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Tan Y, Buedts K. Ankle Instability: Facts and Myths to Protect Your Cartilage Repairing. Foot Ankle Clin 2024; 29:321-331. [PMID: 38679442 DOI: 10.1016/j.fcl.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
The majority of patients with an osteochondral lesion of the talus (OLT) report a history of trauma. Therefore, it is important to assess for concomitant ankle instability when dealing with patients with a symptomatic OLT. The History; Alignment; Ligaments; Others "(HALO)" approach can be a helpful tool in the evaluation of patients with an OLT. If conservative treatment fails, surgery may be indicated. Although there is a lack of comparative studies investigating the effect of stabilization procedures on cartilage repair, we believe that addressing instability is a key factor in improving patient outcome.
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Affiliation(s)
- Yuhan Tan
- Department of Orthopaedics, ZNA Middelheim, Lindendreef 12020 Antwerp, Belgium; Department of Orthopaedics, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium.
| | - Kristian Buedts
- Department of Orthopaedics, ZNA Middelheim, Lindendreef 12020 Antwerp, Belgium
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2
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Cheng X, Su T, Li J, Parekh SG, Hu Y, Jiao C, Guo Q, Li N, Jiang D. Effect of Cigarette Smoking on Postoperative Outcomes After Arthroscopic Bone Marrow Stimulation for Osteochondral Lesions of the Talus. Foot Ankle Int 2024:10711007241250007. [PMID: 38770767 DOI: 10.1177/10711007241250007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Bone marrow stimulation (BMS) is presently considered first-line surgical treatment for osteochondral lesions of the talus (OLTs); however, some patients still experience pain or dysfunction after surgery, and the reasons for success or failure remain somewhat unclear. This study aimed to investigate the effect of smoking on postoperative outcomes after arthroscopic BMS for OLTs. METHODS Consecutive patients with OLTs who underwent BMS between January 2017 and January 2020 were included. Smokers were defined as patients who actively consumed cigarettes before surgery and postoperatively, whereas nonsmokers were patients who never smoked. Visual analog scale (VAS), American Orthopaedic Foot & Ankle Society ankle hindfoot score (AOFAS), Karlsson-Peterson, and Tegner scores were assessed preoperatively and at follow-up. Additionally, a general linear model (GLM) was performed, followed by the interaction analysis to explore the potential influence of smoking. RESULTS The study enrolled 104 patients with a mean follow-up of 30.91 ± 7.03 months, including 28 smokers and 76 nonsmokers. There were no significant differences in patient age (35.2 ± 10.0 years vs 37.6 ± 9.7 years, P = .282) or OLT area (63.7 ± 38.7 mm2 vs 52.8 ± 37.0 mm2, P = .782). Both univariate analysis and GLM revealed that smoking was associated with worse postoperative pain levels, Karlsson-Peterson, and AOFAS scores (P < .05). The interaction analysis showed a significant interaction between smoking and OLT area for postoperative Karlsson-Peterson scores (general ankle function) (P = .031). Simple main effects analysis revealed that the negative effect of smoking on Tegner score significantly increased among patients >32 years old or with OLT area>50 mm2 (P < .05). CONCLUSION Smoking was associated with worse clinical outcomes following BMS of OLTs. As the size of OLTs increased, the difference in general ankle function between smokers and nonsmokers also increased. Furthermore, smokers who were older than 32 years or had larger OLTs were less likely to resume participation in high-level activities.
