Purpose of the study: THe peritalar joints are centered around the talus. They are stabilized by powerful ligaments and oriented along precise alignments. Osteoarthritis of the ankle joint can result from architectural anomalies of the peritalar joints which can be corrected with appropriate surgery. Errors in assessing these disorders is often the cause of failure and consequently the poor reputation of ankle prostheses. This emphasizes the importance of the clinical and radiological preparation. The Méary view with comparative films if possible, enables accurate analysis of the alignments and bone relations as well as the different anomalies of the peritalar joints. Material and methods: Our experience with more than 500 ankle prostheses implanted since 1989 has led to sometimes proposing complementary corrective procedures before the arthroplasty. Here we present 62 cases of AES total ankle arthroplasty (37 men and 25 women, mean age 55 years) with seven years follow-up. Several types of osteotomies were used: fibular, tibial, malleolar, calcaneal. These osteotomies were sometimes associated or combined with other procedures for ligament plasty fo example. Results: The overall score was based on the AFCP 100 point functional scale. The score improved from 31.2 on average preoperatively to 78.8 postoperatively. Complications were: involuntary intraoperative fracture, wound healing disorder, reflex dystrophy, nonunion, prosthetic loosening. Conclusion: Quality Méary views enable an adapted study of the peritalar disorders and the causes of the tibiotarsal osteoarthritic degradation in order to establish a well-adapted surgical plan with the goal of re-establishing normal anatomy. Favorable outcome and thus be expected for ankle prostheses. The indication for arthroplasty can thus be discussed for difficult cases to date treated by arthrodesis

Introduction: Total ankle prostheses (TAP’s) are implanted for end stage cartilage damage especially in patients with rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) or post-traumatic arthritis. Little is known about the long term survival of these prostheses in patients with RA and JIA. In this study we examined the outcome of TAP in these patients. Patients and methods: Between 1994 and 2004 85 TAP’s were implanted in 58 cases (10 males and 48 females) with RA (n=53) or juvenile chronic arthritis (n=5). The records of all patients were reviewed. Every patient was invited for a visit to our outpatient clinic for a history taking, a physical examination and a Kofoed ankle score (a clinical score for ankle function ranging from 0 to 100) was obtained. Results: The record of every patient was available for review. Two patients had died (cause of death was unrelated to the surgery), and 56 patients could be reexamined. A perioperative fracture (8 medial 3 lateral and 2 tibial) occurred in 13 cases. The fractures were fixed in the same operation and healed without complications; none of these prostheses needed a reintervention. After a mean follow up of 2.7 years (range 1 to 9 years) two patients died with the prosthesis in situ, one patient underwent an above knee amputation for infected arthroplasties of ankle and knee and four prostheses were removed because of loosening or malfunctioning of the prosthesis and arthrodeses were performed. The other 51 cases were analysed and showed a mean Kofoed ankle score of 72.8 (SD=15.8). This score is similar to scores obtained from patients receiving ankle arthroplasties for non-rheumatic indications. Conclusions: Placement of total ankle prostheses in patients with RA shows good medium term results. The intra-operative fracture rate is high, but does not affect the outcome; none of the failed arthroplasties was due to a preoperative fracture

Objectives: Total ankle replacement (TAR) is increasingly used for treatment of primary or posttraumatic arthritis of the ankle joint, if joint movement is intended to be preserved. Data on characteristics and treatment of ankle prosthetic joint infection (PJI) is limited and no validated therapeutic algorithm exist. Therefore, we analyzed all infections, which occurred in a cohort of implanted ankle prostheses during a 5-year-period. Methods: Between 06/2004 and 12/2008, all patients with an implanted ankle prosthesis at our institution were retrospectively reviewed. All patients were operated by the same surgical team. Ankle PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract, or microbial growth in periprosthetic tissue or sonication fluid of the removed prosthesis. The surgery on the infected ankle prosthesis and the follow-up were performed by the surgical team, who implanted the prosthesis. A specialized septic team consisting of an orthopaedic surgeon and infectious diseases consultant were included in the treatment. Results: During the study period, 92 total ankle prostheses were implanted in 90 patients (mean age 61 years, range 28–80 years). 78 patients had posttraumatic arthritis, 11 rheumatoid arthritis and 3 other degenerative disorder. Ankle PJI occurred in 3 of 92 TAR (3.3%), occurring 1, 2 and 24 months after implantation; the causative organisms were Enterobacter cloacae, Streptococcus pyogenes and Staphylococcus epidermidis, respectively. The ankle prosthesis was removed in all infected patients, including debridement of the surrounding tissue was debrided and insertion of an antibiotic loaded spacer. Provisional arthrodesis was performed by external fixation in two patients and by plaster cast in one. A definitive ankle arthrodesis with a retrograde nail was performed 6 to 8 weeks after prosthesis removal. One patient needed a flap coverage. All 3 patients received intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 4–6 weeks. At follow-up visit up to 18 months after start of treatment, all patients were without clinical or laboratory signs of infection. Conclusions: The infection incidence after TAR was 3.3%, which is slightly higher than reported after hip (< 1%) or knee arthroplasty (< 2%). A two-step approach consisting of removal of the infected prosthesis, combined with local and systemic antibiotic treatment, followed by definitive ankle arthrodesis shows good results. Larger patient cohort and longer follow-up evaluation is needed to define the optimal treatment approach for ankle PJI

