Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery

BACKGROUND Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss,improve visualization in the surgical field,and to potentially reduce surgical time.There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure,placement site,and duration of use.There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery.AIM To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery.METHODS Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken.Intraoperative tourniquet duration,tourniquet pressure and site,and postoperative pain scores using Visual Analogue Score were collected in immediate recovery,at six hours and at 24 h post-op.Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure,duration,site,and pain scores using Pearson correlation coefficient.RESULTS All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh.There was no correlation between the site of the tourniquet and pain scores in recovery,at six hours and after 24 h.There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op(r=0.14,P=0.04)but not at six or 24 h post-operatively.CONCLUSION This study shows that there was no statistically significant correlation between tourniquet pressure,site and postop pain in patients undergoing foot and ankle surgery.The choice of using a tourniquet is based on the surgeon's preference,with the goal of minimizing the duration of its application at the operative site.

Initial Experience of NIR-II Fluorescence Imaging-Guided Surgery in Foot and Ankle Surgery

Optical imaging in the second near-infrared(NIR-II;900-1880 nm)window is currently a popular research topic in the field of biomedical imaging.This study aimed to explore the application value of NIR-II fluorescence imaging in foot and ankle surgeries.A lab-established NIR-II fluorescence surgical navigation system was developed and used to navigate foot and ankle surgeries which enabled obtaining more high-spatial-frequency information and a higher signal-to-background ratio(SBR)in NIR-II fluorescence images compared to NIR-I fluorescence images;our result demonstrates that NIR-II imaging could provide higher-contrast and larger-depth images to surgeons.Three types of clinical application scenarios(diabetic foot,calcaneal fracture,and lower extremity trauma)were included in this study.Using the NIR-II fluorescence imaging technique,we observed the ischemic region in the diabetic foot before morphological alterations,accurately determined the boundary of the ischemic region in the surgical incision,and fully assessed the blood supply condition of the flap.NIR-II fluorescence imaging can help surgeons precisely judge surgical margins,detect ischemic lesions early,and dynamically trace the perfusion process.We believe that portable and reliable NIR-II fluorescence imaging equipment and additional functional fluorescent probes can play crucial roles in precision surgery.

Foot and ankle surgery:Tourniquet placement site to cause as little postoperative pain as possible

There is controversy in the literature on where to place the tourniquet(thigh,calf,ankle)for foot and ankle surgery.While some authors prefer the ankle tourniquet to the calf tourniquet,others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet,since there was no difference in postoperative pain between them.Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice.The reality is that,unfortunately,there is no consensus on this issue.Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions.It does not seem easy to carry out such a study,but it would be important to be able to answer the question posed in the title of this Editorial once and for all.

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States:A retrospective analysis

BACKGROUND The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships.Utilizing metrics like the H-index and Open Payments Database(OPD)data,it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes,providing a basis for further exploration in this specialized medical field.AIM To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States.METHODS This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level.Academic productivity was defined via H-index and recorded from the Scopus website.Industry earnings were recorded from the OPD.RESULTS Forty-eight foot and ankle orthopedic surgery fellowships(100%of fellowships)in the United States with a combined total of 165 physicians(95.9%of physicians)were included.Mean individual physician(n=165)total life-time earnings reported on the OPD website was United States Dollar(USD)451430.30±1851084.89(range:USD 25.16-21269249.85;median:USD 27839.80).Mean physician(n=165)H-index as reported on Scopus is 14.24±12.39(range:0-63;median:11).There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings(P<0.001;Spearman’s rho=0.334)and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship(P=0.004,Spearman’s rho=0.409).CONCLUSION There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States.This observation is true on an individual physician level as well as on a fellowship level.

Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery

Cutaneous nerve injury is the most common complication following foot and ankle surgery. However, clinical studies including long-term follow-up data after cutaneous nerve injury of the foot and ankle are lacking. In the current retrospective study, we analyzed the clinical data of 279 patients who underwent foot and ankle surgery. Subjects who suffered from apparent paresthesia in the cutaneous sensory nerve area after surgery were included in the study. Pa- tients received oral vitamin B^2 and methylcobalamin. We examined final follow-up data of 17 patients, including seven with sural nerve injury, five with superficial peroneal nerve injury, and five with plantar medial cutaneous nerve injury. We assessed nerve sensory function using the Medical Research Council Scale. Follow-up immediately, at 6 weeks, 3, 6 and 9 months, and 1 year after surgery demonstrated that sensory function was gradually restored in most patients within 6 months. However, recovery was slow at 9 months. There was no significant difference in sensory function between 9 months and 1 year after surgery. Painful neuromas occurred in four patients at 9 months to 1 year. The results demonstrated that the recovery of sensory func- tion in patients with various cutaneous nerve injuries after foot and ankle surgery required at least 6 months.

