Dream-enactment behaviours during the COVID-19 pandemic: an international COVID-19 sleep study.

There has been increasing concern about the long-term impact of coronavirus disease 2019 (COVID-19) as evidenced by anecdotal case reports of acute-onset parkinsonism and the polysomnographic feature of increased rapid eye movement sleep electromyographic activity. This study aimed to determine the prevalence and correlates of dream-enactment behaviours, a hallmark of rapid eye movement sleep behaviour disorder, which is a prodrome of α-synucleinopathy. This online survey was conducted between May and August 2020 in 15 countries/regions targeting adult participants (aged ≥18 years) from the general population with a harmonised structured questionnaire on sleep patterns and disorders, COVID-19 diagnosis and symptoms. We assessed dream-enactment behaviours using the Rapid Eye Movement Sleep Behaviour Disorder Single-Question Screen with an additional question on their frequency. Among 26,539 respondents, 21,870 (82.2%) answered all items that were analysed in this study (mean [SD] age 41.6 [15.8] years; female sex 65.5%). The weighted prevalence of lifetime and weekly dream-enactment behaviours was 19.4% and 3.1% and were found to be 1.8- and 2.9-times higher in COVID-19-positive cases, respectively. Both lifetime and weekly dream-enactment behaviours were associated with young age, male sex, smoking, alcohol consumption, higher physical activity level, nightmares, COVID-19 diagnosis, olfactory impairment, obstructive sleep apnea symptoms, mood, and post-traumatic stress disorder features. Among COVID-19-positive cases, weekly dream-enactment behaviours were positively associated with the severity of COVID-19. Dream-enactment behaviours are common among the general population during the COVID-19 pandemic and further increase among patients with COVID-19. Further studies are needed to investigate the potential neurodegenerative effect of COVID-19.

An Automated Algorithm for Determining Sleep Using Single-Channel Electroencephalography to Detect Delirium: A Prospective Observational Study in Intensive Care Units.

The relationship between polysomnography-based objective sleep and delirium in the intensive care unit (ICU) is inconsistent across studies, suggesting limitations in manually determining the sleep stage of critically ill patients. We objectively measured 24-h sleep using a single-channel electroencephalogram (SleepScope [SS]) and an under-mattress sleep monitor (Nemuri SCAN [NSCAN]), both of which have independent algorithms that automatically determine sleep and wakefulness. Eighteen patients (median age, 68 years) admitted to the ICU after valvular surgery or coronary artery bypass grafting were included, and their sleep time was measured one day after extubation. The median total sleep times (TSTs) measured by SS (TST-SS) and NSCAN were 548 (48−1050) and 1024 (462−1257) min, respectively. Two patients with delirium during the 24-h sleep measurement had very short TST-SS of 48 and 125 min, and the percentage of daytime sleep accounted for >80% in both SS and NSCAN. This preliminary case series showed marked sleep deprivation and increased rates of daytime sleeping in ICU patients with delirium. Although data accuracy from under-mattress sleep monitors is contentious, automated algorithmic sleep/wakefulness determination using a single-channel electroencephalogram may be useful in detecting delirium in ICU patients and could even be superior to polysomnography.

Depressive and anxiety symptoms among Japanese cancer survivors: Japan cancer survivorship research project.

