Aims. Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT. Methods. We retrospectively analyzed 32 consecutive symptomatic patients with OLT who underwent PACT with minimum one-year follow-up. Standard preoperative radiography and MRI were performed for all patients. Follow-up second-look arthroscopy or MRI was performed with patient consent approximately one-year postoperatively. Magnetic resonance Observation of Cartilage Repair Tissue (MOCART) score and International Cartilage Repair Society (ICRS) grades were used to evaluate the quality of the regenerated cartilage. Clinical outcomes were assessed using the pain visual analogue scale (VAS), Foot Function Index (FFI), and Foot Ankle Outcome Scale (FAOS). Results. All patients had ICRS grade IV cartilage lesions, except for one (ICRS grade III). The paired MOCART scores significantly improved from 42.5 (SD 1.53) to 63.5 (SD 22.60) (p = 0.025) in ten patients. Seven patients agreed to undergo second-look arthroscopy; 5 patients had grade I (normal) ICRS scores and two patients had grade II (nearly normal) ICRS scores. VAS, FFI, and all subscales of FAOS were significantly improved postoperatively (p ≤ 0.003). Conclusion. PACT significantly improved the clinical, radiological, and morphological outcomes of OLT. We consider this to be a safe and effective surgical method based on the short-term clinical results of this study. Cite this article: Bone Jt Open 2023;4(12):942–947

Introduction. The prevalence of symptomatic osteoarthritis (OA) in the knee is 11–11% compared to 3.4–4.4% in the ankle. In addition to this, 70% of ankle arthritis is post-traumatic while the vast majority of knee arthritis is primary OA. Several reports have previously implicated biochemical differences in extracellular matrix composition between these joint cartilages; however, it is unknown whether there is an inherent difference in their transcriptome and how this might affect their respective functionality under load, inflammatory environment etc. Therefore, we have analysed the transcriptome of ankle and knee cartilage chondrocytes to determine whether this could account for the lower prevalence and altered aetiology of ankle OA. Methods. Human full-depth articular cartilage was taken from the talar domes (n=5) and the femoral condyles (n=5) following surgical amputation. RNA was extracted and next generation sequencing (NGS) performed using the NextSeq®500 system. Statistical analysis was performed to identify differentially regulated genes (p adj < 0.05). Data was analysed using Integrated Pathway Analysis software and genes of interest validated by quantitative PCR. Results. 809 genes were differentially expressed in this NGS study: 781 genes were significantly up-regulated and 27 significantly down-regulated in ankle cartilage with respect to knee. Preliminary analysis has identified several pathways which are differentially regulated including ‘inflammation mediated by cytokines’, ‘glutamate receptor pathway, ‘heterotrimeric-G-protein signalling pathways’, ‘WNT signalling’ and ‘integrin signalling’. Discussion. This is the first report identifying genes that are differentially expressed in ankle cartilage compared to the knee. Validation is currently being performed to ascertain the importance of these gene changes and correlation with their protein expression in the different joints. An understanding of the inherent biological differences in the cartilage between these two joints will provide invaluable insight into why the ankle is relatively spared from primary OA and the majority of ankle arthritis occurs following trauma

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation.

Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Cite this article: Bone Joint J 2014;96-B:164–71.

Introduction

Studies have compared outcomes of first metatarsophalangeal joint (MTPJ1) implant hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on outcomes. We evaluated data from a prospective, RCT of MTPJ1 implant hemiarthroplasty (Cartiva) and arthrodesis to determine the association between patient factors and clinical outcomes.

We have evaluated the clinical effectiveness of a metal resurfacing inlay implant for osteochondral defects of the medial talar dome after failed previous surgical treatment. We prospectively studied 20 consecutive patients with a mean age of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery. There was statistically significant reduction of pain in each of four situations (i.e., rest, walking, stair climbing and running; p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 62 (interquartile range (IQR) 46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up (p < 0.001). The Foot and Ankle Outcome Score improved on all subscales (p ≤ 0.03). The mean Short-Form 36 physical component scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55) at final follow-up (p = 0.001); the mental component scale did not change significantly. On radiographs, progressive degenerative changes of the opposing tibial plafond were observed in two patients. One patient required additional surgery for the osteochondral defect. This study shows that a metal implant is a promising treatment for osteochondral defects of the medial talar dome after failed previous surgery.

