Talus Avascular Necrosis as a Rare Complication of Cushing's Disease: A Case Report.

Avascular necrosis (AVN), also called osteonecrosis, stems from blood supply interruption to the bone and is often idiopathic. It has risk factors like trauma, alcohol, and corticosteroids. AVN in the talus (AVNT) is less common than in the femoral head. Most cases of talar osteonecrosis are associated with trauma, while a smaller proportion is linked to systemic conditions such as sickle cell disease or prolonged prednisone use. Glucocorticoids are a key nontraumatic cause. We report a middle-aged woman with Cushing's syndrome symptoms, such as hypertension and moon face, since her youth. A few years ago, she experienced pain and swelling in her ankle, which was diagnosed as atraumatic AVNT and treated with hindfoot fusion. Years later, she was diagnosed with Cushing's disease caused by an adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in laboratory tests and imaging, which was resected in 2020. She experienced significant weight loss, and her Cushing's syndrome symptoms were relieved after tumor resection. Mechanisms behind AVN in hypercortisolism involve fat cell hypertrophy, fat embolization, osteocyte apoptosis, and glucocorticoid-induced hypertension. Traditional X-rays may miss early AVN changes; MRI is preferred for early detection. Although there are some cases of femoral AVN caused by endogenous hypercortisolism in the literature, as far as we know, this is the first case of AVNT due to Cushing's disease. AVNT treatment includes conservative approaches, hindfoot fusion, and core decompression. Cushing's disease is a rare cause of AVNT, and a multidisciplinary approach aids in the rapid diagnosis of elusive symptoms.

Total Ankle Replacement Outcome in Patients With Inflammatory Versus Noninflammatory Arthritis: A Systematic Review and Meta-analysis.

BACKGROUND: The decision regarding total ankle replacement (TAR) is challenging in patients with inflammatory arthritis (IA) regarding more inferior bone quality, large bone cysts, and increased risk of infections. This systematic review and meta-analysis aimed to compare the functional outcome, revision rate, complication rate, and survival rate of TAR between IA (including rheumatoid arthritis [RA]) and noninflammatory arthritis (NIA) (primary and posttraumatic). METHODS: After reviewing the full texts, 30 articles fulfilled all inclusion criteria from 1985 until 2021, comparing TAR results. The eligible studies included 5508 patients, of whom 1565 patients had IA and 3943 patients had NIA. At the time of surgery, the average age was 58 years in the IA group and 63 in the NIA group. The average follow-up was 67.2 months in the IA group and 67 months in the NIA group. The outcome measures were the American Orthopaedic Foot and Ankle Society (AOFAS) score and the rate of complications, revisions, and survival. RESULTS: The mean final AOFAS score was 82 (95% confidence interval [CI]: 78-86) in the IA group and 83 (95% CI: 78-88) in the NIA group, with no significant difference. There was no significant difference in the mean preoperative to postoperative AOFAS score change between the IA and the NIA. The complication rate was 16% (95% CI: 9%-27%) in the IA group and 15% (95% CI: 8%-27%) in the NIA group with no significant difference. The revision rate was 12% (95% CI: 10%-15%) in the IA group and 13% (95% CI: 10%-18%) in the NIA group, which was significant (P = .04). There was no significant difference in the survival rate between IA and NIA. CONCLUSION: Total ankle replacement is a safe procedure in inflammatory ankle arthritis, specifically in RA patients with relatively minor and major complications close to other reasons for ankle replacement. LEVELS OF EVIDENCE: Level IV: prognostic.

Comparing the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability: Randomized controlled trial.