BACKGROUND: This study aimed to clarify predictors of depressive symptoms and anxiety symptoms after cancer diagnosis among Japanese cancer survivors (CSs). METHODS: As part of a Japanese cancer survivorship research project commissioned by the Ministry of Health, Labour and Welfare (MHLW) of Japan, we conducted a web-based nationwide survey of CSs in 2018. We analyzed the risk factors for depressive and anxiety symptoms, as measured by the Hospital Anxiety and Depression Scale Japanese version (HADS). RESULTS: Of 1,234 Japanese CSs, mean score of HADS-depression and HADS-anxiety were 4.08 and 4.78, respectively. At the time of the study, the number of CSs with symptoms of depression and anxiety were 111 (9.0%) and 269 (21.8%), respectively. After multivariable analysis, CSs ≥ 60 years old (reference: ≤ 39 years old, odds ratios (OR): 0.39, 95%CI: 0.17-0.90) and those ≥ 10 years from cancer diagnosis (reference: 0-4 years, OR: 0.55, 95%CI: 0.32-0.96) had lower odds for depressive symptoms. And CSs ≥ 60 years old (reference: ≤ 39 years old, OR: 0.27, 95%CI: 0.15-0.49) and those ≥ 10 years from cancer diagnosis (reference: 0-4 years, OR: 0.62, 95%CI: 0.42-0.90) also had lower odds for anxiety symptoms. CSs who received chemotherapy (OR: 1.56, 95%CI: 1.10-2.20) had higher odds for anxiety symptoms. CONCLUSIONS: Based on manifestation of symptoms, CSs who were younger, closer to the time of cancer diagnosis, had advanced-staged cancer, or received chemotherapy may be at higher risk for depressive or anxiety symptoms. Those CSs who have higher risk for depression and anxiety symptoms, should be followed-up more carefully for better cancer survivorship, by medical professionals, companies, and society.

Induced membrane technique using an equal portion of autologous cancellous bone and ß-tricalcium phosphate provided a successful outcome for osteomyelitis in large part of the femoral diaphysis - Case report.

BACKGROUND: No report has yet described good prognosis following the induced membrane technique (IMT) for bone defects over 200 mm. CASE PRESENTATION: A 46-year-old male developed osteomyelitis over a large portion of the right femoral diaphysis, which had an unknown infection route, and subtrochanteric fracture during the waiting period of the planed IMT. Around 3 days after the pathological fracture, the first stage was performed. Aggressive debridement resulted in large segmental bone defect, which was treated with internal fixation using intramedullary nailing and insertion of an antibiotic-impregnated polymethylmethacrylate (PMMA) spacer. Postoperative radiographs showed a radiographic apparent bone gap of 221 mm. A subsequent culture of the debrided bone test identified Corynebacterium as the causative organism, with blood examination indicating normal C-reactive protein, white blood cell count, and erythrocyte sedimentation rate following 4 weeks of intravenous antibiotic administration. Around 7 weeks after the first stage, the second stage was initiated. After removing the PMMA spacer, grafting was performed by filling the bone defect with a combination of autologous cancellous bone harvested from the posterior iliac crest and ß-tricalcium phosphate (ß-TCP), which were mixed in approximately equal proportions. Routine postoperative radiographs confirmed a sequential healing process and callus formation in three out of four cortices 3 years after surgery. CONCLUSIONS: In the present case, IMT was able to successfully treat the osteomyelitis-induced large segmental bone defect of the femoral shaft exceeding 200 mm. Had autologous cancellous bone alone been applied during the second stage, the possible amount of bone defect covered by the IMT would have been limited. However, this limitation can be addressed by applying ß-TCP. Further expansion of IMT indications may help address challenges in the treatment of extensive bone defects.

A Cross-Sectional Study of Evening Hyperphagia and Nocturnal Ingestion: Core Constituents of Night Eating Syndrome with Different Background Factors.

This web-based cross-sectional survey aimed to elucidate the differences between the two core symptoms of night eating syndrome (NES): evening hyperphagia and nocturnal ingestion in the general Japanese population aged 16-79 years. Participants who consumed at least 25% of daily calories after dinner were defined as having evening hyperphagia. Those who consumed food after sleep initiation at least twice a week were determined to have nocturnal ingestion. Of the 8348 participants, 119 (1.5%) were categorized in the evening hyperphagia group, 208 (2.6%) in the nocturnal ingestion group, and 8024 in the non-NES group. Participants with evening hyperphagia and nocturnal ingestion had significantly higher anxiety scores (p < 0.05 and p < 0.001, respectively) and depression (p < 0.001 for both) than those without NES. Multiple logistic regression analysis revealed that evening hyperphagia was significantly and independently associated with higher body mass index, shorter sleep duration, later sleep-wake schedule, and higher insomnia score, while nocturnal ingestion was significantly and independently associated with younger age, smoking habit, living alone, earlier sleep-wake schedule, and higher insomnia score. Sleep duration and sleep-wake schedule characteristics in the two groups were opposite, suggesting differences in the sleep pathophysiology mechanisms.

