There is controversy in the literature on where to place the tourniquet (thigh, calf, ankle) for foot and ankle surgery. While some authors prefer the ankle tourniquet to the calf tourniquet, others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet, since there was no difference in postoperative pain between them. Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice. The reality is that, unfortunately, there is no consensus on this issue. Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions. It does not seem easy to carry out such a study, but it would be important to be able to answer the question posed in the title of this Editorial once and for all.

This study was performed to investigate the effects of fibular osteotomy and release of medial soft tissues including posterior tibial tendon (PTT), and deep deltoid ligaments, which act as medial stabilizing structures in medial open wedge SMO. Twelve fresh frozen human legs were obtained and disarticulated below the knee. Experiments were conducted in four steps. First, medial open wedge tibial osteotomy was performed. Second, fibular osteotomy was performed in an inferomedial direction at the same level as the tibial osteotomy. Third, the deep deltoid ligament was released from tibial attachments. Forth, total tenotomy of the PTT was performed behind the medial malleolus. After finishing each step, contact area and peak and mean pressures were measured in the tibiotalar and talofibular joints. Fibular osteotomy after medial open wedge SMO significantly decreased mean pressure in the tibiotalar joint, mean and peak pressures in the talofibular joint. Medial soft tissue release resulted in a remarkable lateral shift and decreased tibiotalar joint loading. However, no remarkable change was observed in the tibiotalar joint during releasing medial soft tissues. The overall peak pressure distribution tended to shift more laterally compared to the value of normal alignment. In conclusion, concomitant fibular osteotomy and release of the deltoid ligament and PTT provide a useful means of minimizing tibiotalar joint stress.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s13534-024-00370-7.

Ankle arthrodesis is an effective surgical intervention for end-stage arthritis or severe ankle joint deformity. Both internal (IF) and external fixation (EF) techniques are valid options, but there is controversy regarding the most effective technique. This study compares the safety and efficacy of EF and IF fixation techniques for ankle arthrodesis. A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. A literature search of electronic databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL), was performed to identify all studies directly comparing the two techniques. Both fixed and random effects models of analysis were used depending on heterogeneity. Odds of union in the EF and IF groups were comparable (OR=0.60, CI 0.36-1.02, p=0.06) however, EF was associated with greater odds of deep hardware infections (OR=3.67, 1.97-6.83, p <0.05) and amputations (OR=3.17, CI 1.06-9.54, p =0.04). Odds of revision surgery and superficial wound complications were similar between groups. EF techniques had significantly longer operation times (MD=31.23, CI-25.11-37.34, p <0.05) and intraoperative blood loss (MD=46.31, CI-24.93-67.69, p <0.05). No significant difference was noted in pain and functionality scores. IF and EF techniques have reasonable union rates with similar postoperative outcomes. However, IF patients are more likely to achieve primary union and less likely to have deep infections, being mindful that EF techniques were usually indicated for more complex cases. LEVEL OF EVIDENCE: IV.

BACKGROUND: This study aimed to investigate ankle syndesmosis in healthy subjects under non-weight bearing (NWB) and weight bearing (WB) conditions using two US methods.
METHODS: The anterior tibiofibular clear space (ATFCS) was measured in healthy subjects in NWB and WB conditions using two US procedures. Method 1 measured 10 mm above the ankle joint and Method 2 measured 30° from the line of 10 mm above the ankle joint.
RESULTS: A total of 60 ankles from 30 subjects (male/female, 15/15) were included. There was a significant difference in the ATFCS between the two US methods (p < 0.001), and Method 2 was better at detecting the change in diastasis from NWB to WB conditions. The ATFCS was significantly greater on WB than on NWB, irrespective of the US method.
CONCLUSIONS: Method 2 was better at detecting diastasis of the syndesmosis from NWB to WB conditions. The influence of WB needs to be considered when evaluating syndesmosis using US.
METHODS: Cross-sectional cohort study; Level of evidence, Ⅳ.

