Bilateral Os Trigonum Fracture Treated With Simultaneous Posterior Ankle Arthroscopy.

This is a case report of a 21-year-old female undergraduate student who sustained bilateral ankle injuries while jumping from a moving van wearing 3-inch high heel shoes. Upon initial presentation, her injury was treated conservatively as an acute bilateral ankle sprain for 6 weeks. However, the patient reported no improvement of pain and remained unable to self-ambulate. Bilateral MRI and CT scans of both ankles demonstrated bilateral os trigonum fractures. She underwent bilateral posterior ankle arthroscopic débridement of both os trigonum. At the postoperative 36-month follow-up, the patient reported notable improvement of all functional outcomes (36-item Short Form survey and Foot and Ankle Ability Measure), reported return to the same level of sports activities, and experienced no pain (visual analog scale) on either ankle. This is the first report in the literature of bilateral os trigonum fracture treated with simultaneous posterior ankle arthroscopic débridement.

Rotational ankle instability: A current concept review.

Ankle sprains are extremely common. It is important to have a clear insight of the course of recovery after such injury to evaluate the effective strategies to guide management decisions, and understand the potential risk factors involved in the development of chronic problems and recurrent ankle sprains. When a prompt diagnosis is not formulated, ligament tears can remain untreated, and chronic ankle instability can result after acute lateral or medial ankle sprain. When the medial ligament complex (MLC), in particular the anterior fascicle of the deltoid ligament, is involved, rotational ankle instability (RAI) can develop. Generally, a tear of the anterior fibres of the MCL accompanied by anterior talofibular ligament (ATFL) insufficiency has been associated with RAI, while injury of the intermediate fibres of the MLC has been associated with medial ankle instability (MAI). Conservative management is the first line of treatment, with surgery reserved for special cases or if rehabilitation has failed. Regarding surgery, several options are available, including anatomic repair, anatomic reconstruction, and tenodesis procedures. Ankle arthroscopy is increasingly used to address ligament insufficiency and to identify and treat intra-articular pathologies. Repair of MLC tears by an arthroscopic all-inside procedure is effective in both MAI and RAI.

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact.

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Dance-Related Foot and Ankle Injuries and Pathologies.

Dancers are highly vulnerable to injuries due to high dynamic overload, extreme positions and motions, and excessive use. Increased load at the forefoot with jumping and high-impact lands can cause sesamoiditis and stress fractures of the metatarsals. Significant plantarflexion can lead to posterior joint impingement and flexor hallucis longus tendonitis, whereas forced dorsiflexion can cause anterior joint impingement. Most pathologies can be diagnosed on physical examination and various imaging modalities. Treatment should be tailored to the dancers' needs and should begin with a course of conservative therapy with immobilization, physical therapy, and activity cessation.

Risk factor of postoperative incision infection after plate internal fixation of calcaneal fractures: a retrospective study.

BACKGROUND: This study aimed to investigate the risk factors for incision infection after plate internal fixation for calcaneal fractures by a traditional lateral L-shaped approach. METHODS: The clinical data of 302 patients with calcaneal fractures who underwent surgical treatment in our hospital from January 2012 to June 2018 were retrospectively analysed, consisting of 177 males and 125 females. The enrolled patients were aged 21 to 75 years, with a mean age of 47.72 years. According to the Sanders classification, 108 patients were type II, 138 patients were type III, and 56 cases were type IV. A univariate analysis was conducted with sex, age, smoking history, history of diabetes, cause of injury, Sanders type, tension blisters, time from injury to surgery, preoperative haemoglobin, preoperative albumin, operation time, and bone grafting as possible risk factors. The factors with statistically significant differences were selected for multivariate binary logistic regression analysis. The clinical cut-off values of these risk factors were calculated using characteristic curves. RESULTS: The follow-up lasted for at least 1 year for all patients, with a mean follow-up time of 15.8 months. The results demonstrated 7.9% (24/302) infection rate after plate internal fixation of calcaneal fractures by the traditional lateral L-shaped approach. Univariate analysis showed that a history of diabetes, preoperative albumin, preoperative haemoglobin, time from injury to surgery, and operation time were correlated with incision infection (p < 0.05). Additionally, multivariate regression analysis indicated that a shorter time from injury to surgery (OR = 1.475, 95% CI: 1.024-2.125, p = 0.037), lower preoperative albumin (OR = 1.559, 95% CI: 1.191-2.041, p = 0.001), and longer operation time (OR = 1.511, 95% CI: 1.219-1.874, p < 0.001) were risk factors for postoperative incision infection, and their cut-off values were 10.5 days, 38.5 g/L, and 84.5 minutes, respectively. CONCLUSION: Longer preoperative stay and operation time were two risk factors for postoperative incision infection. However, lower preoperative albumin level is the highest risk factor in this study. TRIAL REGISTRATION: The trial was registered in the China Clinical Trial Registry (ChiCTR2100047038).

