BACKGROUND: Anterior tarsal tunnel (ATT) syndrome is caused by the compression of the deep fibular nerve (DFN) within the ATT beneath the inferior extensor retinaculum, bounded by the tendons of the extensor hallucis longus (EHL) and extensor digitorum longus (EDL). Compression may result from direct trauma, repetitive mechanical irritation, and thrombosis of the dorsalis pedis artery. Injury to the contents of ATT could occur during ankle arthroscopy. Therefore, this study was undertaken to provide a detailed description of the anatomy of the ATT and its clinical implications.
METHODS: Ten formalin-fixed cadavers were utilized for the study. The ATT was identified between the tendons of the EHL and EDL. The length at the medial and lateral boundaries and the width at the proximal end, middle, and distal end of the ATT were measured using a digital Vernier calliper.
RESULTS: The mean length of the medial border of the tunnel was 31.42±8.44 mm, while the lateral border was 20.39±4.39 mm. The width of the ATT increased from the proximal to the distal end. DFN was related to the DPA laterally in 15 limbs and medially in five limbs within the tunnel.
CONCLUSIONS: The present study not only describes the intricate anatomy of the ATT but also describes the patterns of DFN and DPA within the tunnel. Understanding the anatomy of ATT is crucial, as it paves the way for safe and efficient surgical interventions, thereby significantly reducing the risk of neurovascular damage during surgical procedures.

OBJECTIVE: Extra-articular open fractures of the leg often result from high energy trauma. After healing, a painful ankle impingement may occur. In the event of anterior and posterior impingements, arthroscopic treatment may require two surgical positions. We propose an operative strategy to treat anterior and posterior ankle impingement after extra-articular open fracture of the leg. Our hypothesis is that this strategy is simple, effective and with a low risk of complication.
METHODS: Anterior ankle impingements were treated by anterior arthroscopy in supine position; anterior and posterior impingements were treated by anterior and posterior arthroscopy in supine position; anterior and posterior impingements associated with retraction of gastrocnemius muscles were treated with anterior arthroscopy in supine position followed by posterior arthroscopy in prone position, and an open tendon lengthening of the calcaneal tendon in the same position. The anterior and posterior arthroscopic release was tested in the cadaver laboratory. Then, the surgical strategy was applied to our patients in our clinical practice. After, we analysed retrospectively the results of the strategy in the first patients treated for a painful ankle impingement after extra-articular open fracture of the leg. The data retrieved were the importance of pain (VAS), the presence of clinical instability, ankle mobility, gastrocnemius retraction and the AOFAS functional score and the post-operative complications. Then, these data were compared before the surgery and at last follow-up.
RESULTS: From the cadaver laboratory, anterior and posterior arthroscopic release was possible in all cases without changing position. From our clinical practice, we included 5 patients (3 women and 2 men, mean age 43 years) suffering from an ankle impingement after extra-articular open fracture of the leg (2 patients with isolated anterior impingement, 1 patient with anterior and posterior impingement, and 2 patients with anterior and posterior impingement plus a gastrocnemius retraction). All post-operative parameters (pain, range of motion and AOFAS score) at mean follow-up of 53 months were improved. No post-operative complication was reported.
CONCLUSIONS: We propose a surgical strategy adapted to the different clinical presentations of ankle impingement after extra-articular open fracture of the leg.

OBJECTIVE: The purpose of this study was to study the effects of the severity of preoperative bone marrow oedema (BME) on the postoperative short-term outcomes following bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) and to propose a new metric that combines volume and signal density to evaluate BME.
METHODS: Sixty-five patients with symptomatic OLTs (<100 mm2) and preoperative BME, who received BMS in our institution from April 2017 to July 2021 with follow-ups of 3, 6 and 12 months, were analysed retrospectively. The area, volume and signal value of the BME were collected on preoperative magnetic resonance imaging. The enroled patients were divided into two groups according to the BME index (BMEI), which was defined as the product of oedema relative signal intensity and the relation of oedema volume to total talar volume. Visual analogue scale, American Orthopedic Foot and Ankle Society (AOFAS), Tegner, Foot and Ankle Ability Measure (FAAM)-activities of daily living (ADL) and Sports scores were assessed before surgery and at each follow-up. The relationship between the scores and the volume, relative signal intensity and BMEI was explored.
RESULTS: Sixty-five patients with preoperative BME were divided into the mild (n = 33) and severe (n = 32) groups based on the BMEI. A significant difference was found for each score with the general linear model for repeated measures through all follow-up time points (p < 0.001). For the preoperative and 12-month postoperative changes of the enroled patients, 53 patients (81.5%) exceeded the minimal clinically important difference of AOFAS and 26 (40.0%) exceeded that of FAAM-sports in this study. The mild group showed significantly more improvement in AOFAS scores at 12 months (89.6 ± 7.0 vs. 86.2 ± 6.2) and FAAM-ADL scores at 6 months (83.6 ± 7.6 vs. 79.7 ± 7.7) and 12 months (88.5 ± 8.5 vs. 84.4 ± 7.7) than the severe group (p < 0.05). No significant difference of all the scores between the groups was found at 3 months. No significant correlation was found in each group between BMEI and clinical outcomes.
CONCLUSIONS: The severity of the preoperative BME negatively affected short-term clinical outcomes following arthroscopic BMS for OLTs. Worse clinical outcomes were shown at postoperative 6 and 12 months in patients with a high preoperative BMEI, which could be a favourable parameter for assessing the severity of BME and assist in developing personalised rehabilitation plans and determining the approach and timing of surgery.
METHODS: Level III.