OBJECTIVE: To compare the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability (CAI). DESIGN: Two-arm, parallel-group, randomized, double-blind, controlled trial. PARTICIPANTS: 60 patients with unilateral CAI. INTERVENTION: integral physiotherapy (n = 30) or conventional physiotherapy (n = 30). OUTCOMES: Visual Analog Scale (VAS), dorsiflexion and plantarflexion range of motion, Star Excursion Balance Test (SEBT), Single Leg Hop (SLH) test, Foot and Ankle Outcome Score (FAOS), Lower Extremity Functional Score (LEFS), global rating of change, were gathered pre and post-intervention. RESULTS: The ANOVA results revealed statistically significant interaction for FAOS, and LEFS outcome measures (P < 0.05) and the mean change results showed there were a favorable clinical difference incline toward the integral group (meanintegral = 20.14 (14.95-25.37), meanConventional = 29.46 (24.09-34.83)). There were no interactions between group and time among other outcome measures (P > 0.05). The group main effect did not show any statistical significance (P > 0.05). CONCLUSION: Hip strengthening and balance exercises added to ankle rehabilitation could be more favorable on improving the patients' functional ability.

The Impact of Lateral Decubitus vs. Beach Chair Positioning on the Clinical Outcome of the Patients with Isolated SLAP Type II Repair: A Systematic Review and Meta-analysis.

Background: A superior labrum from anterior to posterior (SLAP) repairs can be performed in either beach chair (BC) or lateral decubitus (LD). The purpose of this study was to perform a systematic review and meta-analysis to compare the outcomes of surgical repair of type II SLAP injuries between the BC vs. LD positions. We hypothesized no statistically significant differences in the functional, pain, and motion outcomes between the BC vs. LD positions after type II SLAP repair. Methods: A comprehensive literature search was performed using MEDLINE, Scopus, Web of Science, Embase, and Cochrane to identify studies reporting outcomes after type II SLAP repair. Outcome measures consisted of pain using the visual analog score (VAS), range of motion (ROM), and functional scores, including the University of California at Los Angeles Shoulder (UCLA) score, American Shoulder and Elbow Surgeons (ASES), and Constant score. The outcomes were pooled and analyzed for eligibility and stratified into two subgroups for a random-effects model meta-analysis. Results: Of the 8,016 identified studies through a database search, 13 papers (378 patients) were eligible for statistical analysis in the BC and 10 articles (473 patients) were included in the LD group. The mean follow-up for BC and LD was 35 and 44 months, respectively. The SLAP repair in both positions demonstrated improvements in postoperative clinical outcomes and ROM. Comparing the two positions, the LD group demonstrated significantly greater improvements in VAS which contributed to better functional outcomes, while the BC group showed a significantly greater improvement in abduction. No other differences were identified including ASES, UCLA, and Constant score as well as remaining ROM. Conclusion: Based on the findings of this systematic review and meta-analysis, both the BC and LD positions provide patients better outcomes following operative repair of type II SLAPs. While LD represented a better improvement in functional outcome measures, the BC position demonstrated better abduction with no other significant differences between both positions. An individualized approach to position selection concerning the patient's complaint (pain vs. motion) as well as the surgeon's discretion is recommended.

Role of Hip Arthroscopy in the Treatment of Avascular Necrosis of the Hip: A Systematic Review.

Background: Avascular necrosis (AVN) or osteonecrosis of the femoral head occurs as a result of a vascular supply disruption that could lead to hip osteoarthritis. Recently, several joint-preserving procedures have been suggested to improve the outcome of AVN, including hip arthroscopy. This systematic review aimed to investigate the role of hip arthroscopy to preserve hip joints suffering from AVN. Methods: This review was conducted to collect data on hip arthroscopy from the available literature for the management of AVN. The collected articles included those that were focused mainly on the management of AVN assisted by arthroscopy and published up to 2020 that were searched in four databases using such keywords as "Avascular Necrosis", "AVN", and "Osteonecrosis" in combination with "Hip Arthroscopy" or "Arthroscopic Hip Surgery". Results: In total, 13 articles met the eligibility criteria, and no severe complications were reported after arthroscopy in patients with AVN. Moreover, the Harris scores were higher than 79 after the operation. The majority of the assessments showed that the use of arthroscopy was effective in the diagnosis and treatment of patients with AVN, except for one study, which had been performed on patients with stage IV AVN. Conclusion: The findings supported the idea that hip arthroscopy is effective in the treatment of AVN. This approach is becoming more popular for the diagnosis and treatment of hip disorders.

