Effect of Limb Dominance on Chronic Ankle Instability: Does It Matter?

Our study aimed to examine preoperative differences in strength and balance between dominant foot (DF) and nondominant foot (non-DF) of individuals undergoing ligament stabilization surgery in the general population. Patients with records of preoperative evaluation, including isokinetic dynamometric strength evaluation, Y-balance test (YBT), and Foot and Ankle Outcome Score (FAOS), were included in the study. The DF was the preferred leg for accurately kicking a ball through a goal. Statistical analysis determined the differences between DF and non-DF and the correlations between muscle strength, balance, and FAOS. There was no statistically significant difference between DF and non-DF regarding evertor and invertor muscle strength (p=0.082-0.951). The YBT revealed no significant difference between the two groups (p=0.082-0.951). There was a significant correlation between the evertor peak torque and total work deficits at 30°/s (p=0.022), as well as the evertor peak torque deficit at 120°/s (p=0.048). No significant differences in muscle strength and balance were found between DF and non-DF in nonathletes with chronic ankle instability. Peroneal muscle strength deficit was associated with functional impairment. Tailored interventions are needed to address limb dominance and muscle strength deficits in CAI management.

Current concept review of Achilles tendinopathy.

Achilles tendinopathy is a common overuse injury affecting the ankle and foot. It manifests as a clinical condition that includes pain, edema, and decreased functionality. This condition can be broadly categorized into two main types based on anatomical location: insertional and noninsertional tendinopathy. The development of Achilles tendinopathy involves various factors, both internal and external. Patients with Achilles tendinopathy often experience stiffness worsened by prolonged rest, and pain exacerbated by physical activity. These symptoms can limit work activity and sports participation, with many patients facing discomfort while wearing shoes due to heel sensitivity. Diagnosis is primarily clinical, although MRI and ultrasound imaging can aid in differential diagnosis. Identifying risk factors and understanding the patient's biomechanics assist in accurate diagnosis and subsequent management. Management of Achilles tendinopathy involves a range of conservative and surgical options. However, due to varying results in clinical studies, a definitive gold standard treatment has not emerged. Eccentric exercises are a valuable tool in managing the condition. The recommend treatments such as shock wave therapy or nitric oxide patches are sought if symptoms do not improve. Peritendinous injections could be options if physical therapy proves ineffective. Surgical intervention is required after six months of conservative treatment. Recent research on Achilles tendinopathy emphasizes the need for individualized treatment plans that address its multifaceted nature. Combining biomechanical analysis, advanced imaging, and patient-specific factors is key to achieving optimal outcomes. Additionally, preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of this condition. In conclusion, this article provides a current overview of Achilles tendinopathy. It highlights the importance of a comprehensive approach to understanding its causes, pathophysiology, diagnosis, and management strategies.

Novel Surgical Approach for Large Intraosseous Subchondral Cysts of Talus: A Case Report and Technical Innovation.

Large subchondral bone cysts in the medial talar body and dome are common and can cause persistent pain and swelling during axial loading. Open debridement and bone grafting are often necessary to treat these lesions but can require extensive soft-tissue dissection or malleolar osteotomies. A 40-year-old woman presented with ankle pain and swelling for 1 year, worsening with activity and no history of trauma. X-rays showed a cystic lesion in the medial talar dome with no joint line disruption. CT confirmed the cystic lesion without bone collapse or expansion. An anterior approach to the ankle joint was extended to access the talar neck. A window was created in the talar neck to debride and curette the medial talar dome, and the void was filled with allograft. The patient was non-weight-bearing for 6 weeks, followed by gradual weight-bearing and ankle range of motion exercises starting on postoperative day 1. The patient returned to her pre-injury status within 3 months and was asymptomatic at the 6-year follow-up, with good bone graft integration and no symptoms. This technical note presents a novel approach to lesions of the medial talar body and dome through the talar neck, avoiding the need for malleolar osteotomy or disruption to the tibiotalar joint, and resulting in good functional outcomes.

Anterior Tarsal Tunnel Syndrome: Entrapment of the Articular Branch of Deep Peroneal Nerve: A Case Report.

