“Double-bundle” tibialis anterior tendon transfer for prevention of pes equinus after Chopart amputation

Objective: Assess patient performance and quality of the stump after amputation at the Chopart (midtarsal) joint, with double-bundle transfer of the tibialis anterior muscle tendon to the talar neck. Methods: This study evaluated the medical records of 5 patients who underwent Chopart amputation with double-bundle transfer of the tibialis anterior tendon to the talar neck, assessing pre and postoperative performance and gait. Results: The patients were operated on between January 2008 and December 2018, and the data obtained from the survey allow us to conclude that, after the proposed procedure, all patients reported an improvement in walking, besides noting a significant reduction in the degree of stump equinus. Conclusion: The surgical technique described in this article produced a significant improvement in patient performance as assessed by the AOFAS hindfoot score, and prevented the formation of ulcers in the anterior region of the stump. Level of Evidence IV; Therapeutic Study; Case Series.

Study of the radiographic parameters of normal ankles

Objective: The authors carried out a bibliographic search for the radiographic parameters used to determine tibiotalar joint alignment, and suggest a set of parameters that constitute the minimum radiographic evaluation sufficient for the proper assessment of tibiotalar alignment. Methods: The search was conducted between May 2019 and January 2020 on the online platforms PudMed and Google Scholar with the following terms, used separately or jointly: “ankle arthritis, radiographic measurement, ankle alignment, alignment, anterior ankle instability, X-ray, and ankle injury”. Results: We selected twelve studies evaluating radiographic patterns of normal ankles, and identified a total of 15 radiographic measurements. Conclusion: The authors believe that a minimum radiographic assessment of tibiotalar alignment should include the following parameters on the anteroposterior radiograph: the distal tibial articular angle, the talar tilt and talus center migration. On the lateral radiograph, it should include: lateral distal tibial angle and lateral talar station. Level of Evidence V; Diagnostic Study; Expert Opinion.

Insertional Achilles tendinopathy

Objective: Retrospectively analyze surgical procedures performed on patients with insertional Achilles (calcaneal tendon) tendinopathy, focusing on outcomes and the impact on the patients’ functional quality. Methods: A descriptive, retrospective, case series study drawn up by collecting data directly from the patients’ medical records. For the functional analysis of patients, we used the questionnaire of the adapted American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS). An assessment was carried out on each of the patients who underwent surgery at our hospital from 2010 to 2019, using the surgical technique described in this article, i.e., resection of the affected portion of the tendon with its subsequent reinsertion. Results: All surgical patients achieved an improvement in their AOFAS score and in pain levels, with good functional performance only three months into the postoperative period, from 50.1 to 83.75 (p<0.001). Conclusion: The use of the technique proved very effective, particularly in terms of the maintenance of foot function and important improvement in pain levels, thus producing a relevant increase in function among patients. Level of Evidence IV; Therapeutic Study; Case Series.

Lateral ankle stabilization with a polyester fiber construct implant as a revision for failed primary lateral ligament reconstruction

Objective: The aim of this study is to demonstrate an original technique in which a stable construct is made by fibular and calcaneal bone tunnels producing a figure of 8 with a Polyester implant as revision for failed primary ligament reconstruction. Methods: This is a retrospective study of 19 patients with persistent lateral ankle instability diagnosis after a primary ligament repair treated between 2011 and 2019. The surgical technique is described in detail in which stabilization of the lateral ankle is performed. 11 men and 8 women with a mean age of 30.94 years (15-53). Follow up was 29.05 months (6-109). Pre and postoperative AOFAS ankle score were used as well as an AVS and a satisfaction questionnaire. Results: There was a significant improvement in AOFAS score, 76.31 to 91.47 (<0.001). All the patients except one, stated to have a stable ankle and be Very satisfied (16) or satisfied (2) with the procedure. No infection was presented in any patient. Conclusion: This technique is a reliable alternative in patients in which primary ankle ligaments have failed and no autograft or allograft are wanted to be used. Level of Evidence V; Therapeutic Study; Expert Opinion.

Supraintercondylar fracture of the proximal phalanx of the hallux

Toe phalanx fractures are prevalent worldwide. The proximal phalanx of the hallux requires different treatment from the other four lateral phalanges. Poor positioning of rotation and angulation is not acceptable for this bone, since it can result in significant functional deficit. Indications for surgical treatment are: joint fractures with deviations greater than 2 mm, metadiaphyseal fractures with rotational and/or angular deviation, open fractures and unstable fractures. The classic medial approach in surgical treatment involves some high-risk neurovascular structures and does not allow the correct positioning of osteosynthesis systems in some cases. The aim of this study is to present an option for the surgical treatment of deviated and unstable supraintercondylar fractures of the proximal phalanx of the hallux by the dorsolateral approach, with a traction screw through the plate and a lateral neutralization plate. Level of Evidence V; Therapeutic Study; Expert Opinion.

Patients’ perspective on the surgical treatment of hallux valgus

Objective: To evaluate patients’ perspectives on the risk factors for hallux valgus, and their quality of life before and after surgery. Methods: This is a cross-sectional, retrospective study, conducted in a tertiary hospital with 50 patients undergoing surgical treatment of hallux valgus. Data were tabulated using three methodological figures: central idea, key expressions and collective subject discourse. Results: Regarding the risk factors, most of the patients demonstrated knowledge, expressed through central ideas such as: heredity, and wearing inappropriate shoes. In relation to quality of life before surgery, impairment was noted, inferred by central ideas such as: pain and discomfort, restriction in the use of shoes, functional limitation and aesthetic impairment; and regarding postoperative quality of life, most patients expressed satisfaction with the results. Conclusion: Authentic discourses in the context of a prevalent pathology have expressed, for the first time, the conceptions of risk factors, quality of life before and after hallux valgus surgery. Level of Evidence V; Therapeutic Study; Expert Opinion.

