Tenosynovitis was first described by Velpeau in 1818. Many others, including de Quervain in 1895, have noted the importance of this common condition and the painful symptoms associated with this pathology around the ankle. In 1936, Dr Kulowski of St Joseph's, Missouri, was the first to publish on posterior tibial tendon (PTT) tendovaginitis (tenosynovitis). Since his initial description of the pathology, the condition has evolved into a complex spectrum of disease termed PTT insufficiency (PTTI). PTTI is the most common cause of adult-acquired flatfoot deformity (AAFD) and affects an estimated 3–10% of the population. The exact etiology of the condition remains unknown.

Introduction: Posterior heel pain is a frequently observed manifestation of foot and ankle discomfort. The condition is primarily attributed to many types of soft tissue disorders, such as bursitis and tendinopathy, as well as bone abnormalities such as posterosuperior deformity and posterior calcaneal spur. The management of these diverse entities should be delineated based on the underlying etiology of pain. Lateral calcaneus radiography is employed to detect bone pathology associated with this condition. Nevertheless, the predictive efficacy of all bone and spur measuring parameters remains equivocal. The objective was to assess the predictive efficacy of a novel radiographic test, known as bone prominence measurement (BPM), in comparison to existing methods. Materials and methods: A total of 184 individuals were categorized into two groups based on the presence or absence of posterior heel pain: symptomatic and asymptomatic. The weight-bearing lateral radiography measurements of the X/Y ratio, Fowler–Philip angle (FPA), Heneghan–Pavlov parallel pitch line (HPPPL), Chauveaux–Liet angle (CLA), and BPM were examined using a Chi-squared test. Results: There was no statistically significant difference between the two symptomatic groups in terms of X/Y ratio, FPA, and CLA. The HPPPL exhibited a notable disparity in the symptomatic group but demonstrated low specificity and positive predictive value (PPV). The 5 mm bony prominence's BPM parameter demonstrated a PPV of 90.4%, a sensitivity of 90.4%, and a specificity of 90.0%. A statistically significant difference was seen in BPM with a p-value of 0.001. Conclusion: BPM is a useful marker for confirming the presence of symptomatic posterior heel pain. The size of the posterior heel spur may be associated with improper tension on the Achilles tendon and the alleviation of symptoms following surgical removal.

Background: The Ponseti method has revolutionized the management of idiopathic clubfoot, and early initiation of casting is recommended for better outcomes. Methods: This prospective study aimed to evaluate the association between the timing of clubfoot casting in infants and treatment outcomes, including the duration of therapy, number of corrective casts, and Pirani score before and after casting. A total of 76 feet in 50 patients with idiopathic clubfoot were divided into two groups based on age: group A (0–1 month) and group B (1–12 months). All patients were managed using the Ponseti method of casting. Results: The mean age of patients was 2.66 ± 2.79 months, and 55.3% of the participants were under one month of age (group A). There was a significant difference between the two groups in terms of duration of treatment (in weeks) and number of casts, with the median number of casts being highest in the age-group over 1 month. Conclusion: The findings of this study support the recommendation to initiate clubfoot casting as soon as medically reasonable, preferably within the 1st month of life, as it leads to good outcomes in terms of duration of therapy, number of corrective casts, and Pirani score before and after casting. However, starting casting beyond one month of age does not appear to adversely affect outcomes, but the number of casts and duration of therapy are less if treatment is started in the 1st month of life. Level of evidence: II.

Introduction: Distal tibial metadiaphyseal fractures are challenging fractures that need multiple principles of fixation for optimal stability. Conventionally, when the distal locking screw hole of tibia interlock nail coincides with the fracture site, either the screw hole is left empty or the inserted screw through the fracture site does not have a good hold of the screw. We propose the use of screw with washer for compression of fracture fragments through the distal locking screw hole of tibia interlock nail in specific distal tibia fractures. Materials and methods: Fifty patients with distal third tibia fractures were treated with interlock nail with use of screw with washer for compression of fracture fragments at distal locking screw holes. Distal tibia fractures with medial spike or comminution overlapping distal locking screw holes needed compression to align them and prevent any malangulation at the fracture site. There were 13 (43A1) type fractures, 18 (43A2) type fractures, and 19 (43A3) type fractures. Fibula fixation was done in 22 patients. Poller screw fixation was done in 28 patients. Functional outcome was assessed based on the Johner and Wruhs radiological and clinical criteria. Results: Forty-eight patients had excellent to good scores; 2 patients had fair score based on Johner and Wruhs radiological and clinical criteria. Conclusion: Screws inserted with washers generate significantly more compressive forces than screws inserted without washers. A screw with washer is an effective tool during fracture fixation to optimize compression, minimize the risk of intrusion of the screw head during insertion through the fracture site and avoid leaving empty distal locking screw holes at fracture site, which is prone to implant failure (nail breakage).

Objective: To identify ultrasonographic manifestations of isolated superior anterior talofibular ligament (sf-ATFL) injury. Methods: A cadaveric experiment was conducted on a fresh–frozen specimen, during which the superior fascicle was visualized using an open anterior ankle approach, and a stainless-steel clip was applied near its fibular insertion. First, a portable ultrasound examination was performed to reveal normal sonographic features of the sf-ATFL. The ligament was then detached from its fibular insertion, and ultrasound examination was repeated to observe the sonographic signs of sf-ATFL rupture. Results: The sectioned superior fascicle was observed on ultrasound as slack and discontinuous with its fibular insertion. Conclusion: This proof-of-concept study confirms that portable ultrasound can detect a fibular detachment of the sf-ATFL. In clinical practice, the use of portable ultrasound may enable surgeons to diagnose and promptly manage ankle micro-instability.