Cite this article: Bone Joint J 2013;95-B:1650–5.

Introduction. Autologous Matrix Induced Chondrogenesis (AMIC) for surgical treatment of osteochondral lesions of the talus (OCLT) has shown excellent clinical and radiological results at short term follow up two years after surgery. However, no mid-term follow up data is available. Aim. 1. To evaluate the clinical outcome after AMIC-aided reconstruction of osteochondral lesions of the talus at a minimum follow up time of five years. 2. To evaluate the morphology and quality of the regenerated cartilage by magnetic resonance imaging (MRI) at on at a minimum follow up time of five years. Methods. Seventeen patients prospectively underwent surgery receiving a AMIC-aided repair of OCLT consisting of debridement, autologous grafting, and sealing of the defect with a collagen scaffold (Chondro-Gide, Geistlich Surgery, Wolhusen, Switzerland). Clinical and radiological assessment was performed before and after a minimum of 60 months after surgery (average 78 months, range, 60–120). Clinical examination included the American Orthopaedic Foot & Ankle Society (AOFAS) ankle score and the Visual Analogue Scale (VAS). Radiological imaging consisted of MRI. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was applied. Results. The AOFAS ankle score improved significantly from a mean of 60 points preoperatively (range, 17–79) to 91 points (range, 70–100) postoperatively (p< 0.01). The preoperative pain score averaged a VAS of 5 (range, 2–8), improving to an average of 1.1 (range 0–8) (p< 0.01). The MOCART score for cartilage repair tissue on postoperative MRI averaged 71 points (range, 50–90). Conclusion. The AMIC-procedure is safe for the treatment of OCLT with overall good clinical and magnetic resonance imaging results at five years follow up

Introduction. The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space. Methods. We retrospectively reviewed 32 CT scans of new Freiberg's diagnoses in Sheffield over a 10 year period using the PACS system. We identified the sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx and measured the diseased segment of the corresponding metatarsal head as an arc (in degrees). This arc segment was divided by 360°. This gave a ratio of the affected arc in the sagittal plane. Results. 28 out of 32 cases involved the 2nd metatarsal with the remaining 4 involving the 3rd metatarsal head. Of 32 cases, 18 had fragmentation. Surgically, 20 had debridement only, 5 also had an osteotomy and 1 had a fusion. 6 of the 32 cases were managed non-operatively. 11 cases out of 32 had an arc ratio of < 0.3. Of these, only 3 had an osteotomy, 3 had no procedure and 5 had a simple debridement. Of those that had osteotomies (5/32), 3 of the 5 cases had an arc ratio of < 0.3 with the other 2 being 0.42 and 0.38. Discussion. We hypothesise that those cases with an arc ratio of less 0.3 would be amenable to a dorsal closing wedge osteotomy and those with a ratio of more than 0.4 would be better suited to a simple debridement. For those cases between 0.3–0.4, we feel either option is viable. Further work to prove or disprove outcomes related to our classification is required

Introduction/Purpose. A randomized clinical trial of first MTP joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. Recognizing that many hemiarthroplasty and total toe implants have initially good results that deteriorate over time, the purpose of this study was to prospectively assess the safety and efficacy outcomes for the synthetic cartilage implant population and to determine if the excellent outcomes were maintained at >5 years. Methods. One hundred nineteen patients were evaluated at 5+ years; 23 could not be reached for follow-up, but implant status was available for 7 of these subjects. Patients completed a pain visual analogue scale (VAS) and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, preoperatively and at 2, 6, 12, 26, 52, 104 and 260 weeks postoperatively. Minimal clinically important differences are: ≥30% difference for pain VAS, 9 points for FAAM Sports, and 8 points for FAAM ADL. Great toe active dorsiflexion, weight-bearing radiographs, secondary procedures, and safety parameters were evaluated. Results. Of 119 patients available at mean 5.8 years follow-up (SD ±0.7; range: 4.4–8.0), 9 underwent implant removal and conversion to fusion in years 2–5, leaving 106 patients. The implant survival rate was 92.4% at 5.8 years. Pain and function outcomes at 5.8 years were similar to those at 2 years. VAS Pain, FAAM Sports, ADL Scores were maintained or improved at 5.8 years. No evidence of avascular necrosis, device migration or fragmentation was observed. There were no unanticipated safety events through 5.8 years. Ninety-three (93%) percent would have the procedure again. Conclusion. The synthetic cartilage hemiarthroplasty implant continues to demonstrate safety and efficacy for the treatment of advanced first MTP joint osteoarthritis with evidence of therapeutic effect and acceptable safety profile at 5.8 years