Chronic Ankle Instability: Therapeutic Exercise and Data Analysis

Background and Objectives: Ankle injuries are the most common type of injury in healthy active individuals. If not treated properly, recurrent sprains can lead to a condition of chronic ankle instability (CAI). The present paper examines some subjects with a previous history of acute inversion ankle sprain who have developed a subsequent condition of instability, grouping them according to inclusion criteria and analyzing them through four field tests considered objective by the scientific literature: SEBT test, BEES test, TIBT test, SHT test. The data obtained were stored in order to compare them following a re-education protocol aimed at improving proprioception, balance, walking and strengthening the extrinsic and intrinsic muscles of the foot. per year. The subjects were then divided into two categories: subjects with CAI > 1 year and subjects with CAI ≤ 1 year. A protocol lasting 6 weeks was administered to both groups, trying to work on improving balance in single stance, improving static and dynamic stability, strengthening the gluteus medius and maximus (pelvis stabilizers) and strengthening of the intrinsic muscles of the foot. At the end of the protocol the subjects were all re-evaluated with the same field tests used previously and the data obtained were compared both with the pre-protocol data and with the data measured by the control subjects.

Analysis of a passive ankle exoskeleton for reduction of metabolic costs during walking

Modern conflicts demand substantial physical and psychological exertion,often resulting in fatigue and diminished combat or operational readiness.Several exoskeletons have been developed recently to address these challenges,presenting various limitations that affect their operational or everyday usability.This article evaluates the performance of a dual-purpose passive ankle exoskeleton developed for the reduction of metabolic costs during walking,seeking to identify a force element that could be applied to the target population.Based on the 6-min walk test,twenty-nine subjects participated in the study using three different force elements.The results indicate that it is possible to reduce metabolic expenditure while using the developed exoskeleton.Additionally,the comfort and range of motion results verify the exoskeleton's suitability for use in uneven terrain and during extended periods.Nevertheless,the choice of the force element should be tailored to each user,and the control system should be adjustable to optimise the exoskeleton's performance.

Functional assessment and influencing factors after staged functional training in patients with ankle fractures

BACKGROUND The recovery of limb function after ankle fracture surgery is a gradual process.The main purpose of implementing early functional exercise,joint mobility,muscle contraction function,passive ankle flexion and extension exercises,or physical factor therapy techniques is to achieve the rapid recovery of normal physiological limb function.However,currently the most effective rehabilitation training method is staged limb functional exercise,which promotes rapid recovery of limb function while preventing adverse consequences caused by overwork or insufficient training.Staged limb functional exercise divides the rehabilitation process into multiple stages,each of which has specific training objectives and contents.This method helps patients gradually restore limb function.Nevertheless,some patients still exhibit poor limb function after standardized exercise.Therefore,a functional evaluation should be performed to analyze the impact of staged functional training after ankle fracture surgery.AIM To perform a functional evaluation and determine the influencing factors of staged functional training in patients with ankle fracture.METHODS A retrospective study enrolled 150 patients who underwent surgical treatment for ankle fracture from May 2020 to May 2022 at our hospital.Univariate and multivariate linear regression analyses were performed on general data,functional exercise compliance scale for orthopedic patients,Social Support Rating Scale(SSRS),American Orthopedic Foot and Ankle Score(AOFAS)Ankle-Hindfoot Score,and pain factors[serum bradykinin(BK),prostaglandin E2(PGE2),5-hydroxytryptamine(5-HT)].RESULTS Based on the AOFAS Ankle-Hindfoot Scale,the cases were divided into the excellent function(n=111)and ordinary function(n=39)groups.Univariate analysis revealed that monthly family income,education level,diabetes mellitus,functional exercise compliance scale of orthopedic patients score,SSRS,BK,PGE2,and 5-HT significantly influenced limb function after ankle fracture(P<0.05);Multiple linear regression analysis showed that the functional exercise compliance scale score,SSRS,BK,PGE2,and 5-HT were independent risk factors affecting functional performance after staged functional exercise(P<0.05).CONCLUSION Exercise compliance,SSRS,and pain level are the independent risk factors affecting functional performance after staged functional training following ankle surgery.Clinical nursing care after ankle surgery should include analgesic and health education measures to ensure optimal recovery of limb function.