Introduction:. The Scandinavian Total Ankle Replacement (STAR) is a three-component, uncemented implant in widespread use throughout Europe. STAR has achieved encouraging results with short and medium term outcome. We present the long term (13–19 year) results of a consecutive series of 200 STAR ankles. Methods:. Between November 1993 and February 2000, a total of 200 consecutive STARs were carried out in 184 patients. Patients were followed up both clinically and radiologically, until death or failure, with time to decision to revision or fusion as the endpoint. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. Results:. Of the 200 STARs, 109 (105 patients) were alive at latest review. 12 STARs (11 patients) were lost to follow-up, leaving 97 ankles for clinical review. Of these, 76 ankles were surviving and 21 ankles had failed [13 underwent arthrodesis, 4 had an exchange of poly insert, and 4 had a revision TAR], with mean time to failure 82 months (2–156 months). For the 91 ankles in 79 patients who died during the study, 8 had failed [6 underwent revision TAR and 2 had an arthrodesis]. The implant survival at 15 years with endpoint of revision for any reason was 76.9% [95% CI 66.4 to 87.3]. The mean AOFAS score was 72 [20 to 96]. The mean annual failure rate was 1.5%, which was steady across the study period. Conclusion:. The 15 year survivorship for the STAR prosthesis was 76.9%, which provides a benchmark for other later design ankle prostheses. We found no drop off in failure rate or function over the study period

Aim. This controlled study uses gait analysis to evaluate patients' pre- and post-ankle arthroplasty, post-ankle arthrodesis and compares the results with a healthy control group to assess whether these theoretical benefits are borne out in clinical practice. Method. Five patient groups (arthrodesis, arthroses, arthroplasty after 6 and 12 months and control) each consisting of 12 patients were analysed in our gait laboratory and the following parameters obtained at two different walking speeds: velocity, cadence, step length, stride length, the timing of toe off and the duration of stance phase. In addition, the ground reaction force during the whole gait cycle was recorded, as well as the range of movement of the knee and of the foot in relation to the tibia in walking and functional tests. Results. Subjects who had undergone arthrodesis were able to go faster with a longer step length on the affected side than their counterparts with an ankle prosthesis. However, this gain seemed to be at the expense of a symmetrical gait pattern and increased knee movement. Ankle prostheses also produced a stance phase and ground reaction force that was closer to the control group in duration and timing and also a more symmetrical timing of toe off. Discussion. Overall, our data supports the clinical observation that the gait pattern after total ankle replacement is more symmetrical with a less pronounced limp than in ankle arthrodesis. It is hoped that this will lead to decreased strain on neighbouring joints; however, the long term benefit of this is not yet established. It is not yet clear whether the long term implant survivorship of total ankle replacement is of sufficient duration to justify this unproven benefit

Purpose: Total ankle arthroplasty remains a difficult procedure. Some patients require revision surgery for arthrodesis. Material and methods: We report nine patients with total ankle arthroplasties mainly implanted for post-traumatic osteoarthritis whose results deteriorated, requiring arthrodesis. One of these patients had rheumatoid arthritis. Revision surgery was performed six months to seven years after arthroplasty. Arthrodesis was required for pain related or not to implant loosening or talar necrosis. One patient developed a major deviation of the hind foot secondary to progressive loosening. One patient developed infection early. An iliac graft was used to fill the bone defect in eight patients. An anterior plate-screw fixation was used for six patients, crossed screws for one, a tibiotalar nail for one, and an external fixator for one (with infection). Results: Eight patients achieved bone healing with good pain relief. The functional result depended on the type of arthrodesis: talocrural alone or extended to the torsion couple. Discussion: The evolution of ankle prostheses toward better bone sparing has allowed, in our experience, for revision arthrodesis under relatively good conditions using an iliac graft. We have not preferred one standard type of fixation but the anterior plate fixation has provided excellent stability