Aim and background: The popularity of ankle arthroscopy is increasing in diagnostic and therapeutic procedures. The surgical technique has evolved over time. Distraction is used for better visualization of the entire joint and ease of instrumentation. Multiple invasive and noninvasive methods have been described. However, a cost-effective and simple setup ideal for a developing country is lacking and needs attention. Technique: The setup consists of a metal stand, generally used for administering intravenous drugs (IV stand), a clamp, and an ankle strap. With the limb on the lithotomy stand, the traction is applied. Using this technique, anterior and posterior portals can be made with ease. Conclusion: This is a convenient and cost-effective setup that can be used for distraction during ankle arthroscopy. The setup comprises equipment commonly found in a hospital setting. Outcomes have been satisfactory among our patients. Clinical significance: A low-cost distraction technique is required in developing countries for good outcomes in ankle arthroscopy. Commercially available distraction setups are expensive. The procedure described provides a good technique that can also be used in a peripheral Indian hospital setting.

Background: There is an increasing incidence of geriatric ankle fractures worldwide. We aim to review the management and outcomes of geriatric open ankle fractures at our institution. Materials and methods: A retrospective review of medical records of all patients above 60 years of age who had surgery for open ankle or distal tibia and fibula fractures between the years 2017 and 2021 was performed. Demographic data, ambulatory outcomes, comorbidities, surgical management, length of stay, complications, and radiographic data were recorded. A descriptive analysis of their management and outcomes was performed. Results: Around 12 of 99 patients above the age of 60 years had open ankle/distal tibia and fibula fractures. The mean age was 69.5 years (61–85 years), and seven were female patients (58%). Around 67% (n = 8) of patients had low-energy falls. The average follow-up was 8.6 months (2 weeks–32 months). Around 42% were Gustilo–Anderson grade 1, 33% grade 2, 8% grade 3A, and 17% grade 3B injuries. The mean length of stay for patients with open fractures was 13.5 days compared to 10.8 days for closed fractures. Patients spent a mean of 52.6 days (28–77 days) at the step-down facility. The 1-year mortality rate was 8%. Around 50% of patients returned to their previous ambulatory status. The rate of malunion and posttraumatic arthritis was 11% each. There were no cases of deep surgical site infection or amputation. Conclusion: Patients with open geriatric ankle fractures required a long length of stay at the institution, and only 50% returned to their previous ambulatory status.

Background: Alkaptonuria is a rare inherited genetic disorder in which there is a deficiency of the enzyme homogentisate 1,2-dioxygenase. The three characteristics of alkaptonuria are homogentisic-aciduria, ochronosis, and ochronotic arthropathy. Alkaptonuria is usually asymptomatic until the third decade. Dark stains due to discoloration of the urine may be seen in early childhood, but the diagnosis could be delayed until ochronosis has developed. Alkaptonuria, although a rare disease, is highly prevalent among the Gypsy (Vagiriyar/Romani) community in South India. The founder splice mutation found in this population is c.87 + 1G>A (ivs2 + 1G>A). Patients and methods: We have seen seven such patients presenting with chronic tendoachilles rupture (CTR): four hailing from nearby Gypsy settlements and three non-Gypsy patients. The prior knowledge of the association of low backache with tendoachilles enthesopathy enabled us to make a clinical diagnosis of alkaptonuria-induced ochronotic arthropathy. The patients were assessed clinically and investigated radiologically for enthesopathy, ochronotic spondyloarthropathy, and gonarthrosis, along with serological and urinary tests specific for alkaptonuria. Results: Of the seven patients with a mean age of 56, four were female and three were male. We employed the Achilles tendon Total Rupture Score (ATRS) system for the five patients available for follow-up. The patients with higher ATRS scores have knee deformities and kyphosis affecting their ambulation significantly. It is now known that spontaneous tendoachilles rupture is common among alkaptonuria patients. To improve their quality of life, it is advisable to treat them surgically earlier. The recent introduction of nitisinone in India at a reasonable cost raises hope for disease control for the next generation. Conclusion: A high index of suspicion is suggested when assessing a middle-aged patient with the three cardinal symptoms. Diagnosis and evaluation can be performed through cost-effective urine screening and ultrasonography alone. Early surgical intervention must be considered to avoid disabilities that affect longevity.

Aim and background: Tillaux–Chaput fractures are rare in adults and typically occur due to high-impact injuries. Accurate diagnosis often requires advanced imaging techniques, as standard radiographs may miss these fractures. This case report presents a 37-year-old patient with a Tillaux–Chaput fracture treated successfully with a distal radius T-plate fixation. Case description: A 37-year-old male presented with a swollen and tender ankle following a road traffic accident. Initial radiographs revealed an anterolateral ankle fracture, confirmed by computed tomography (CT) with 3D reconstruction. An open reduction and internal fixation (ORIF) was performed using a distal radius T-plate through an anterolateral Böhler type approach. The patient's postoperative recovery was uneventful, with full ankle mobility and excellent functional scores [American Orthopedic Foot and Ankle Society Score (AOFAS) 98, foot and ankle ability measure (FAAM) 98%] at the 1-year follow-up. Conclusion: Tillaux–Chaput fractures in adults require careful evaluation and advanced imaging for accurate diagnosis. ORIF with a distal radius T-plate provides effective fixation and excellent functional recovery in cases with significant fragment displacement. Clinical significance: This case highlights the importance of tailored surgical approaches and comprehensive postoperative care in managing rare Tillaux–Chaput fractures in adults. The successful outcome demonstrates that advanced imaging and appropriate surgical intervention are critical for optimal recovery.