This work evaluated and validated the translation and cross-cultural adaptation of 4-Domain Sport PROM (4-DSP) into Chinese, assessing its understandability and reproducibility in all questionnaire domains for Chinese-speaking patients.

Cross-sectional study, level of evidence II. Twenty patients with sports injuries who underwent surgical treatment and postoperative rehabilitation in the Sports Medicine Surgery Department of Huashan Hospital were selected to evaluate whether the translation was understandable. Then, the 4-DSP was applied to 120 patients who had undergone trauma surgical procedures. The translation and cross-cultural adaptation of 4-DSP involved 6 steps: (1) Translation, (2) Synthesis of translation, (3) Back Translation, (4) Testing of the Prefinal Version-Expert committee review, (5) Prefinal testing among the patients, and Reliability and Consistency Testing. The questionnaire was self-administered by 120 patients (53 males and 67 females; mean age: 30.41 ± 6.8 years.) who had undergone arthroscopic surgery or conservative therapy from a sports physical therapist and had 3-month to 1-year follow-up. All patients filled in the 4-DSP questionnaire without direct supervision of their trainer/coach or researcher. All data were collected and processed anonymously.

97% of the experts (n = 10) considered the translation accuracy understandable; each item and overall content validity showed 96% agreement, and the bilingual translation accuracy was rated as 98.5%, presenting a global Cronbach's alpha of 0.72.

The Chinese cross-cultural adaptation and validation of the original English version of the 4-DSP questionnaire proved reproducible and properly understandable in all four domains. It can safely and reliably assess treatment outcomes for sports injuries in Chinese-speaking patients and is a helpful tool to collect and assess athletic population data.

To evaluate the clinical outcomes of arthroscopic all-inside anterior talofibular ligament (ATFL) repair on the basis of the quality of the remnant ATFL.

We retrospectively analyzed consecutive patients with chronic ankle instability who underwent arthroscopic ATFL repair with a minimum follow-up period of 24 months. Patients were categorized into 2 groups on the basis of the arthroscopic ATFL grade: group G, characterized by good-to-moderate tissue quality with distension or ATFL discontinuity; and group P, characterized by poor tissue quality with a hypoplastic ATFL. Outcome measurements were obtained preoperatively and postoperatively. Patients-reported outcomes were assessed using the visual analog scale score, Foot and Ankle Outcome Score (FAOS), and Karlsson ankle functional score. Objective outcomes included posturographic analysis and radiologic evaluations, such as stress radiographs and axial view magnetic resonance imaging.

Both groups exhibited postoperative improvements in the subjective and objective clinical outcomes (all P < .05). For the sports unit of FAOS, 75.3% of group G exceeded the minimal clinically important difference threshold, compared with 57.8% of group P, showing a statistically significant difference (P = .027). Group P had significantly lower FAOS scores in the sports unit (group G: 86.9 ± 32.8, group P: 61.9 ± 26.4, P = .016), an increased fall risk as determined using posturography at the final follow-up (group G: 28.6 ± 22.4, group P: 49.7 ± 23.3, P = .019), and a greater retear rate on axial-view MRI (group G: 2.6%, 2/77, group P: 10.9%, 7/64, P = .044).

Arthroscopic all-inside ATFL repair is an effective treatment for chronic ankle instability, regardless of the quality of the remnant ligament. However, patients with poor ligament quality have inferior clinical outcomes, particularly in terms of sports-related activities, as reflected by both lower scores and fewer patients exceeding the minimal clinically important difference threshold. In addition, the fall risk index and retear rates were greater in patients with poor ligament quality, highlighting the impact of ligament quality on postoperative stability and functional recovery.

Level III, retrospective cohort study.

For patients with rheumatoid arthritis (RA) undergoing total ankle arthroplasty (TAA), conflicting data have been reported regarding complications and patient-reported outcome (PRO) improvement when compared with patients with osteoarthritis (OA). The purpose of this study was to compare complication rates and PROs among patients with RA, primary OA, or posttraumatic arthritis.

This was a retrospective study of 1,071 primary TAAs performed at a single institution between March 2000 and October 2020. Minimum follow-up was 2 years. Patients were stratified by indication for TAA (OA, n = 372; posttraumatic arthritis, n = 642; RA, n = 57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared among the groups using univariable statistics. Cox regression was performed to assess the risk of implant failure. The overall cohort had a mean age of 63.4 years, 51.3% were male, and 94.8% were White. The mean duration of follow-up (and standard deviation) was 5.7 ± 3.1 years.

Compared with the OA and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest American Society of Anesthesiologists (ASA) score (p < 0.001). Univariable analysis showed no significant difference in the infection rate among the groups (p = 1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2 of 57, 3.5%; p < 0.040). Cox regression analysis showed no increased risk of implant failure for the RA cohort (p = 0.08 versus the OA cohort, 0.14 versus the posttraumatic arthritis cohort). For the Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36, Foot and Ankle Outcome Score (FAOS)-symptoms subscale, and FAOS-activities of daily living subscale, the RA group reported significantly worse scores in the postoperative period (p < 0.001). However, the RA cohort demonstrated improvements in all PROs.

In the largest single-institution study to date, patients with RA reported poorer PRO scores compared with the OA and posttraumatic arthritis groups but experienced functional outcome improvement from the preoperative baseline.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smoking is known to negatively affect the outcomes of orthopedic procedures, but its impact on arthroscopic microfracture for osteochondral lesions of the talus (OLT) remains unclear. We aimed to compare clinical outcomes and the status of repaired cartilage following arthroscopic microfracture for small to medium-sized OLT in smokers versus nonsmokers.

We enrolled 239 patients (250 ankles), dividing them into smoker (56 patients, 59 ankles) and nonsmoker groups (183 patients, 191 ankles). The primary outcome measure was the FAOS (Foot and Ankle Outcome Score). The AOFAS (American Orthopaedic Foot & Ankle Society) ankle-hindfoot scale, SF-36 PCS (Short Form-36 Physical Component Summary) score, and VAS (Visual Analog Scale) for pain were included as secondary outcomes. Preoperative magnetic resonance imaging (MRI) assessed lesion size, location, and subchondral cyst presence. Postoperative cartilage repair status was evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score on 3.0-T MRI.

The mean OLT sizes were 74.4 mm2 in smokers and 69.9 mm2 in nonsmokers on preoperative MRI. The mean age was 35.9 years in smoker group and 38.8 years in nonsmoker group (p = 0.157). The overall mean follow-up duration was 83.6 months (range, 24-217), with no significant intergroup difference (p = 0.582). There was no significant difference in primary and secondary clinical outcome variables between the two groups at the final follow-up (p > 0.05). In terms of postoperative MRI, 75 ankles (18 smokers, 57 nonsmokers) assessed repaired cartilage status and the mean total MOCART score was significantly lower in smokers (65.0, range 30.0-85.0) compared with nonsmokers (73.7, range 40.0-95.0; p = 0.027). Particularly, the smoker group had significantly lower MOCART scores for surface for repair tissue and signal intensity of the repair tissue variables, respectively (p = 0.019, p = 0.008).

Although smoker group showed worse status of repaired cartilage on postoperative MRI, the smoker group reported comparable clinical outcomes to those of the nonsmoker group following arthroscopic microfracture for small to medium-sized OLT over a mean follow-up of 7 years. However, caution should be taken in interpreting our conclusion and further larger studies are needed for robust conclusions.

The natural history of untreated tarsal coalitions is largely unknown. It is thought atypical biomechanics of limited hindfoot motion may contribute to early degeneration and foot pain or dysfunction. Consequently, there is no data on long-term outcomes of nonoperatively managed asymptomatic tarsal coalitions. This study sought to define the frequency of radiographically apparent tarsal coalitions among a cross-section of a population not seeking care for foot symptoms. Ultimately, we aimed to observe the natural history of these coalitions by comparing multiple functional scores and radiographic foot osteoarthritis between participants with and without radiographic coalition to see if coalition presence is associated with worsened scores and or radiographic osteoarthritis.

Utilizing existing data from a community-based study, radiographs were reviewed for findings of calcaneonavicular (CN) and talocalcaneal (TC) coalitions. Patient and foot-specific outcome scores [patient-reported outcomes measurement information system (PROMIS), foot and ankle outcome score (FAOS)] and radiographic foot osteoarthritis scoring were compared between "Coalition present"(C) and "No Coalition" (NC) groups.

Among 299 participants (592 feet) in this study (mean age: 72 y, 34% male, 41% Black), radiographic coalitions were found in 9.3% of feet, with 6.4% CN and 3.0% TC. PROMIS and FAOS were not significantly different between the NC and C groups. There was no statistically significant association between radiographic osteoarthritis and coalition presence. An unadjusted subanalysis of the coalition subtype found a modest association between CN coalitions and talonavicular osteoarthritis. TC coalitions had marginally worse FAOS symptoms, pain, sports and rec, and QOL subscores, though most TC participants had minimal dysfunction, with >60% reporting mild or no symptoms.