Configuration and Kinematics of a 3-DOF Generalized Spherical Parallel Mechanism for Ankle Rehabilitation

The kinematic equivalent model of an existing ankle-rehabilitation robot is inconsistent with the anatomical structure of the human ankle,which influences the rehabilitation effect.Therefore,this study equates the human ankle to the UR model and proposes a novel three degrees of freedom(3-DOF)generalized spherical parallel mechanism for ankle rehabilitation.The parallel mechanism has two spherical centers corresponding to the rotation centers of tibiotalar and subtalar joints.Using screw theory,the mobility of the parallel mechanism,which meets the requirements of the human ankle,is analyzed.The inverse kinematics are presented,and singularities are identified based on the Jacobian matrix.The workspaces of the parallel mechanism are obtained through the search method and compared with the motion range of the human ankle,which shows that the parallel mechanism can meet the motion demand of ankle rehabilitation.Additionally,based on the motion-force transmissibility,the performance atlases are plotted in the parameter optimal design space,and the optimum parameter is obtained according to the demands of practical applications.The results show that the parallel mechanism can meet the motion requirements of ankle rehabilitation and has excellent kinematic performance in its rehabilitation range,which provides a theoretical basis for the prototype design and experimental verification.

Type Synthesis of Self-Alignment Parallel Ankle Rehabilitation Robot with Suitable Passive Degrees of Freedom

The current parallel ankle rehabilitation robot(ARR)suffers from the problem of difficult real-time alignment of the human-robot joint center of rotation,which may lead to secondary injuries to the patient.This study investigates type synthesis of a parallel self-alignment ankle rehabilitation robot(PSAARR)based on the kinematic characteristics of ankle joint rotation center drift from the perspective of introducing"suitable passive degrees of freedom(DOF)"with a suitable number and form.First,the self-alignment principle of parallel ARR was proposed by deriving conditions for transforming a human-robot closed chain(HRCC)formed by an ARR and human body into a kinematic suitable constrained system and introducing conditions of"decoupled"and"less limb".Second,the relationship between the self-alignment principle and actuation wrenches(twists)of PSAARR was analyzed with the velocity Jacobian matrix as a"bridge".Subsequently,the type synthesis conditions of PSAARR were proposed.Third,a PSAARR synthesis method was proposed based on the screw theory and type of PSAARR synthesis conducted.Finally,an HRCC kinematic model was established to verify the self-alignment capability of the PSAARR.In this study,93 types of PSAARR limb structures were synthesized and the self-alignment capability of a human-robot joint axis was verified through kinematic analysis,which provides a theoretical basis for the design of such an ARR.

Intraosseous device for arthrodesis in foot and ankle surgery: Review of the literature and biomechanical properties

BACKGROUND Arthrodesis is the surgical fusion of a diseased joint for the purposes of obtaining pain relief and stability.There have been numerous fixation devices described in literature for foot and ankle arthrodesis,each with their own benefits and drawbacks.AIM To review the use of intraosseous devices in foot and ankle surgery.METHODS There were 9 papers included in the review(6 clinical and 3 experimental studies)all evaluating arthrodesis in the foot and ankle using the IOFIX device(Extremity Medical™,Parsippany,NJ,United States).Outcome scores,union rates,as well as complications were analysed.RESULTS IOFIX appears to be safe and effective in achieving arthrodesis of the 1st metatarsophalangeal,and talonavicular joints with early rehabilitation.In comparison to plate/screw constructs there were fewer soft tissue complications and issues of metalwork prominence.Cadaveric and biomechanical studies on the use of intramedullary fixation for fusion of the tarsometatarsal and ankle joint showed decreased load to failure,cycles to failure and stiffness in comparison to traditional fusion methods using plates and screws,however IOFIX devices produced higher compressive forces at the joint.CONCLUSION We describe the reasons for which this biomechanical behavior of the intraosseous fixation may be favorable,until prospective and comparative studies with largersample size and longer follow-up confirm the effectiveness and limitations of the method.