Early postoperative Barthel index score and long-term walking ability in patients with trochanteric fractures walking independently before injury: a retrospective cohort study.

INTRODUCTION: Trochanteric fractures are one of the most common fragility fractures, and the number of the patients is increasing worldwide. Identifying prognostic factors is important to manage and minimize the social losses caused by postoperative walking impairment. The purpose of this retrospective study is to clarify the association between early postoperative Barthel index score and postoperative long-term walking ability among patients with trochanteric fractures who could walk independently before injury. MATERIALS AND METHODS: Consecutive patients with trochanteric fractures aged ≥ 65 years who were walking independently before injury were included. Patients were divided into two groups according to the Barthel index score measured within 1 week after surgery; the cut-off value was set at 20 points. The prevalence of walking impairment after 1 year was compared between these two groups after adjusting for confounding factors in a complete case analysis and using the data introduced by the multiple imputation method. RESULTS: Among the 758 eligible patients, 254 patients (34%) had their walking ability evaluated after 1 year from injury. The patients in the lower Barthel index group showed a significantly impaired walking ability in both analyses (adjusted odds ratio 5.5 and 2.4, 95% confidence intervals 2.4-13 and 1.5-3.8, respectively). CONCLUSIONS: The present results suggested that the Barthel index score measured in the early postoperative period after trochanteric fractures was associated with the level of long-term walking impairment in patients who could walk independently before injury.

Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon.

BACKGROUND: The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture. METHODS: A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up. RESULTS: Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up (P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively (P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery. CONCLUSION: The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Prevalence and Associated Factors of Nocturnal Eating Behavior and Sleep-Related Eating Disorder-Like Behavior in Japanese Young Adults: Results of an Internet Survey Using Munich Parasomnia Screening.

Nocturnal (night) eating syndrome and sleep-related eating disorder have common characteristics, but are considered to differ in their level of consciousness during eating behavior and recallability. To date, there have been no large population-based studies determining their similarities and differences. We conducted a cross-sectional web-based survey for Japanese young adults aged 19-25 years to identify factors associated with nocturnal eating behavior and sleep-related eating disorder-like behavior using Munich Parasomnia Screening and logistic regression. Of the 3347 participants, 160 (4.8%) reported experiencing nocturnal eating behavior and 73 (2.2%) reported experiencing sleep-related eating disorder-like behavior. Smoking (p < 0.05), use of hypnotic medications (p < 0.01), and previous and/or current sleepwalking (p < 0.001) were associated with both nocturnal eating behavior and sleep-related eating disorder-like behavior. A delayed sleep-wake schedule (p < 0.05) and sleep disturbance (p < 0.01) were associated with nocturnal eating behavior but not with sleep-related eating disorder-like behavior. Both nocturnal eating behavior and sleep-related eating disorder-like behavior had features consistent with eating disorders or parasomnias. Nocturnal eating behavior but not sleep-related eating disorder-like behavior was characterized by a sleep-awake phase delay, perhaps representing an underlying pathophysiology of nocturnal eating syndrome.

Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis.