Open ankle fractures: Factors influencing unplanned reoperation.

INTRODUCTION: Ankle fractures are amongst the most common open fracture injuries presenting to major trauma centres (MTC) and their management remains a topic of debate. Incidence is increasing particularly in the elderly population however the optimal surgical approach and risk factors for unplanned reoperation remain scarce. We therefore conducted a retrospective case study to analyse our institution's outcomes as well as identify risk factors for early unplanned reoperation. MATERIALS AND METHODS: Sixty-five consecutive open ankle fractures were identified using our institutional database between July 2016 and July 2020. Medical records and operation notes were reviewed to identify patient age at injury, Sex, co-morbidities and other co-morbidities, fracture configuration, extent of soft tissue injury, fixation type and post-operative complications. The data was categorised into four groups for analysis, 1) age, 2) AO-OTA classification 3) Sex 4) Gustilo-Anderson grade. Statistical analysis was undertaken to identify predictors of unplanned reoperation. RESULTS: The mean age of patients at the time of injury was 60.8. Unplanned reoperation rate was 17.5%. Age and Gustilo-Anderson classification grade were both statistically significant predictors of unplanned reoperation. AO-OTA classification, Sex and Diabetes were not statistically significant factors associated with unplanned reoperation. CONCLUSION: Age and quality of soft tissue envelope are significant risk factors for unplanned reoperation. Patients with these risk factors may benefit from an alternative surgical approach.

Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture.

PURPOSE: This study aimed to address the relationship between surgeon volume and the risk of complications following surgeries of displaced intra-articular calcaneal fractures (DIACFs). METHODS: We retrospectively reviewed the medical records and the follow-up registers for patients who underwent open reduction and internal fixation with plate/screws in our center between January 2015 and June 2020. Surgeon volume was defined as the number of surgically treated calcaneal fractures within the past 12 months, and was dichotomized on basis of the optimal cut-off value. The outcome measure was the documented overall complications within 1 year after surgery. Four logistics regression models were constructed to examine the potential relationship between surgeon volume and complications. RESULTS: Among 585 patients, 49 had documented complications, representing an overall rate of 8.4%. The overall complication rate was 20.0% (22/111) in patients operated on by the low-volume surgeons and 5.7% (27/474) by the high-volume surgeons, with a significant difference (p < 0.001). The 4 multivariate analyses showed steady and robust inverse volume-complication relationship, with OR ranging from 3.8 to 4.4. The restricted cubic splines adjusted for total covariates showed the non-linear fitting "L-shape" or "reverse J-shape" curve (p = 0.041), and the OR was reduced until 10 cases, beyond which the curve leveled. CONCLUSIONS: Our findings reflected the important role of maintaining necessary operative cases, potentially informing optimized surgical care management.

Sinus Tarsi Approach With Percutaneous Screw Fixation for Intra-Articular Calcaneal Fractures.

The aim of this study was to evaluate the outcomes of surgical treatment of intra-articular calcaneal fractures by using the sinus tarsi approach combined with percutaneous medial reduction by leverage technique and percutaneous screw fixation. We assessed the outcomes of 29 patients treated using sinus tarsi approach with percutaneous screw fixation. All patients were evaluated both clinically and radiologically. The Böhler and Gissane angle were evaluated postoperatively using radiographs. During the median follow-up period of 27.0 ± 10.3 months, no cases with failure to reduce or displace hardware were detected. All cases achieved the restoration of a normal Böhler and Gissane angle. The median preoperative Böhler angle was 12.3° ± 2.5° while postoperatively it was 30.5° ± 5.7° (p < .01). The median preoperative Gissane angle was 98.1° ± 7.5°, which was 125.9° ± 3.6° postoperatively (p < .01). At the last follow-up, the median American Orthopedic Foot and Ankle Society hindfoot score was 87.7 ± 5.9, and the median Maryland foot score was 88.6 ± 5.9. Our technique for intra-articular calcaneal fractures can effectively correct calcaneal tuberosity outward displacement, medial wall overlapping, and the hindfoot varus deformity with less soft tissue damage. This technique is a good alternative for the treatment of calcaneal fractures, resulting in minimal soft tissue damage, few wound complications, and excellent radiological and clinical outcomes.