We found few observable relationships between subclinical coalitions and osteoarthritis or clinically significant foot dysfunction. Individuals with TC coalitions may have slightly lower functional scores than participants with no coalition over a lifetime. These data can be used to counsel participants with tarsal coalitions regarding their long-term outcomes. We recommend continued non-operative management of asymptomatic tarsal coalitions.

Level III.

To compare patient-reported outcomes between acute ligamentous ankle injuries 1) without anterior syndesmosis involvement and 2) with anterior syndesmosis involvement (without clinical instability).

Prospective cohort study.

Between September 2016 and December 2020 all athletes (≥18) with an acute ankle injury presenting within 7 days post-injury were screened for eligibility. Athletes were excluded if imaging demonstrated a frank fracture or 3T magnetic resonance imaging could not be acquired within 10 days post-injury. Athletes with unstable syndesmosis injuries or athletes who underwent surgery within 1-year post-injury were excluded. Athletes underwent criteria-based rehabilitation and functional outcomes (Karlsson & Peterson score, Foot and Ankle Outcome Score) were assessed at 6 weeks, 6 months, and 1 year.

A total of 94 athletes were included. In 28 athletes (30 %) the anterior syndesmosis was injured. In the first six weeks post-injury, median Karlsson & Peterson score improved from 37 (interquartile range 20.5-49) to 80 (interquartile range 70-90) for the group without involvement versus 35 (interquartile range 25-62) to 82 (interquartile range 72-87) for the group with involvement. FAOS sports improved similarly in both groups. No statistically significant between group differences in functional outcome scores were observed at six weeks, six months and 1 year follow-up.

In athletes, acute ligamentous ankle injuries with involvement of the anterior syndesmosis ligament (without clinical instability) are not associated with worse functional outcome at 6 weeks, 6 months, and 1-year post-injury compared to acute ligamentous ankle injuries without involvement.

A peroneus longus to brevis tendon transfer is recommended for a severely torn peroneus tendon, but there is little research on the outcome. We conducted a prospective cohort study to examine patient-reported outcomes after this procedure.

Thirty-two patients underwent a peroneus longus to brevis tendon transfer and lateral ankle ligament reconstruction, 11 had an additional calcaneal osteotomy. The Foot and Ankle Outcome Score (FAOS) and Short Form-36 (SF-36) were assessed preoperatively, six and 12 months after surgery.

Preoperative mean FAOS was 51.7 (SD 17.8) compared with 72.7 (SD 21.2) at 12 months, an improvement of 21 (95 % CI 12.7-28.0) (p < 0.0001). SF-36 improved significantly in the three domains involving physical function and bodily pain (p < 0.007).

Patient-reported outcomes improved significantly through peroneus longus to brevis tendon transfer. This procedure is worth considering for patients with a severely damaged peroneus tendon.

Level II: Prospective cohort study.

Chronic ankle instability (CAI) is a common consequence of a lateral ankle sprain. Sex differences in functional outcomes exist, but there is a lack of female-specific intervention studies. Hop stabilization training is effective in male athletes with CAI but has not been investigated in female athletes. Therefore, the purpose of this investigation was to describe the effect of hop stabilization exercises on functional movement patterns and patient-reported outcomes in female athletes with CAI. We also compared the current effect sizes with those observed in an all-male cohort following an identical intervention.

Randomized controlled trial.

Fourteen female CAI participants completed hop stabilization training (age = 25.29 [5.86] y), and 14 female CAI participants were in the control group (age = 24.73 [6.97] y). Inclusion criteria were consistent with the International Ankle Consortium recommendations. The hop stabilization program consisted of three 20-minute sessions per week for 6 weeks. Sessions consisted of increasing foot-to-ground contacts each week until a taper in the final week. Exercise difficulty was also modified throughout the program. Functional movement patterns via the Functional Movement Screen and Fusionetics Scores, dorsiflexion range of motion, and select region-specific patient-reported outcomes were captured.

The hop training group (pre: 12.68 [1.32] cm, post: 13.42 [1.35] cm) had a significant improvement (P< .001) in dorsiflexion range of motion relative to the control group (pre: 13.62 [1.22] cm, post: 13.68 [1.16] cm). Hop training also significantly improved (P,<0.01) functional movement patterns and all patient-reported outcomes. Relative to an all-male cohort who previously underwent the same hop stabilization program, the current female cohort demonstrated larger effect sizes, but all 95% CIs overlapped.

A 6-week hop training program significantly improves patient-reported outcomes, dorsiflexion range of motion, and functional movement patterns in female athletes with CAI .

Despite extensive validation, the impact of medical comorbidities on the outcomes of the Hip Disability and Osteoarthritis Outcome Score (HOOS), Knee Injury Osteoarthritis Outcome Score (KOOS), and Foot and Ankle Outcome Score (FAOS) remains underexplored. This study aimed to evaluate the effect of medical comorbidities on HOOS, KOOS, and FAOS subscales using a large, nationally representative sample.

This national register-based cohort study invited 26,877 participants to complete HOOS, KOOS, or FAOS questionnaires. Medical comorbidities-including diabetes, chronic obstructive pulmonary disease/asthma, rheumatological diseases, osteoporosis, stroke, obesity, and heart disease-were identified through the Danish National Patient Register.

A total of 7850 participants (29%) responded, with 1863 (24%) having medical comorbidities. HOOS/KOOS/FAOS subscale scores were significantly worse in patients with comorbidities, particularly in the Sport/Rec, ADL, and QOL subscales. Mean score differences between participants with and without comorbidities were pain (- 5.7, 95% CI - 6.6 to - 4.7), symptoms (- 4.6, 95% CI - 5.5 to - 3.6), ADL (- 7.1, 95% CI - 8.0 to - 6.1), Sport/Rec (- 10.4, 95% CI - 11.9 to - 8.9), and QOL (- 6.9, 95% CI - 8.2 to - 5.7). Diabetes, rheumatological diseases, and obesity were associated with the greatest complaints.

Patients with medical comorbidity reported significantly lower HOOS/KOOS/FAOS subscale scores compared to participants without medical comorbidity. Diabetes, chronic rheumatological diseases, and adiposities were observed with the most complaints. Key Points • Medical comorbidity predicts considerably lower HOOS/KOOS/FAOS subscale scores. • Diabetes, rheumatological diseases, and obesity exerted the most pronounced negative effects on the HOOS/KOOS/FAOS. • Findings underscore the importance of considering comorbidities when interpreting HOOS/KOOS/FOAS subscale scores.

Background/Objectives: As a representative anatomic ankle ligament repair technique, the Broström procedure continues to be modified to reach better clinical outcomes, superior mechanical stability, early rehabilitation, and minimal risk of recurrent instability. This study aimed to evaluate the intermediate-term clinical outcomes after the modified Broström procedure (MBP) with suture-tape augmentation for chronic lateral ankle instability. Methods: Ninety-four patients with chronic lateral ankle instability were followed for ≥3 years after MBP augmented with suture tape. The patient-reported clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). The changes in mechanical ankle stability were evaluated with physical examination and periodic stress radiography. The changes in static and dynamic postural control ability were assessed with the single-leg stance test and Biodex posturography. Results: FAOS and FAAM scores significantly improved from preoperative means of 52.6 and 54.2 points to 91.8 and 90.5 points at final follow-up, respectively (p < 0.001). Talar tilt angle and anterior talar translation significantly improved from preoperative means of 15.4° and 14.3 mm to 2.7° and 4.5 mm at final follow-up, respectively (p < 0.001). Two patients (2.1%) complained of a recurrence of mechanical and functional instability. One patient (1.1%) showed non-specific inflammation related to a suture tape. Balance retention time significantly improved from a preoperative mean of 3.7 to 6.4 s at final follow-up (p < 0.001), with a non-significant side-to-side difference. The overall stability index significantly improved from a preoperative mean of 3.7 to 1.9 at final follow-up (p < 0.001), with a significant side-to-side difference. Conclusions: The MBP augmented with suture tape appears to be an effective surgical technique for chronic lateral ankle instability. Through anatomic repair of attenuated ankle ligaments and suture-tape augmentation, this modified procedure can provide reliable stability and minimal risk of recurrent instability. In addition, static and dynamic postural control ability may be improved through continuous proprioceptive-oriented rehabilitation following surgery.