BACKGROUND: While recent meta-analyses have reported the superiority of antipsychotic polypharmacy (APP) over antipsychotic monotherapy (APM) in schizophrenia, switching to APM can be beneficial in terms of side effects. To determine whether patients receiving APP should switch to APM or stay on APP, we conducted a systematic review and meta-analysis. METHODS: Randomized controlled trials (RCTs) examining a switch from APP to APM vs. staying on APP were systematically selected from a previous meta-analysis comparing APP with APM in patients with schizophrenia. In addition, we conducted an updated systematic literature search using MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Data on study discontinuation, relapse, psychopathology, neurocognition, extrapyramidal symptoms, and body weight/body mass index (BMI) were extracted and synthesized. RESULTS: A total of 6 RCTs involving 341 patients were included. All studies examined a switch from 2 antipsychotic agents to a single agent. Clozapine-treated patients were included in 3 studies. There was a significant difference in study discontinuation due to all causes in favor of staying on APP (N = 6, n = 341, RR = 2.28, 95% CI = 1.50-3.46, P < 0.001). There were no significant differences in relapse, any psychopathology, neurocognition, extrapyramidal symptoms, or body weight/BMI between the 2 groups. The quality of evidence was low to very low. CONCLUSIONS: The findings suggest that clinicians should closely monitor patient condition when switching to APM after receiving 2 antipsychotics. Given the low to very low overall quality of the evidence, the findings should be considered preliminary and inconclusive.

Prevalence and distribution of air in the leg on preoperative multidetector high-resolution computed tomography in closed and low-grade open tibial shaft fractures.

PURPOSE: The prevalence and distribution of air present in the leg in closed and low-grade open tibial shaft fractures are unknown on multidetector high-resolution computed tomography (CT). The purpose of this study was to determine the rate of surgical site infection (SSI) in cases where debridement was not performed in the area of air infiltration. METHODS: Eighty-one closed and low-grade open tibial shaft fractures that underwent multidetector high-resolution CT on admission and were treated with an intramedullary nail were examined retrospectively. RESULTS: Of the 36 Gustilo type I or II open fractures, all had local air around the fracture site (within 5 cm proximal and distal from the fracture center). Of these, 25 showed remote air (more than 5 cm away from the fracture center). The most frequent site of remote air was in the subcutaneous tissue, followed by the anterior compartment and deep posterior compartment. All open fractures were treated with local irrigation and debridement, regardless of the presence of remote air, followed by a reamed intramedullary nail. No SSI developed until bone union. Of the 45 closed fractures, 3 patients showed air in the leg on the CT. No debridement was performed for closed fractures. One patient who did not have air in the leg developed SSI. All fractures united eventually. CONCLUSIONS: In low-grade open tibial shaft fractures, air can spread far from the fracture site. Even in closed tibial shaft fractures, air can be identified in the leg. The debridement of the area of air infiltration, however, is not necessary for prevention of SSI.

Comparison of the operative time for open door laminoplasty using titanium plate spacers or hydroxyapatite block spacers: a retrospective study.

BACKGROUND: Titanium plate (TP) and hydroxyapatite (HA) spacers are widely used during open-door laminoplasty, performed with the patient in a prone position. Reducing operative time is an important consideration, particularly to reduce the risk of postoperative complications in older patients. The purpose of this retrospective cohort study was to compare the operative time for open-door laminoplasty using TP or HA spacers. METHODS: Consecutive patients with a spinal cord injury, without bone injury, and ≥ 50 years of age were included. Multivariate regression analysis was used to compare the operative time between patients in the TP and HA group, adjusting for known factors that can influence surgical and postoperative outcomes. Propensity score matching was used to confirm the robustness of the primary outcome. The cumulative incidence of postoperative complications over 1-year after surgery was also compared. RESULTS: Of the 164 patients forming our study group, TP spacers were used in 62 and HA in 102. Operative time was significantly shorter for the TP (128 min) than HA (158 min) group (p < 0.001). Both multivariate and propensity score matching analyses confirmed a significant reduction in operative time for the TP, compared to HA, group (regression coefficient, - 30 min and - 38 min, p < 0.001 and p < 0.001, respectively). There was no significant difference in the cumulative incidence of postoperative complications. CONCLUSIONS: The use of TP spacers reduced the operative time for cervical open-door laminoplasty by about 30 min, compared to the use of HA spacers, with no difference in the rate of postoperative complications.

Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert.

PURPOSE: The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions. METHODS: A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects. RESULTS: Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3-6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered. CONCLUSIONS: Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI. LEVEL OF EVIDENCE: V.

Unilateral Upper Lung Field Pulmonary Fibrosis Radiologically Consistent with Pleuroparenchymal Fibroelastosis after Thoracotomy: A New Disease Entity Related to Thoracotomy.

BACKGROUND: Pleuroparenchymal fibroelastosis (PPFE) is a rare bilateral idiopathic interstitial pneumonia defined by pleural-parenchymal involvement. In clinical practice, we encountered patients with upper lung field pulmonary fibrosis (Upper-PF), which was radiologically consistent with PPFE, but apparently limited to the unilateral lung. OBJECTIVES: The purpose of the study was to clarify the clinical characteristics in those patients. METHODS: We examined the medical records of all the consecutive patients from 2012 to 2016 to see whether there were patients having unilateral Upper-PF. RESULTS: We found 6 patients with unilateral Upper-PF. The most common symptom was dyspnea, and all patients had a low body mass index and severe restrictive pulmonary impairment. Notably, all patients had a history of thoracotomy for resecting lung or esophageal cancer, and the lesions were limited to the operated side. Dynamic breathing chest MRI showed an impaired thoracic movement in the operated side. Serial chest CT from prethoracotomy to the first visit was obtained in 5 patients: before thoracotomy, only a slight apical cap, defined as a wedge- and triangle-shaped opacity with broad pleural contact, was observed only in the operated side, but progressed into the lesion after a median of 8.4 years following thoracotomy. After the first visit, the unilateral lesion rapidly deteriorated in all patients. CONCLUSIONS: Unilateral Upper-PF had some characteristics in common with PPFE. Because the lesion was limited to the operated side, unilateral Upper-PF would be a new disease entity related to thoracotomy. Our results indicate that thoracotomy impairs thoracic movement in the operated side and subsequently triggers unilateral Upper-PF development, especially in patients with an apical cap.

Bony landmarks available for minimally invasive lateral ankle stabilization surgery: a cadaveric anatomical study.

PURPOSE: The purpose of this study was to determine the clinical utility of three bony tubercles: fibular obscure tubercle, talar obscure tubercle and tuberculum ligamenti calcaneofibularis, to serve as anatomical landmarks for defining the precise location of the origins and insertions of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). METHODS: Twelve lower extremity cadaveric specimens were procured. The detectability of the tubercles was tested using palpation and fluoroscopy with subsequent confirmation after dissection. If the tubercles were present, then distances from the identified tubercles to the footprint centres and the intersection of the ATFL and CFL were measured to allow precise localization of the ATFL and CFL origin and intersection sites. Further, if the tubercles were not detectable, then an attempt to provide an alternative means of localizing ATFL and CFL origin and insertion sites was made by measuring distances between alternative landmarks and other important structures. All the measurements were performed by two researchers, and the results were averaged. RESULTS: The fibular obscure tubercle existed and was detectable in all specimens. It was located 1.3 mm proximal to the articular tip of the fibula, 2.7 mm to the intersection of the ATFL and CFL, 3.7 mm distal to the ATFL and 4.9 mm proximal to the CFL origins. The talar obscure tubercle existed 58 % of specimens and was detectable in 57 %. The talar obscure tubercle was located 1.4 mm to the ATFL. The ATFL insertion point was located 60 % of the distance from the inferolateral corner to the anterolateral corner of the of talar body along the anterior border of the talar lateral articular facet. The tuberculum ligamenti calcaneofibularis existed in 33 % of specimens and was detectable in 8 %. The CFL inserted 17 mm on a perpendicular projected line distal from the subtalar joint. CONCLUSIONS: The fibular obscure tubercle was clinically relevant and reliable bony landmark of the ATFL and CFL origin location. However, the talar obscure tubercle was less reliable and the tuberculum ligamenti calcaneofibularis was rarely available and as such alternative landmarks for the ATFL and CFL insertion location should be utilized. The present study describes the utility of clinically relevant bony landmarks that may assist in identifying the origins and insertions of the ATFL and CFL to facilitate minimally invasive ankle stabilization surgery.