CASE: A 28-year-old male patient who injured his ankle 2 years ago presented with unilateral ankle pain, tingling, and numbness for 1 year. Clinically, tenderness and positive Tinel sign were localized on anterior aspect of ankle. On exploration, deep peroneal nerve and mainly its articular branch were encased in fibrotic tissue. Decompression of both nerves resulted in symptomatic relief after surgery. CONCLUSION: High index of suspicion, a thorough medical history, meticulous clinical examination, complete knowledge of nerve anatomy, proper radiological studies, and careful surgical decompression are all necessary for the diagnosis and management of such atypical cases.

Correction: Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

[This corrects the article DOI: 10.1007/s43465-023-00942-2.].

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

Background: Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis. Methods: Sixty-five patients, >60 year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score. Results: Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively. Conclusion: Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

Is Ultrasound (US)-Guided Platelet-Rich Plasma Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up.

Background: Lateral elbow tendinopathy (LET) has an array of modalities described for its management. The present study analyzed two modalities used for managing the condition. Methods: The present study included 64 non-athletes with LET who failed conservative treatment that included avoiding strenuous activities, ice-fomentation, non-steroidal anti-inflammatory drugs, bracing, and physiotherapy for 6 months. A random allocation of the participants was done, with one group injected with platelet-rich plasma (PRP) and the other group with corticosteroids. The procedure was performed by the same blinded orthopedic surgeon after localizing the pathology using ultrasound. Visual analog scale (VAS) scores, disabilities of the arm, shoulder and hand (DASH) scores, Patient-Rated Tennis Elbow Evaluation (PRTEE) scores, and handgrip strengths were recorded by blinded observers other than the surgeon administering the injection. Results: The average age of the patients was 40 years. The mean VAS score at the latest follow-up of 2 years in the PRP group was 1.25 and it was significantly better than the score of 3.68 in the steroid group (p < 0.001). The mean DASH score at the latest follow-up of 2 years in the PRP group was 4.00 and it was significantly better than the score of 7.43 in the steroid group (p < 0.001). The mean PRTEE score at the latest follow-up of 2 years in the PRP group was 3.96 and it was significantly better than the score of 7.53 in the steroid group (p < 0.001). The scores were better in the steroid group at a short-term follow-up of 3 months (p < 0.05), while they were better in the PRP group at a long-term follow-up of 2 years (p < 0.05). Hand-grip strength was comparable in the PRP group (84.43 kg force) and steroid group (76.71 kg force) at the end of the 2-year follow-up with no statistically significant difference (p = 0.149). Conclusions: Corticosteroid injections alleviated symptoms of LET over short-term follow-up providing quicker symptomatic relief; however, the effect faded off over the long term. PRP injections provided a more gradual but sustained improvement over the long-term follow-up, indicating the biological healing potential of PRP.

Anti-retroviral Therapy-Induced Multiple Pathological Fractures in a HIV-Positive Young Female: A Case Report and Review of Literature.

Introduction: A higher prevalence of osteoporosis and osteopenia, as well as an increased risk of fracture is seen in patients with HIV infection. Anti-retroviral therapy (ART) is the one of the factors associated with pathological fractures in those patients. We present one case with multiple pathological fractures secondary to severe osteoporosis in a known case of HIV on Tenofovir-based ART. The patient was managed with a combined surgical and conservative approach with a satisfactory outcome at 1-year follow-up. Case Report: We analyzed a 35-year-old female patient with HIV infection on ART for 5 years. She was diagnosed with right-sided subtrochanteric femur and bilateral forearm fracture and stress fracture in the left lower limb. Tenofovir was substituted with Zidovudine before surgery. Subtrochanteric femur fracture and right forearm fracture were managed surgically, whereas the other fractures were managed conservatively. The patient was followed up till 1 year and assessed with serial X-rays, blood investigations, Harris Hip Score, and Upper Extremity Functional Index. Functional outcome in all four limbs was found to be satisfactory. Conclusion: The patient taking ART based on Tenofovir should be monitored for pathological fractures. ART-induced fractures can be managed surgically and conservatively like any other pathological fracture. Tenofovir-containing regimens may be gradually replaced with alternative regimens for the treatment of HIV infection, especially in those at a higher risk for fragility fractures.

Non-traumatic Bilateral Lower Limb Fractures in Human Immunodeficiency Virus Positive Individuals on Long-Term Antiretroviral Therapy: Two Case Reports and Literature Review.

