Francesc Malagelada

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Tendoscopic Procedure Associated With Peroneal Tendons

Tendoscopy of the peroneal tendons is a useful tool to diagnose and treat peroneal tendon disorders. It provides a minimally invasive alternative to the already existing open surgical approaches. Tendoscopic approaches are safe when anatomic landmarks are identified and the portals are performed properly. Advantages of endoscopic procedures over open surgical procedures include reduced morbidity and postoperative pain, earlier mobilization, and better cosmetic results. Results of tendoscopic procedures are encouraging when compared with those following open surgery of the peroneal tendons. This article presents safe, reliable, and reproducible peroneal tendoscopy techniques.

Management of chronic Achilles tendon ruptures—A review

Achilles tendon ruptures are increasingly common yet up to a fifth of them are undiagnosed after medical consultation. Those undiagnosed will become chronic ruptures causing considerable functional morbidity and represent a challenge to the treating doctor. The purpose of this article is to discuss the presentation and management of chronic Achilles tendon ruptures. Due to the paucity of data, evidence-based recommendations are unavailable. A number of different surgical techniques are presented and a working algorithm is described to aid in the treatment of these lesions.

Anatomical variations of flexor hallucis longus tendon increase safety in hindfoot endoscopy

PurposeThe flexor hallucis longus (FHL) tendon is the main anatomical landmark during hindfoot endoscopy, and anatomical variations related to the FHL can pose a risk to the tibial nerve and posterior tibial vessels during hindfoot endoscopy. The aim of this study was to determine the distance between the FHL tendon and the tibial neurovascular bundle in the posterior ankle joint when an anatomical variant of the FHL is present. The hypothesis was that the shortest distance between the tibial neurovascular bundle and the FHL tendon in the working area of the hindfoot endoscopy is increased when an anatomical variant of the FHL is present.MethodsA retrospective review was performed using consecutive ankle magnetic resonance imaging (MRI) scans obtained during 1xa0year. All scans with anatomical variations related to the FHL were included in the study. A control group including scans without anatomical variations was obtained for comparison. The shortest distance between the FHL tendon and the neurovascular tibial bundle was measured in both groups.ResultsThree-hundred and fifty-five ankle MRIs were reviewed. 35 scans with anatomical variants of the FHL (9.8%) were found and comprised the study group that was compared to 35 scans without variants (control group). The mean distance from FHL to the neurovascular tibial bundle in the control group was 0.9xa0mm. The study group consisted of 18 cases with distal muscle belly insertion (5.1%), and 17 cases with an accessory tendon corresponding to a flexor digitorum accessorius longus (4.5%). In these subgroups, the mean distance from FHL to the neurovascular tibial bundle was 1.1 and 1.5xa0mm respectively. Overall this distance was found to be higher in the group with anatomical variants (1.3xa0mm) when compared to the control group (0.9xa0mm) (pu2009<u20090.05).ConclusionDuring hindfoot endoscopy, the presence of an anatomical variant related to the FHL tendon has proven safer anatomically than in its absence, due to the increased distance between the FHL tendon and the tibial neurovascular bundle in the working area. However, the minimal difference observed in safety distances still poses a major risk of injury during hindfoot endoscopic procedures in all cases.

Ankle Arthroscopy: An Update

A number of evidence-based arthroscopic techniques have been advocated to treat ankle pathology, including ankle instability, impingement, osteochondral lesions, and end-stage osteoarthritis.For anterior ankle arthroscopy, one technique that has gained favor involves insertion of the arthroscope wit

The impact of the Ponseti treatment method on parents and caregivers of children with clubfoot: a comparison of two urban populations in Europe and Africa

PurposeWith the Ponseti treatment method established as the gold standard, children with clubfeet face a prolonged treatment regime that might impact on their families. We aimed to determine how Ponseti treatment influences the lives of parents and caregivers and what coping strategies they use. Secondarily, we aimed to identify any potential differences between two urban referral centres for clubfoot.MethodsA total of 115 parents of children affected with idiopathic clubfoot were recruited and included in two groups: one from the United Kingdom (UK) and the other from South Africa (SA). The participants completed the following three instruments: the Impact on Family Scale (IOFS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Brief COPE.ResultsDuring the bracing phase, the IOFS showed a trend towards lower scores when compared to the casting phase for both cohorts (pxa0=xa00.247 and pxa0=xa00.434, respectively). The SA population scored higher than the UK in the MSPSS in both casting (pxa0=xa00.002) and bracing phases (pxa0=xa00.004) and used coping strategies at a significantly higher level when compared to the UK population (pxa0<xa00.05) in both treatment phases.ConclusionThis is the first study to show that Ponseti treatment for clubfoot causes an impact on family function. In SA, perceived social support is higher and coping strategies are used more often than in the UK to deal with the stressful circumstances of treatment.