Leech Therapy Protects Free Flaps against Venous Congestion, Thrombus Formation, and Ischemia/Reperfusion Injury: Benefits, Complications, and Contradictions.

The use of free cutaneous or myocutaneous flaps in some surgeries, especially in reconstructive surgeries, is routine and imperative; nevertheless, it is controversial because of fear of flap loss due to tissue congestion and partial or complete necrosis. Different mechanisms are discussed in this process, and based on the involved mechanisms, various agents and approaches are suggested for flap salvage. Among these agents and strategies, leech therapy (hirudotherapy) can be a valuable complementary treatment; however, in this way, full attention should be given to all beneficial and harmful aspects to reach the best results. This study included a literature review of the essential complications following free tissue transfer and explained the effects of leech therapy for the respective complications. Based on the review of the literature, the essential complications following free tissue transfer were (I) venous obstruction and congestion, (II) delay in blood flow reestablishment, (III) ischemia/reperfusion injuries, and (IV) thrombus formation. Leech therapy can protect free flaps against the mentioned complications as a complementary treatment. Leech therapy is an appropriate complement, however, not a definite approach for flap salvage. Therefore, in some patients, other alternative methods or even flap removal may be a better option.

Kinematic Tibiofibular Syndesmotic Measurements as Indicators of Tibiotalar Osteoarthritis: Exploratory Analysis Using 4-Dimensional Computed Tomography.

OBJECTIVE: The aim of this study was to evaluate the association between 4-dimensional computed tomography (4DCT)-derived measurements of tibiofibular syndesmosis during active dorsiflexion-plantarflexion motion and the presence of tibiotalar osteoarthritis (OA). METHODS: Sixteen ankle joints underwent 4DCT imaging during active dorsiflexion-plantarflexion. Syndesmotic anterior distance (SAD) and syndesmotic translation (ST) were obtained by a foot-and-ankle surgeon. We used Kellgren-Lawrence (KL) grading to determine tibiotalar OA. RESULTS: Of 16 scanned ankles, 12 ankles had KL ≥2 at the tibiotalar joint. In these ankles, SAD (-0.4, P = 0.02) and ST (-0.9, P = 0.006) measurements significantly changed during the dorsiflexion-plantarflexion motion. Changes in SAD measurements were significantly correlated with the KL grades (correlation coefficient: -0.688, P = 0.003); however, the changes in ST measurements were not significantly correlated with the KL grade. CONCLUSIONS: Our exploratory cross-sectional analysis shows that SAD measurement changes during motion using 4DCT are correlated with the tibiotalar OA grading. This measurement may be used but requires confirmation in larger studies including patients with actual syndesmotic injuries.

Amputation as a Complication after Total Knee Replacement, is it a Real Concern to be Discussed?: A Systematic Review.

Total knee replacement (TKR) is a growing attractive treatment for a degenerative knee disease. However, there remain some certain devastating complications to be discussed with patients preoperatively, including limb amputation. This systematic review aimed to determine the rate of amputation following TKR. In this study, the literature was searched up to 2019. The papers were included in which knee amputation was reported following TKR. The primary search concluded the articles from EMBASE, SCOPUS, PubMed, Web of Science, MEDLINE, OvidSP, CINAHL, EBSCO, Web of Science™, and CENTRAL. After screening and excluding case reports, 40 papers were included in the present study. The present review showed that amputation is a real end result of knee replacements either in primary or revision knee arthroplasties, which needs to be discussed with patients for their decision-making. Prevalence of amputation in terms of failure or complications after TKR procedures was estimated between 0.1-10% in different studies , with 5.1% amputation rate in infected TKR and 0.025% amputation rate in primary TKR as a result of infection in our review. Deep infection was the main cause of amputation. Vascular complications and fractures associated with bone loss and compartment syndrome were other reasons for amputation.

The effect of platelet-rich plasma-fibrin glue dressing in combination with oral vitamin E and C for treatment of non-healing diabetic foot ulcers: a randomized, double-blind, parallel-group, clinical trial.