Introduction: Dance is a physically demanding art form that often results in musculoskeletal injuries. To effectively treat these injuries, standardized and reliable assessment tools designed to the dancer's needs are required. Thus, the aim of this review is to identify studies that have employed validated tools to assess musculoskeletal injuries in ballet, modern, and contemporary dancers, focusing on describing the content and psychometric quality of the tools used. Methods: This systematic review is registered at PROSPERO (CRD42022306755). PubMed, Cochrane, LILACS, Web of Science and SPORTDiscus databases were searched by two independent reviewers. Articles assessing musculoskeletal injuries with validated tools in ballet, modern and/or contemporary dancers and written in English, Portuguese, or Spanish were included. Non-peer reviewed articles, books, conference abstracts, thesis/review articles, or case design studies were excluded. The original validation studies were compiled when necessary. Two independent reviewers conducted a standardized data extraction and evaluated the methodological quality using an adapted Downs and Black checklist. Results: From the 3933 studies screened, 172 were read to verify if they met the inclusion criteria, resulting in 37 studies included accounting for 16 unique validated tools. Two were imaging exams, one was an injury classification system, and 13 were self-reported injury questionnaires. Only four injury assessment tools were validated for dancers, emphasizing the need for further validation studies for the dance population. Most of the articles (57%) achieved high-quality methodological scores and the remaining (43%) reported medium-quality scores. Conclusions: Valid, reliable, and specific tools to assess dance injuries are lacking in general. For enhanced methodological rigor in future studies, the incorporation of validated tools is recommended to improve methodological quality and facilitate cross-study comparisons. Researchers may consider conducting validation studies, involving processes such as translation into another language, validation of modifications to the original tool, or reporting reliability within the article itself.

Arthrodesis is a common procedure in the treatment of forefoot conditions affecting the first metatarsophalangeal (MTP) joint. Although this procedure has been shown to significantly improve individuals' activities of daily living and effectively relieve pain, there is a lack of research specifically investigating younger patients below 60 yrs of age wishing to return to sports. Our aim is to evaluate their ability to return to sports after 1st MTP joint arthrodesis. A retrospective analysis of clinical records of 159 patient that had undergone first MTP arthrodesis performed by a single surgeon was undertaken to determine pre- and postoperative sf-FAOS and sporting activity scores. The Tobit constant censoring limit model was used to analyze change in sf-FAOS scores. After the application of inclusion and exclusion criteria, 58 patients (median age 54 years, range 30 - 59) were included in the final cohort with a mean follow up of 5.3 years (range 2.0 to 9.44, SD 2.10). There was a significant improvement in the mean pain score (p<0.001), as well as an improvement in the mean function score (p<0.001). The number of hours spent in sporting activities per week were significantly higher (p<0.001) post-surgery (5.29 hours, SD 5.0) in comparison to preoperative levels (4.26 hours, SD 3.1). There was no significant change in the intensity of sporting activities (p=0.176). First MTP joint arthrodesis remains a good treatment option for younger individuals wishing to achieve a satisfactory return to sports.

Research on outcomes measures after foot and ankle surgery is limited and methodological quality is not always assessed. We aimed to evaluate the measurement properties of patient-related outcome measures used in patients after foot- and ankle surgery.

A Medline, Embase and Web of Sciences systematic review was performed including dates from 2000 up to April 2022. Inclusion criteria were foot and/or ankle surgery, described outcome(s) and it's assessed measurement properties. Methodological quality assessment was performed using the NOS-scale and the COSMIN-criteria.

143 studies (n = 18383) were included for final review, 82 about PROMs, 61 about clinical outcomes. A total of 23 different PROMs were evaluated, with a positive result in all measurement properties for the FAOS. There were positive results too for most measurement properties of the LEFS and the MOXFQ. Most clinical outcomes were radiological measures, with a high reliability for most measurements on plain radiographs and CT-scans.

To monitor foot and ankle outcome and evaluate treatment, we recommend the FAOS as the most suitable foot and ankle PROM.

2.

Autologous osteochondral transplantation (AOT) is an option to treat large osteochondral lesions of the talus (OLTs), accompanying subchondral cyst, and previous unsuccessful bone marrow stimulation (BMS) procedures. Although there is extensive literature on the outcomes of surgical interventions for medial osteochondral lesions, research focusing on lateral lesions remains limited. This article presents the intermediate-term clinical and radiologic outcomes following AOT for lateral OLTs.

Twenty-eight patients with lateral OLTs were followed up for a minimum of 3 years after AOT. Clinical evaluations included the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessments evaluated articular surface (subchondral plate) irregularity, progression of degenerative arthritis, and changes in talar tilt and anterior talar translation. The quality of osteochondral graft was evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score.

The average FAOS and FAAM scores significantly increased from 39.6 to 91.2 and from 37.8 to 89.8 points, respectively, at the final follow-up (P < .001). Radiologic assessments revealed 2 patients (7.1%) with articular step-off ≥2 mm and 1 patient (3.6%) with progressive arthritis. The average MOCART score reached 92.8 points. Postoperative complications included 2 patients with wound problems, 1 with a superficial peroneal nerve injury, and 1 with donor site morbidity. The rate of return to preinjury level of sports activity was 82.1%. At a mean follow-up of 68.5 months, no patient required reoperation for OLT or recurrent ankle instability.

AOT for lateral OLTs demonstrated favorable intermediate-term clinical and radiologic outcomes. Most lateral OLTs were accessible via lateral ankle ligament division and capsulotomy, with minimal occurrence of iatrogenic complications such as recurrent ankle instability. AOT appears to be an effective surgical option for patients with large lateral osteochondral lesions unresponsive to conservative treatment, large subchondral cysts, and prior unsuccessful BMS procedures.

To compare clinical outcomes of autologous osteoperiosteal transplantation versus bone marrow stimulation (BMS) for medium-sized (100-150 mm2) cystic osteochondral lesions of the talus (OLTs) and assess the correlation between patient demographics and outcomes. It was hypothesised that autologous osteoperiosteal transplantation would provide better clinical outcomes than BMS for medium-sized cystic OLTs.

Patients who underwent autologous osteoperiosteal transplantation or BMS for medium-sized cystic OLTs between 2014 and 2019 were retrospectively evaluated. According to their characteristics, a 1:1 propensity-score matching was performed and 33 pairs of patients were matched. The visual analogue scale, American Orthopaedic Foot and Ankle Society (AOFAS) score, Foot Ankle Outcome Score (FAOS) and Ankle Activity Score were collected preoperatively and at the last follow-up. In addition, a general linear model analysis was performed between patient demographics and clinical outcomes in two groups separately to detect potential risk factors.

Finally, 28 patients in the grafted group and 27 patients in the BMS group completed the follow-up and were enrolled with a mean follow-up period of 63.5 ± 13.9 months. Both groups showed significant improvement in all patient-reported outcomes (p < 0.01). At the final follow-up, no significant differences between groups were found in all postoperative scores except FAOS Pain (p = 0.02). Correlation analysis showed a moderate correlation between cyst depth and the postoperative AOFAS score in the BMS group (r = -0.48, p = 0.01). Based on the regression line, the patients in the BMS group with a cyst deeper than 6 mm showed a lower AOFAS score than the mean score (88.7 ± 9.5) of the grafted group.

Autologous osteoperiosteal transplantation and BMS are both safe and effective for medium-sized cystic OLTs. However, autologous osteoperiosteal transplantation is expected to provide better clinical outcomes than BMS when the cysts are deeper than 6 mm.

Level III.

Ankle fractures are among the most common types of fractures in the orthopaedic field, and the Lauge-Hansen classification is commonly used to categorize rotational ankle fractures. This study evaluated and compared the clinical and radiological outcomes of surgically treated supination external rotation (SER) and pronation external rotation (PER) injuries of grades III or IV.

We retrospectively reviewed and enrolled 104 patients who underwent open reduction and internal fixation for SER or PER injuries classified as Grades III or IV between January 2016 and December 2021, all performed at a single center. Of these, 72 belonged to the SER group and 32 to the PER group. The average postoperative follow-up durations were 31.3 months (range, 24 to 74) for the SER group and 32.1 months (range, 24 to 71) for the PER group. Clinical and radiological outcomes were assessed 24 months after surgery and compared between the two groups. Details of concomitant surgical procedures performed and postoperative complications were also evaluated.

All clinical outcome variables, including the Foot and Ankle Outcome Score, Visual Analog Scale for pain, and ankle range of motion, were comparable between the two groups. Similarly, no statistically significant differences were observed in the development of post-traumatic arthritis or in the frequency of syndesmotic widening 24 months postoperatively. However, the time required for fibular union was significantly longer in the PER group, taking 5.6 ± 2.2 months compared to 3.4 ± 1.3 months in the SER group on average (p < 0.001).

Our study demonstrated that both types of rotational ankle fractures can achieve equivalent clinical and radiological outcomes with surgical treatment. Given the prolonged time to fibular union in the PER group, careful monitoring during postoperative follow-up is required.

