Arthroscopic repair of chronic ankle instability: preliminary results

Objective To evaluate the clinical efficacy and safety of all-inside arthroscopic repair of anterior talofibular ligament (ATFL) for chronic lateral ankle instability (CLAI). Methods From Oc-tober 2016 to September 2017, 19 patients with CLAI were treated with all-inside arthroscopic repair of ATFL at Department of Orthopaedic Surgery, Zhejiang Provincial People’s Hospital and Department of Foot and Ankle Surgery, Guangzhou Orthopaedic Hospital.They were 12 men and 7 women, aged from 18 to 35 years (mean, 27.3 years).Their defective ATFLs had no effective tension.After the fibular foot-print zone of ATFL was refreshed, an absorbable anchor was inserted accurately and its suture was threaded into the remnant of ATFL using the all-inside arthroscopic technique.The remnant of ATFL was fixated by the suture using Las-so-Loop method and anatomically repaired into the foot-print zone to restore the ligamentous tension.The American Orthopedic Foot and Ankle Surgery Society (AOFAS) ankle-hindfoot score, Karlsson ankle function score, Tegner activity score and visual analogue scale (VAS) were used to assess funtion of ankle before and after operation. Results All the 19 patients were followed up for a mean time of 15.6 months (from 12 to 22 months).Their ankle symptoms were all relieved after operation; their ankles recovered fine range of motion; their anterior drawer tests and varus stress tests were negative.Their preoperative AOFAS scores (64.6±11.4), Karlsson ankle function scores (63.5±11.4), Tegner activity scores (3.2±0.7) and VAS(5.8±1.7) were significantly improved at the final follow-up (92.3±3.2, 91.2±4.4, 5.7±0.6 and 1.4±1.0, respectively) (P<0.05).Complications such as incision and articular infections, superficial peroneal nerve injury, sural nerve injury and iatrogenic fracture were not demonstrated in the cohort.By the final follow-up, no patient had been found who needed a secondary revision. Conclusions The all-inside arthroscopic repair of ATFL can be used effectively and safely for CLAI, because it leads to accurate anchor insertion, anatomic repair, limited invasion, and reliable restoration of ligamentous tension.To avoid com-plications, surgeons should familiarize themselves with arthroscopic procedures. Key words: Ankle; Lateral ligament, ankle; Arthroscopy; Chronic anterolateral ankle in-stability; Anatomical ligament repair

To investigate the effectiveness of the suture anchor technique without knots for reconstruction of the anterior talofibular ligament (ATFL) combined with the reinforcement of the inferior extensor retinaculum in treating chronic lateral ankle instability (CLAI). The clinical data of 31 patients with CLAI who were admitted between August 2017 and December 2023 and met the selection criteria were retrospectively analyzed. There were 18 males and 13 females, with an age range from 20 to 48 years (mean, 34.6 years). All patients had a history of repeated ankle sprain, with a disease duration of 6-18 months (mean, 9.65 months). The anterior drawer test and inversion stress test were positive, and tenderness was present in the ligament area. Stress X-ray films of the ankle joint showed a talar tilt angle of (10.00±2.78)° and an anterior talar displacement of (9.48±1.96) mm on the affected side. MRI revealed discontinuity, tortuosity, or disappearance of the ATFL structure. Preoperatively, the visual analogue scale (VAS) score was 5.2±2.1, and the American Orthopaedic Foot and Ankle Society (AOFAS) score was 62.9±7.1. All patients underwent arthroscopic debridement of the ankle joint followed by reconstruction of the ATFL using the suture anchor technique without knots combined with reinforcement of the inferior extensor retinaculum. Postoperatively, pain and function were assessed using the VAS and AOFAS scores. Stress X-ray films were taken to measure the talar tilt angle and anterior talar displacement to evaluate changes in ankle joint stability. Patient satisfaction was assessed according to the Insall criteria. All 31 surgeries were successfully completed. One case had wound exudation, while the remaining surgical incisions healed by first intention. Two cases experienced numbness on the lateral aspect of the foot, which disappeared within 1 month after operation. All patients were followed up 15-84 months (mean, 47.2 months). No complication such as anchor loosening, recurrent lateral ankle instability, superficial peroneal nerve injury, rejection reaction, or wound infection occurred postoperatively. The anterior drawer test and inversion stress test were negative at 3 months after operation. Stress X-ray films taken at 3 months after operation showed the talar tilt angle of (2.86±1.72)° and the anterior talar displacement of (2.97±1.32) mm, both of which were significantly different from the preoperative values ( t=12.218, P<0.001; t=15.367, P<0.001). At last follow-up, 2 patients had ankle swelling after exercise, which resolved spontaneously with rest; all 31 patients returned to their pre-injury level of sports or had no significant discomfort in daily activities. At last follow-up, 25 patients were pain-free, 4 had mild pain after exercise, and 2 had mild pain after walking more than 2 000 meters. The VAS score was 0.8±0.9 and the AOFAS score was 91.6±4.1, both of which were significantly different from the preoperative scores ( t=10.851, P<0.001; t=-19.514, P<0.001). According to the Insall criteria, 24 patients were rated as excellent, 4 as good, and 3 as fair, with a satisfaction rate of 90.3%. The suture anchor technique without knots for reconstruction of the ATFL combined with reinforcement of the inferior extensor retinaculum provides satisfactory short- and mid-term effectiveness in treating CLAI.