OBJECTIVE: The current study assesses the effects of platelet-rich plasma-fibrin glue (PRP-FG) dressing along with oral vitamin E and C on wound healing and biochemical markers in patients with non-healing diabetic foot ulcers (non-healing DFU). METHODS: This randomized controlled trial was performed on 25 patients with non-healing DFU. Patients were treated with PRP-FG dressing plus oral vitamin E and C (intervention group) or PRP-FG dressing plus placebo (control group) for 8 weeks. RESULTS: Eight weeks after treatment, six wounds in the intervention group and two wounds in the control group were completely closed, and also wound size significantly reduced in both intervention and control groups (p < 0.05). This reduction in wound size was significantly greater in the intervention group compared to the control group (p = 0.019). Also, a significant decrease in prooxidant-antioxidant balance (PAB) , ESR, and hs-CRP was observed in the intervention group compared to the control group (p < 0.05). CONCLUSION: Our results showed that PRP-FG dressing along with oral vitamin E and C could be used to increase wound healing in patients with non-healing DFU by enhancing the wound healing process and reducing oxidative stress. TRIAL REGISTRATION: This trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT04315909).

The Use of Antibiotic Impregnated Cement Spacers in the Treatment of Infected Total Joint Replacement: Challenges and Achievements.

Two stage total hip arthroplasty revision surgery includes foreign material debridment, insertion of antibiotic impregnated cement spacer, and finally, reimplantation of the prosthesis. This review has aimed to evaluate the efficacy of antibiotic impregnated cement spacers in infection control and eradication in arthroplasties. A total of 85 articles on total hip arthroplasty were used in this narrative literature review. High concentrations of the antibiotic in targeted drug delivery by means of using antibiotic impregnated cement spacers is effective against infections while reduces the side effects of systemic antibiotic therapy. This results in prevention of bone and muscle atrophy as well as size discrepancy. Also, antibiotic impregnated cement spacers reduce dead space and help stabilize the limb in total hip arthroplasty. Despite all reported drawbacks, antibiotic impregnated cement spacers seem effective in eradicationg infections, although a consensus has not been yet achieved.

Rhenium-188 radiosynovectomy for chronic haemophilic synovitis: Evaluation of its safety and efficacy in haemophilic patients.

INTRODUCTION: Radiocolloids labelled with less costly and more accessible radionuclides such as rhenium-188 are of interest to developing countries compared with those labelled with rhenium-186 and yttrium-90. AIM: This study was aimed to evaluate the efficacy and safety of radiosynovectomy using rhenium-188 in patients with chronic haemophilic synovitis and recurrent hemarthrosis. METHODS: In this quasi-experimental prospective study, 20 haemophilic patients were evaluated at preinjection, and at 1, 3, 6 and 12 months after injection. Magnetic resonance imaging (MRI) was done to measure synovial thickness and to calculate Denver score. Joint radiographs were taken to measure the Pettersson score. The Gilbert questionnaire, Functional Independence Score in Hemophilia (FISH) and visual analogue scale (VAS) for pain were completed, and the number of bleeding episodes and factor consumption were recorded at each follow-up visit. RESULTS: The number of bleeding episodes, the amount of factor consumption per month, VAS pain scores and synovial thickness decreased significantly over time (P < .05). Gilbert and FISH scores showed significant improvement (P < .001). However, Pettersson score and Denver score showed no significant changes after injection. Minor complications including temporary pain and swelling occurred in 20% of patients, and no major complication was observed after rhenium-188 injection. CONCLUSION: Our results indicated high clinical impact, efficacy, safety and low invasion of rhenium-188 in radiosynovectomy of haemophilic patients. Considering the availability and relatively low cost of rhenium-188 in developing countries, this can be a good treatment option for haemophilic patients with recurrent hemarthrosis, particularly when the synovial hypertrophy is not massive yet.

Reliability and Validity of the Persian Version of the Foot Function Index in Patients with Foot Disorders.