OBJECTIVE: End-stage ankle arthrosis causes severe pain and limited movement. Tibiotalocalcaneal arthrodesis with arthroscopy-assisted hindfoot nailing can be used to achieve a high union rate and low complication rate. We aimed to examine the early- and mid-term results of patients treated with this technique from various perspectives and to evaluate them by comparing them with the current literature.
METHODS: Data were collected from 25 patients who met the established criteria and underwent TTCA with arthroscopic-assisted hindfoot nailing. In addition to the demographic data of the patients, their clinical and pain scores were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Additionally, the union time and complication data during the follow-up period were examined.
RESULTS: When the AOFAS and VAS scores of the 25 patients were examined, a significant improvement was observed in the preoperative period and early postoperative period comparisons (p < .001). No significant change was observed between the comparison of the postoperative 12th month and last postoperative control clinical scores. While the union rate of the patients was observed to be 92%, the average union time was 13.1 ± 3.5 weeks. During follow-up, peri-implant fracture, deep infection, and non-union were observed in one patient each (12%).
CONCLUSIONS: The early- and mid-term postoperative results of patients treated with TTCA surgery with posterior approach arthroscopic-assisted hindfoot nailing show that this technique may be an option with low complication and high union rates for the appropriate group of patients planned for ankle arthrodesis.

OBJECTIVE: To compare the patient-reported outcomes and radiologic outcomes of the patients with medial and lateral cystic osteochondral lesions of the talus (OLTs) following bone marrow stimulation (BMS).
METHODS: Patients with cystic OLTs who underwent BMS between January 2016 and February 2021 were retrospectively analyzed, and the minimum follow-up time was more than 24 months. Patients were paired in a 1:1 ratio (medial cystic OLT [MC-OLT]/lateral cystic OLT [LC-OLT]) based on the OLT area within 30 mm2, follow-up within 1 year, age within 5 years, and ligament surgery (yes/no). The visual analog scale and Foot and Ankle Ability Measure (FAAM)-Activities of Daily Life and Sports scores were assessed preoperatively and postoperatively. The magnetic resonance observation of cartilage repair tissue scores and presence of cysts after BMS were also evaluated. Additionally, the receiver operating characteristic curve was performed.
RESULTS: The matched patients were divided into the MC-OLT (n = 31, 43.35 ± 12.32 months) and LC-OLT groups (n = 31, 43.32 ± 14.88 months, P = .986). Thirty patients of each group achieved a power of 80% and an α = 0.05 in this study. The MC-OLT group showed significantly less improvement in FAAM-Activities of Daily Life and sports scores (P = .034, P < .001, respectively), lower magnetic resonance observation of cartilage repair tissue scores (80.80 ± 11.91 vs 86.00 ± 8.50, P = .010), and higher presence rate of cysts after BMS (45.16% vs 16.12%, P = .013). Regarding FAAM sports scores, the LC-OLT group had significantly more patients exceeding the minimal clinically important difference (80.64% vs 51.61%, P = .031). Furthermore, an OLT depth of 7.23 mm (sensitivity: 78.6%; specificity: 70.6%) might serve as a cutoff value for predicting the presence of cysts in medial cystic OLTs following BMS.
CONCLUSIONS: Medial cystic OLTs exhibited markedly lower sports levels, higher cyst presence rate, and inferior radiologic outcomes following BMS than lateral counterparts. Additionally, an OLT depth of 7.23 mm could be the cutoff value for predicting the presence of cysts regarding medial cystic OLTs after BMS.
METHODS: Level III, retrospective comparative study.