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Affiliation(s)
- Xiangyun Cheng
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Tong Su
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Jian Li
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Selene G Parekh
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yuelin Hu
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Qinwei Guo
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Dong Jiang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, Beijing, China
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Meyer R, Loncar LR, Jensen E, Raja A, Tunis B, Moreland ML, Tunis J. The Role of Ultrasound in the Management of Ankle Sprains and a Clinically Relevant Geisinger Ankle Sprain Sports Ultrasound Protocol. Curr Sports Med Rep 2023; 22:320-327. [PMID: 37678351 DOI: 10.1249/jsr.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
ABSTRACT Ankle sprains are the most common lower extremity injury in physically active individuals. These injuries are classified as lateral, medial, and/or syndesmotic. Treatment may include functional rehabilitation, bracing, weight-bearing restriction, medications, injections, and surgery. While most sprains heal rapidly, permanent disability and pain may arise. Diagnostic ultrasound has been demonstrated to be accurate in diagnosing ligamentous injuries, but it is often excluded from management algorithms that rely on physical examination alone to diagnose significant injuries. This article proposes a comprehensive, evidence-based diagnostic ankle ultrasound protocol to implement in conjunction with thorough history and physical examination. We also review the current literature to describe where this protocol most improves diagnostic accuracy compared with physical examination alone.
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Affiliation(s)
| | | | | | - Altamash Raja
- Department of Rehabilitation Medicine, Rowan-Virtua School of Osteopathic Medicine, Sewell, NJ
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Anastasio AT, Adams SB. Addressing the Need for a Better Understanding of Foot and Ankle Pathology Relevant to the Adolescent Athlete. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1342. [PMID: 37628340 PMCID: PMC10453569 DOI: 10.3390/children10081342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023]
Abstract
Foot and ankle pathology in the adolescent athlete is a growing area of basic science, translational, and clinical research [...].
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Affiliation(s)
- Albert T. Anastasio
- Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, Duke University, Durham, NC 27710, USA;
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Ahmad ZY, Rasiej MJ. Imaging of the Ankle Ligaments and Cartilage Injuries as an Aid to Ankle Preservation Surgery. Semin Ultrasound CT MR 2023; 44:319-331. [PMID: 37437970 DOI: 10.1053/j.sult.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Ankle sprains are among the most common musculoskeletal injuries and can lead to ankle ligament and cartilage injuries. Imaging plays an important role in differentiating ligament injuries from other causes of ankle pain such as fractures, osteochondral lesions or tendon injuries that helps guide further management. Chronic untreated ankle ligamentous and cartilage injuries can further progress to ankle osteoarthritis, hence the need for timely diagnosis and treatment. Surgical treatment is often required in patients not responding to conservative treatment and ranges from repair and reconstruction procedures for ligament injuries to arthroscopic debridement and repair procedures for cartilage injuries. Cartilage defects and deficiency may be augmented depending on the extent of cartilage loss and associated subchondral changes on MRI. Awareness of operative techniques utilized is essential to interpret imaging findings in postoperative settings.
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Affiliation(s)
- Zohaib Y Ahmad
- Department of Radiology, Division of Musculoskeletal Radiology, New York-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY.
| | - Michael J Rasiej
- Department of Radiology, Division of Musculoskeletal Radiology, New York-Presbyterian Hospital-Columbia University Irving Medical Center, New York, NY
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Azam MT, Butler JJ, Duenes ML, McAllister TW, Walls RC, Gianakos AL, Kennedy JG. Advances in Cartilage Repair. Orthop Clin North Am 2023; 54:227-236. [PMID: 36894294 DOI: 10.1016/j.ocl.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Osteochondral lesions of the ankle joint are typically associated with a traumatic etiology and present with ankle pain and swelling. Conservative management yields unsatisfactory results because of the poor healing capacity of the articular cartilage. Smaller lesions (<100 mm2 or <10 mm) can be treated with less invasive procedures such as arthroscopic debridement, anterograde drilling, scaffold-based therapies, and augmentation with biological adjuvants. For patients with large lesions (>100 mm2 or >10 mm), cystic lesions, uncontained lesions, or patients who have failed prior bone marrow stimulation, management with autologous osteochondral transplantation is indicated.