BACKGROUND: Foot function index (FFI) is a worthy subjective patient reported outcome measures (PROM) tool for evaluation of the outcomes of medical interventions on foot and ankle. This study was conducted to assess the validity of the Persian version of the foot function index (FFI). METHODS: After translating the original FFI into Persian, back-translation was performed on the agreed Persian version and the final version was established. A total of 113 Persian-speaking patients with foot and ankle problems were enrolled in this study and were asked to fill in the FFI. RESULTS: The Cronbach's alpha for subsections of FFI and MOXFQ was above 0.8 and 0.7, respectively, while it was 0.95 and 0.93 for total FFI and MOXFQ, respectively. The ICC for all subsections of MOXFQ and FFI was above 0.7. The Pearson's correlation coefficient for all subsections of FFI and MOXFQ was significant (P<0.01). CONCLUSION: The Persian version of FFI is valid and reproducible in Persian speaking population. LEVEL OF EVIDENCE: IV.

Hindfoot alignment of adult acquired flatfoot deformity: A comparison of clinical assessment and weightbearing cone beam CT examinations.

BACKGROUND: Clinical assessment of hindfoot alignment (HA) in adult acquired flatfoot deformity (AAFD) can be challenging and weightbearing (WB) cone beam CT (CBCT) may potentially better demonstrate this three-dimensional (3D) deformity. Therefore, we compared clinical and WB CBCT assessment of HA in patients with AAFD. METHODS: In this prospective study, we included 12 men and 8 women (mean age: 52.2, range: 20-88) with flexible AAFD. All subjects also underwent WB CBCT and clinical assessment of hindfoot alignment. Three fellowship-trained foot and ankle surgeons performed six hindfoot alignment measurements on the CT images. Intra- and Inter-observer reliabilities were calculated using intra-class correlation (ICC). Measurements were compared by paired T-tests, and p-values of less than 0.05 were considered significant. RESULTS: The mean of clinically measured hindfoot valgus was 15.2 (95% confidence interval [CI]: 11.5-18.8) degrees. It was significantly different from the mean values of all WB CBCT measurements: Clinical Hindfoot Alignment Angle, 9.9 (CI: 8.9-11.1) degrees; Achilles tendon/Calcaneal Tuberosity Angle, 3.2 (CI: 1.3-5.0) degrees; Tibial axis/Calcaneal Tuberosity Angle, 6.1 (CI: 4.3-7.8) degrees; Tibial axis/Subtalar Joint Angle 7.0 (CI: 5.3-8.8) degrees, and Hindfoot Alignment Angle 22.8 (CI: 20.4-25.3) degrees. We found overall substantial to almost perfect intra- (ICC range: 0.87-0.97) and inter-observer agreements (ICC range: 0.51-0.88) for all WB CBCT measurements. CONCLUSIONS: Using 3D WB CBCT can help characterize the valgus hindfoot alignment in patients with AAFD. We found the different CT measurements to be reliable and repeatable, and to significantly differ from the clinical evaluation of hindfoot valgus alignment. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Hip Surgery in Quiescent or Active Tubercular Hip Arthritis; Is Reactivation Risk Really a Matter.

About 15 % of all musculoskeletal tuberculosis (TB) have hip involvement. Early anti-tubercular drug therapy and other conservative treatment including short-term traction and mobilization programs could prevent hip joint destruction. Reactivation of TB accounts for a significant of active TB incidence, especially in the developed countries with a low TB prevalence. The risk of TB activation for population with the latent form of disease is about 5-10%. According to the existing literature surgery in tubercular hip arthritis would be safe once sufficient debridement and precise anti tubercular chemotherapy has been done.

Validation of the Persian Version of the American Orthopedic Foot and Ankle Society Score (AOFAS) Questionnaire.