Introduction: It has been noticed that human immunodeficiency virus (HIV) infection and anti-retro viral (ART) therapy, both individually lead to bone metabolic disorders, and hence, such patients have an increased propensity for fractures following trivial trauma. Case Report: We present two cases, first a 52-year-old female with the right hip pain and inability to walk since 1 week following trivial trauma and associated dull pain in the left hip since 2 months ago. Radiographs revealed a right intertrochanteric fracture and a left unicortical fracture at level of lesser-trochanter. The patient was managed with closed proximal femoral nailing bilaterally and subsequently mobilized. Second, a 70- year-old female with bilateral leg pain and swelling following trivial trauma since 3 days. Radiographs revealed a distal one-third shaft tibia and fibula fracture bilaterally managed with closed nailing bilaterally and subsequently mobilized. Both patients had HIV infection since 10 and 14 years, respectively, and were on combination ART. Conclusion: There should be a high index of suspicion to the possibility of fragility fractures in HIV affected patients on ART. Principles of fracture fixation and early mobilization should be followed.

Combined Deltoid and Spring Ligament Reconstruction Using the Quadrangular Construct: Our Experience and Review of the Literature.

Background A combined reconstruction of chronic deltoid and spring ligament insufficiency is uncommon. Our study aims to share our experience in treating post-traumatic, chronic deltoid, and spring ligament insufficiency using the "quadrangular construct" technique. Material and methods Five patients who had post-traumatic combined deltoid and spring ligament insufficiency were included in the study. All patients reported a "giving-way" sensation. Preoperatively, each patient underwent weight-bearing radiographs of the ankle and foot. The talo-first metatarsal angle and hindfoot alignment angle were noted. The superficial deltoid ligament was repaired using a suture anchor augmented with Internal BraceTM (Arthrex, Naples, USA) FiberTape® to form a quadrangular construct that anatomically mimics various components of the deltoid-spring ligament complex. Due to the associated excessive heel valgus, three patients also underwent medial displacement calcaneum osteotomy. Additionally, one patient required lateral ligament repair, and another patient required syndesmotic stabilization. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to evaluate preoperative and postoperative ankle function. Results All five patients were followed up for a mean of 20 months (range: 12-24 months). The mean preoperative talo-first metatarsal angle improved from 8.46 degrees to 4.84 degrees. The preoperative mean hindfoot alignment angle was reduced from 10.9 to 5.76 degrees postoperatively. One patient had irritation due to the anchor, which needed removal after one year. Postoperatively, no patients re-experienced the feeling of "giving way". The AOFAS scores postoperatively showed two patients as excellent, two as good, and one as fair. All the patients returned to their pre-injury work. Conclusion  We have developed a technique for combined deltoid and spring ligament reconstruction using a quadrangular construct. This technique helps to restore anatomical stability, is safe, easily reproducible, and has shown positive short-term results in follow-up. The level of evidence is one of the methods used to categorize the quality and reliability of research, and our study falls under the category of level IV evidence.

An Unusual Presentation of a Rare Disease: Eosinophilic Fasciitis.

Eosinophilic fasciitis is an uncommon disorder presenting with diffuse fasciitis and peripheral eosinophilia. Due to the rarity of this disorder and limited literature, its diagnosis and treatment are often delayed. We present the case of a young male wherein the diagnosis of eosinophilic fasciitis was initially delayed due to an atypical presentation. However, after the diagnosis was confirmed, the patient was successfully managed with oral corticosteroids. A well-written informed consent was obtained from the patient prior to the preparation of this manuscript. An 18-year-old right-hand dominant male presented with a sudden onset, progressive, non-traumatic, left forearm swelling associated with a weak hand grip. The swelling was tender on examination with a local rise in temperature. Radiographs taken at the time of presentation revealed no osseous pathology. As the initial blood investigations were suggestive of a localized inflammatory pathology involving the forearm, the patient was managed with non-steroidal anti-inflammatory drugs and analgesics. He returned 6 months later with a recurrence of the symptoms. A magnetic resonance imaging scan of the left forearm was performed to further investigate the pathology and it was suggestive of a diffuse plaque-like thickening involving the myofascial layer of the muscles. Blood investigations showed peripheral eosinophilia, raised immunoglobulin G count, and raised inflammatory markers. A full-thickness forearm biopsy showed the presence of lymphocytic infiltration. A diagnosis of eosinophilic fasciitis was suspected and the patient was managed with oral corticosteroids, given as a tapering dose. Following this, the patient had symptomatic improvement with the resolution of the deranged blood parameters. He was asymptomatic at the latest follow-up of 4 years.