Background: The number of total ankle replacements has been raising in the last years. Most publications present short- and medium-term results. Comparison of outcomes is difficult because of inconsistent terminology and different parameters used. Moreover, poorly performing implants cannot be identified quickly because of low numbers, delayed reporting or publication bias. Methods: Therefore, we have developed a module for total ankle prostheses in the framework of the International Documentation and Evaluation System (IDES) for standardized and centralized documentation of TAA outcomes. Content validation was conducted with a single surgeon series of 74 HINTEGRA_ ankle replacements. Results: Between March 2004 and February 2008 74 patients were treated. The preoperative diagnosis was 18.9% osteoarthritis, 32.4% rheumatoid arthritis, 43.3% posttraumatic, 1.4% osteonecrosis and 4% others. There were intraoperative complications in 4%, local postoperative complications in 17.6% and revision surgeries in 16.2% of patients. The AOFAS hind-foot score improved from 23.8 points preoperative to 75.3 points after a mean followup time of 8.4 months. No significant differences in outcome were revealed between the various diagnostic groups. Conclusion: The IDES-forms facilitate a structured and standardized data collection that is feasible in a research orientated but also purely clinical setting; this because of the different extents to which data can be recorded. The consistent use of the system assures a stringent internal quality assurance, and more interesting, an external quality assurance by means of comparisons and benchmarking with other users feeding the data pool with the exact same variables and outcomes. The Hintegra ankle appeared as a safe device with low complication rates in the hands of a foot and ankle specialist. A surgical learning curve was seen in the first two years

Introduction: Arthrodesis has been recommended for the treatment of end-stage osteoarthritis of the ankle joint, especially as the results of prosthetic ankle replacement are not comparable with those achieved with total hip or knee replacement. In vitro studies revealed that ankle arthrodesis restricts kinematics more than total ankle replacement in terms of range of motion as well as movment transfer. However, little is known about in vivo gait patterns in patients with arthrodesis of the ankle joint. Aim of this retropective study was to determine plantar pressure distribution in patients who underwent ankle arthrodesis with a standardized screw fixation technique in a single surgeon population. Methods: 21 patients (7 male/14 female) who underwent isolated unilateral ankle arthrodesis with 3 crossed 7,3 mm AO screws (Synthes Gmbh, Austria) in a standardized technique by a single surgeon between October 2000 and January 2008 have been included in this study. At a mean follow-up of 25 months (range 12 – 75) pedobarograhy (Novel GmbH., Munich), clinical evaluation using the AOFAS hindfoot score and weight-bearing x-rays of the foot were performed. Results: Pedobarographic assessment revealed no statistically significant difference between the operated foot and the contralateral foot eighter in terms of peak pressure, maximum force, contact area and contact time or the gait line parameters velocity of center of pressure, lateral-medial force indices or lateral-medial area indices. The average AOFAS score was 80,5 (range 46 – 92) and mean tibioplantar angle determined on the lateral standing radiograph was 91° (82° – 100°). Non-union didn’t occur in any patient. Discussion: The results of the present study indicate that ankle arthrodesis restores plantar pressure distribution patterns to those of healthy feet. Therefore, the functional outcome of ankle arthrodesis seems to be good as long as the fusion is in fixed in an appropriate position

With the increasing number of implantation of total ankle arthroplasty a higher rate of pitfalls and failures has to be expected. Intra- and postoperative complications in total ankle arthroplasty, their sources of failure and revision options are demonstrated. In the time of 7/97 until 1/06 269 S.T.A.R. total ankle prostheses have been implanted at our hospital. Intraoperative complications occurred in 7 cases (4 fractures of the malleolus medialis, 2 fractures of distal fibula, 1 fissure of talus). We observed early complications in form of delayed wound healing (n=31) and 4 deep infections. A higher incidence of secondary wound healing is shown in rheumatoid arthritis patients in comparison to patients with OA. Late complications included persisting intraarticular synovitis, especially in rheumatoid arthritis, an impingement (11 cases) and osteolysis (4 cases). Revision surgery was performed in 45 cases (16.7%) 1.5 years after primary implantation (14 operations with problems in secondary wound healing, 9 lengthenings of the Achilles tendon with a dorsal capsulotomy (2 rheumatoid arthritis patients), 11 revisions of the PE gliding core with resection of periarticular hypertrophic bone formation, 4 revisions of singular components, 2 complete revisions of the prosthesis, 4 ankle fusions, 1 amputation. Only in 18 cases (6.7%) these complications and the following surgical procedures influenced the satisfaction of the patients. Despite the demonstrated complications, total ankle arthroplasty is more than an alternative to open ankle arthrodesis in the progressive phases of arthritic joint destruction, also in RA at a LDE stage ≥ III