BACKGROUND: American Orthopedic Foot and Ankle Society Score (AOFAS) is a reliable and reproducible measurement tool which is commonly used for the assessment of foot and ankle conditions. In this study we aimed to translate and assess the psychometric properties of the Persian version of AOFAS questionnaire. METHODS: In this study, we enrolled 53 patients with ankle and hindfoot conditions. Our study was conducted according to five staged cross-cultural adaption steps including translation, synthesis, back translation, expert committee review, and pretesting. After that reliability of the subjective parts calculated by Cronbach's alpha and the intraclass correlation coefficient (ICC) and the reliability of the objective items estimated using Cohen's kappa test. Also, construct validity was assessed by testing the Persian AOFAS against the SF-36 questionnaire. RESULTS: Chronbach's alpha coefficient was 0.696, which was considered acceptable. Furthermore, the test-retest reliability measured by using the ICC for the subjective subscales was 0.853 (P<0.001). The reliability of testing the objective subscales was calculated by using Kappa, which indicated acceptable values. Pearson correlation coefficient between AOFAS and SF-36 was 0.415 (P=0.008). In addition, floor and ceiling effects were calculated 1.9% and 7.5% respectively. CONCLUSION: In our study, Persian translation of AOFAS demonstrated acceptable validity and reliability with no need to be culturally adapted.

Translation and Cross-cultural Adaptation of the Hip Disability and Osteoarthritis Score into Persian Language: Reassessment of Validity and Reliability.

BACKGROUND: This study aimed Persian translation and validation of the hip disability and osteoarthritis outcome score (HOOS) questionnaire. METHODS: The study was carried out in two phases. First, we translated the HOOS according to acceptable guidelines. We assessed HOOS content convergent validity on 203 hip osteoarthritis patients using SF-36. Internal consistency was tested using Cronbach's alpha coefficient if each item removed and intraclass correlation coefficient (ICC) for the assessment of test-retest reproducibility. RESULTS: Patients had mean (standard deviation) age of 39 (17). Test-retest ICC in whole was 0.95 (P = 0.014) showing excellent reliability. ICC was 0.92 for the "pain" subscale (P = 0.02), 0.81 for the "symptom" subscale (P = 0.002), 0.81 for the "function of daily living (FDL)" (P = 0.022), 0.88 for the "function of sports and recreational activities" (P = 0.006), but it was 0.62 (P = 0.1) for the "quality of life (QOL)." Cronbach's alpha was 0.92, 0.73, 0.97, 0.86, 0.80, and 0.80 for the pain, symptom, FDL, function of sports, QOL, and stiffness, respectively, showing good to excellent internal consistancy. Having SF-36 for the assessment of convergent validity, there was a strong correlation between total HOOS score and the physical component summary domain of SF-36 (r = 0.64, P = 0.0001), whereas the t correlation with the mental component summary domain was weak (r = 0.16, P = 0.04). CONCLUSIONS: The Persian version of the HOOS questionnaire is a valid (regarding physical not mental aspects) and reliable assessment tool in patients with hip osteoarthritis.

Current Concepts in Scaffolding for Bone Tissue Engineering.

Bone disorders are of significant worry due to their increased prevalence in the median age. Scaffold-based bone tissue engineering holds great promise for the future of osseous defects therapies. Porous composite materials and functional coatings for metallic implants have been introduced in next generation of orthopedic medicine for tissue engineering. While osteoconductive materials such as hydroxyapatite and tricalcium phosphate ceramics as well as some biodegradable polymers are suggested, much interest has recently focused on the use of osteoinductive materials like demineralized bone matrix or bone derivatives. However, physiochemical modifications in terms of porosity, mechanical strength, cell adhesion, biocompatibility, cell proliferation, mineralization and osteogenic differentiation are required. This paper reviews studies on bone tissue engineering from the biomaterial point of view in scaffolding. Level of evidence: I.

Anatomic Spring Ligament and Posterior Tibial Tendon Reconstruction: New Concept of Double Bundle PTT and a Novel Technique for Spring Ligament.

A new technique in spring ligament reconstruction using medial half of posterior tibial tendon is demonstrated as a means of supporting the arch. In addition a new concept of double bundle PTT reconstruction based on anatomical attachments of original PTT is presented with the goal of obtaining the full function of PTT.