To compare the clinical outcomes of inferior extensor retinaculum (IER) augmentation following repair of the anterior talofibular ligament (ATFL) with isolated ATFL repair in patients with an arthroscopically confirmed grade 3 lesion of the ATFL.

We conducted a retrospective study of consecutive chronic lateral ankle instability (CLAI) patients who underwent arthroscopic ATFL repair between March 2018 and August 2022. The average age of the patients was 31.5 ± 7.4 years (range, 16-50 years). All patients underwent all-inside arthroscopic repair, and were divided into two groups based on the ligament repair method: the Broström-Gould group (n = 64) and the Broström group (n = 67). At 3, 6, 12 and 24 months after surgery, ankle inversion stress tests and anterior drawer tests were employed to assess the stability of the ankle joint. The American Orthopedic Foot and Ankle Society ankle hindfoot scale(AOFAS-AH) and Karlsson ankle function score (KAFS) were employed to assess ankle function; the Tegner score was employed to assess the patient's level of exercise; the Foot and Ankle Outcome Score [FAOS, including score of symptoms-diseases, pain, function-daily living score, function in sports and recreational activities, and quality of life] was used to assess the patient's daily activity ability.

The Tegner score, FAOS-function-daily living score, and FAOS-function in sports and recreational activities in the Broström-Gould group consistently outperformed the Broström group at 3 months and 6 months post-surgery, with the differences being statistically significant (all P < 0.05). However, although the differences are statistically significant, the clinical relevance of this statistical significance remains uncertain. At 12 and 24 months, there were no statistically significant differences between the two groups.

For CLAI patients with arthroscopic grade 3 lesion of the ATFL, both the all-inside arthroscopic Broström-Gould procedure and the Broström procedure provide stability and enhance ankle joint function, resulting in similar functional outcomes at a 2-year follow-up. IER augmentation following ATFL repair may facilitate earlier recovery exercises compared to isolated all-inside ATFL repair.

While there are several scales for measuring patients' outcomes after chronic ankle instability (CAI) surgery, a study comparing the predictive ability of these scores with regard to return to sports (RTS) at the preinjury level is lacking.

The purpose of this study was to compare the Ankle Ligament Reconstruction-Return to Sport After Injury (ALR-RSI), American Orthopaedic Foot and Ankle Society (AOFAS), and Karlsson scores in predicting 2-year RTS outcomes after arthroscopic treatment of CAI. It was hypothesized that ALR-RSI would be superior in predicting 2-year RTS outcomes after CAI surgery and that a quantifiable increase in this score would significantly improve RTS outcomes.

Cohort study; Level of evidence, 2.

This prospective cohort study analyzed patients who underwent surgery for CAI at a sports surgery center between 2016 and 2018. The inclusion criteria focused on adult patients undergoing their first surgery for CAI with a minimum 2-year follow-up. The primary outcome was RTS at 2 years. The study evaluated 3 scores at 1 year postoperatively to predict RTS at the same level as the preinjury level at 2 years-ALR-RSI, AOFAS Ankle-Hindfoot Scale, and Karlsson score. The most predictive score, with its corresponding optimal threshold, was determined using the receiver operating characteristic (ROC) curve. This threshold signifies the score value above which the likelihood of RTS at the preinjury level is significantly increased. Once identified, the secondary outcome evaluated the impact of a 10-point increase in this score on RTS, after adjusting for confounding factors.

A total of 159 patients (age, 35.7 ± 11.4 years) were included. Two years after surgery, 40.25% of patients returned to their preinjury level of sports. ROC curve analysis of the tested scores at 1-year postoperatively showed the ALR-RSI score had the best predictive ability for RTS (area under the curve [AUC], 0.70 [95% CI, 0.6-0.77]), whereas Karlsson and AOFAS scores were less predictive (AUC, 0.53 [95% CI, 0.43-0.63] and 0.61 [95% CI, 0.52-0.70], respectively). The optimal threshold for the ALR-RSI score was identified at 83 (Youden index = 0.35, sensitivity = 63%, and specificity = 71%). Confounder identification revealed earlier surgery and arthroscopic techniques were associated with higher RTS rates. A 10-point increase in the ALR-RSI score correlated with increased odds of RTS (1.27 [95% CI, 1.12-1.46]; P = .0004) in univariate analysis and (1.29 [95% CI, 1.06- 1.61]; P = .01) in multivariate analysis.

This study showed that none of the scores were great predictors of RTS after surgery for CAI. The ALR-RSI score was a stronger predictor of RTS to the same preinjury level after CAI surgery than AOFAS and Karlsson scores. The ALR-RSI optimal threshold identified was 83. A 10-point increase in the ALR-RSI score boosted the odds of RTS by 1.29 times.

During the modified Broström procedure for chronic ankle instability, surgeons often experience cases with insufficiently restored mechanical stability even after anatomical ligament repair. In these cases, longer postoperative immobilization and delayed rehabilitation can be required, and a risk for recurrence of instability may persist. This study aimed to evaluate the clinical usefulness of suture-tape augmentation based on intraoperative stress radiographs during anatomical ligament repair for chronic ankle instability.

Twenty-four patients who underwent additional suture-tape reinforcement because of residual mechanical instability on intraoperative stress radiographs were followed up ≥3 years. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Changes in mechanical stability were analyzed through periodic stress radiographs, and postural control ability was evaluated with the modified Romberg test.

FAOS and FAAM scores improved significantly from preoperative mean 55.1 and 52.4 points to 92.3 and 90.2 points at final follow-up, respectively (P < .001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 15.8 degrees and 13.6 mm to 2.9 degrees and 4.2 mm, respectively (P < .001). Balance retention time improved significantly from preoperative mean 3.6 to 6.4 seconds (P < .001). Although 9 patients experienced sprain injury after surgery, no patient showed recurrence of mechanical and subjective instability, and 21 patients (87.5%) were able to return to preinjury level of sports activity.

Evaluation of residual mechanical instability through intraoperative stress view and additional suture-tape augmentation showed satisfactory clinical outcomes at midterm follow-up. Suture-tape augmentation based on intraoperative stress radiographs seems to be a useful surgical option for patients with insufficiently restored mechanical stability even after anatomical ligament repair. This combined procedure can provide a reliable mechanical stability that can be performed after recognition of residual instability during the index surgery.

This study aimed to compare the clinical and radiologic outcomes among grades according to the arthroscopic classification of chronic ATFL lesions after arthroscopic lateral ligament repair.

We retrospectively analyzed 135 patients with chronic lateral ankle instability who underwent arthroscopic lateral ligament repair at 3 institutions between 2018 and 2020. The patients were divided into four groups according to the arthroscopic classification of the ATFL remnants. The Karlsson ankle functional score (KAFS) and foot and ankle outcome score (FAOS) were evaluated preoperatively and at the last follow-up. On stress radiographs, the talar tilt and anterior talar translation were measured preoperatively and at the last follow-up.

Of the 135 included patients, 41 (30.4 %), 42 (31.1 %), 34 (25.2 %), and 18 (13.3 %) were in groups 1, 2, 3, and 4, respectively. There were no significant differences among the groups with respect to the preoperative patient characteristics, except for concomitant injuries. The mean KAFS and FAOS improved significantly at the last follow-up in all groups; however, no significant differences occurred among the groups in any scores preoperatively or at the last follow-up. The mean talar tilt and anterior talar translation decreased significantly at the last follow-up in all the groups. Group 1 exhibited significantly less preoperative talar tilt than that in the other groups (P < .001). However, no significant difference occurred in talar tilt among the groups at the last follow-up. There were no differences among the groups in the preoperative anterior talar translation or values at the last follow-up.

The present study demonstrated that arthroscopic lateral ligament repair showed good functional and stress radiographic outcomes regardless of the quality of ATFL remnant.

This work aims to evaluate and validate the process of cross-cultural adaptation and validation of the 4-Domain Sports PROM (4-DSP) into Italian, assessing its understandability and reproducibility in all questionnaire domains for Italian-speaking patients.

Cross-sectional study, level of evidence II. The questionnaire was self-administered by 100 patients (80 males and 20 females) who had undergone anterior cruciate ligament (ACL) reconstruction and had a one-year minimum follow-up. The mean age and standard deviation (SD) was 31.20 ​± ​12.65 years. According to their level of sports participation, 51% were recreational, 31% were regional, 12% were national, and 6% were international athletes. All patients filled in the 4-DSP questionnaire without direct supervision of their trainer/coach or researcher. All data were collected and processed anonymously. The translation and cultural adaptation of the 4-DSP involved six phases: (1) translation, (2) synthesis, (3) back-translation, (4) pre-test, (5) expert committee review and (6) final version approval by the author of the original version for publication.

The cross-cultural validation of the questionnaire 4-DSP into Italian presented a global Cronbach's alpha of 0.65, Conceptual equivalence to translation and relevance were 99.09% and 99.81%, respectively, and the percentage of agreement was 99.09%.

