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Mario Herrera-Pérez, Victor Valderrabano, Alexandre L Godoy-Santos, César de César Netto, David González-Martín, and Sergio Tejero

  • Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients.

  • Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active.

  • The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA.

  • Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms.

  • After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures.

  • In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease.

  • Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.

Helen Anwander, Philipp Vetter, Christophe Kurze, Chui J Farn, and Fabian G Krause


  • 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.


  • 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.


  • 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.


  • Patient groups with bigger lesions and inferior preoperative scores did improve the most after surgery.

Level of evidence

  • IV.

Fabian Krause and Helen Anwander

  • 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.

Ulrike Wittig, Gloria Hohenberger, Martin Ornig, Reinhard Schuh, Andreas Leithner, and Patrick Holweg

  • 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).

George D Chloros, Christos D Kakos, Ioannis K Tastsidis, Vasileios P Giannoudis, Michalis Panteli, and Peter V Giannoudis

  • 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.

Gherardo Pagliazzi, Enrico De Pieri, Michèle Kläusler, Morgan Sangeux, and Elke Viehweger

  • 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.

Lorenz Pisecky, Matthias Luger, Antonio Klasan, Tobias Gotterbarm, Matthias C. Klotz, and Rainer Hochgatterer

  • 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

E. Carlos Rodríguez-Merchán and Inmaculada Moracia-Ochagavía

  • 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

Halah Kutaish, Antoine Acker, Lisca Drittenbass, Richard Stern, and Mathieu Assal

  • 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

Nuno Corte-Real and João Caetano

  • 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