Construction and validation of a nomogram model for predicting different sites of ankle pain in runners with chronic ankle instability.

This study aimed to establish a risk prediction nomogram model for anterolateral, mediolateral, and posterolateral ankle pain in runners with chronic ankle instability (CAI) and analyse the potential risk factors for pain at different ankle sites. Thirty recreational runners with CAI who reported ankle pain in the anterolateral, mediolateral, or posterolateral regions were recruited for this study. Kinematic, kinetic, and electromyographic data during running were collected using motion capture system, 3-D force platform, and surface electromyography system. These data were used to generate a dynamic nomogram. The results showed that anterolateral ankle pain in runners with CAI may be caused by insufficient gastrocnemius muscle strength (OR 0.85, 95% CI 0.73-0.97), excessive ground reaction force (GRF, OR 2.64, 95% CI 1.25-6.22), and an increased percentage of ankle energy absorption (OR 9.11, 95% CI 1.50-77.79). Mediolateral ankle pain might be contributed by greater ankle inversion angle (OR 1.08, 95% CI 1.01-1.00) and GRF (OR 2.13, 95% CI 1.17-4.31). Moreover, posterolateral ankle pain was predicted by increased ankle adduction angle (OR 1.06, 95% CI 1.00-1.12), increased GRF (OR 2.16, 95% CI 1.07-4.80), and decreased dynamic stability (OR 0.20, 95% CI 0.05-0.68). To prevent ankle pain, runners with CAI should be encouraged to focus on improving the neuroreceptor sensitivity of the gastrocnemius muscles, and retraining their energy absorption patterns.

Good rate of satisfaction but suboptimal clinical outcome at long-term follow-up in a large series of patients who had operative stabilization of the deltoid ligament of the ankle.

PURPOSE: To report results following deltoid ligament reconstruction in a large series of patients. METHODS: For consecutive patients who had a medial ankle ligament stabilization 2010-2018 information from their medical files was registered, and they were invited for follow-up in 2021-2022. They answered questions about satisfaction with the treatment and current symptoms, and they completed the Foot and Ankle Measurement (FAAM) questionnaire. RESULTS: Of the 503 patients, 342 (68%) had a history of trauma to the ankle and 114 (23%) had previous ankle surgery. 67% had other procedures (besides synovectomy) simultaneous to medial ligament reconstruction. 269 patients (54%) responded to the invitation for follow-up. For 182 (71%) of the responders, the operation solved their ankle problems. 163 (63%) were satisfied with the surgery. 192 (71%) would repeat the operation. 173 (67%) had pain in the ankle during the past week, and 86 (50%) of these were not able to run. FAAM ADL-scores were significantly higher than in a mixed group of ankle/foot patients but not normal. CONCLUSION: The relatively high degree of satisfaction despite suboptimal clinical results may reflect the complex nature of the deltoid ligament insufficient ankle. It is concluded that repair or reconstruction of the deltoid ligament is only performed in patients reporting ankle instability and with peroperatively demonstrated medial instability and pathology to the ligament. LEVEL OF EVIDENCE: Level III.

Distal Fibular Metastasis of Colorectal Carcinoma: A Case Report.

Case: A 62-year-old woman presenting with ankle pain was initially treated for a non-displaced fracture. Persistent pain despite months of conservative management for her presumed injury prompted repeat radiographs which demonstrated the progression of a lytic lesion and led to an orthopedic oncology referral. Following a complete work-up, including biopsy and staging, she was diagnosed with colorectal carcinoma metastatic to the distal fibula. Conclusion: Secondary tumors of the fibula are uncommon but an important diagnosis to consider for intractable lower extremity pain especially in patients with history of malignancy or lack of age-appropriate cancer screening.

Mosaicplasty in the Treatment of Osteochondral Lesions of the Talus: A Report of Two Cases.