The cross-culturally validated version of the 4-DSP into Italian proved to be adequately understandable and reproducible in all questionnaire domains and can be safely and reliably used in Italian-speaking patients.

Study level II.

Unlike hip and knee OA, there is little evidence to guide the management of ankle osteoarthritis (OA) and there are no clinical guidelines for ankle OA. Regardless of the body region, guidelines for treating OA typically include education, weight loss and exercise as the key components of management. Such an intervention has not been investigated in people with ankle OA.

To determine the feasibility of conducting a randomised controlled trial (RCT) that compares physiotherapist-delivered education plus exercise to physiotherapist-delivered general advice for people with ankle OA. Secondarily, to inform planning for future RCTs.

A randomised parallel-group feasibility trial.

Study participants were recruited, assessed for eligibility, and randomised using 1:1 concealed allocation to receive either physiotherapist-delivered education plus exercise, or physiotherapist-delivered general advice. Primary feasibility outcomes were evaluated based on predetermined feasibility criteria. Secondary participant-reported and physical outcomes were collected to inform the design of future RCTs.

Thirty participants (67% (n = 20) women, mean (standard deviation) age: 66.1 (11.5) years) were randomised. Data for key feasibility outcomes met a priori feasibility criteria: consent rate (97%), participant adherence with their allocated intervention arm (71%), fidelity of the intervention (94%) and rate of completion of outcome measures at 3 months (87%).

This study demonstrates that it is feasible to run an adequately powered RCT comparing physiotherapist-delivered education plus exercise versus physiotherapist-delivered general advice for people with ankle OA. Study data will inform the planning of a full-scale RCT.

We aimed to investigate whether there is clinical and MRI evidence of healing of lateral ligaments 6 weeks after acute lateral ankle sprain (LAS). We prospectively enrolled 18 participants (age 32.7 ± 7.5 years) who sustained an acute LAS and underwent conservative treatment. An ankle MRI was acquired up to 48 hours and 6 weeks following the LAS. A partial tear of the anterior talofibular ligament (ATFL) was observed in 10/18 and a complete tear in 8/18 of the patients. The calcaneofibular ligament (CFL) was partially torn in 11/18 and completely torn in 1/18 of the patients. The healing status, intensity, and thickness of the ligaments, Anterior Drawer Test (ADT), and FAOS scale were assessed. A control group (CG) was composed by 17 participants (age 40 ± 13.9 years). Six weeks after the LAS, 89% of the participants presented MRI evidence of ATFL healing. The repaired ATFL was thicker in comparison with the CG (p < .001). The cut-off of 2.5 mm for ATFL thickness in the 6th week maximized sensitivity (62.5%) and specificity (100%). CFL and PTFL presented 94% and 100% of healing signs, respectively. In the 6th week, 11/18 (61%) participants showed mild residual instability and a mean FAOS of 80 ± 11. The MRI revealed signs of the repair process in 89% of ATFL and 94% of CFL tears, 6 weeks after a moderate or severe LAS. The MRI findings were concomitant with enhancements in mechanical ankle stability and function.

To assess short term recovery between individuals with Achilles tendinopathy with varying degrees of kinesiophobia when treated with the Silbernagel protocol. Secondarily to investigate short term change in degree of kinesiophobia.

Prospective single cohort analysis.

University/Clinical.

116 participants with midportion Achilles tendinopathy were grouped from their baseline Tampa Scale of Kinesiophobia (TSK) score: Low (≤33), Medium (34-41), and High (≥42).

Symptom severity, Achilles tendon structure, and function were assessed at baseline and 8-weeks following initiation of the Silbernagel protocol. Differences in recovery between TSK groups were analyzed.

No group by time interactions were observed for symptoms, structure, or function. A significant interaction of group by time was observed for TSK score. The Medium (n = 66) and High (n = 28) TSK groups significantly decreased TSK score after 8 weeks by 2.4 and 4.4 points respectively while the Low TSK group (n = 22) did not change.

There were no differences in short term recovery of symptoms, Achilles tendon structure, and function in individuals with midportion Achilles tendinopathy treated with the Silbernagel protocol regardless of baseline degree of kinesiophobia. Those with moderate and high levels of kinesiophobia at baseline decreased TSK score in the short term.

In recent years, there has been an increasing demand for patient-reported outcome measures (PROMs) to assess the outcome following orthopedic surgery. But, we are lacking a standard set of PROMs to assess the outcome of hallux valgus surgery. The aim of this study was to analyze the chosen patient rated outcome scores used in studies reporting on hallux valgus surgery.

The study was based on a previously published living systematic review. Included were prospective, comparative studies of different surgical procedures or the same procedure for different degrees of deformity. Four common databases were searched for the last decade. Study selection, data extraction, and risk of bias assessment were made by two independent reviewers. Data assessed were the individual PROMs used to assess the outcome of hallux valgus surgery.

46 studies (30 RCTs and 16 non-randomized prospective studies) met the inclusion criteria. The most commonly used clinical outcome measures were the AOFAS (55%) and the VAS (30%). No differences were found between frequency of the individual scores per the level of evidence or the type of osteotomy.

Based on a systematic literature review, the AOFAS and VAS are the most frequently used outcome tools in studies assessing the outcome following hallux valgus surgery. Based on the literature available, the MOXFQ is a more valid alternative.

Level I; systematic review of prospective comparative (level II) and randomized controlled trials (level I).

The Ankle Ligament Reconstruction-Return to Sport After Injury (ALR-RSI) scale can be utilized for assessing patients who have previously sustained lateral ankle ligament injury before returning to sport. Given its original development for use in different languages, it is essential to translate and validate this scale for application to the Chinese population.

To translate and culturally adapt the ALR-RSI scale into a Chinese version and assess its reliability and validity.

Cohort study (Diagnosis); Level of evidence, 2.

The procedure of translation and cross-cultural adaptation was performed following the recommended guidelines and the Chinese version of ALR-RSI (ALR-RSI-CHN) was conducted in patients with lateral ankle ligament surgery. Feasibility was assessed by floor/ceiling effects. Reliability was assessed by using Cronbach α as a measure to analyze internal consistency, while the intraclass correlation coefficient was utilized to examine test-retest reliability. Validity was assessed by using Spearman coefficients to analyze the correlations between ALR-RSI-CHN, the Karlsson scale, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale.

A total of 66 participants were included. The ALR-RSI-CHN scale showed good feasibility with no floor/ceiling effects. The internal consistency of the scale was adequate with a Cronbach α of 0.93, and test-retest reliability was excellent with an interclass correlation coefficient of 0.97 (95% CI, 0.92-0.99). The ALR-RSI-CHN scale demonstrated moderate correlation with the Karlsson scale (r = 0.48 [range, 0.26-0.65]) and strong correlation with the AOFAS scale (r = 0.55 [range, 0.35-0.71]). A significant difference in ALR-RSI-CHN scores was observed between patients who returned to sports and those who did not, with respective scores of 53.60 (range, 44.50-62.69) and 42.25 (range, 35.51-49) (P = .04).

The study demonstrated that the ALR-RSI-CHN scale had satisfactory psychometric properties, rendering it a feasible, reliable, and valid instrument for evaluating patients who have lateral ligament surgery in China.

A lateral ankle sprain is the most common musculoskeletal injury in the physically active population. However, it is unclear how the clinical condition evolves during the period after the injury and what proportion of patients develops chronic symptoms. Therefore, the purpose of this study is to assess the evolution of patient-reported outcome measures after a first time lateral ankle sprain.

A prospective clinical study assessed the patient-reported outcome measures (PROMs) of a consecutive group of 100 patients during 1 year after a first lateral ankle sprain. The Karlsson score and Foot and Ankle Outcome Score (FAOS) were assessed at 6 weeks, 3 months, 6 months, 9 months and 1 year. The Cumberland Ankle Instability Tool (CAIT)-score was assessed at 6 months, 9 months and 1 year. The difference between the time points of all scores was analysed using the positive change over time (binomial test versus 50%) and the difference in score (signed rank test). The time to sustained excellent level was also assessed overall and in several subgroups: age, gender, degree of injury (2 or 3), avulsion fracture, use of crutches, use of cast. Differences between subgroups were assessed by a generalized log-rank test.

All clinical scores demonstrated an improvement up to 12 months after the sprain. The median Karlsson score (interquartile range) improved from 62 (50-80) at 6 weeks to 90 (72-100) at 3 months, to 97 (82-100) at 6 months to 100 (90-100) at 9 months, to 100 (100-100) at 1 year. The analysis of positive change over time demonstrated a significant positive change (P-value <.0005) between all time points except between 6 weeks and 12 weeks when using the FAOS quality score. The difference in score demonstrated a significant change (P-value <.01) between all time points except between 36 weeks and 48 weeks when using the FAOS pain and FAOS sports score. Age and presence of an avulsion fracture were correlated with a slower recovery and worse results. At 1 year, in total 13 patients (13%) had a worse outcome corresponding to a Karlsson score < 81 or CAIT score < 24.