Evaluation of calcaneal enthesophytes in insertional Achilles tendinopathy by radiography and magnetic resonance imaging: intra- and inter-observer reliability

Objective: Evaluate intra- and inter-observer variation in the presence of enthesophytes in patients with insertional Achilles tendinopathy on radiographic (X-ray) and magnetic resonance imaging (MRI) images. Methods: We selected X-ray and MRI images of 20 patients diagnosed with an injury. We sent a questionnaire to five foot and ankle surgeons and five radiologists. We obtained answers about diagnosis accuracy and the presence of insertional enthesophytes (bone spurs). Results: Intra-observer agreement with regards to diagnosis accuracy in the MRI analysis was a K of 0.77 (0.62 to 1.00), while in the X-ray analysis, the K was 0.95 (0.77 to 1.00). Intra-observer agreement on the presence of enthesophytes in the MRI analysis had a K coefficient of 0.90 (0.68 to 1.00) and intra-observer agreement in the X-ray of 0.93 (0.86 to 1.00). The evaluation of inter-observer agreement on the diagnosis accuracy had a K coefficient between 0.09 and 0.20. Inter-observer agreement regarding the presence of enthesophytes was a K value between 0.59 and 0.63 for the MRI and a K between 0.81 and 0.82 for the X-ray results. Conclusion: Intra-observer values for diagnosis accuracy of the MRI and X-ray tests indicated strong to almost perfect agreement, similar to the intra-observer values for evaluation of the presence of enthesophytes, but the X-ray had better agreement. In both tests, intra-observer agreement on the presence of osteophytes was weak in comparison to inter-observer agreement, yet in the inter observer evaluation of the presence of enthesophytes, the X-ray agreement was greater than the MRI values. Level of Evidence III; Diagnostic Study.

A new path for the Journal of the Foot & Ankle - JFA

Hard work is the key to success. It may sound like a cliché, but the preparation and the release of this first edition of the new Journal of the Foot & Ankle (JFA) were based on this very concept, and we took it very seriously! For years many of us have dedicated time and efforts to bring this Journal to life. After countless meetings, discussions, phone calls, WhatsApp messages, and an infinite amount of writing, our collaborative hard work and friendship finally brought us here! Now we need to stay focused and ahead of the game, looking forward to the future and the innovations. We should aim to publish high-quality, unbiased research, with emphasis on strong clinical evidence. Our vision is to support researchers and research that can enable the Orthopaedic Foot and Ankle Surgery Community to understand better the complexity of the pathologies, guide treatment, and, most importantly, improve the treatment results and quality of life of our patients. Our thoughts are that keeping all these goals in mind will allow us to achieve the expected acceptance and respect of the research community, as well as the desired indexation. It is not an easy task! But we are confident we can get there with your help! We’re great believers in working as a team towards a common goal, and we are sure that with the help of our dedicated Foot and Ankle colleagues and researchers, we will soon make our vision become a reality! Let’s do it together!

Minimally invasive technique with intramedullary nail for treatment of severe hallux valgus

Objective: The purpose of the study was to evaluate early clinical and radiological results with a novel minimally invasive surgery (MIS) technique for Lapidus arthrodesis using intramedullary nail. Methods: Retrospective review of patients with hallux valgus surgery during an 18-month period. Patients with a procedure other than MIS Lapidus nail fixation were excluded. We describe surgical technique with a percutaneous joint preparation and fixation with an intramedullary nail through a MIS approach. Demographic variables, early complications and radiographic parameters were measured. Results: Ten feet in 8 patients with severe HV underwent a Lapidus procedure performed with a minimal invasive technique using intramedullary nail for fixation. No soft tissue complications and 1 patient required screw removal after bone healing. Mean HVA decreased from 31,4 degrees (range 17 to 47) SD (±9,3) to 10,3 degrees (range, -8,8 to 31,5) SD (±8,4), mean IMA decreased from 17,91 degrees (range, -17 to 20) SD (±0,9) to 5,46 degrees (range, –7,3 to 15.3) SD (±2,9) and mean DMAA decreased from 20,36 (range, 10-40) SD (±8,4) to 7,67 (range, -5 to 30) SD (±8,0). Conclusion: Intramedullary nail for Lapidus arthrodesis with minimally invasive technique showed satisfactory radiographic correction and minimal complications, but further follow up is needed to analyze clinical-radiographic results. Level of Evidence IV; Therapeutic Study; Case Series.

Patients’ expectations with regard to the quality of orthopedic medical care

Objective: To assess, through the Surgical and Medical Experience Questionnaire translated and adapted into Portuguese, the opinions and expectations of patients with regard to the treatment protocols and medical training of the foot and ankle orthopedic specialist. Methods: This cross-sectional observational study assessed, through the application of a questionnaire, the opinions and expectations of patients with regard to orthopedic protocols adopted by the foot and ankle specialist. Results: One hundred and thirty patients were selected. Among the participants, 33.8% were male and 66.2% female. The predominant characteristics of a good physician were good outcomes, according to 31% of the participants, followed by quality of care according to 28.6%, and qualities of a good surgeon, chosen by 27.6%. Approximately 89% of patients do not conduct any research on their physician. Correlation was found between the study level and the choice of physician. Conclusion: The demand for physicians with highly specialized skills has increased over the years. It is evident that in the case of better educated patients, a physician’s resume is much more important, unlike less educated patients. It is possible to observe that, for patients, there are still multiple barriers and variables. Level of Evidence V, Therapeutic Study; Expert Opinion.