Osteochondral damage to the talus is one of the most frequent causes of ankle pain. In contrast to other joints in the lower limb, osteochondral damage of the talus is often attributed to traumatic events. One option of treatment is mosaicplasty, which has proved to be a feasible choice for the treatment of osteochondral lesions of the talus; it has the potential to alleviate ankle pain and facilitate engagement in daily activities as well as sports. We present two different cases of osteochondral lesions of the talus, illustrating how this pathology can present clinically. Both cases involve males with no notable pathological antecedents. The first was the victim of a traffic accident, the second was the victim of a sports accident; they were admitted for the management of chronic ankle pain unimproved by analgesic treatment. Radiological findings revealed a talus osteochondral lesion in both patients, treated with an osteochondral autograft from the homolateral knee. Both patients progressed well, with the resumption of daily activities and sports. The notable result of current research is that mosaicplasty has been shown to have good results in those with large osteochondral lesions who want to return to normal activity.

A Large Ankle Mass in a Figure Skater: A Case Report.

A 19-year-old male competitive figure skater presented to clinic with a 3-year history of right ankle swelling. Exam demonstrated a ~6cm diameter mass over the medial malleolus. MRI revealed a well-circumscribed fluid-filled mass. After failing conservative management, the patient underwent surgical excision. Anatomic pathology revealed a pseudocyst with pseudosynovial metaplasia, consistent with malleolar bursitis. Competitive figure skaters can develop significant medial malleolar bursitis due to excessive shear forces from ill-fitting skates. If non-operative management is ineffective, patients can be managed successfully with surgical excision. The patient made a full recovery and has returned to competitive skating without recurrence.

Residual Medial Ankle Pain After the Delayed Union of a Lateral Malleolus Fracture: A Case Report.

A 17-year-old girl sprained her left ankle and was diagnosed with a lateral malleolar fracture. She was treated conservatively for six months but had medial ankle pain with activity. Imaging revealed an oblique lateral malleolar fracture, with posterolateral displacement and partial fusion of the bone fragments, and bone marrow edema on the medial articular surface of the talus and medial malleolus. We diagnosed ankle instability due to delayed union with a displacement of the lateral malleolus, which caused an osteochondral lesion. We performed arthroscopic and open surgery eight months after the injury, reducted the lateral malleolus anatomically, and fixed it with a plate. Postoperatively, the pain improved rapidly, and the bone marrow edema had almost disappeared on an MRI. In this case, we think rotational instability of the ankle mortise caused abnormal pressure and continuous stress on the medial malleolus after injury, which may have contributed to persistent medial ankle pain.

The Relationship between Types of Os Trigonum and Findings of Conventional Ankle Magnetic Resonance Imaging: A Study Based on Three-Dimensional Magnetic Resonance Imaging.

This study aimed to investigate the dimensions and types of the os trigonum and evaluate their relationship with various pathologic conditions on the posterior ankle using ankle MRI images. A total of 124 non-contrast-enhanced ankle and foot MR images of 123 consecutive patients were included in this retrospective study. The images were presented randomly, and they contained no patient information. The MR images were retrospectively and independently reviewed by two reviewers with a fellowship-trained musculoskeletal radiologist. The images were classified as type I and II based on the ossicle's medial border overlying the talus's posterior process and the groove for the flexor hallucis longus tendon (FHL). The study revealed that patients with type II os trigonum had a longer transverse diameter of the ossicle than type I, and there were statistically significant differences. Detachment status tended to be less in type I than in type II os trigonum, and the differences between the groups were statistically significant. There were no significant differences between type I and II os trigonum regarding posterior talofibular ligament (PTFL) abnormality, bone marrow edema, FHL tenosynovitis, and posterior synovitis. The study concluded that the os trigonum is a common cause of posterior ankle impingement, and type II os trigonum has a longer transverse diameter of the ossicle than type I.

Increased medial talar tilt may incite ankle pain and predispose ankle osteoarthritis after correction of severity of knee varus deformity among patients undergoing bilateral total knee arthroplasty: a prospective observation.

