutaneous medial K-wire inserted into the medullary canal. For all these procedures, intraoperative fluoroscopic control is necessary.

• Open hallux valgus surgery can be divided into proximal, diaphyseal and distal osteotomies of the first metatarsal. Reviewing the available literature suggests minimally invasive and percutaneous hallux valgus correction leads to similar clinical and radiological results to those for open chevron or SCARF osteotomies. First generation minimally invasive techniques are primarily recommended for minor deformities. In second generation minimally invasive hallux valgus surgery, up to 61% malunion of the metatarsal head is reported. Once surgeons are past the learning curve, third generation minimally invasive chevron osteotomies can present similar clinical and radiological outcomes to open surgeries. Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques.

Cite this article: EFORT Open Rev 2021;6:432-438. DOI: 10.1302/2058-5241.6.210029

• Low intensity pulsed ultrasound (LIPUS) therapy has demonstrated clinical effectiveness in achieving union in a variety of fracture situations.

• Few studies have investigated the effectiveness of LIPUS therapy in foot and ankle surgery.

• The overall rate of union in all published studies relating to the use of LIPUS in a variety of foot and ankle fracture and fusion situations is 95%.

• Some studies suggest lower healing rates (~ 67%) when LIPUS therapy is used to treat hindfoot fusion nonunion.

• A well-powered, high-quality, randomized controlled trial is needed to demonstrate the clinical and cost effectiveness of LIPUS therapy in foot and ankle surgery.

Cite this article: EFORT Open Rev 2021;6:217-224. DOI: 10.1302/2058-5241.6.200045

• Aseptic necrosis may be defined as a group of diseases that have bone necrosis as a common denominator. They usually appear in the epiphyses and in the carpal and tarsal bones. They generally appear during a growth period and principally at those skeletal points subjected to particular stress.

• In Müller–Weiss disease in the advanced stages, talonavicular-cuneiform arthrodesis, with or without back foot correction, is the best surgical option.

• In Freiberg–Kohler disease, treatment can be conservative and we can maintain the head of the metatarsal by performing a joint debridement of the metatarsophalangeal joint with removal of loose bodies. The lateral upper and lower faces of the distal extremity of the metatarsal are resected, preserving the joint cartilage that in its centre portion is always healthy. The osteophyte border that may be present in the phalanx is resected.

• Most frequently, avascular necrosis (AVN) of the talus is a sequel to talar fractures, with the possibility that the AVN increases with the severity of the trauma and the damage associated with the already precarious blood supply of the talus.

• The surgical treatment used for sesamoid AVN is partial excision of the affected bone.

Cite this article: EFORT Open Rev 2020;5:684-690. DOI: 10.1302/2058-5241.5.200007