BACKGROUND: Although sloped surfaces are common in daily living, most studies of body balance are carried out on flat surfaces, and few data are available for sloping angles below 14°.
OBJECTIVE: The purpose of this study was to explore the effect of forward and backward sloping surfaces at 7° and 15° on postural equilibrium and the activity of flexor/extensor ankle muscles.
METHODS: Fifteen healthy subjects (8 males and 7 females) (27.67 ± 3.9 years) underwent a posturographic examination associated with a surface electromyogram (EMG) of tibialis anterior (TA), soleus (Sol) and gastrocnemius medialis (GasM) under five conditions of support inclination: 0° (H0), backward inclination at 7° and 15° (DF7 and DF15), forward inclination at 7° and 15° (PF7 and PF15).
RESULTS: Results showed that the center of pressure (CP) was shifted according to the surface slope, with a forward move in PF7 (p <0.001) and PF15 (p <0.001) and a backward move in DF7 (p <0.01) and in DF15 (p <0.001). The mean displacement of the CP along the anterior-posterior axis (Xm) was increased in DF15 (p <0.01) relative to the H0 condition but reduced in PF7 (p <0.01). The normalized EMG revealed higher values when the muscles were in a shortened position (PF7 for Sol, p <0.05; PF15 for GasM, p <0.01; DF15 for TA, p<0.01) and lower values of GasM and Sol when lengthened (DF15, p <0.05).
CONCLUSIONS: Our findings indicate that standing on a backward sloped surface impairs body balance, while low-angle forward sloped surfaces might improve postural stability. Muscular activity variations of the ankle flexors/extensors, which are stretched or shortened, also seem to be related to the length-tension relationship of skeletal muscles.

Conventional passive ankle foot orthoses (AFOs) have not seen substantial advances or functional improvements for decades, failing to meet the demands of many stakeholders, especially the pediatric population with neurological disorders. Our objective is to develop the first comfortable and unobtrusive powered AFO for children with cerebral palsy (CP), the DE-AFO. CP is the most diagnosed neuromotor disorder in the pediatric population. The standard of care for ankle control dysfunction associated with CP, however, is an unmechanized, bulky, and uncomfortable L-shaped conventional AFO. These passive orthoses constrain the ankle\'s motion and often cause muscle disuse atrophy, skin damage, and adverse neural adaptations. While powered orthoses could enhance natural ankle motion, their reliance on bulky, noisy, and rigid actuators like DC motors limits their acceptability. Our innovation, the DE-AFO, emerged from insights gathered during customer discovery interviews with 185 stakeholders within the AFO ecosystem as part of the NSF I-Corps program. The DE-AFO is a biomimetic robot that employs artificial muscles made from an electro-active polymer called dielectric elastomers (DEs) to assist ankle movements in the sagittal planes. It incorporates a gait phase detection controller to synchronize the artificial muscles with natural gait cycles, mimicking the function of natural ankle muscles. This device is the first of its kind to utilize lightweight, compact, soft, and silent artificial muscles that contract longitudinally, addressing traditional actuated AFOs\' limitations by enhancing the orthosis\'s natural feel, comfort, and acceptability. In this paper, we outline our design approach and describe the three main components of the DE-AFO: the artificial muscle technology, the finite state machine (the gait phase detection system), and its mechanical structure. To verify the feasibility of our design, we theoretically calculated if DE-AFO can provide the necessary ankle moment assistance for children with CP-aligning with moments observed in typically developing children. To this end, we calculated the ankle moment deficit in a child with CP when compared with the normative moment of seven typically developing children. Our results demonstrated that the DE-AFO can provide meaningful ankle moment assistance, providing up to 69% and 100% of the required assistive force during the pre-swing phase and swing period of gait, respectively.