BackgroundChronic Lateral Ankle Instability (CLAI) is a common condition treated using either Anterior Talofibular and Calcaneofibular Ligament (ATFL and CFL) reconstruction or Modified Brostrom Procedure (MBP). However, the comparative efficacy of these approaches is not well-studied.MethodsIn this study, clinical data were retrospectively collected from 101 patients diagnosed with CLAI who underwent either ATFL and CFL reconstruction (n = 51) or the MBP (n = 50). Patients were comparable in terms of age, sex, Body Mass Index (BMI), post-injury duration, preoperative American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson score, Visual Analog Score (VAS), Anterior Talar Translation, and Talar Tilt Angle.ResultsThe post-operative measures showed no significant differences in AOFAS Score, Karlsson Score, and VAS between both treatment groups. However, patients who underwent ATFL and CFL reconstruction showed significantly lower follow-up Anterior Talar Translation (mean = 4.1667 ± 1.3991 mm) and Talar Tilt Angle (mean = 5.0549 ± 1.6173°) compared to those who underwent MBP. Further, patients treated with ATFL and CFL reconstruction experienced a significantly longer postoperative recovery time (median = 6 weeks) compared to MBP (median = 3 weeks).ConclusionsAlthough both therapeutic techniques were generally effective in treating CLAI, the ATFL and CFL reconstruction approach delivered superior control of Anterior Talar Translation and Talar Tilt Angle. However, its longer recovery time merits further study to optimize the balance between therapeutic efficacy and recovery speed.

The anterior talofibular ligament is the weakest and most vulnerable lateral ligament to be injured, and it can replace anatomical position through anatomical reconstruction. The purpose of this study is to evaluate clinical outcomes after an autologous half-bundle peroneus longus tendon anatomical reconstruction. We conducted a retrospective analysis by enrolling 34 patients [22 male and 12 female, median age 21 (range 19–26) years] with anterior talofibular ligament injury from January 2018 to March 2020. All patients underwent a ligament anatomical reconstruction operation with autologous half-bundle peroneus longus tendon and followed up with an average time of 16.21 ± 3.20 (range 12–24) months, with no loss of patients to follow-up during the study period. The American Orthopedic Foot, Ankle Society Score (AOFAS), Visual Analogue Score (VAS), and Anterior Tibiotalar Translation were used to assess the curative effect. All the indexes were compared between the preoperative and at the final follow-up to discover the related statistical differences. The AOFAS score improved significantly from an average preoperative score of 56.91 ± 3.79 to 94.12 ± 2.51 at the final followed-up (p < 0.001). Meanwhile, the pre-operation VAS pain score decreased from 5.94 ± 1.32 to 1.71 ± 0.87 (p < 0.001). Additionally, the Anterior tibiotalar translation decreased from 16.40 ± 1.85 to 5.20 ± 0.57 mm at the final followed-up (p < 0.001). The anterior drawer test was negative for all patients after the operation. Considering the outcomes, we concluded that anatomical reconstruction of the anterior talofibular ligament with autologous half-bundle peroneal longus tendon was a proper and safe procedure for chronic lateral ankle instability, and it had good clinical results and minimal complications.