The clinical condition after a first ankle sprain demonstrated a significant improvement in PROMs between the different time points in the first year. Twelve months after a first lateral ankle sprain 13% had a fair or poor outcome. Higher age and presence of an avulsion fracture were correlated with a slower recovery and worse results. This information is useful in clinical practice to predict further progression and inform patients. Moreover, it is valuable to improve treatment strategies.

Level II (prospective cohort study).

Postoperative outcomes may be affected by the patient's preoperative morbidity. It is hypothesized that patient's pain catastrophization prior to foot and ankle surgery may affect their patient-reported outcomes. Methods: This study prospectively assessed a consecutive cohort of 46 patients undergoing foot and ankle reconstruction to describe the relationship between Pain Catastrophizing Scale (PCS) and patient-reported outcomes measured by 12-item Short Form Health Survey and Foot and Ankle Outcome Score (FAOS).

The 1-year postoperative FAOS pain, activities of daily living, and quality of life scores correlated significantly with all baseline PCS subcategories. We found that the mental domain of the SF-12 had a statistically significant correlation with the rumination and helplessness PCS subcategories.

This study showed a significant association between a high preoperative PCS and a worse 1-year FAOS. As such, catastrophization could be screened for and potentially treated preoperatively to improve patient-reported outcomes in elective foot and ankle surgery.

Therapeutic, Level III Evidence.

Ankle symptoms are a common reason to consult the general practitioner and often persist for years. In a population referred for ankle radiography, the prevalence of radiographic osteoarthritis (OA) is substantial, but its additional predictive value for persistent symptoms is unknown. Therefore, we examined the prognosis of symptoms 2-3 years after referral for ankle radiography, assessed clinical prognostic factors, and the additional predictive value of radiographic OA for persistent ankle complaints.

We included 893 adults referred for ankle radiography and studied the following candidate prognostic factors at baseline: age, sex, body mass index (BMI), referral for chronic complaints (>3 months), pain during activity (NRS-11) and presence of stiffness and functional loss as predominant symptom. X-rays were scored for radiographic OA. After 2-3 years participants were invited for a follow-up questionnaire including persistence of ankle complaints. To assess prognostic factors for persistent complaints, uni- and multivariable logistic regression were used.

Of the 194 responders at follow-up, ankle complaints persisted in 71(36.6 %). BMI (OR 1.08; 95 % CI 1.01-1.15), stiffness as predominant symptom (OR 1.69; 95 % CI 0.89-3.21), and chronic complaints (OR 2.84; 95 % CI 1.45-5.57) were in the initial model for persistent complaints (AUC=0.69). After adding radiographic OA (OR 2.36; 95 % CI 1.01-5.50), the AUC of the final model became 0.70.

Ankle complaints persist in a considerable proportion of patients 2-3 years after referral for ankle radiography. BMI, chronic complaints and radiographic OA are prognostic factors for persistent complaints, but the additional predictive value of radiographic OA on top of clinical factors is negligible.

Ankle fracture is one of the most common lower limb fractures. Whilst immobilisation of the ankle can support and protect the fracture site during early healing, this also increases the risk of ankle weakness, stiffness, and residual pain. Rehabilitation aims to address the after-effects of this injury, to improve ankle function and quality of life. Approaches are wide-ranging and include strategies to improve ankle joint movement, muscle strength, or both. This is an update of a Cochrane review last published in 2012.

To assess the effects of rehabilitation interventions following surgical or non-surgical management of ankle fractures in adults.

We searched CENTRAL, MEDLINE, Embase, three other databases, and two clinical trials registers in May 2022, and conducted additional searches of CENTRAL, MEDLINE, and Embase in March 2023. We also searched reference lists of included studies and relevant systematic reviews.

We included randomised controlled trials (RCTs) and quasi-RCTs comparing any rehabilitation intervention delivered to adults with ankle fracture. Interventions could have been given during or after the initial fracture management period (typically the first six weeks after injury), which may or may not have included surgical fixation. We excluded participants with multi-trauma, pathological fracture, or with established complications secondary to ankle fracture.

We used standard methodological procedures expected by Cochrane. We collected data for five outcomes: activity limitation (ankle function), health-related quality of life (HRQoL), participant satisfaction with treatment, pain, and adverse events (we focused on re-operation, defined as unplanned return to theatre). We report the findings up to six months after injury.

We included 53 studies (45 RCTs, 8 quasi-RCTs) with 4489 adults with ankle fracture. In most studies, orthopaedic management included surgical fixation but was non-surgical in five studies, and either surgical or non-surgical in six studies. Here, we summarise the findings for three common rehabilitation comparisons; these included the most data and were the most clinically relevant. Because of different intervention approaches, we sometimes included a study in more than one comparison. Data for other less common comparisons were also available but often included few participants and were imprecise. All studies were unavoidably at high risk of performance and detection bias. We downgraded the certainty of all evidence for this reason. We also downgraded for imprecision and when we noted inconsistencies between studies that precluded meta-analysis of data. Early (within 3 weeks of surgery) versus delayed weight-bearing (12 studies, 1403 participants) Early weight-bearing probably leads to better ankle function (mean difference (MD) 3.56, 95% confidence interval (CI) 1.35 to 5.78; 5 studies, 890 participants; moderate-certainty evidence); however, this does not include a clinically meaningful difference. Early weight-bearing may offer little or no difference to HRQoL compared to delayed weight-bearing (standardised mean difference (SMD) 0.15, 95% CI -0.01 to 0.30; 5 studies, 739 participants; low-certainty evidence); when translated to the EQ-5D scale (a commonly-used HRQoL questionnaire), any small difference was not clinically important. We were unsure whether there were any differences in participant satisfaction or pain because these outcomes had very low-certainty evidence. For adverse events, there may be little or no difference in re-operation (risk ratio (RR) 0.50, 95% CI 0.09 to 2.68; 7 studies, 1007 participants; low-certainty evidence). Removable versus non-removable ankle support (25 studies, 2206 participants) Following surgery, using a removable ankle support may lead to better ankle function (MD 6.39, 95% CI 1.69 to 11.09; 6 studies, 677 participants; low-certainty evidence). This effect included both a clinically important and unimportant difference. There is probably an improvement in HRQoL with a removable ankle support, although this difference included both a clinically important and unimportant difference when translated to the EQ-5D scale (SMD 0.30, 95% CI 0.11 to 0.50; 3 studies, 477 participants; moderate-certainty evidence). No studies reported participant satisfaction. We were unsure of the effects on pain because of very low-certainty evidence (1 study, 29 participants). There may be little or no difference in re-operations (RR 1.20, 95% CI 0.39 to 3.71; 6 studies, 624 participants; low-certainty evidence). Following non-surgical management, there may be little or no difference between removable and non-removable ankle supports in ankle function (MD 1.08, 95% CI -3.18 to 5.34; 3 studies, 399 participants), and HRQoL (SMD -0.04, 95% CI -0.24 to 0.15; 3 studies, 397 participants); low-certainty evidence. No studies reported participant satisfaction. We were unsure of the effects on pain (2 studies, 167 participants), or re-operation because of very low-certainty evidence (1 study, 305 participants). Physical therapy interventions versus usual care or other physical therapy interventions (9 studies, 857 participants) Types of interventions included the use of active controlled motion, a spring-loaded ankle trainer, an antigravity treadmill, and variations of enhanced physiotherapy (e.g. additional stretching, joint mobilisation, neuromuscular exercises), delivered during or after the initial fracture management period. We were unable to pool data because of the differences in the design of interventions and their usual care comparators. Studies often included very few participants. The certainty of the evidence for all outcomes in this comparison was very low, and therefore we were unsure of the effectiveness of these therapies. No studies in this comparison reported re-operation.

Early weight-bearing may improve outcomes in the first six months after surgery for ankle fracture, but the difference is likely to be small and may not always be clinically important. A removable ankle support may also provide a better outcome, but again, the difference may not always be clinically important. It is likely that neither approach increases the re-operation risk. We assume that the findings for these comparisons are applicable to people with closed ankle fractures, and that satisfactory fracture stabilisation had been achieved with surgery. For people who have non-surgical treatment, there is no evidence that either a removable or non-removable ankle support may be superior. We were uncertain whether any physical therapy interventions were more effective than usual care or other physical therapy interventions. We encourage investigators of future studies on rehabilitation interventions for ankle fracture to use a core outcome set.