UNASSIGNED: Bone marrow stimulation (BMS) is presently considered first-line surgical treatment for osteochondral lesions of the talus (OLTs); however, some patients still experience pain or dysfunction after surgery, and the reasons for success or failure remain somewhat unclear. This study aimed to investigate the effect of smoking on postoperative outcomes after arthroscopic BMS for OLTs.
UNASSIGNED: Consecutive patients with OLTs who underwent BMS between January 2017 and January 2020 were included. Smokers were defined as patients who actively consumed cigarettes before surgery and postoperatively, whereas nonsmokers were patients who never smoked. Visual analog scale (VAS), American Orthopaedic Foot & Ankle Society ankle hindfoot score (AOFAS), Karlsson-Peterson, and Tegner scores were assessed preoperatively and at follow-up. Additionally, a general linear model (GLM) was performed, followed by the interaction analysis to explore the potential influence of smoking.
UNASSIGNED: The study enrolled 104 patients with a mean follow-up of 30.91 ± 7.03 months, including 28 smokers and 76 nonsmokers. There were no significant differences in patient age (35.2 ± 10.0 years vs 37.6 ± 9.7 years, P = .282) or OLT area (63.7 ± 38.7 mm2 vs 52.8 ± 37.0 mm2, P = .782). Both univariate analysis and GLM revealed that smoking was associated with worse postoperative pain levels, Karlsson-Peterson, and AOFAS scores (P < .05). The interaction analysis showed a significant interaction between smoking and OLT area for postoperative Karlsson-Peterson scores (general ankle function) (P = .031). Simple main effects analysis revealed that the negative effect of smoking on Tegner score significantly increased among patients >32 years old or with OLT area>50 mm2 (P < .05).
UNASSIGNED: Smoking was associated with worse clinical outcomes following BMS of OLTs. As the size of OLTs increased, the difference in general ankle function between smokers and nonsmokers also increased. Furthermore, smokers who were older than 32 years or had larger OLTs were less likely to resume participation in high-level activities.

OBJECTIVE: Rotational ankle instability can be diagnosed in up to 18% of cases of chronic lateral ankle instability. It is characterised by an abnormal increase of talar rotation within the tibiofibular mortise, due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligament. The aim of this prospective observational study was to investigate the clinical outcomes following arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability.
METHODS: A prospective observational study of consecutive patients undergoing arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with minimum 6-month follow-up. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire. Secondary outcomes included the EQ-5D, European Foot and Ankle Society score and complications.
RESULTS: Between 2020 and 2023, 12 patients underwent primary arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with pre- and post-operative PROMs available for all 12 patients. The mean ± standard deviation age was 33.9 ± 7.2 years and the mean follow-up was 1.9 ± 1.2 (range: 0.5-3.8, interquartile range: 0.9-3.0) years. There was a significant improvement in all Manchester-Oxford Foot Questionnaire domain scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ-5D-5L Index, VAS and VAS Pain; however, these were not statistically significant. There was one complication-a superficial peroneal nerve injury which resolved with a corticosteroid injection.
CONCLUSIONS: The arthroscopic all-inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9-year follow-up.
METHODS: Level IV.

UNASSIGNED: Arthroscopic-assisted treatment of ankle fractures has proven useful in the adult population, but little evidence exists for the utilization of arthroscopic-assisted ankle fracture fixation in the pediatric population. The purpose of this systematic review is to examine the management of pediatric ankle fractures using arthroscopy.
UNASSIGNED: A systematic review was performed using PubMed, Web of Science, CINAHL, and MEDLINE from database inception to February 22nd, 2023. Inclusion criteria for this systematic review was pediatric population less than age 18, arthroscopic surgery management, and ankle fracture.
UNASSIGNED: A total of 19 articles (n=30 patients) out of 176 articles met final inclusion criteria with all articles consisting of case reports or case series. The average patient age was 13.8±1.6 years. Sixteen of the patients (53%) had arthroscopic surgery along with an adjunct surgery as indicated, whereas 14 patients (47%) had arthroscopic surgery with or without percutaneous fixation. A high majority of patients demonstrated full range-of-motion and large improvements in function.
UNASSIGNED: Arthroscopy is used with percutaneous fixation or in adjunct to open approaches for pediatric ankle fracture management with good results. More research is needed to determine the utility of arthroscopy in the management of pediatric ankle fractures.

OBJECTIVE: Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy.
METHODS: Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture.
RESULTS: In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer.
CONCLUSIONS: The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy.
METHODS: Not applicable.

Osteochondral lesion of the talus (OLT) is a commune cause of chronic ankle pain. Symptomatic lesions require surgical treatment. Currently, lesions with diameter less than 107.4 mm2 are treated with bone marrow stimulating technique with notable success rate. However, more extensive lesions show less predictable surgical results. Autologous matrix-induced chondrogenesis has proven to provide satisfactory medium and long-term results on OLTs. In the current review, we describe an all-arthroscopic technique and the Milan-Tel Aviv lesion assessment protocol.