Aims. The aim of this study was to evaluate antegrade autologous bone grafting with the preservation of articular cartilage in the treatment of symptomatic osteochondral lesions of the talus with subchondral cysts. Patients and Methods. The study involved seven men and five women; their mean age was 35.9 years (14 to 70). All lesions included full-thickness articular cartilage extending through subchondral bone and were associated with subchondral cysts. Medial lesions were exposed through an oblique medial malleolar osteotomy, and one lateral lesion was exposed by expanding an anterolateral arthroscopic portal. After refreshing the subchondral cyst, it was grafted with autologous cancellous bone from the distal tibial metaphysis. The fragments of cartilage were fixed with 5-0 nylon sutures to the surrounding cartilage. Function was assessed at a mean follow-up of 25.3 months (15 to 50), using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot outcome score. The radiological outcome was assessed using MRI and CT scans. Results. The mean AOFAS score improved from 65.7 (47 to 81) preoperatively to 92 (90 to 100) at final follow-up, with 100% patient satisfaction. The radiolucent area of the cysts almost disappeared on plain radiographs in all patients immediately after surgery, and there were no recurrences at the most recent follow-up. The medial malleolar screws were removed in seven patients, although none had symptoms. At this time, further arthroscopy was undertaken, when it was found that the mean International Cartilage Repair Society (ICRS) arthroscopic score represented near-normal cartilage. Conclusion. Autologous bone grafting with fixation of chondral fragments preserves the original cartilage in the short term, and could be considered in the treatment for adult patients with symptomatic osteochondral defect and subchondral cysts. Cite this article: Bone Joint J 2018;100-B:590–5

Aims

Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger patients. 9-14. . Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration. 15. , distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By mounting the fixator components to the bone on each side of the joint, and then lengthening the rods connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage regeneration during distraction are not yet understood. A possible negative consequence of joint fixation is cartilage degeneration due to immobilization during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be detrimental to articular cartilage. 16-18. . Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage cartilage regeneration. 19-22. Toward this end, considerable effort has been invested in the application of hinges to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in distraction treatment, as well. 10. This is borne out by data from an RCT comparing the use of a rigid vs motion external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of symptoms

It is recognised that as the severity of hallux valgus (HV) worsens, so do the clinical and radiological signs of arthritis in the first metatarsophalangeal joint. However, few studies specifically document the degenerate changes. The purpose of this study is to determine if intraoperative mapping of articular erosive lesions of the first MTP joint can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity. Materials & Methods. We prospectively analysed 50 patients who underwent surgery between Jan 2009 & Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS scores were recorded. Radiographic measurements were obtained from weight bearing radiographs. Intraoperative evaluation of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading. Results. three patients did not have scoring or cartilage wear documentation carried out and were excluded. The mean age was 56 years. The mean hallux valgus angle was 31 degrees. The mean IMA was 15 degrees. The mean AOFAS score was 62. Patients with no inferomedial (IM) and inferolateral (IL) wear had significantly better AOFAS score than patients who had IM & IL wear (p < 0.05). Patients who had IM & IL wear had a significantly higher HVA (p < 0.05). There was a significant positive correlation between hallux valgus angle and AOFAS score. We also found correlation between sesamoid wear and AOFAS score and HV angle. Conclusion. we conclude that preoperative clinical and radiographic measurements can be used to predict the incidence and location of articular erosions in the 1st MTPJ and are helpful in the preoperative assessment of the HV deformity