Foot and ankle problems are frequently prevalent, especially among the elderly, ranging from 70 to 80%. In primary care, foot, and ankle complaints stand out as one of the most frequent reasons for orthopedic consultations. Patient-reported outcome measures are significant in the assessment burden of any condition on the effects of intervention as well as research. The Foot Function Index (FFI) is a region-specific tool that was identified as one of the most commonly used evaluation tools for foot complaints. This study aimed to translate, cross-cultural adapt, and test the psychometric properties of FFI in the Urdu language.

The FFI was translated into Urdu language (FFI-U) following Beaton et al. translation guidelines. The data were collected from 230 Urdu-speaking participants with different foot and ankle pathologies. Data collection started after the written informed consent from the participants. All participants completed the FFI-U, Visual Analogue Scale (VAS), SF-36, and the Foot and Ankle Outcome Score (FAOS) at baseline while only 30 participants completed ULFI-U after one week for test-retest reliability. The psychometric properties involved reliability and validity testing. Reliability was assessed where internal consistency was measured using Cronbach's alpha and test-retest reliability through the intra-class correlation coefficient (ICC). FFI-U was tested for face validity and construct validity (convergent and discriminant). Psychometric criteria were examined against priori hypotheses, and alpha level (p-value < 0.05) was considered statistically significant.

FFI-U demonstrated good reliability with internal consistency (α = 0.86) and test-retest reliability with intra-class correlation coefficient = 0.845 (0.78-0.89). A moderate correlation was found using Pearson correlation between FFI-U total score and physical components of SF-36, VAS (pain, disability), and FAOS (γ= -0.65, 0.72, 0.71, -0.68) respectively, indicating convergent validity however, a weak correlation was found with mental components of SF-36 (γ=-0.25) demonstrating discriminant validity. Face validity was assessed at the pre-final testing stage by interviewing patients. There were no floor and ceiling effects found for FFI-U.

The FFI-U has been found reliable, valid, and feasible tool to be used as a patient-reported outcome measure to assess functional levels with different foot and ankle disorders in Urdu speaking population.

Acute ankle sprains represent one of the most common traumatic injuries to the musculoskeletal system. Many individuals with these injuries experience unresolved symptoms such as instability and recurrent sprains, leading to chronic ankle instability (CAI), which affects their ability to maintain an active lifestyle. While rehabilitation programs focusing on sensorimotor, neuromuscular, strength and balance training are primary treatments, some patients require surgery when rehabilitation fails. A critical analysis of the patient-reported outcome tools (PROs) used to assess CAI surgical outcomes raises some concerns about their measurement properties in CAI patients, which may ultimately affect the quality of evidence supporting current surgical practice. The aim of this research is to develop and validate a new PRO for the assessment of ankle instability and CAI treatment outcomes, following recent methodological guidelines, with the implicit aim of contributing to the generation of scientifically meaningful evidence for clinical practice in patients with ankle instability.

Following the COnsensus-based Standards for the selection of Health Measurement Instruments (COSMIN), an Ankle Instability Treatment Index (AITI) will be developed and validated. The process begins with qualitative research based on face‒to‒face interviews with CAI individuals to explore the subjective experience of living with ankle instability. The data from the interviews will be coded following an inductive approach and used to develop the AITI content. The preliminary version of the scale will be refined through an additional round of face‒to‒face interviews with a new set of CAI subjects to define the AITI content coverage, relevance and clarity. Once content validity has been examined, the AITI will be subjected to quantitative analysis of different measurement properties: construct validity, reliability and responsiveness.

The development of AITI aims to address the limitations of existing instruments for evaluating surgical outcomes in patients with CAI. By incorporating patient input and adhering to contemporary standards for validity and reliability, this tool seeks to provide a reliable and meaningful assessment of treatment effects.

Not applicable.

Ligamentous lesions of the ankle joint are common. Isolated medial ligament injuries are rare but are often associated with lateral ligament injuries, isolated medial ligament lesions are often overlooked. The present study aimed to evaluate the clinical and functional differences in the outcomes of isolated lateral and combined medial and lateral ligament reconstruction. The study is based on patient-reported outcome measurements and motion sensor technology to assess these outcomes.

The purpose of this study was to compare the clinical and functional outcomes of isolated lateral and combined lateral and medial ankle ligament reconstruction.

From December 2014 to August 2018, 111 patients underwent either isolated lateral ligament (LG) or medial and lateral ligament (MLG) reconstruction. Of the 104 patients meeting the inclusion criteria, 49 had LG and 55 had MLG reconstruction. Outcome measures included the Short Form-36 Health Survey SF-36, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAMG), Tegner Activity Scale, the European Foot and Ankle Society (EFAS), American Orthopaedic Foot and Ancle Society (AOFAS) hindfoot score, and the Karlsson Peterson Score. Mobility and stability were assessed using the Ortheligent™ motion sensor for both healthy and treated ankles.

While there were no significant differences in outcome scores between the groups, overall scores improved after treatment (p >0.00). Notably LG showed improved movement, with better dorsal extension measured by the Sensor (p ÷ 0.02). The sensor's results correlated significantly with FAOS subscales for pain (p ÷0.05), stiffness (p ÷ 0.01), ADL (p ÷0.02), and sports (p >0.00).

Postoperative results, regardless of LG or MLG, showed significant subjective well-being improvement. LG's advantages were highlighted by a significant improvement in dorsal extension, supported by correlated results from a portable motion sensor assessing ankle stability.

Pediatric idiopathic pes planovalgus can correct itself with growth. Otherwise, in the event of functional impairment and after failed conservative treatment, surgery can be considered. Based on a multicenter retrospective study, we report the functional and radiographic results obtained after subtalar arthroereisis.

We hypothesized that this surgery improves functional and radiological parameters in childhood.

Forty-eight medical records of children (78 feet) operated on between 2010 and 2019 were studied. Functional (FAOS score) and radiographic (Djian angle, calcaneal slope, lateral talocalcaneal divergence and calcaneus/M5 alignment, talonavicular coverage measurement, AP talocalcaneal divergence) results were studied. The analysis of these different criteria was carried out between the preoperative period and the last follow-up.

The functional outcome was satisfactory with an average FAOS questionnaire score of 95.5 out of 100 total points. All the radiographic parameters studied were significantly improved (p<0.001). The average age at the time of surgery was 11.3 years (range: 7 to 16) with a mean follow-up of 35 months (range: 18 months to 84). Spontaneous screw expulsion and subtalar pain were the main complications found.

The results obtained are consistent with those in the literature. The age at the time of the surgery is an essential factor to consider with the goal of optimal correction.

This technique is reliable and effective in the short term. It can be offered as first-line therapy in the management of symptomatic pes planovalgus in children. The follow-up is short, which necessitates longer term studies of this population. The ideal age for surgery remains to be determined.

IV.

Osteoarthritis (OA) care should be more person-centered based on physical, emotional and social aspects, instead of the current stepped-care approach solely based on physical symptoms, according to OA patients. By developing a novel module for OA in the Assessment of Burden of Chronic Condition (ABCC)-tool, a tool based on these three aspects, experienced quality of OA care and shared-decision making are expected to improve.

The development of the novel OA module involved a triangular iterative process, interviewing OA patients and healthcare professionals in the field of OA, an expert panel and a literature search to identify the needs to improve OA care. Patients provided feedback on the first version of the OA module, leading to a second version. This second version was used to evaluate content validity. OA patients and healthcare professionals in the field of OA were asked to evaluate relevance, comprehensiveness and comprehensibility, based on the COSMIN methodology. For healthcare professionals, the item-content validity index (I-CVI) was calculated.

The module includes questions about pain, kinesiophobia and joint stiffness. For all three questions, 94% of the patients found these questions important for patients with OA. The I-CVI scores of the healthcare professionals ranged from 1.0 (pain, kinesiophobia) to 0.75 (joint stiffness).

A novel, condition-specific OA module is developed for the ABCC-tool, as a supplement to the generic questions. The module includes three questions, to measure OA specific complaints. This novel module is intended to make the ABCC-tool more elaborate and useable for a larger population.

This study aimed to calculate region and diagnosis-specific minimal important changes (MICs) of the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM) in patients requiring foot and ankle surgery and to assess their variability across different foot and ankle diagnoses.

The study used routinely collected data from patients undergoing elective foot and ankle surgery. Patients had been invited to complete the FAOS and FAAM preoperatively and at 3-6 months after surgery, along with two anchor questions encompassing change in pain and daily function. Patients were categorised according to region of pathology and subsequent diagnoses. MICs were calculated using predictive modelling (MICPRED) and receiver operating characteristic curve (MICROC) method and evaluated according to strict credibility criteria.