Subtalar distraction arthrodesis (SDA) is a surgical procedure designed to treat hindfoot deformities associated with isolated subtalar joint arthritis. In 1996, Fitzgibbons was the first to observe that, in some cases, hindfoot fusion appeared to be associated with the development of tibiotalar valgus tilt. Since then, few studies have addressed this issue. Given that hindfoot fusion can be performed using various techniques, this study investigated the potential tibiotalar joint frontal or sagittal modifications resulting from the modified Grice-Green technique. All the consecutive patients who underwent the modified Grice-Green procedure were included. The patient records were reviewed to extract demographic data. Weight-bearing foot and ankle radiographs were assessed to measure the talar tilt angle and the tibiotalar ratio on the same picture archiving and communication system by three independent observers. A total of 69 patients met the criteria for inclusion. The mean talar tilt showed no substantial changes, since the increase from 1.46 ± 1.62 preoperatively to 1.93 ± 2.19 at a minimum of 8 months postoperatively was not statistically significant (p = 0.47). The average preoperative tibiotalar ratio significantly increased from 33.4 ± 4.4% to 35 ± 4% postoperatively (p = 0.007), although remaining within the normal range, indicating a possible realignment of the posterior facet of the subtalar joint. In conclusion, this study highlights the effectiveness of the modified Grice-Green procedure in achieving a favorable realignment without impacting the ankle joint, particularly regarding tibiotalar valgus tilt.

BACKGROUND: Isolated tibiotalar dislocation is an extremely rare injury. They are most often caused by high-energy trauma.
METHODS: The authors report the case of an acute pure posteromedial tibiotalar joint dislocation in a 45-year-old patient, which occurred as a result of a road traffic accident. The reduction was performed as an emergency procedure under general anesthesia, followed by a 6-week cast immobilization. Twenty months after the injury, at the last follow-up, a very good functional result was observed, with a stable and painless ankle and satisfactory mobility.
CONCLUSIONS: A pure dislocation of the tibiotalar joint without an associated fracture is a rare injury. The posterior type is the most common dislocation. Treatments include close reduction, short leg cast immobilization, and open dislocation. However, certain factors can lead to unfavorable outcomes, such as delayed therapy, damage to the inferior tibiotalar ligaments, anterior tibial artery rupture, and soft tissue damage.
CONCLUSIONS: It is rare for a tibiotalar joint dislocations to occur as an isolated injury. The necessity of immediate orthopedic intervention in the management of this lesion is demonstrated by our observation.

UNASSIGNED: Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively.
UNASSIGNED: Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained.
UNASSIGNED: 288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don\'t routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus.
UNASSIGNED: Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.

BACKGROUND: Interventions on ankle motor control are important to prevent recurrent ankle sprains. Training using whole-body vibration may easily and effectively improve ankle motor control, but the effects have not been investigated. Therefore, this study aimed to clarify the effects of 6 weeks of training with whole-body vibration on ankle motor control in a dynamic movement task among healthy participants.
METHODS: Twenty healthy university students (6 males and 14 females) were randomly allocated to whole-body vibration training and control groups, with 10 participants in each group. The training was performed twice a week for 6 weeks in both groups. Primary outcome was mean ankle angular jerk cost in the star excursion balance test. Secondary outcomes were maximum ankle motion angle and maximum reach distance in the star excursion balance test, ankle proprioception, and range of ankle dorsiflexion motion in the loaded position.
RESULTS: There was a significant group × period (pre- and postintervention) interaction for mean ankle angular jerk cost in the direction of ankle abduction/adduction during posterolateral reaching, which was significantly lower at postintervention than that at preintervention in the whole-body vibration group In the whole-body vibration group, the maximum ankle dorsiflexion motion angle during anterior and posterolateral reaching was significantly higher at postintervention than that at preintervention.
CONCLUSIONS: Training with whole-body vibration improves ankle motor control in dynamic movement tasks, although the direction of reach and plane of motion are limited. Additionally, training with whole-body vibration is also effective in increasing the ankle dorsiflexion angle during dynamic movement tasks.