Introduction. Total ankle arthroplasty is increasingly used as an alternative to arthrodesis to treat advanced ankle arthritis. In an attempt to assess the survivorship and patient outcome as well as peri- and postoperative complications and possible risk factors, we retrospectively analyzed the demographics, clinical outcome and radiographic characteristics of 100 ankle prostheses (97 patients). Patients and methods. Between 3/2005 and 5/2010 114 S.T.A.R. Prostheses were implanted by one surgeon at our institution. Indication for TAA was primary and secondary osteoarthritis, 81 cases were posttraumatic. From the 53 female and 44 male patients the mean age was 63 and the mean BMI was 28,4. 11 patients had been smoking for longer than 12 years, 29 patients either had a history of diabetes, peripheral vascular or cardiovascular disease or varicosis. All operations were performed with a tourniquet, using a standard anterior midline incision. All patients received the same postoperative rehabilitation and follow up program. Postoperative evaluation included the AOFA Score and clinical radiographic follow ups 6 weeks after surgery and yearly thereafter. Additional procedures during surgery included lengthening of the Achilles tendon for 12 patients and fusion of the subtalar ankle for 5 patients. Results. The average follow up was 36 months. The preoperative AOFA Score of 36.87 (22–58) increased to 75.99 postoperative. 87 cases reported a better life quality and 82 cases would go for surgery again. 27 ankles incurred complications after primary surgery. 21 prostheses had to go for revision surgery. Most complications were due to aseptic loosening/ implant failure. Other complications include arthrofibrosis and impingement as well as delayed wound healing and deep infection. Four patients had to be revised to an athrodesis. Conclusion. Our study shows a high satisfaction rate after total ankle replacement and clear pain relief which is the primary indication for ankle arthroplasty. Patients with a body mass Index higher than 30 as well as patients with a history of diabetes or peripheral vascular disease and smokers showed a higher rate of complications. Although these are encouraging results, the rate of complications should be discussed with patients. Compared with ankle fusion, the rates of complications seem to be comparable

Background. Total ankle arthrpoplasty (TAA) was performed frequently for ankle deformity caused by rheumatoid arthritis (RA) and osteoarthritis (OA). TAA has some advantages over ankle arthrodesis in range of motion (ROM). However, loosening and sinking of implant have been reported with several prostheses, especially constrained designs. Recently, we have performed mobile bearing TAA and report short term results of this prosthesis followed average 3 years. Method. 20 total ankle prostheses were implanted in patients with RA (n=14) or OA (n=6) in 19 patients (5 male and 14 female, one bilateral), between 2005 and 2009. We used FINE total ankle arthroplasty that is mobile bearing system (Nakashima Medical Co., Ltd, Okayama, Japan). All patients were assessed for American Orthopaedic Foot and Ankle Society (AOFAS) score, ROM in plantar flexion and dorsiflexion at the point of pre-operation and final follow-up. We evaluated radiolucent line, sinking, and alignment of prostheses at final follow-up. Results. At the operation, patients were, on average, 64.1 years old. The mean follow-up period was 34.0 (6∼55) months. We found excellent satisfaction and a significant improvement of AOFAS score. Plantar flexion and dorsiflexion also improved compared with the preoperative state, but not significantly (table 1). At final follow-up, five ankles (25%) showed radiolucent line around the components or sinking of prostheses. Three ankles (15%) was performed reoperation, due to early infection, progressive medial OA change by sinking, and loosening of the talus component. Discussion. Radiolucent line around the components or sinking of prostheses occurred at high frequency (25%). But, only two ankles (10%) were had to reoperation, cause by pain. We take account of the fact that the symptom was lack in spite of radiological changes. Good clinical results can be achieved with FINE total ankle arthroplasty system. However, this series was short term of follow-up. We need to evaluate mid- and long- clinical results. Mobile bearing total ankle arthroplasty is a treatment option for RA and OA