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Affiliation(s)
- Mohammad T Azam
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA
| | - James J Butler
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA
| | - Matthew L Duenes
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA
| | - Thomas W McAllister
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA; University of Cambrdige School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge CB2 0SP, UK
| | - Raymond C Walls
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA
| | - Arianna L Gianakos
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA
| | - John G Kennedy
- Foot and Ankle Division, Department of Orthopaedic Surgery, NYU Langone Health, 171 Delancey Street, New York, NY 10002, USA.
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Guo H, Chen Z, Wei Y, Chen B, Sun N, Liu Y, Zeng C. Autologous Osteoperiosteal Transplantation for the Treatment of Large Cystic Talar Osteochondral Lesions. Orthop Surg 2022; 15:103-110. [PMID: 36380533 PMCID: PMC9837294 DOI: 10.1111/os.13586] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/21/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The effectiveness of autologous osteoperiosteal transplantation (AOPT) for the treatment of large cystic talar osteochondral lesions (OCLs) should be further evaluated, and the postoperative cartilage coverage is questionable. The purpose of this retrospective observational study was to investigate the clinical outcomes of AOPT for the treatment of large cystic talar OCLs and to report second-look arthroscopic results. METHODS From June 1, 2017, to June 1, 2021, all talar OCLs at our center were reviewed. Painful cystic lesions treated with AOPT were included in the study. The American Orthopaedic Foot and Ankle Society (AOFAS; 0-100 points) ankle-hindfoot score, Foot Function Index (FFI; 0-100 points), visual analog scale (VAS; 0-10 points) score, and Tegner score (0-10 points) were used to describe pain and functional outcomes. Furthermore, complications, patient-reported satisfaction degrees, imaging results (including computed tomography and magnetic resonance), and second-look arthroscopic evaluation data were also collected for analysis. RESULTS A total of 29 cases were eligible for the study, and 26 responded to the latest follow-up request, with a mean follow-up duration of 30.2 (range, 12-57) months. The AOFAS score improved from 69.2 ± 10.9 preoperatively to 80.9 ± 10.0 at the latest follow-up (p = 0.000). The FFI score improved from 30.4 ± 18.4 preoperatively to 16.3 ± 14.0 at the latest follow-up (p = 0.000). The VAS pain score improved from 4.0 ± 2.1 preoperatively to 2.5 ± 2.0 at the latest follow-up (p = 0.001). No donor site morbidity was found. The mean postoperative MOCART score was 57.7 ± 9.5. Second-look arthroscopy showed a fibrillated cartilage-like surface at the lesion site in most cases, while two cases exhibited a nearly normal surface. CONCLUSION The transplantation of osteoperiosteal cylinder autografts taken from the iliac crest for the treatment of large cystic talar OCLs yielded acceptable clinical results. Good integration of the bony part was observed, but cartilage regeneration remained uncertain.