Exploring influences and risk of bias of studies on return to sport and work after lateral ankle sprain:A systematic review and metaanalysis

BACKGROUND Lateral ankle sprains are the most common traumatic musculoskeletal injuries of the lower extremity,with an incidence rate of 15%-20%.The high incidence and prevalence highlights the economic impact of this injury.Ankle sprains lead to a high socioeconomic burden due to the combination of the high injury incidence and high medical expenses.Up to 40%of patients who suffer from an ankle sprain develop chronic ankle instability.Chronic instability can lead to prolonged periods of pain,immobility and injury recurrence.Identification of factors that influence return to work(RTW)and return to sports(RTS)after a lateral ankle sprain(LAS)may help seriously reduce healthcare costs.AIM To explore which factors may potentially affect RTW and RTS after sustaining an LAS.METHODS EMBASE and PubMed were systematically searched for relevant studies published until June 2023.Inclusion criteria were as follows:(1)Injury including LAS or chronic ankle instability;(2)Described any form of treatment;(3)Assessment of RTW or RTS;(4)Studies published in English;and(5)Study designs including randomized controlled clinical trials,clinical trials or cohort studies.Exclusion criteria were:(1)Studies involving children(age<16 year);or(2)Patients with concomitant ankle injury besides lateral ankle ligament damage.A quality assessment was performed for each of the included studies using established risk of bias tools.Additionally quality of evidence was assessed using the GRADEpro tool in cases where outcomes were included in the quantitative analysis.A best evidence synthesis was performed in cases of qualitative outcome analysis.For all studied outcomes suitable for quantitative analysis a forest plot was created to calculate the effect on RTW and RTS.RESULTS A total of 8904 patients were included in 21 studies,10 randomized controlled trials,7 retrospective cohort studies and 4 prospective cohort studies.Fifteen studies were eligible for meta-analysis.The overall RTS rate ranged were 80%and 83%in the all treatments pool and surgical treatments pool,respectively.The pooled mean days to RTS ranged from 23-93 d.The overall RTW rate was 89%.The pooled mean time to RTW ranged from 5.8-8.1 d.For patients with chronic ankle instability,higher preoperative motivation was the sole factor significantly and independently(P=0.001)associated with the rate of and time to RTS following ligament repair or reconstruction.Higher body mass index was identified as a significant factor(P=0.04)linked to not resuming sports or returning at a lower level(median 24,range 20-37),compared to those who resumed at the same or higher level(median 23,range 17-38).Patients with a history of psychological illness or brain injury,experienced a delay in their rehabilitation process for sprains with fractures and unspecified sprains.The extent of the delayed rehabilitation was directly proportional to the increased likelihood of experiencing a recurrence of the ankle sprain and the number of ankle-related medical visits.We also observed that 10%of athletes who did return to sport after lateral ankle sprain without fractures described non-ankle-related reasons for not returning.CONCLUSION All treatments yielded comparable results,with each treatment potentially offering unique advantages or benefits.Preoperative motivation may influence rehabilitation after LAS.Grading which factor had a greater impact was not possible due to the lack of comparability among the included patients.

Perceived barriers and facilitators of day-case surgery for major foot and ankle procedures?A cross-sectional survey of United Kingdom surgeons

BACKGROUND Advances in minimally invasive surgery and improved post-operative pain management make it possible to consider performing even major foot/ankle operations as day-case.This could have significant benefits for patients and the health service.However there are theoretical concerns about post-operative complications and patient satisfaction due to pain.AIM To scope the current practice of foot and ankle surgeons on day-case surgery for major foot and ankle procedures in the United Kingdom(UK).METHODS An online survey(19 questions)was sent to UK foot and ankle surgeons via the British Orthopaedic Foot&Ankle Society membership list in August 2021.Major foot and ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge,with day surgery as the intended treatment pathway.RESULTS 132 people responded to the survey invitation with 80%working in Acute NHS Trusts.Currently 45%of respondents perform less than 100 day-case surgeries per year for these procedures.78%felt that there was scope to perform more procedures as day-case at their centre.Post-operative pain(34%)and patient satisfaction(10%)was not highly measured within their centres.Lack of adequate physiotherapy input pre/post-operatively(23%)and lack of out of hours support(21%)were the top perceived barriers to performing more major foot and ankle procedures as day-case.CONCLUSION There is consensus among UK surgeons to do more major foot/ankle procedures as day-case.Out of hours support and physiotherapy input pre/post-op were perceived as the main barriers.Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed.There is a need for nationally agreed protocols to optimise the delivery of and measurement of outcomes in this type of surgery.At a local level,the provision of physiotherapy and out of hours support should be explored at sites where this is a perceived barrier.