Introduction and aims. Recently many implants for ankle arthroplasty have been developed around the world, and especially some mobile bearing, three-component implants have good results. Nevertheless, at our institution fixed two-component, semi-constrained alumina ceramic total ankle arthroplasty (TAA) with TNK Ankle had been performed since 1991 and led to improved outcomes. We report clinical results and in vivo kinematic analyses for TNK Ankle. Method. Between 1991 and 2006, total ankle arthroplasties with TNK Ankle were performed with 102 patients (106 ankles) with osteoarthritis at our institution. There were 91 women and 11 men. The mean age was 69 years and mean follow-up was 5.4 years. These cases were evaluated clinically and radiographically. Besides in vivo kinematics, in TNK Ankle was analysed using 3D-2D model registration technique with fluoroscopic images. Between 2007 and 2008, prospectively ten TAA cases examined with fluoroscopy at postoperative one year. Results. In clinical results, excellent were 48 cases, good were 31 cases, fair were 10 cases, poor were nine cases, and death and loss to follow-up were 10 cases. Reoperations are performed on eight cases, one was arthrodesis, seven were talar component revision or talar revision with ceramic whole talus prosthesis. TNK Ankle have the rough surfaces by beadworks, and added surface treatment with hydroxyapatite granules, calcium phosphate paste or tissue engineered mesenchymal cells. Recently, only talar components were fixed with bone cement. Loosening has been more frequent in talar than tibial, whereas no reoperation was on cemented talar component cases. According to 3D-2D model registration, both components rotated a little each other and the contact region between both components variously sifted during weight bearing flexion of ankle. It was supposed that replaced position and angle of components concerned with the contact region. Conclusions. TAA with TNK Ankle have led to better results with improvement for surface treatments. Kinematics of ankle prostheses was derived by 3D-2D model registration, more appropriate position and angle to replace

Purpose: The purpose of this work was to evaluate the mid-term clinical and radiological outcome of a homogeneous and continuous series of third-generation total ankle prostheses (resurfacing, cylindric, noncemented, triple-compartment). Material and methods: From March 1990 to June 1996, 26 patients aged 57 years (32–73) were treated with a New Jersey LCS (n=5) or Buechel-Pappas (n=21) prosthesis. Most of the patients (n=21) had a posttraumatic ankle. Preoperatively, mean ankle motion was 17°. The AOFAS score was used for the clinical assessment. The position of the prosthesis and its stability over time were assessed on the x-rays together with the insert, the bone-prosthesis interface, the bone structure and periprosthetic ossifications. Results: Intra and postoperative complications were malleolar fracture (n=5), haematoma (n=1), late wound healing (n=1), insert instability (n=2), and medial malleolar conflict (n=1) requiring reoperation with preservation of the implant. At mean follow-up of seven years, two patients had died and one was lost to follow-up. Three had an arthrodesis: failed fixation at two years, secondary talar mobilisation at seven years, and secondary infection at eight years. For the other twenty patients: the AOFAS score was poor for two patients (including one with patent wear), fair in two, and good in 16. Mean joint motion at last follow-up was 24°. Radiographically, there were no significant changes in the position of the tibial and talar elements. Anchorage of the tibial element was fibrous in half of the patients and ossesous in the other half. A macro defect aspect was observed below the talar element in four patients. There were active periprosthetic ossifications in the majority of the patients. Discussion: The insufficient ancillary for this prosthesis and its old concept explain the frequency of malleolar fractures and the level of the functional outcomes. Improved prostheses should be used. The stability of the results observed in this series of patients followed up to 12 years is an argument favouring indicating prosthesis insertion as an alternative to arthrodesis, particularly since revision of an arthrodesis is not particularly difficult, even with an iliac graft. The radiographic evidence of periprosthetic ossifications or bone resorption, particularly under the implant, emphasises the need for prolonged surveillance

