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Haroon Majeed, James Barrie, Wendy Munro, and Donald McBride

  • The aim of this article is to systematically identify and analyse research evidence available to compare the outcomes of minimally invasive reduction and percutaneous fixation (MIRPF) versus open reduction and internal fixation (ORIF) for displaced intra-articular calcaneal fractures.

  • Articles from 2000 to 2016 were searched through MEDLINE (PubMed), Cochrane Library, Embase, ScienceDirect, Scopus and ISI Web of Knowledge using Boolean logic and text words. Of the 570 articles identified initially, nine were selected including three randomized controlled trials and six retrospective comparative studies.

  • All nine studies had a total of 1031 patients with 1102 displaced intra-articular calcaneal fractures. Mean follow-up was 33 months. Of these, 602 (54.6%) were treated with MIRPF and 500 (45.4%) were treated with ORIF.

  • Overall incidence of wound-related complications in patients treated with MIRPF was 4.3% (0% to 13%) compared with 21.2% (11.7% to 35%) in the ORIF group

  • Functional outcomes were reported to be better in the minimally invasive group in all studies; however, the results did not reach statistical significance in some studies. All the studies had methodological flaws that put them at either ‘unclear’ or ‘high’ risk of bias for multiple domains.

  • Overall quality of the available evidence is poor in support of either surgical technique due to small sample size, flaws in study designs and high risk of bias for various elements. Individual studies have reported minimally invasive techniques to be an effective alternative with lower risk of wound complications and better functional outcomes.

Cite this article: EFORT Open Rev 2018;3:418-425. DOI: 10.1302/2058-5241.3.170043

Farhan Syed and Anthony Ugwuoke

  • Total ankle arthroplasty offers a reasonable alternative to ankle arthrodesis in carefully selected patients.

  • It is debatable whether rheumatoid arthritis patients have better outcomes compared with those who have ankle arthroplasty for either primary osteoarthritis or post-traumatic arthritis.

  • Aseptic loosening and infection are the most common complications requiring revision.

  • It is worth noting that some of the best survival rates are seen in the surgeon-designer case series.

  • The uncemented mobile or fixed bearing prostheses have better outcomes compared with their older counterparts.

  • There is no convincing evidence to suggest superiority of one design over another among the currently available prostheses.

  • Ankle arthroplasty surgery has a steep learning curve; the prosthesis choice should be driven by the surgeon’s training and experience.

Cite this article: EFORT Open Rev 2018;3:391-397. DOI: 10.1302/2058-5241.3.170029

Önder İ. Kılıçoğlu, Mehmet Demirel, and Şamil Aktaş

  • Although there are various types of therapeutic footwear currently used to treat diabetic foot ulcers (DFUs), recent literature has enforced the concept that total-contact casts are the benchmark.

  • Besides conventional clinical tests and imaging modalities, advanced MRI techniques and high-sensitivity nuclear medicine modalities present several advantages for the investigation of diabetic foot problems.

  • The currently accepted principles of DFU care are rigorous debridement followed by modern wound dressings to provide a moist wound environment. Recently, hyperbaric oxygen and negative pressure wound therapy have aroused increasing attention as an adjunctive treatment for patients with DFUs.

  • For DFU, various surgical treatments are currently available, including resection arthroplasty, metatarsal osteotomies and metatarsal head resections.

  • In the modern management of the Charcot foot, surgery in the acute phase remains controversial and under investigation. While conventional fixation techniques are frequently insufficient to keep alignment postoperatively, superconstruct techniques could provide a successful fixation.

  • Retrograde intramedullary nailing has been a generally accepted method of achieving stability. The midfoot fusion bolt is a current treatment device that maintains the longitudinal columns of the foot. Also, Achilles tendon lengthening remains a popular method in the management of Charcot foot.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170073

François Lintz, Cesar de Cesar Netto, Alexeij Barg, Arne Burssens, Martinus Richter, and Weight Bearing CT International Study Group

  • The 3D anatomical complexity of the foot and ankle and the importance of weight-bearing in diagnosis have required the combination of conventional radiographs and medical CT.

  • Conventional plain radiographs (XR) have demonstrated substantial limitations such as perspective, rotational and fan distortion, as well as poor reproducibility of radiographic installations. Conventional CT produces high levels of radiation exposure and does not offer weight-bearing capabilities.

  • The literature investigating biometrics based on 2D XR has inherent limitations due to the technology itself and thereby can focus only on whether measurements are reproducible, when the real question is whether the radiographs are.

  • Low dose weight-bearing cone beam CT (WBCT) combines 3D and weight-bearing as well as ‘built in’ reliability validated through industry-standardized processes during production and clinical use (quality assurance testing).

  • Research is accumulating to validate measurements based on traditional 2D techniques, and new 3D biometrics are being described and tested.