Background: Subfibular ossicles are frequently found in patients with chronic lateral ankle instability (CLAI). However, there is a lack of consensus about the optimal surgical treatment for CLAI with subfibular ossicle. Purpose: To evaluate the clinical and radiographic outcomes of the modified Broström procedure with subfibular ossicle excision compared with the same procedure for CLAI without subfibular ossicle. Study Design: Cohort study; Level of evidence, 3. Methods: Ninety-six patients (96 ankles) treated with the modified Broström procedure using bone tunnel and suture anchor techniques for CLAI constituted the study cohort. The 96 ankles were divided into 2 groups with and without subfibular ossicles. The ossicle group (42 ankles) and nonossicle group (54 ankles) consisted of patients with a mean age of 26.6 and 30.3 years, respectively, at the time of surgery with a mean follow-up duration of 63.7 and 62.1 months, respectively. Subfibular ossicles were excised in the ossicle group. Results: Mean Karlsson scores improved from 55.2 to 95.3 in the ossicle group and from 56.4 to 94.8 in the nonossicle group at final follow-up. Mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores also improved from 63.3 to 95.9 in the ossicle group and from 62.8 to 95.1 in the nonossicle group at final follow-up. Mean talar tilt angles were 14.0° in the ossicle group and 12.2° in the nonossicle group preoperatively and 7.6° and 6.8° at the final follow-up, respectively. Mean anterior talar translations in the ossicle group and nonossicle groups improved from 9.3 and 9.4 mm preoperatively to 5.8 and 5.7 mm at final follow-up, respectively. No significant differences were found between the 2 groups in terms of Karlsson score, AOFAS score, talar tilt angle, and anterior talar translation at final follow-up (P > .05). Conclusion: The modified Broström procedure with subfibular ossicle excision provided similarly good clinical and radiographic outcomes compared with the same procedure without subfibular ossicle excision. Accordingly, the study results suggest that these procedures appear to be effective and reliable method for the treatment of CLAI with subfibular ossicle.

Objective: To investigate the effect of simultaneous bone marrow stimulation in the treatment of osteochondral lesions of the talus (OLTs) on arthroscopic repair of anterior talofibular ligament. Methods: The clinical data of 33 patients with ankle instability treated by operation in Sun Yat-Sen Memorial Hospital from January 2018 to December 2019 were retrospectively analyzed. There were 20 males and 13 females with a mean age of (31±9) years. According to the type of surgery, the patients were divided into two groups: ligament repair group (arthroscopic anterior talofibular ligament repair) and bone marrow stimulation group (arthroscopic anterior talofibular ligament repair+talus microfracture). Visual analogue scale (VAS), American Orthopedic Foot And Ankle Society (AOFAS) score, time to return to work and time to return to sport were compared between the two groups. Results: In the ligament repair group, the preoperative VAS score and the AOFAS score was 5.0±1.9 and 72.4±9.0, respectively, and it was 1.1±1.6 and 95.5±5.2 at the last follow-up, respectively. In the bone marrow stimulation group, the preoperative VAS score and the AOFAS score was 5.8±1.9 and 64.8±12.6, respectively, and it was 1.8±1.5 and 93.1±5.6 at the last follow-up, respectively. The scores of VAS and AOFAS were significantly improved in both groups after the operation, but there was no significant difference between the two groups (both P>0.05). There was no significant difference in time to return to work and return to sport between the two groups (both P>0.05). Conclusion: When repairing the anterior talofibular ligament under arthroscopy, simultaneous bone marrow in the treatment of osteochondral lesions of the talus does not affect the postoperative functional recovery and the time to return to work/sport, and satisfactory clinical results also can be obtained.