Substantial variability of the MICs between forefoot and ankle/hindfoot region was observed, as well as among specific foot and ankle diagnoses, with MICPRED and MICROC values ranging from 7.8 to 25.5 points and 9.4 to 27.8, respectively. Despite differences between MICROC and MICPRED estimates, both calculation methods exhibited largely consistent patterns of variation across subgroups, with forefoot conditions systematically showing smaller MICs than ankle/hindfoot conditions. Most MICs demonstrated high credibility; however, the majority of the MICs for the FAOS symptoms subscale and forefoot conditions exhibited insufficient or low credibility.

The MICs of the FAOS and FAAM vary across foot and ankle diagnoses in patients undergoing elective foot and ankle surgery and should not be used as a universal fixed value, but recognised as contextual parameters. This can help clinicians and researchers in more accurate interpretation of the FAOS and FAAM change scores.

Level IV.

Our study aimed to examine preoperative differences in strength and balance between dominant foot (DF) and nondominant foot (non-DF) of individuals undergoing ligament stabilization surgery in the general population. Patients with records of preoperative evaluation, including isokinetic dynamometric strength evaluation, Y-balance test (YBT), and Foot and Ankle Outcome Score (FAOS), were included in the study. The DF was the preferred leg for accurately kicking a ball through a goal. Statistical analysis determined the differences between DF and non-DF and the correlations between muscle strength, balance, and FAOS. There was no statistically significant difference between DF and non-DF regarding evertor and invertor muscle strength (p=0.082-0.951). The YBT revealed no significant difference between the two groups (p=0.082-0.951). There was a significant correlation between the evertor peak torque and total work deficits at 30°/s (p=0.022), as well as the evertor peak torque deficit at 120°/s (p=0.048). No significant differences in muscle strength and balance were found between DF and non-DF in nonathletes with chronic ankle instability. Peroneal muscle strength deficit was associated with functional impairment. Tailored interventions are needed to address limb dominance and muscle strength deficits in CAI management.

The present study aimed to compare the clinical outcomes and safety at a 1-year follow-up after 5 or 6 weeks of non-weight bearing after a Talar OsteoPeriostic grafting from the Iliac Crest (TOPIC) for a medial osteochondral lesion of the talus (OLT).

A retrospective comparative case-control analysis of prospectively followed patients who underwent a TOPIC procedure with medial malleolus osteotomy was performed. Patients were matched in two groups with either 5 or 6 weeks of non-weight bearing. Clinical outcomes were evaluated using the Numeric Rating Scale (NRS) during walking, rest, running, and stairclimbing. Additionally, the Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were assessed. Moreover, radiology and complications were assessed.

Eleven patients were included in the 5-week non-weight bearing group and 22 in the 6-week non-weight bearing group. No significant differences were found in any of the baseline variables. The NRS during walking in the 5-week group improved by 3.5 points and 4 points for the 6-week group (p = 0.58 at 1-year post-operatively). In addition, all other NRS scores, FAOS subscales and the AOFAS scores improved (all n.s. at 1 year follow-up). No significant differences in radiological (osteotomy union and cyst presence in the graft) were found. Moreover, no significant differences were found in terms of complications and reoperations.

No statistical significant differences were found in terms of clinical, radiological and safety outcomes between 5 or 6 weeks of non-weight bearing following a TOPIC for a medial OLT.

Level III, Therapeutic.

Although adolescent flexible flatfoot deformity (FFD) is common, little is known regarding the effect of weight on associated symptomatology. This study uses pedobarography and patient-reported outcome measures (PROs) to determine if overweight adolescents with FFD have more severe alterations in dynamic plantar pressures than normal body mass index percentiles (wnBMI) with FFD and if such alterations correlate with pain and activity.

A retrospective review of patients aged 10 to 18 years with nonsyndromic symptomatic FFD was performed. Overweight (BMI percentile ≥ 85%) patients were compared with wnBMI patients with regard to dynamic plantar pressure measures and PRO scores. Pedobarographic data were subdivided into regions: medial/lateral hindfoot and midfoot, and first, second, and third to fifth metatarsals. Plantar pressure variables were normalized to account for differences in foot size, body weight, and walking speed. Contact area (CA%), maximum force by body weight (MF%), and contact time as a percentage of the rollover process (CT%) were calculated. Two foot-specific PROs were assessed, including the Foot and Ankle Outcome Score and the Oxford Ankle Foot Measure for Children.

Of the 48 adolescents studied, 27 (56%) were overweight and 21 (44%) were wnBMI. After normalization of the data, overweight patients had significantly greater medial midfoot MF%, whereas CT% was increased across the medial and lateral midfoot and hindfoot regions. Correlations showed positive trends: as BMI percentile increases, so will CA and MF in the medial midfoot, as well as CT in the medial and lateral midfoot and hindfoot. Significant differences were seen between groups, with the overweight group reporting lower sports and recreation subscores than the wnBMI group. No significant differences were seen in the pain and disability subscores.

Although overweight adolescents with FFD exhibit greater forces and more time spent during the rollover process in the medial midfoot than normal-weight patients, they did not report worse pain or disability associated with their flat foot deformity.

Therapeutic level 3.

Large numbers of people are subject to alterations and pathologies in the foot. To quantify how these problems of foot function affect the quality of life, clinicians and researchers have developed measures such as the Foot Function Index (FFI). Our aim is to determine the methodological quality of the FFI including adaptations to other languages.

The studies considered in this review were extracted from the PubMed, Embase and CINAHL databases. The inclusion criteria were followed: (1) studies of patients with no previous foot or ankle pathology and aged over 18 years; (2) based on English-language patient-reported outcome measures that assess foot function; (3) the patient-reported outcome measures should present measurement properties based on COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria.

The systematic review was conducted following the COSMIN criteria to establish the methodological quality of the original FFI, together with its variants and adaptations. The last search was carried out in May 2024.

Of the 1994 studies obtained in the preliminary search, 20 were eligible for inclusion in the final analysis. These results are the validations and cross-cultural adaptations to the following languages: the original FFI has cross-cultural adaptation in 13 languages and the FFI-Revised Short Form has been adapted and validated for use in 2 languages.

In terms of methodological quality, the FFI-Revised Short Form questionnaire is a valuable instrument for evaluating ankle and foot function and could usefully be expanded to be available in more languages.

Functional Ankle Instability (FAI) is the subject of extensive research in sports and other environments. Given the importance of accurately measuring this latent construct, it is imperative to carry out a careful assessment of the available tools. In this context, the aim of this review was to take an in-depth look at the six most cited measurement tools to assess FAI, with a specific focus on patient-reported outcome measures related to ankle and foot. Four electronic databases (Web of Science, Scopus, Pubmed, and SportDiscus) were searched (up to November 2022) to identify the six most cited questionnaires for assessing FAI. Our analysis showed that the most cited questionnaires are the following: the Lower Extremity Functional Scale (LEFS), the Foot Function Index (FFI), the Foot and Ankle Ability Measure (FAAM), the Foot and Ankle Outcome Score (FAOS), the Olerud and Molander Ankle Score (OMAS), and the Cumberland Ankle Instability Tool (CAIT). Each questionnaire was thoroughly assessed and discussed in three sections: Development, Reliability, and Summaries. In addition, bibliometric data were calculated to analyze the relevance of each questionnaire. Despite variations in terms of validity and reliability, conceptualization, structure, and usefulness, the six questionnaires proved to be robust from a psychometric point of view, being widely supported in the literature. The bibliometric analyses suggested that the FAOS ranks first and the FFI ranks sixth in the weighted average of the impact factors of their original publications.

To investigate retired elite female rugby players' health outcomes (and their relationships) in five key areas (musculoskeletal, cognitive, mental, reproductive/endocrinological and cardiovascular) and how those compare with the general population.

Female rugby players aged ≥18 years old and retired from elite competition ≥2 years were recruited via email or social media to complete a 179-item online questionnaire and neurocognitive assessment. Data from general population controls (matched for age and sex) were obtained where available.

159 participants responded (average age 43 (±5) years). 156 (98%) reported a hip/groin, knee, foot/ankle or lower back injury during their career, of which 104 (67%) reported ongoing pain. Participants reported worse hip and knee outcomes compared with the general population (p<0.0001). 146 (92%) reported sustaining one or more concussions. History of concussion was associated with lower-than-average scores on neurocognitive assessment. Compared with general population data, retired female rugby players reported less anxiety (OR=0.079 (95% CI 0.03 to 0.19)), depression (OR=0.67 (95% CI 0.57 to 0.78)) and distress (OR=0.17 (95% CI 0.15 to 0.19)). Amenorrhoea rates were higher compared with matched controls, and the age at menopause was younger. The prevalence of hypertension was higher. The rugby players perceived that their health decreased in retirement and cited a lack of physical activity as a main contributor.

Our findings point to the potential value of screening and monitoring, and identifying preventative measures during sporting careers to promote health and long-term quality of life for athletes.