The fibula and talus position difference in functional and mechanical ankle instability: MRI findings.

PURPOSE: This study aimed to use MRI to evaluate the fibula and talus position difference in functional and mechanical ankle stability patients. METHODS: 61 and 68 patients with functional and mechanical instability, and 60 healthy volunteers were involved. Based on the axial MRI images, the rotation of the talus was identified through the Malleolar Talus Index (MTI). The position relative to the talus (Axial Malleolar Index, AMI) and medial malleolus (Intermalleolar Index, IMI) were used to evaluated the displacement of the fibula. RESULTS: Post hoc analysis showed that the values of malleolar talus index was significantly larger among mechanical instability (89.18° ± 2.31°) than that in functional instability patients (86.55° ±61.65°, P < 0.001) and healthy volunteers (85.59° ± 2.42°, P < 0.001). The axial malleolar index of the mechanical instability patients (11.39° ± 1.41°) were significantly larger than healthy volunteers (7.91° ± 0.83°) (P < 0.0001). There were no statistically significant differences in the above three indexes between the functional instability patients and healthy volunteers. CONCLUSION: The functional instability patients didn't have a posteriorly positioned fibula and an internally rotated talus. The malleolar talus index was significantly larger among mechanical instability patients than that in functional instability patients. Increased malleolar talus index may become a new indirect MRI sign for identifying functional and mechanical instability patients.

Posterior Malleolar Fractures: A Critical Analysis Review.

In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play).

Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.

Posterior Ankle Impingement and Flexor Hallucis Longus Pathology.

Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS: First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

Extracorporeal Shock Wave Therapy for Pain Relief After Arthroscopic Treatment of Osteochondral Lesions of Talus.

Arthroscopic treatment is an effective technique for osteochondral lesion of talus (OLT); however, some patients still suffer pain and limitation of activities after surgery. The purpose of this study was to evaluate the efficacy of extracorporeal shock wave therapy (ESWT) after ankle arthroscopy for OLT. We reviewed the clinical history of a series of 78 patients with OLT who underwent arthroscopic microfracture. ESWT was prescribed for 15 patients who complained of ankle pain and restriction of weightbearing activities 3 months postoperatively. The parameters assessed were visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale scores (before ESWT, at 6 and 12 weeks, and at last follow-up after ESWT) and magnetic resonance imaging (MRI) before and 1 year after ESWT. Follow-up was 27.8 ± 15.2 months. VAS and AOFAS scores showed a significant improvement at 12 weeks after ESWT and a progressive trend at last follow-up. Areas of lesions in sagittal plane in MRI were distinctly reduced at last follow-up. ESWT for osteochondral lesions of talus after arthroscopy results in good clinical outcomes.

[Stingray injury: A case in French Polynesia]. / Piqûre de raie pastenague : un cas en Polynésie française.

INTRODUCTION: Stingray injuries occur when people inadvertently step on these fish. Penetration of the barb results in puncture and/or laceration wounds and lesions related to the venom. PATIENTS AND METHODS: We report the case of a 76-year-old woman in French Polynesia who was stung on her right ankle by a stingray. She initially had a hypertensive episode with encephalopathy and a haemorrhagic wound due to an indwelling fragment of the barb. Necrosis due to the poison required medical-surgical management with debridement, which yielded a favourable outcome. DISCUSSION: Stingray injuries are rare and not well-known by doctors. They can be serious due to injury by the barb and to venom poisoning, leading to enzymatic tissue destruction, ischaemia and intense pain. The initial treatment consists in immersion in hot water, as the venom is thermolabile; antibiotics and surgery may be necessary, depending on the condition of the wound.

An Epidemiological Study of Foot and Ankle Motocross Motorcycling Injuries in the United Kingdom.