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Affiliation(s)
- Hao Guo
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Zhuhong Chen
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Yuxuan Wei
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Botao Chen
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Nian Sun
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Yijun Liu
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Canjun Zeng
- Department of Foot and Ankle Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
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Migliorini F, Schenker H, Maffulli N, Eschweiler J, Lichte P, Hildebrand F, Weber CD. Autologous matrix induced chondrogenesis (AMIC) as revision procedure for failed AMIC in recurrent symptomatic osteochondral defects of the talus. Sci Rep 2022; 12:16244. [PMID: 36171261 PMCID: PMC9518950 DOI: 10.1038/s41598-022-20641-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022] Open
Abstract
Autologous matrix induced chondrogenesis (AMIC) is a bone marrow stimulating technique used for the surgical management of chondral defects of the talus. The present study evaluated the clinical outcomes and imaging of AMIC as revision procedure for failed AMIC surgery for osteochondral defects of the talus. Forty-eight patients with symptomatic osteochondral defects who received a revision AMIC were evaluated after a minimum of two years follow-up. Patients with previous procedures rather than AMIC, those who required additional surgical procedures (e.g. ligament repair or deformity correction), or those who had evidence of kissing, bilateral, or multiple lesions were excluded. Outcome parameters included the Visual Analogic Scale (VAS), Tegner Activity Scale, the American Orthopedic Foot and Ankle Score (AOFAS), and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All patients were followed by an assessor who was not involved in the clinical management. 27 patients were enrolled in the present study. The mean age of the patient was 34.9 ± 3.1 years, and the mean BMI 27.2 ± 5.1 kg/m2. The mean defect surface area was 2.8 ± 1.9 cm2. The mean follow-up was 44.3 ± 21.4 months. The mean hospital length of stay was 4.4 ± 1.4 days. At final follow-up, the mean VAS score was 4.1 ± 3.1, the mean Tegner 3.5 ± 1.6, the mean AOFAS 58.8 ± 20.6. The preoperative MOCART score was 22.1 ± 13.7 points, the postoperative MOCART score was 42.3 ± 27.9 points (+ 20.2%; P = 0.04), respectively. 30% (8 of 27 patients) experienced persistent pain and underwent a further chondral procedure. Concluding, AMIC could be a viable option as revision procedure for failed AMIC in recurrent symptomatic osteochondral defects of the talus. The PROMs indicated that patients were moderately satisfied with the procedure, and the MOCART score demonstrated a significant improvement from baseline to the last follow-up. A deeper understanding in prognostic factors and patient selection is critical to prevent failures.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany.
| | - Hanno Schenker
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, ST4 7QB, Stoke On Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, E1 4DG, London, England
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Philipp Lichte
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany
| | - Christian David Weber
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 31, 52074, Aachen, Germany
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Abas S, Kuiper JH, Roberts S, McCarthy H, Williams M, Bing A, Tins B, Makwana N. Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study. Cells 2022; 11:cells11040629. [PMID: 35203279 PMCID: PMC8869915 DOI: 10.3390/cells11040629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/10/2022] Open
Abstract
Osteochondral defects of the ankle (OCD) are being increasingly identified as a clinically significant consequence of injury to the ankle, with the potential to lead to osteoarthritis if left untreated. The aim of this retrospective cohort study was to evaluate a single-stage treatment of OCD, based on bone marrow aspirate (BMA) centrifuged to produce bone marrow concentrate (BMC). In a dual syringe, the concentrate was mixed with thrombin in one syringe, whereas hyaluronan and fibrinogen were mixed in a second syringe. The two mixtures were then injected and combined into the prepared defect. Clinical outcome and quality of life scores (MOXFQ and EQ-5D) were collected at baseline and yearly thereafter. Multilevel models were used to analyse the pattern of scores over time. Ninety-four patients were treated between 2015 and 2020. The means of each of the three components of the MOXFQ significantly improved between baseline and 1 year (p < 0.001 for each component), with no further change from year 1 to year 3. The EQ-5D index also improved significantly from baseline to 1 year, with no evidence for further change. Our results strongly indicate that this BMC treatment is safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favourable outcomes and a low complication rate at 36 months.
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Affiliation(s)
- Sameera Abas
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- Correspondence: (S.A.); (N.M.)
| | - Jan Herman Kuiper
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, Newcastle upon Tyne ST5 5BG, UK
| | - Sally Roberts
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, Newcastle upon Tyne ST5 5BG, UK
| | - Helen McCarthy
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, Newcastle upon Tyne ST5 5BG, UK
| | - Mike Williams
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, Newcastle upon Tyne ST5 5BG, UK
| | - Andrew Bing
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
| | - Bernhard Tins
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
| | - Nilesh Makwana
- Department of Foot and Ankle Surgery, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry SY10 7AG, UK; (J.H.K.); (S.R.); (H.M.); (M.W.); (A.B.); (B.T.)
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, Newcastle upon Tyne ST5 5BG, UK
- Correspondence: (S.A.); (N.M.)
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