  • Time- and cost-efficient use in medical imaging will require the use of automatic measurements. Merging WBCT and clinical data will offer new perspectives in terms of research with the help of modern data analysis techniques.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170066

Haroon Majeed and Donald J. McBride

  • Fractures of the lateral and the posterior processes of the talus are uncommon and frequently missed because of a low level of suspicion and difficulty in interpretation on plain radiographs. Missed fractures can lead to persistent pain and reduced function.

  • Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.

  • The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon.

  • The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion.

  • There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size.

  • Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.

Cite this article: EFORT Open Rev 2018;3:85-92. DOI: 10.1302/2058-5241.3.170040

Alessio Bernasconi, François Lintz, and Francesco Sadile

  • Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults.

  • It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome.

  • Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.

  • Sinus tarsi pain is the most frequent complication, often requiring removal of the implant.

  • To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear.

Cite this article: EFORT Open Rev 2017;2:438–446. DOI: 10.1302/2058-5241.2.170009

Jorge de-las-Heras Romero, Ana María Lledó Alvarez, Fernando Moreno Sanchez, Alejandro Perez Garcia, Pedro Antonio Garcia Porcel, Raul Valverde Sarabia, and Marina Hernandez Torralba

  • Injuries to the tibioperoneal syndesmosis are more frequent than previously thought and their treatment is essential for the stability of the ankle mortise.

  • Recognition of these lesions is essential to avoid long-term morbidity.

  • Diagnosis often requires complete history, physical examination, weight-bearing radiographs and MRI.

  • Treatment-oriented classification is mandatory.

  • It is recommended that acute stable injuries are treated conservatively and unstable injuries surgically by syndesmotic screw fixation, suture-button dynamic fixation or direct repair of the anterior inferior tibiofibular ligament.

  • Subacute injuries may require ligamentoplasty and chronic lesions are best treated by syndesmotic fusion.

  • However, knowledge about syndesmotic injuries is still limited as recommendations for surgical treatment are only based on level IV and V evidence.

Cite this article: EFORT Open Rev 2017;2:403–409. DOI: 10.1302/2058-5241.2.160084

Young Yi and Woochun Lee

  • Various types of re-alignment surgery are used to preserve the ankle joint in cases of intermediate ankle arthritis with partial joint space narrowing.

  • The short-term and mid-term results after re-alignment surgery are promising, with substantial post-operative pain relief and functional improvement that is reflected by high rates of patient satisfaction.

  • In this context, re-alignment surgery can preserve the joint and reduce the pathological load that acts on the affected area.

  • Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques.

Cite this article: EFORT Open Rev 2017;2:324-331. DOI: 10.1302/2058-5241.2.160021

Nicola Krähenbühl, Tamara Horn-Lang, Beat Hintermann, and Markus Knupp

  • Subtalar joint anatomy is complex and can vary significantly between individuals.

  • Movement is affected by several adjacent joints, ligaments and periarticular tendons.

  • The subtalar joint has gained interest from foot and ankle surgeons in recent years, but its importance in hindfoot disorders is still under debate.

  • The purpose of this article is to give a general overview of the anatomy, biomechanics and radiographic assessment of the subtalar joint.

  • The influence of the subtalar joint on the evolution of ankle joint osteoarthritis is additionally discussed.

Cite this article: EFORT Open Rev 2017;2:309-316. DOI: 10.1302/2058-5241.2.160050

Kinner Davda, Karan Malhotra, Paul O’Donnell, Dishan Singh, and Nicholas Cullen

  • Pathological abnormality of the peroneal tendons is an under-appreciated source of lateral hindfoot pain and dysfunction that can be difficult to distinguish from lateral ankle ligament injuries.

  • Enclosed within the lateral compartment of the leg, the peroneal tendons are the primary evertors of the foot and function as lateral ankle stabilisers.

  • Pathology of the tendons falls into three broad categories: tendinitis and tenosynovitis, tendon subluxation and dislocation, and tendon splits and tears. These can be associated with ankle instability, hindfoot deformity and anomalous anatomy such as a low lying peroneus brevis or peroneus quartus.

  • A thorough clinical examination should include an assessment of foot type (cavus or planovalgus), palpation of the peronei in the retromalleolar groove on resisted ankle dorsiflexion and eversion as well as testing of lateral ankle ligaments.

  • Imaging including radiographs, ultrasound and MRI will help determine the diagnosis. Treatment recommendations for these disorders are primarily based on case series and expert opinion.

  • The aim of this review is to summarise the current understanding of the anatomy and diagnostic evaluation of the peroneal tendons, and to present both conservative and operative management options of peroneal tendon lesions.

Cite this article: EFORT Open Rev 2017;2:281-292. DOI: 10.1302/2058-5241.2.160047