The objective of this study was to investigate whether brain volume changes occur in patients with chronic ankle instability (CAI) using voxel-based morphometry and assessing correlations with clinical tests. Structural magnetic resonance imaging data were prospectively acquired in 24 patients with CAI and 34 healthy controls. CAI symptoms and pain intensity were assessed using the Foot and Ankle Ability Measure (FAAM), Cumberland Ankle Instability Tool (CAIT), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and visual analog scale (VAS). The gray matter volume (GMV) of each voxel was compared between the two groups while controlling for age, sex, weight, and education level. Correlation analysis was performed to identify associations between abnormal GMV regions and the FAAM score, AOFAS score, VAS score, disease duration, and body mass index. Patients with CAI exhibited reduced GMV in the right precentral and postcentral areas, right parahippocampal area, left thalamus, left parahippocampal area, and left postcentral area compared to that of healthy controls. Furthermore, the right parahippocampal (r = 0.642, p = 0.001), left parahippocampal (r = 0.486, p = 0.016), and left postcentral areas (r = 0.521, p = 0.009) were positively correlated with disease duration. The left thalamus was positively correlated with the CAIT score and FAAM activities of daily living score (r = 0.463, p = 0.023 and r = 0.561, p = 0.004, respectively). A significant positive correlation was found between the local GMV of the right and left parahippocampal areas (r = 0.487, p = 0.016 and r = 0.763, p < 0.001, respectively) and the AOFAS score. Neural plasticity may occur in the precentral and postcentral areas, parahippocampal area, and thalamus in patients with CAI. The patterns of structural reorganization in patients with CAI may provide useful information on the neuropathological mechanisms of CAI.

To explore the clinical efficacy of reconstruction the anterior talofibular ligament and calcaneofibular ligament with autologous peroneus brevis tendon for the treatment of chronic lateral ankle instability. The clinical data of 42 patients with chronic lateral ankle instability treated by anatomical reconstruction of anterior talofibular ligament and calcaneofibular ligament with autologous peroneus brevis tendon from July 2016 to July 2019 was retrospectively analyzed. Including 30 males and 12 females, age ranged from 25 to 46 years old with an average of (37.6±12.4) years. There were 15 cases of left foot and 27 cases of right foot, the time from injury to operation was 3 to 12 months with a mean of (7.4±2.8) months. And 14 patients had tenderness in lateral collateral ligament area, 28 patients complained of multiple ankle sprains while walking on the flat ground. At 12 months after operation, the talar tilt angle and visual analogue scale(VAS)were observed, ankle joint varus stress and anterior drawer test were performed to check the mechanical stability of the ankle joint, American Orhopaedic Foot and Ankle Society(AOFAS) was used to score the ankle and hindfoot functions and evaluate the curative effect. Forty patients were followed up for 12 to 48 months with an average of (28.3±10.0) months, 2 cases were lost. The VAS decreased from(4.50±0.93) scores before surgery to (1.10±0.30) scores at 12 months after surgery;the talar tilt angle was reduced from (12.26±1.13)° before operation to (4.60±0.45)° at 12 months after operation;the AOFAS score increased from (65.10±7.50)scores before surgery to (84.40±3.95) scores at 12 months after surgery;all the differences were statically significant(P<0.05). According to the AOFAS score, 27 cases got excellent results, 7 good, 5 fair, and 1 poor. One patient had the symptoms of sural nerve injury after operation, and the symptoms were relieved after oral Mecobalamin for 3 months. The remaining patients had no complications such as nerve injury, infection, and skin necrosis. There was no instability of ankle joint, and both ankle varus stress test and drawer test were negative. Autologous peroneal brevis tendon with double bone channel pass through the tendon (modified Chrisman-Snook operation) can anatomically reconstruct the anterior talofibular ligament and the calcaneofibular ligament, restore the stability of the patient's ankle joint, reduce postoperative complications, and restore ankle joint function well.