Aims

The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

Introduction. A randomized clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a synthetic cartilage implant demonstrated equivalent pain, function and safety outcomes to first MTP joint arthrodesis at 2 years. The implant cohort continues to be followed under an extension of the original study and we report on prospectively determined 5+ year outcomes for subjects assessed to date. Methods. Patients treated with hemiarthroplasty implant as part of the previously mentioned trial are eligible for enrollment in the extended study (n=135). At the time of this report, 57 patients had reached the 5+ years postoperative time point, of which 5 were lost to follow-up. The remaining 52 patients with mean age of 58.5 (range, 38.0–0.0) underwent physical examination, radiographic evaluation, assessment of implant survivorship and collection of patient completed VAS pain, and Foot and Ankle Ability Measure (FAAM) sports subscale and activities of daily living (ADL) subscale scores. Mean follow-up is 5.8 (range, 4.8–8.4) years. Results. Patient reported pain and function outcome measures showed clinically and statistically meaningful improvements over baseline at 5.8 years. Mean VAS pain scores decreased 57.9 points (86% pain reduction). The mean FAAM Sports and ADL subscale scores increased from baseline 47.9 points (126%) and 32.7 points (55%) respectively. Patients maintained first MTP joint motion with mean active peak MTP dorsiflexion of 25.9° (range, 0–0°) which was a 3° improvement from baseline. Implant survivorship at 5.8 years was 92%; four were converted to fusion because of persistent pain at mean time 42 months post-operation (range, 26–26 months). These results are equivalent to the outcomes reported at 2 years follow-up. 1. Conclusion. The synthetic cartilage hemiarthroplasty implant continues to demonstrate safety and efficacy for the treatment of advanced first MTP joint osteoarthritis with mid-term evidence of a therapeutic effect and an acceptable safety profile at 5.8 years

Aims

In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

Introduction. Mesenchymal stem cells (MSCs) are a potential source of cells for the repair of articular cartilage and osteochondral defects (OCD) in the ankle. Synovial tissue has been shown to be a rich source of MSCs with the ability to undergo chondrogenic differentiation. Although these cells represent a heterogenous population, clonal populations have not been previously studied. Methods. MSCs were isolated from synovial tissue of a patient undergoing joint arthroplasty and expanded in culture. Six clonal populations were also isolated and expanded. The cells from the mixed parent population and the derived clonal populations were characterised for stem cell surface epitopes, and then cultured in chondrogenic mediums. Various assays were determined to analyse for features of differentiation. Results. Cells from the mixed parent population and the derived clonal populations stained strongly for markers of adult mesenchymal stem cells including CD44, CD90 and CD105, and they were negative for the haematopoietic marker CD34 and for the neural and myogenic marker CD56. Interestingly, a variable number of cells were also positive for the pericyte marker 3G5 both in the mixed parent and clonal populations. The clonal populations exhibited a variable chondrogenic response. Conclusion. Pericytes are a candidate stem cell in many tissues and our results show that all six clonal populations derived from the heterogenous synovium population express the pericyte marker 3G5. The chondrogenic potential of synovial tissue could be optimised by the identification of clonal populations with a propensity to differentiate down particular differentiation pathways. Our study demonstrates a role for MSCs in of osteochondral defects (OCDs) and areas of focal cartilage damage in the ankle joint