X-shaped inferior extensor retinaculum and its doubtful use in the Bröstrom-Gould procedure

PurposeThe inferior extensor retinaculum (IER) is an aponeurotic structure located in the anterior aspect of the ankle. According to the literature, it can be used to reinforce a repair of the anterior talofibular ligament in ankle instability. Despite its usual description as an Y-shaped structure, it is still unclear which part of the retinaculum is used for this purpose, or if it is instead the crural fascia that is being used. The purpose of this study is to define the anatomical characteristics of the IER to better understand its role in the Broström–Gould procedure.MethodsTwenty-one ankles were dissected. The morphology of the IER and its relationship with neighbouring structures were recorded.ResultsSeventeen (81%) of the IER in this study had an X-shaped morphology, with the presence of an additional oblique superolateral band. This band, by far the thinnest of the retinaculum, is supposed to be used to reinforce the repair of the anterior talofibular ligament. The intermediate dorsal cutaneous nerve (lateral branch of the superficial peroneal nerve) was found to cross the retinaculum in all cases.ConclusionsThe IER is most commonly seen as an X-shaped structure, but the fact that the oblique superolateral band is a thin band of tissue probably indicates that it may not add significant strength to ankle stability. Furthermore, the close relationship of the retinaculum with the superficial peroneal nerve is another factor to consider before deciding to perform a Broström–Gould procedure. These anatomical findings advise against the use of the Gould augmentation.

Combined arthroscopic all-inside repair of lateral and medial ankle ligaments is an effective treatment for rotational ankle instability

Purpose When the anterior fascicle of the deltoid ligament is injured in patients with chronic ankle instability, the diagnosis of rotational ankle instability is supported. The aim of this study was to report the results of an all-arthroscopic technique to concomitantly repair the lateral collateral and deltoid ligaments to treat patients with rotational ankle instability. Methods Thirteen patients [12 men and 1 woman, median age 32 (15–54) years] with rotational ankle instability were treated by arthroscopic means after failing non-operative management. Median follow-up was 35 (18–42) months. Using a suture passer and knotless anchors, the ligaments were repaired with an arthroscopic all-inside technique. Results During diagnostic arthroscopy, 12 patients showed an isolated anterior talofibular ligament (ATFL) injury, and in one patient, both the ATFL and calcaneofibular ligament were affected. Arthroscopic examination of the deltoid ligament demonstrated a tear affecting the anterior area of the ligament in all cases. The tear was described as an open book tear, because the ligament was separated from the medial malleolus when applying passive internal rotation of the tibio-talar joint. This gap was closed when the tibio-talar joint was in neutral rotation or externally rotated. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair. The median AOFAS score increased from 70 (44–77) preoperatively to 100 (77–100) at final follow-up. Conclusion Rotational ankle instability can be successfully treated by an arthroscopic all-inside repair of the lateral and medial ligaments of the ankle. Level of evidence Level IV, retrospective case series.

Increasing the safety of minimally invasive hallux surgery—An anatomical study introducing the clock method

BACKGROUNDnThe purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures.nnnMETHODSnTen fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section RESULTS: The DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5-45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5-40).nnnCONCLUSIONSnUsing the clock method the DMDN and DLDN were found consistently between 10 oclock and 2 oclock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.

Anatomical considerations for minimally invasive osteotomy of the fifth metatarsal for bunionette correction — A pilot study

INTRODUCTIONnOperative correction of symptomatic bunionette by means of minimally invasive (MI) osteotomies of the 5th metatarsal (M5) has gained popularity. This study aims to investigate the safe zones of commonly used techniques and the risk of injury to neurological structures.nnnMATERIALS AND METHODSnTen human fresh frozen cadaveric feet were dissected and branches of the sural nerve were identified. A frontal section of the feet was performed at the site of the skin incision described for M5 MI osteotomies (corresponding to distal and mid diaphyseal osteotomies). The location of the lateral dorsal cutaneous nerve (LDCN) of the sural nerve or its branches was documented using a goniometer and oclock references placed on the frontal section of the M5.nnnRESULTSnThe LDCN showed variations in the distribution of its branches, forming the dorsolateral branch - a single terminal branch for the 5th toe - in 6/10 cases or two terminal branches - the dorsolateral and dorsomedial - in 4/10. At the point of osteotomies, the dorsolateral branch was identified at a mean of 22.7° from the extensor tendon around the M5 circumference and in all cases between 12 and 2 oclock in a right foot or 10 oclock to 12 oclock in a left.nnnCONCLUSIONnThe studied M5 osteotomies can place the dorsolateral branch of the fifth toe at risk and safe zones lie between 10 oclock to 2 oclock in any foot laterality. If these landmarks are considered, the risk of nerve damage is minimized when performing MI osteotomies of the M5.