BackgroundThe aim of this study is to report our institution’s experience regarding the application of allogeneic tendons for the reconstruction of malunited lateral malleolar avulsion fractures with chronic lateral ankle instability.MethodsThis retrospective study included 34 (34 ankles) patients surgically treated for malunited lateral malleolar avulsion fractures with chronic lateral ankle instability from January 2016 to December 2019. All patients underwent allogeneic tendon reconstruction. The pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores、Karlsson Ankle Functional Scores (KAFS) and visual analogue scale (VAS) scores were used to evaluate the functional recovery of the ankle joint. The final follow-up, based on radiographic assessment, including talar tilt and anterior talar translation, was performed to evaluate the stability of the postoperative ankle joints.ResultsThirty-two patients (32 ankles) returned for final clinical and radiologic follow-up at an average of 29 (range 24–35) months and 2 patients (2 ankles) were lost to follow-up. The preoperative talus inclination angle (13.6 ± 1.9°) and anterior displacement (9.6 ± 2.8 mm) were re-examined under X-ray and found to be reduced to 3.4 ± 1.2° and 3.8 ± 1.1 mm, respectively (p＜0.01). The AOFAS scores increased from 58.5 ± 4.0 to 90.9 ± 3.8 and the Karlsson scores improved from 52.2 ± 3.6 to 89.8 ± 4.5, which was obviously better and the difference was statistically significant (P < 0.01). The VAS scores were significantly reduced from a preoperative mean of 6.8 ± 1.0 to 2.8 ± 0.9 postoperatively (p＜0.01).ConclusionIn this population and with this follow-up, the application of allogeneic tendons to treat malunited lateral malleolar avulsion fractures combined with chronic lateral ankle instability appeared safe and effective.

Objective To investigate the clinical result of treating Tillaux-Chaput fractures using the full ankle arthroscopy technique. Methods A retrospective analysis was made on 21 patients with Tillaux-Chaput fractures followed up after treatment by the full ankle arthroscopy technique from May 2013 to May 2015. There were 16 males and 5 females, with the age range of 6-55 years [(25.5±12.8)years]. Right ankle was involved in 12 patients and left ankle in 4 patients. Sixteen patients had single Tillaux-Chaput fractures and 5 patients had combined proximal fibular fractures. Diagnosis of Tillaux-Chaput fractures was confirmed by X-rays in 18 patients an CT in 3 patients. Ankle arthroscopy was used through the anterolateral and anteriormedal approaches for closed reduction and internal fixation using one or two Herbert screws. Wound healing, bone union and visual analogue score (VAS) were detected postoperatively. Function assessment was performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. Results All incisions healed by first intention, without evidence of nerve, vessel and tendon injuries. Period of follow-up was (15.3±7.1)months (range, 12-25 months). Fracture healed within 12 to 36 weeks [(22.6±4.6)weeks] after operation.VAS was (0.8±0.3)points after operation, obviously lower than preoperative (8.3±1.3)points (P<0.05). At the final follow-up, all patients regained normal ankle function and normal walking gait, without the presence of ankle pain and weight-bearing walking pain. AOFAS score was improved from preoperative (51.2±12.5)points to postoperative (92.7±16.5)points (P<0.05). Based on the AOFAS score, the results were excellent in 19 patients and good in 2 patients, with the excellent-good rate of 100%. Conclusion Full ankle arthroscopy by the anterolateral and anteriormedal approaches provides a precise and effective method for closed reduction and internal fixation of Tillaux-Chaput fractures and deserves clinical application. Key words: Ankle injuries; Arthroscopes; Surgical procedures, minimally invasive