Introduction. Osteoarthritis commonly affects the first metatarsophalangeal joint. Stress across this joint has been postulated to increase the incidence of osteoarthritis. Certain foot structures have been associated with a higher incidence of osteoarthritis of the big toe. Utilizing finite elemental analysis, bone stress across the first metatarsophalangeal joint was calculated during mid stance phase of gait and compared in different foot structures. Method. A geometrically accurate three dimensional model of the first metatarsophalangeal joint was created utilising a high resolution 7 tesla MRI and Mimics v14 imaging software. Planus, rectus and cavus feet were simulated by varying the metatarsophalangeal declination angle to 10.1, 20.2 and 30.7 degrees, respectively. A non-manfold computer aided design technique in Mimics v14.2 and finite element method in ANSYS v12 FE were utilised to create the boundary conditions, representing the double support stance phase of gait. Using information from 61 asymptomatic patients with different foot types walking over a Novel emed-x plantar pressure measuring system, plantar loading conditions were applied. Finite elemental analysis was used to predict stress in the first metatarsophalangeal joint in the different foot types. Results. The peak stresses in the distal first metatarsophalangeal joint cartilage were 1.1×10(6) Pa, 6.0×10(5) Pa and 9.7×10(5) Pa for planus, rectus and cavus foot types, respectively. This corresponds to 83.3 percent and 61.6 percent increases in first metatarsophalangeal joint contact stress for the planus and cavus feet relative to the rectus foot. Conclusion. The results suggest there is a higher contact stress of the first metatarsophalangeal joint in patients with pes planus and pes cavus compared to the rectus foot. This may account for the increase risk of first metatarsophalangeal joint osteoarthritis in patients with pes planus. Further work has been initiated utilising this model to measure first metatarsophalangeal joint stress with different hindfoot loading

Peroneal tendon subluxation although rare, is a commonly misdiagnosed cause of lateral ankle pain and instability. The orientation and depth of the lateral retromalleolar groove is a major contributor to peroneal stability, but is little understood. We attempt to quantify the groove using three directional mapping techniques. Eight age and sex matched embalmed cadaveric feet were dissected to expose the peroneal tendons and the retromalleolar groove. A hand held digitiser was used to map the version and inclination of the groove in a 3D virtual environment. The length and depth of the groove and its orientation were calculated using the cartilage boundary and the centroid of the curved surface. Four male and four female specimens (mean age 80 Yrs) were studied. The groove was noted to be concave in 62%, flat in 25 % and concave in 12.5 %. Flatter groove were more commonly noted in (2/4) females. There was a significant difference in length and width of the groove between male and female feet. The mean length of the groove in male specimens was 6.2cm (5.4–6.7cm), and in female specimens 5.5cm (4.4–5.9cm). The mean width in males was 5.3mm (5.0–6.1mm) and in females 4.5mm (3.7–5.3mm). There was no significant difference noted in the depth of the groove between male and female feet. The mean depth in males was 2.3mm (0.8–3.1) and in female 2.2mm (0–2.4mm). Knowledge of peroneal groove geometry in treatment of peroneal tendon instability is important. There appears to be a consistent difference in the anatomy of the groove between the sexes. Although men have longer and wider grooves than woman, the depth is the same in both sexes

Introduction. Freiberg's disease is an uncommon condition of anterior metatarsalgia that involves the head of metatarsals. Avascular necrosis of the metatarsal head is thought to arise during puberty. Treatment is usually conservative and operative treatment reserved for cases that do not respond to these measures. Materials and Methods. We retrospectively reviewed a consecutive series of ten patients who presented to our institution who did not respond to conservative methods. These patients were treated surgically with a previously undescribed operative technique involving microfracture of the metatarsal heads and reattachment of the cartilage flap. Results. Mean follow up was 49 post operative months (18–96). Mean pain score at rest and on mobilising was 2.1 (0–3) and 3.1 (0–5) respectively. At 6 months, all 10 patients had reported a satisfactory outcome and return to acceptable activity levels. Discussion. The aim of the treatment for late stage Freiberg's disease is to relieve pain and improve the mobility of the patient by restoring the metatarsophalangeal joint function. Other techniques described involve osteotomies or minimal resection of the base of the proximal phalanx and insertion of metallic spacers which are removed several weeks later. However none has shown to be significantly superior to another. All of our patients reported a significant reduction of pain in their feet and all were able to walk and run almost pain free. There were no reported cases of severe restriction of movement or fixed deformity of the toe. Conclusion. This technique involves a single operative procedure that encourages metatarsal head remodelling and restoration of the joint articular surface. It is advantageous as we have seen remodelling of the metatarsal heads without causing shortening or other anatomical abnormalities in the area