BACKGROUND: Motocross is a recreational and competitive sport involving motorcycle racing on off-road circuits. Participants have enjoyed their sport worldwide for over 100 years. In the United Kingdom, there are over 200 clubs, with over 900 events annually. Unfortunately, little evidence exists on motocross injuries and their prevention. The aim of this study is to report and to quantify the different foot and ankle injuries observed in motocross. METHODS: Data was collected prospectively between August 2010 to August 2015 at our regional trauma unit, regardless of whether the sport was performed competitively or recreationally. RESULTS: Foot and ankle related injuries were identified in 210 patients (age range 4-78 years), with the majority being male participants (189, 90%). The majority of injuries occurred within the 21- to 30-year-old-age group. Most injuries were sustained around the start of the motocross season, in early spring and the summer months. A total of 76 patients (36%) required operative intervention. The most common injury was ankle fracture (49, 23%), followed by ankle sprain (44, 21%). CONCLUSION: This is the first epidemiological study in the United Kingdom documenting foot and ankle injuries in motocross. The frequency and severity of motocross-related injuries is presented. This may serve to provide recommendations and guidelines in the governing bodies of this sport. The surge in motocross popularity is correlates with an increase in injuries and inevitably the resources required to treat them. LEVEL OF EVIDENCE: Prospective descriptive epidemiological study. Level 1.

Incidence of symptomatic os trigonum among nonathletic patients with ankle sprain.

PURPOSE: Os trigonum syndrome is a rare condition, often affecting athletes. A paucity of data exists on the incidence of os trigonum syndrome in nonathletic population. The study aimed to determine the incidence and clinical characteristics of os trigonum syndrome in nonathletic patients with sprained ankles. METHODS: The sample consisted of 798 adolescent and adult patients that attended the emergency department or Foot and Ankle Clinic with acute ankle sprain. Lateral and/or oblique lateral radiographs of the feet were screened for the presence of os trigonum in relation to age and gender. A cohort of 163 patients with os trigonum was followed up prospectively over a 48-month period to correlate the presence of the os trigonum with patient symptomatology. RESULTS: Os trigonum was found in 20.4% (163/798) of sprained ankles. Patients aged 18-35 exhibited most os trigonum [42.3% (69/163)], with higher incidence in females. 5.5% (9/163) of the os trigonum patients developed an os trigonum syndrome after a standard treatment of an ankle sprain [3.8% (3/78) of males and 7.1% (6/85) of females]. Females aged between 18 and 35 years had higher incidence of os trigonum syndrome compared to males of a similar age. CONCLUSION: Os trigonum syndrome should be suspected in nonathletic patients with an ankle sprain unresponsive to standard treatment. About 1.1% of acute ankle sprain patients develop an os trigonum syndrome. This finding can help identify the source of a patient's symptoms, leading to an accurate diagnosis, appropriate treatment and reducing the potential chronic symptoms.

Distal Peroneus Longus Dislocation and Pseudohypertrophy of the Peroneal Tubercle: A Systematic Review.

Peroneal tendon injuries at the peroneal tubercle are rare. No systematic research regarding this pathology is currently available. In this systematic literature review, the author evaluated the present knowledge about peroneal tendon lesions at the lateral calcaneal wall. These lesions are predominantly associated with peroneal tubercle enlargement. Information on 25 respective patients (26 cases) has been published in 14 articles. Until now, only 3 reports presented 5 patients with dislocation of the peroneus longus tendon combined with inferior peroneal retinaculum lesions. In these cases, the peroneal tubercle was not enlarged. All reviewed patients were treated surgically. Enlarged peroneal tubercles were resected. Groove deepening and inferior peroneal retinaculum reconstruction addressed distal peroneus longus tendon dislocations. The reported results were either excellent or good. Recurrent dislocations can cause lesions of the peroneus longus tendon at the peroneal tubercle. This pathology is rare and can be addressed surgically. In cases without tendon dislocation, the enlarged peroneal tubercles are removed or shaped, whereas dislocations in normal shaped peroneal tubercles require groove deepening and inferior peroneal retinaculum reconstruction.

Arthroscopic Implantation of a Cartilage Matrix for an Osteochondral Defect of the Talus: A Case Report.

Advances have been made in the treatment for osteochondral defects of the talus, but these injuries continue to be a challenge for foot and ankle surgeons. We present an arthroscopically assisted technique that uses an allogenic cartilage graft in treating an osteochondral lesion of the medial dome of the talus. A brief discussion on current surgical options for osteochondral defects of the talus is also provided.