Objective To evaluate Evans lateral lengthening calcaneal osteotomy(E-LLCOT) in the treatment of talocalcaneal coalitions (TCCs) with forefoot abduction deformity in the teenagers. Methods From February 2014 to August 2018, 11 teenaged patients (14 feet) were treated at Department of Foot and Ankle Surgery, Zhengzhou Orthopaedics Hospital for TCCs with severe forefoot abduction deformity. They were 6 males (8 feet) and 5 females (6 feet), aged from 13 to 17 years (average, 15 years). Their diseases involved bilateral feet in 3 cases and unilateral foot in 8, the left foot in 7 cases and the right in 7. All patients underwent TCCs resection followed by E-LLCOT. Their talonavicular coverage angles (TCA) and talar-second metatarsal angles (T2-MT) on the anteroposterior film and talar horizontal angles (TH) and talar-first metatarsal angles (T1-MT) on the lateral film were measured preoperatively and at the last follow-up. The foot functions were evaluated preoperatively and at the last follow-up using the ankle- hindfoot scores of American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS). Results All the 11 patients were followed up for 12 to 24 months (average, 16.5 months). The mean preoperative TCA (22.3°, from 20° to 26°) was improved to 10.5° (from 8° to 13°) at the last follow-up; the mean T-2MT was improved from preoperative 17.6° (from 16° to 20°) to 6.5° (from 5° to 11°) at the last follow-up; the mean TH on the lateral view was improved from preoperative 35° (from 25° to 40°) to 17.5° (from 16° to 21°) at the last follow-up; the mean T-1MT was improved from preoperative 15.5° (from 10° to 22°) to 3.5° (from 2° to 6°) at the last follow-up; the mean AOFAS score was improved from 56.5 (from 50 to 62) preoperatively to 90.6 (from 75 to 95) at the last follow-up; the mean VAS score was improved from 6.0 (from 5 to 7) preoperatively to 2 (from 0 to 3) at the last follow-up. Conclusion For TCCs with severe forefoot abduction deformity in the geenagers, E-LLCOT after TCCs resection can effectively correct deformity, relieve pain and achieve significant functional and radiographic improvements. Key words: Foot; Talus; Calcaneus; Talocalcaneal coalition; Osteotomy

Objective To discuss the application of suture anchors in the treatment of chronic lateral ankle instability using the modified Brostr(o)m technique.Methods From May 2009 to May 2011,we admitted 16 patients with ankle sprain of degree Ⅲ who had had little improvement after conservative treatment for more than 6 months and deteriorated into chronic lateral ankle instability.They were 7 men and 9 women,aged from 19 to 31 years (average,23.6 years).They all had mild swelling,pain and instability at the lateral ankle.We treated them with suture anchors using the modified Brostr(o)m technique.The pre-and post-operative ankle functions were evaluated by American Orthopaedic Foot and Ankle Society(AOFAS) scores.The patients' subjective feeling after operation was evaluated by the Good grading system.Results The patients were followed up for 6 to 24 months (average,16 months).The AOFAS ankle and hindfoot score improved significantly from preoperative 65.00 ± 6.65 points to postoperative 92.06 ± 3.13 points,the talar antedisplacement from preoperative 11.38 ±2.23 mm to postoperative 3.19 ± 1.1 mm,and the talar tilt angle from preoperative 13.44° ± 2.25° to postoperative 4.69° ± 1.35° (P ＜ 0.05).By the Good grading system for postoperative symptoms,there were 8 cases of grade Ⅰ,6 cases of grade Ⅱ,2 cases of grade Ⅲ and no case of grade Ⅳ,giving a good to excellent rate of 87.5％.Conclusion Suture anchors and modified Brostr(o)m technique is a reasonable and effective surgical method for the treatment of chronic lateral ankle instability. Key words: Sports medicine; Bone nails; Lateral ligament, ankle