PURPOSE: Patients with varus knee osteoarthritis usually compensate at the ankle and typically walk with hindfoot valgus alignment. As the neutral weight-bearing axis of the lower limbs is restored with Total Knee Arthroplasty (TKA), ankle and hindfoot biomechanics also acutely change. This study aims to investigate whether any ankle clinical-radiographical changes occur as a result of bilateral mechanical TKA in patients with bilateral Osteoarthritis knee at a minimum follow-up of 6 months. METHODS: The prospective observational study included 61 patients (122 knees) undergoing simultaneous bilateral TKA (mechanical alignment). Tibio-talar angle(TTA), tibial Anterior Surface angle (TAS), lateral distal tibial angle (LDTA), talar-tilt angle (TT), anatomical talocrural angle (aTC), ground surface and distal tibial plafond angle (GP), ground surface and an upper surface of talus angle (GT)and tibial plateau and tibial plafond angle (PP) were measured on long-film radiographs to look for changes in the ankle, whereas functional assessment was done using American Foot and Ankle Society (AOFAS), Foot and Ankle Disability Index (FADI), and Forgotten Joint (FJS-12) scores. Patients were sub-grouped based on the Hip-Knee-Ankle (HKA) axis, and the effect of the severity of knee varus on the ankles after TKA was also analyzed. The minimum follow-up was 6 months. RESULTS: A significant decrease in the tibial plateau-tibial plafond (PP), ground-tibial plafond (GP), and ground-talar dome (GT) angles was noted after TKA (p-value < 0.05). Postoperative functional parameters were comparable to the preoperative status except for FADI, which significantly improved (p-value-0.03). Sub-group analysis based on the severity of knee varus (HKA) revealed GT to be most significantly reduced (p-value-0.036), while the talar tilt (TT) increased (p-value-0.044). Functional outcomes of the ankles clinically improved with the correction of severe knee varus after TKA. At a mean follow-up of 13.2 months post-TKA, 7 out of 61 (11.4%) patients complained of post-TKA ipsilateral ankle pain. CONCLUSION: Mechanically aligned bilateral TKA in severe varus deformity of the knee significantly decreases the GT angle but increases the varus tilt of the talus with lateral talar incongruency and under-coverage. Although the acute correction of severe knee varus deformity aligns the tibia more neutrally, resulting in an overall clinically evident improvement in ankle functional outcome, the increased varus talar tilt remains a deep concern. LEVEL OF EVIDENCE: Prospective, observational, comparative study Level II.

A clinical guide to the medial ligaments of the ankle: Anatomy, function, diagnosis of injuries and treatment of instability-a narrative review.

BACKGROUND: The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability. METHODS: Literature search on PubMed. RESULTS: Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse. CONCLUSION: There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.

Falls and falls-related injuries in individuals with chronic ankle symptoms: a cross-sectional study.

BACKGROUND: Falls are a major public health concern globally. While falls are associated with osteoarthritis and persistent pain at the hip and knee, falls have not been investigated in people with chronic ankle symptoms. This study aimed to compare self-reported history of falls between adults with and without chronic ankle symptoms. Secondary aims were to compare concern about falling and balance confidence between groups, and to identify factors associated with falling. METHODS: A total of 226 participants (134 with chronic ankle pain and/or stiffness and 92 controls) participated in this cross-sectional case-control study. Participants completed an online questionnaire about falls in the past 12 months, injuries associated with falling, concern about falling, balance confidence, function, pain and multimorbidity. RESULTS: Eighty-six (64%) participants with chronic ankle symptoms and 24 (26%) controls reported at least one fall in the last 12 months (p < 0.001). Participants with chronic ankle symptoms reported more falls, more injurious falls, and more hospitalisations because of a fall than controls (p > 0.002). There was a small effect for lower balance confidence and higher concern about falling in symptomatic participants (standardised mean difference: 0.39-0.49; p > 0.017). Logistic regression analysis identified that falling was associated with the presence of ankle symptoms (3.08 (1.20, 7.92); p = 0.02) and concern about falling (odds ratio (95% confidence intervals): 1.13 (1.05, 1.23); p = 0.002). CONCLUSIONS: Falls and falls-related injuries are a problem in individuals with chronic ankle symptoms. The high falls occurrence and concern about falling in individuals with chronic ankle symptoms suggest the need for clinicians to assess these factors in this population.