Introduction: Ankle arthropathy is associated with a decreased motion of the ankle-hindfoot during ambulation. Ankle arthrodesis was shown to result in degeneration of the neighbour joints of the foot. Inversely, total ankle arthroplasty conceptually preserves the adjacent joints because of the residual mobility of the ankle but this has not been demonstrated yet in vivo. It has also been reported that degenerative ankle diseases, and even arthrodesis, do not result in alteration of the knee and hip joints. We present the preliminary results of a new approach of this problem based on ambulatory gait analysis. Patients and Methods: Motion analysis of the lower limbs was performed using a Physilog® (BioAGM, CH) system consisting of three-dimensional (3D) accelerometer and gyroscope, coupled to a magnetic system (Liberty©, Polhemus, USA). Both systems have been validated. Three groups of two patients were included into this pilot study and compared to healthy subjects (controls) during level walking: patients with ankle osteoarthritis (group 1), patients treated by ankle arthrodesis (group 2), patients treated by total ankle prosthesis (group 3). Results: Motion patterns of all analyzed joints over more than 20 gait cycles in each subject were highly repeatable. Motion amplitude of the ankle-hindfoot in control patients was similar to recently reported results. Ankle arthrodesis limited the motion of the ankle-hindfoot in the sagittal and horizontal planes. The prosthetic ankle allowed a more physiologic movement in the sagittal plane only. Ankle arthritis and its treatments did not influence the range of motion of the knee and hip joint during stance phase, excepted for a slight decrease of the hip flexion in groups 1 and 2. Conclusion: The reliability of the system was shown by the repeatability of the consecutive measurements. The results of this preliminary study were similar to those obtained through laboratory gait analysis. However, our system has the advantage to allow ambulatory analysis of 3D kinematics of the lower limbs outside of a gait laboratory and in real life conditions. To our knowledge this is a new concept in the analysis of ankle arthropathy and its treatments. Therefore, there is a potential to address specific questions like the difficult comparison of the benefits of ankle arthroplasty versus arthrodesis. The encouraging results of this pilot study offer the perspective to analyze the consequences of ankle arthropathy and its treatments on the biomechanics of the lower limbs ambulatory, in vivo and in daily life conditions

Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. Sectioning of the deltoid ligament has been shown to decrease tibiotalar contact area by 43%. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. Pankovich and Shivaram described the deltoid ligament as having superficial and deep components based on insertion sites. The superficial layer originates from the anterior colliculus of the medial malleolus and inserts on the navicular, calcaneus and talus. The deep layer originates from the intercollicular groove and posterior colliculus and inserts on the talus. Boss and Hintermann noted that the most consistent and strongest bands of the deltoid were the tibiocalcaneal and posterior deep tibiotalar ligaments. Chronic deltoid ligament insufficiency may be seen in several disorders including trauma and sports injuries, posterior tibial tendon disorders, prior triple arthrodesis with valgus malunion, or total ankle arthroplasty with improper component positioning or pre-existing ligament laxity. The reconstruction of the deltoid ligament in these settings may be critical to the prevention of tibiotalar arthrosis or failure of ankle prostheses from edge loading and polyethylene wear. The reconstructive technique we describe, under low torque, was able to restore eversion and external rotation stability to the talus, which was statistically similar to the native deltoid ligament. In addition, though we maximally tension this graft to give the most secure repair possible, we did not note any increased stiffness in the ankle joint through our measurement techniques. This unusual, positive secondary effect is different from that noted in studies of lateral ligament reconstruction, where ligament tensioning by all methods attempts to reproduce the native tension and not exceed it. All medial ankle ligament repairs of substance involve some type of tendon-weave (whether autograft or allograft) to achieve reconstruction. Our technique develops its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone. The use of Endobuttons allows the entire graft to sit within the tunnels, without the potential violation of the graft ends achieved through techniques utilizing interference screw fixation. Tensioning the graft proximally through the tibia against a rigid distal construct allows greater tension to be placed on the graft at the deltoid ligament site itself than techniques which employ distal tensioning while holding the ankle into inversion. Finally, the use of a looped graft proximally secured with a post that may be moved even further proximally at the surgeon's discretion creates superior tension to achieve medial column rigidity in grossly unstable situations. Thus, given the critical importance of the deltoid ligament and the relative paucity of repair/reconstruction options available, we believe this novel approach will assist the clinician in anatomically reconstructing this challenging condition. Deltoid ligament reconstruction technique using semitendinosis allograft, with superimposed line drawing demonstrating orientation of looped graft

The December 2015 Foot & Ankle Roundup³⁶⁰ looks at: The midfoot fusion bolt: has it had its day?; Ankle arthroplasty: only for the old?; A return to the Keller’s osteotomy for diabetic feet?; Joint sparing surgery for ankle arthritis in the context of deformity?; Beware the subtalar fusion in the ankle arthrodesis patient?; Nonunion in the foot and ankle a predictive score; Cast versus early weight bearing following Achilles tendon repair; Should we plate Lisfranc injuries?