Background:In this study, we aimed to evaluate the effectiveness of extracorporeal shockwave treatment (ESWT) on pain and ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS) score of patients with chronic Achilles tendinopathy (AT).Materials and Methods:In this double-blind clinical trial, 43 patients with chronic AT were selected and randomly allocated in two groups to receive a basic treatment with ESWT or sham SWT (radial and focused shock waves, four sessions once a week for 4 weeks). AOFAS and pain scores for each patient were recorded at baseline (before intervention), immediately after intervention, and 4 and 16 weeks after intervention using AOFAS and visual analog scale (VAS) scaling method.Results:A total of 43 patients (22 ESWT and 21 sham SWT) were participated in this study. Both groups improved during the treatment and follow-up period. The mean VAS score decreased from 7.55 to 3 in the intervention group and from 7.70 to 4.30 in the sham SWT group. Mean AOFAS and VAS scores were significantly different between ESWT and no ESWT groups at 16 weeks of follow-up (P = 0.013) (P = 0.47). There was no significant difference in terms of AOFAS and VAS scores between both the groups in the other follow-up times.Conclusion:Overall, ESWT causes decrease in VAS score and increase in AOFAS score. However, due to the small sample size, the results were not statistically significant. It is recommended to plan more interventional studies with larger sample size in the future.

We have read the article published by Toyooka et al., titled “Talus Position Correlates With Dorsiflexion Range of Motion Following a Lateral Ankle Sprain: A Cross-Sectional Study” (Health Science Reports, 2025) [1]. In this study, the authors ideally highlighted the correlation between anterior talus deviation and dorsiflexion range of motion (DFROM) followed by lateral ankle sprain. There are some limitations that we want to emphasize to further magnify this novel topic; Firstly, the sample size of the study is only 36 patients, principally consisting of young age, which limits the findings to other age groups with varying physical activity, and also does not clarify the grading of sprain. The Wisthoff et al. cross-sectional study, which has a sample size of over 36, offers important information about this relationship. Acute lateral ankle sprains occurred in 55 of the 108 participants in the Wisthoff et al. study. DFROM was found to have increased over time, suggesting a trend toward recovery. The study discovered that following an acute lateral ankle sprain, mechanical laxity and DFROM change over time, with significant variations in DFROM between sprain grades. In contrast to those with grade I sprains, participants with grade III sprains showed less DFROM, indicating that more severe sprains may result in more dorsiflexion restrictions because of altered talus positioning [2]. Secondly, this study keenly concentrates on the correlation between the anterior talofibular ligament (ATFL) and DFROM through an MRI assessment; it did not give ideas about other ligaments like the posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). Ultrasound and dynamic assessments can evaluate the correlation between talus position and dorsiflexion range of motion after a lateral ankle sprain. The effects of ligament injuries on ankle mechanics are revealed by these methods. Ultrasound allows a clear view of the lateral ligament complex and other lesions, which is essential for understanding talus position changes and dorsiflexion range of motion. Ultrasound can detect ATFL, PTFL, and CFL injuries, which affect ankle stability and talus position. Ultrasound can detect isolated ATFL injuries and those with ligament injuries, giving a complete ankle assessment [3]. Furthermore, this study did not determine the intensity of pain. Studies examining the impact of mobilization techniques on ankle sprains have shown that the Visual Analog Scale (VAS) is commonly used to numerically assess the intensity of pain during dorsiflexion movements. This scale is frequently used to gauge how painful dorsiflexion movements are for people with lateral ankle sprains. It offers a measurable indicator of pain, making it possible to evaluate how much pain has changed after mobilization and other interventions [4]. In addition, this study evaluates the talus deviation only in non-weight bearing or unstressed positions. When a patient has a lateral ankle sprain, weight-bearing DFROM tests, like the weight-bearing lunge test, are essential for identifying limitations that might not be noticeable in non-weight-bearing circumstances. This is so because functional movement patterns and joint stability after an injury are more accurately reflected under weight-bearing conditions. Weight-bearing DFROM in injured limbs can be considerably reduced when compared to uninjured ones, according to studies, even when non-weight-bearing DFROM seems normal [5]. Lastly, this study did not mention the long-term complications of talus anterior deviation like chronic ankle instability (CAI), anterior ankle impingement syndrome, and posttraumatic osteoarthritis. The degenerative changes linked to chronic lateral ankle instability may be exacerbated by altered kinematics in the talus position. One possible explanation for the increased incidence of joint cartilage lesions in chronic ankle instability is increased talar anterior deviation. Previous studies have shown a correlation between early onset of posttraumatic osteoarthritis and lateral ankle instability. Several researchers have hypothesized that changing kinematics and cartilage loading may account for osteoarthritic lesions on the medial talus in chronic ankle instability [6]. Also, there is a lack of effectual interventions like manual therapy which helps to improve dorsiflexion and to restore the normal talus position. In conclusion, we are thankful to the author for giving us the privilege for further investigation on this appreciable topic to enhance the findings regarding the limitations. Future research is recommended to further amplify this study. Syed Hassan Ali: conceptualization, data curation, formal analysis, resources, and writing – original draft. Shanza Shakir: formal analysis, data curation, resources, writing – original draft, writing – review and editing. Javed Iqbal: writing – original draft, writing – review and editing. The authors would like to thank the study entitled “Talus Position Correlates With Dorsiflexion Range of Motion Following a Lateral Ankle Sprain: A Cross-Sectional Study” and its authors for sharing their insights. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.