Anatomy of anterior talofibular ligament and calcaneofibular ligament for minimally invasive surgery: a systematic review.

PURPOSE: To gain a better understanding of the precise anatomy of the lateral ligaments of the ankle through a systematic review of published cadaveric studies in order to improve anatomical minimally invasive surgery (MIS) for treatment of chronic ankle instability (CAI). METHODS: A systematic review of the literature was performed using the PubMed, EMBASE, Cochrane databases and Web of Science on June 2015 with the two search concepts: "lateral ligament of the ankle" and "anatomy". Anatomical studies that reported gross anatomy of the anterior talar fibular ligament (ATFL) and calcaneal fibular ligament (CFL) in English were included to assess the morphology and origins and insertions of the ligaments. All records found in the literature search were screened by title and abstract. Potentially relevant articles were selected for full-text review. Each of the identified articles was reviewed and included in qualitative synthesis. The following data were abstracted from the included articles: authors, date of publication, sample size, mean age, the length and the width of the each ligament, number of bundle of the ATFL and the location and the footprint of the origins and insertions for the ATFL and CFL. RESULTS: Sixteen studies were identified indicating the length of the ATFL and CFL was 12-24.8 and 18.5-35.8 mm, respectively, while the width was 5-11.1 and 4.6-7.6 mm, respectively. Fibular origins of the ATFL and CFL were located on the anterior border of distal fibula at a distance of 10-13.8 and 5.3-8.5 mm proximal to the tip of the fibula, respectively. The talar insertion of the ATFL was located 14.2-18.1 mm to the subtalar joint or 11.3-14.8 mm to the anterolateral corner of the talar body. The calcaneal insertion of the CFL was located 12.1-13 mm to the subtalar joint or 13.2-27.1 mm to the peroneal tubercle on the lateral wall of calcaneus. CONCLUSION: Systematic review of the literature of the research for the ATFL and CFL has identified the morphology of the ligaments and their location of origins and insertions. This is the best available data about the ATFL and CFL which will facilitate more precise anatomical MIS for treatment of CAI. LEVEL OF EVIDENCE: Systematic review, Level IV.

Minimally invasive surgical treatment for chronic ankle instability: a systematic review.

PURPOSE: The purpose of this study was to determine the evidence-based support for the treatment for chronic ankle instability (CAI) using minimally invasive surgery (MIS) techniques. METHODS: A systematic comprehensive review of the literature was performed on 4 September 2015 using PubMed, EMBASE, Cochrane databases and Web of Science along with the two search concepts: lateral ligament of the ankle (patients) and minimally invasive surgical procedure (intervention). Articles of clinical study on MIS for CAI were included in this review and classified into four MIS categories (arthroscopic repair, non-arthroscopic minimally invasive repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction) based on the adopted surgical procedure. Included articles were reviewed and assigned a classification according to the research method quality of evidence (Level I-V evidence). Analysis of these studies was then conducted to provide a grade of recommendation for each MIS category. RESULTS: The systematic literature review generated 430 articles, and 33 articles met our inclusion criteria. The highest recommendation was Grade C (poor-quality evidence) to support the use of the arthroscopic repair, arthroscopic reconstruction and non-arthroscopic minimally invasive reconstruction. Insufficient evidence was currently available to make any recommendation (Grade I) for non-arthroscopic minimally invasive repair category. CONCLUSIONS: Despite recent increases in publications on MIS for the treatment for CAI, there was currently poor quality of evidence that was insufficient to allow a high grade of recommendation to support the use of the MIS. This paper should stimulate those surgeons performing higher quality studies in the form of prospective and preferably randomized comparative studies that will be necessary to allow better recommendations for the treatment for CAI with MIS. The present study showed thorough evidence-based recommendation for the clinical use of the MIS based on the comprehensive review of the literature. LEVEL OF EVIDENCE: Systematic review, Level IV.

Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle.

INTRODUCTION: To compare the early result between arthroscopic and traditional open repair of the anterior talofibular ligament (ATFL) with inferior extensor retinaculum (IER) reinforcement for lateral instability of the ankle (LIA). MATERIALS AND METHODS: We retrospectively reviewed cases that had been surgically treated for LIA and compared two treatment groups: those treated with an open procedure (Group O) vs those treated with an arthroscopic procedure (Group A). The parameters compared between the groups were visual analog scale (VAS) score at 3 days and 2 weeks after surgery, duration of surgery, time to return to daily activities and sports activities, postoperative complications, recurrence of the instability, and Japanese Society for Surgery of the foot ankle-hindfoot (JSSF) scale score before and at 1 year after surgery. RESULTS: Significant differences were seen in the mean duration of surgery, mean VAS score at 3 days, and mean time to return to daily activities between the groups. Two patients had temporary numbness in Group A, while 3 patients had wound irritation and 1 patient had temporary numbness in Group O. Ankle instability did not recur in either group. There was no significant difference in either preoperative or postoperative JSSF scale score between the groups. CONCLUSIONS: Compared with the open procedure, arthroscopic ATFL repair with IER reinforcement for LIA had an equivalent clinical result at the 1-year follow-up and allowed early recovery after surgery.

Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle.

UNLABELLED: Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive. LEVEL OF EVIDENCE: Therapeutic study, Level V.

Simultaneous ankle arthroscopy and hindfoot endoscopy for combined anterior and posterior ankle impingement syndrome in professional athletes.

INTRODUCTION: This study aimed to evaluate the clinical outcome of simultaneous less-invasive ankle arthroscopy and hindfoot endoscopy for combined anterior ankle impingement syndrome (AAIS) and posterior ankle impingement syndrome (PAIS) in professional athletes. MATERIALS AND METHODS: Between October 2009 and October 2011, 12 feet of 9 professional athletes (8 men, 1 woman; mean age 25 years; range 19-34 years) with combined AAIS and PAIS underwent simultaneous ankle arthroscopy and hindfoot endoscopy. Radiography, computed tomography, and magnetic resonance imaging were performed in all patients. Ultrasound-guided anesthetic injection was administered for the diagnosis of PAIS. Active plantar and dorsal flexion angles of the ankle before and after surgery, occurrence of complications, and time to return to competitive sports were evaluated. RESULTS: All feet had osteophytes in the anterior ankle joint. Ostrigonum and a large posterior talar process were found in 8 and 4 feet, respectively. Combined disorders that were noted were lateral ankle instability in 6 feet and an osteochondral lesion of the talus in 4 feet. Median JSSF and VAS scores improved significantly from 63 (range 55-69) points preoperatively to 82 (range 77-100) points postoperatively (p < 0.01), and from 85 (range 70-95) points preoperatively to 8 (range 3-15) points postoperatively (p < 0.01), respectively. Median active plantar and dorsal flexion angles improved significantly from 40° (range, 30°-50°) and 10° (range 5°-20°) preoperatively to 50° (range 40°-55°) and 15° (range 10°-20°) postoperatively, respectively (p < 0.01 and p < 0.05, respectively). One patient complained of numbness in the vicinity of the sural nerve, which resolved spontaneously by the 4th week after surgery. Median time to return to competitive sports was 12 (range 12-15) weeks. CONCLUSION: Simultaneous ankle arthroscopy and hindfoot endoscopy for combined AAIS and PAIS enables professional athletes to return to athletic activity.