Pulmonary embolism after shoulder surgery:Is it a real threat?

Pulmonary embolism(PE)is a rare but devastating complication of shoulder surgery.Apart from increased morbidity and mortality rates,it may significantly impair postoperative recovery and functional outcome.Its frequency accounts for up to 5.7%of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years.It is most commonly associated with thrombophilia,diabetes mellitus,obesity,smoking,hypertension,and a history of malignancy.PE usually occurs secondary to upper or lower-extremity deep vein thrombosis(DVT).However,in rare cases,the source of the thrombi cannot be determined.Prophylaxis for PE following shoulder surgery remains a topic of debate,and the standard of care does not routinely require prophylactic medication for DVT prophylaxis.Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin,low-molecular-weight heparin,and vitamin K antagonists are indicated for high-risk patients,long-lasting operations,or concomitant severe acute respiratory syndrome coronavirus 2 infection.The most common symptoms of PE include chest pain and shortness of breath,but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia.Patients with DVT may also present with swelling and pain of the respective extremity.The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable,respectively.Hemodynamic instability may require transfer to the intensive care unit,and cardiovascular arrest can be implicated in fatal events.An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay.Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

The relationship between pain and associated characteristics of chronic ankle instability:A retrospective study

Background'. Up to 74% of people with a history of ankle sprain develop chronic ankle instability (CAI). One commonly reported residualimpairment is ankle pain;however, it has not been included in models or inclusion criteria for CAL We investigated the prevalence of pain inpeople with CAI and the association between presence of pain and other CAI characteristics.Methods'. Retrospective data from 1147 participants with CAI (age 26.6 ± 10.7 years, 59% female) were collated from previous studies that usedthe Cumberland Ankle Instability Tool as an assessment tool. Pain was assessed from Item 1 of the Cumberland Ankle Instability Tool, whichasks participants about ankle pain. Responses were divided into 3 categories: pain during daily activities, pain during moderate/vigorous physicalactivities, and no pain. The presence of pain was analyzed with descriptive statistics, the correlation between pain category and CAI characteris・tics was analyzed by /2 tests and factors associated with each pain category were analyzed by logistic regression.Results'. Among the participants, 60.1% (n = 689) reported ankle pain. Of all participants, 12.4% (n = 142) reported pain during daily activities,47.7% (n = 547) reported pain during moderate/vigorous physical activities, and 39.9% (n = 458) reported no pain. There was a strong associationbetween ankle instability and ankle pain (/2 = 122.2, p < 0.001, OR = 53& 95% confidence interval (CI): 3.84—7.53). Perceived ankle instability,age and unilateral ankle sprains were independently associated with pain (ankle instability: /2 = 43.29, p < 0.001;age: /2 = 30.37,p < 0.001;unilateral ankle sprains: /2 = 6.25, p < 0.05). There was no significant difference in the presence of pain between genders.Conclusion-. The prevalence of pain in people with CAI was high and was related to perceived ankle instability. Number of sprains, age, genderand unilateral or bilateral sprain did not modify this result except for the first pain category (pain during daily activities). There is large gap incurrent knowledge about the impact of pain in people with CAI, and this topic needs further investigation.

Do ankle braces provide similar effects on ankle biomechanical variables in subjects with and without chronic ankle instability during landing?

Purpose:The purpose of this study was to examine effects of a sport version of a semi-rigid ankle brace (ElementTM) and a soft ankle brace (ASO) on ankle biomechanics and ground reaction forces (GRFs) during a drop landing activity in subjects with chronic ankle instability (CAI)compared to healthy subjects with no history of CAI.Methods:Ten healthy subjects and 10 subjects who had multiple ankle sprains participated in the study as the control and unstable subjects,respectively.The CAI subjects were age,body mass index and gender matched with the control subjects.The arch index and ankle functions of the subjects were measured in a subject screening session.During the biomechanical test session,participants performed five trials of drop landing from 0.6 m,wearing no brace ( NB),ElementTM brace and ASO brace.Simultaneous recording of three-dimensional kinematic (240 Hz)and GRF (1200 Hz) data were performed.Results:The CAI subjects had lower ankle functional survey scores.The arch index and deformity results showed greater arch deformity of ElementTM against a static load than in NB and ASO due to greater initial arch position held by the brace.CAI participants had greater eversion velocity than healthy coutrols.The ASO brace reduced the first peak vertical GRF whereas ElementTM increased 2nd peak vertical GRF.ElementTM brace reduced eversion range of motion (ROM) and peak eversion velocity compared to NB and ASO.In addition,ElementTM reduced dorsiflexion ROM and increased peak plantarflexion moment compared to NB and ASO.Conclusion:Results of static arch measurements and dynamic ankle motion suggest that the restrictions offered by both braces are in part due to more dorsiflexed ankle positions at contact,and higher initial arch position and stiffer ankle for ElementTM.