Objective To investigate the cause of metastatic metatarsalgia after hallux valgus surgery and the clinical outcomes of Weil osteotomy for metastatic metatarsalgia after hallux valgus surgery. Methods From July 2009 to Janurary 2012, data of 27 patients （27 feet） with metastatic metatarsalgia of 2nd to 4th head of metatarsal bone after hallux valgus surgery who had been treated by Weil osteotomy were retrospectively analyzed. There were 1 male and 26 females with an average age of 51 years （range, 28-73 years）. Metatarsalgia occurred 6-24 months after operation for hallux valgus. 13 feet underwent mini-invasive cervi-cal wedge osteotomy of the first metatarsal, 7 with Chevron procedure, 5 with Akin procedure, and 2 with Lapidus procedure. No shortening in first metatarsal was found in 5 feet with Akin osteotomy, while there were varying degrees of shortening in first meta-tarsal in the remaining 22 feet. The clinical results were evaluated by American Orthopaedic Foot and Ankle Society （AOFAS） and visual analogue scale （VAS） scores. The preoperative and postoperative plantar pressure changes were tested by plantar pressure tester. Results 25 Patients were followed up for 12-42 months （average, 24 months）. Among these 25 cases, the metatarsalgia of 23 cases were completely disappeared. The metatarsal plantar lateral metastatic pain occurred in the remaining 2 cases （2 feet） and 1 was relieved by the foot pad, 1 was cured by re-Weil osteotomy. AOFAS score was 46.82 ± 6.13 before surgery and 90.63 ± 1.65 after surgery. The VAS score was 7.5 （6, 7） before surgery and 0.5 （0, 1.0） after surgery. The last follow-up, according to the score of AOFAS toe metatarsophalangeal-interphalangeal joint, of which 23 cases were excellent, 1 good, 1 poor;the excellent and good rate was 96%（24/25）. Preoperative pressure under 2nd to 5th metatarsal head were 3.12±1.62 Pa, 5.81±1.92 Pa, 4.63± 2.10 Pa, 3.37±1.57 Pa, 1.67±1.20 Pa and postoperative were 3.33±1.35 Pa, 3.89±1.08 Pa, 3.65±1.96 Pa, 2.25±1.23, （1.48±1.11） Pa. Postoperative pressure under 2nd to 5th metatarsal head were significantly decreased. Conclusion Weil osteotomy can effec-tively adjust the length of the metatarsal and the height of metatarsal head, thus effectively improve the pressure under the metatar-sal head, so it could reach a good effect in the treatment of metastatic metatarsalgia after hallux valgus surgery. Key words: Metatarsalgia Hallux valgus Osteotomy Surgical procedures; operative