Management and prevention of acute and chronic lateral ankle instability in athletic patient populations

Acute and chronic lateral ankle instability are common in high-demand patient populations. If not managed appropriately, patients may experience recurrent instability, chronic pain, osteochondral lesions of the talus, premature osteoarthritis, and other significantlong-term disability. Certain populations, including young athletes, military personnel and those involved in frequent running, jumping, and cutting motions, are at increased risk. Proposed risk factors include prior ankle sprain, elevated body weight or body mass index, female gender, neuromuscular deficits, postural imbalance, foot/ankle malalignment, and exposure to at-risk athletic activity. Prompt, accurate diagnosis is crucial, and evidence-based, functional rehabilitation regimens have a proven track record in returning active patients to work and sport. When patients fail to improve with physical therapy and external bracing, multiple surgical techniques have been described with reliable results, including both anatomic and nonanatomic reconstructive methods. Anatomic repair of the lateral ligamentous complex remains the gold standard for recurrent ankle instability, and it effectively restores native ankle anatomy and joint kinematics while preserving physiologic ankle and subtalar motion. Further preventative measures may minimize the risk of ankle instability in athletic cohorts, including prophylactic bracing and combined neuromuscular and proprioceptive training programs. These interventions have demonstrated benefit in patients at heightened risk for lateral ankle sprain and allow active cohorts to return to full activity without adversely affecting athletic performance.

Multi-objective Optimization of a Parallel Ankle Rehabilitation Robot Using Modified Differential Evolution Algorithm

Dimensional synthesis is one of the most difficult issues in the field of parallel robots with actuation redundancy. To deal with the optimal design of a redundantly actuated parallel robot used for ankle rehabilitation, a methodology of dimensional synthesis based on multi-objective optimization is presented. First, the dimensional synthesis of the redundant parallel robot is formulated as a nonlinear constrained multi-objective optimization problem. Then four objective functions, separately reflecting occupied space, input/output transmission and torque performances, and multi-criteria constraints, such as dimension, interference and kinematics, are defined. In consideration of the passive exercise of plantar/dorsiflexion requiring large output moment, a torque index is proposed. To cope with the actuation redundancy of the parallel robot, a new output transmission index is defined as well. The multi-objective optimization problem is solved by using a modified Differential Evolution（DE） algorithm, which is characterized by new selection and mutation strategies. Meanwhile, a special penalty method is presented to tackle the multi-criteria constraints. Finally, numerical experiments for different optimization algorithms are implemented. The computation results show that the proposed indices of output transmission and torque, and constraint handling are effective for the redundant parallel robot; the modified DE algorithm is superior to the other tested algorithms, in terms of the ability of global search and the number of non-dominated solutions. The proposed methodology of multi-objective optimization can be also applied to the dimensional synthesis of other redundantly actuated parallel robots only with rotational movements.

Ankle arthrodesis:A systematic approach and review of the literature

Ankle arthrodesis is a common treatment used for patients with end-stage ankle arthritis(ESAA). The surgical goal of ankle arthrodesis is to obtain bony union between the tibia and talus with adequate alignment [slight valgus(0°-5°)], neutral dorsiflexion, and slight external rotation positions) in order to provide a pain-free plantigrade foot for weightbearing activities. There are many variations in operative technique including deferring approaches(open or arthroscopic) and differing fixation methods(internal or external fixation). Each technique has its advantage and disadvantages. Success of ankle arthrodesis can be dependent on several factors, including patient selection, surgeons' skills, patient comorbidities, operative care, etc. However, from our experience, the majority of ESAA patients obtain successful clinical outcomes. This review aims to outline the indications and goals of arthrodesis for treatment of ESAA and discuss both open and arthroscopic ankle arthrodesis. A systematic step by step operative technique guide is presented for both the arthroscopic and open approaches including a postoperative protocol. We review the current evidence supporting each approach. The review finishes with a report of the most recent evidence of outcomes after both approaches and concerns regarding the development of hindfoot arthritis.