Ankle flossing alters periarticular stiffness and arterial blood flow in asymptomatic athletes.

BACKGROUND: Tissue flossing has been introduced to increase impaired range of motion (ROM) and flexibility, to enhance prevention and rehabilitation, as well as to improve athletic performance; however, limited evidence exists for its efficacy. The aim of the present study was to evaluate the effects of ankle flossing on periarticular stiffness and perfusion via Acoustic Radiation Force Impulse (ARFI) elastography and Power Doppler Sonography (PDS). METHODS: Twenty-one healthy students (age: 24±2 years, BMI: 22±3 kg/m2) were recruited as participants. ARFI was performed to evaluate periarticular ankle stiffness involving the anterior ankle capsule (AC), the anterior talofibular ligament (ATFL) and the peroneus brevis muscle (PBM). Arterial blood flow was assessed in the dorsal pedal artery. Measurements were taken under resting conditions (T0) and twice after standardized ankle flossing (T1: 0 min., T2: 60 min. postintervention). RESULTS: The connective tissue stiffness decreased significantly after ankle flossing compared to baseline (T1, AC: -12%, P=0.009, ATFL: -12%, P=0.003; T2, AC: -8%, P=0.002, ATFL: -9%, P=0.015). The PBM stiffness decreased by 3% (T1, P=0.304) and 4% (T2, P=0.029). The perfusion measures significantly increased by 30% at T1 compared to baseline (P=0.001); no significant changes were observed at T2 (P=0.492). CONCLUSIONS: This is the first study demonstrating decreased AC and ATFL stiffness and reactive hyperemia to be key mechanisms of ankle flossing. Additional studies must be conducted to determine whether changes in biomechanical properties influence dynamic ankle stability.

Quantification of joint blood flow by dynamic contrast-enhanced near-infrared spectroscopy: application to monitoring disease activity in a rat model of rheumatoid arthritis.

Significance: Current guidelines for rheumatoid arthritis (RA) management recommend early treatment with disease modifying antirheumatic drugs (DMARDs). However, DMARD treatment fails in 30% of patients and current monitoring methods can only detect failure after 3 to 6 months of therapy. Aim: We investigated whether joint blood flow (BF), quantified using dynamic contrast-enhanced time-resolved near-infrared spectroscopy, can monitor disease activity and treatment response in a rat model of RA. Approach: Ankle joint BF was measured every 5 days in eight rats with adjuvant-induced arthritis (AIA) and four healthy controls. Arthritis was allowed to progress for 20 days before rats with AIA were treated with a DMARD once every 5 days until day 40. Results: Time and group had separate significant main effects on joint BF; however, there was no significant interaction between time and group despite a notable difference in average joint BF on day 5. Comparison of individual blood flow measures between rats with AIA and control group animals did not reveal a clear response to treatment. Conclusions: Joint BF time courses could not distinguish between rats with AIA and study controls. Heterogeneous disease response and low temporal frequency of BF measurements may have been important study limitations.

Anatomic Risk to the Neurovascular Structures With a Medially Based All-Inside Syndesmosis Suture Button Technique.

Recent evidence suggests that the use of suture button devices for ankle syndesmosis fixation is increasing. Multiple studies have shown some concern about damaging the greater saphenous neurovasculature with placement of the anchor point on the medial tibial cortex. We hypothesized that an all-inside button deployment technique would allow for a low risk to medial soft tissue structures. A total of 40 syndesmosis suture buttons were placed into 10 separate cadaveric lower limbs, using the newly developed technique. Four suture buttons were sequentially placed from distal to proximal in each limb within the zone of typical syndesmosis fixation, using fluoroscopic guidance. A medial incision was then performed to evaluate the relationship of the suture buttons to the medial soft tissue structures and the medial malleolus. Thirteen of 40 suture buttons (32.5%) were placed anterior, 7 (17.5%) posterior, and 20 (50%) with a portion of the button directly deep to the saphenous vein. Two of 40 buttons (5%) were placed within the tibial periosteum, and 38 (95%) were subfascial and directly superficial to the periosteum. Four of 40 (10%) limbs revealed a perforation in the saphenous vein from the guidepin. In conclusion, risks to the medial neurovascular structures exist with the medial deployment technique, but they appear to be mitigated compared with previous publications. The necessity of a medial incision to evaluate for soft tissue entrapment may not be necessary in all patients, as this technique appears to be safe, accurate, and reproducible.

Level and modalities of origin of the small saphenous vein: toward codification of the proximal approach level.

PURPOSE: The proximal approach to the small saphenous vein (SSV) must be performed according to precise anatomical landmarks to respect the esthetic profile of venous insufficiency surgery. In this work, we propose the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as palpable landmarks from which to easily identify the situation of this vein. METHODS: This was a cadaveric dissection study involving 62 members of fresh and embalmed anatomical subjects. We used a horizontal line passing through the tip of the lateral malleolus and the lateral edge of the calcaneal tendon as reference marks. Once the origin of the SSV as dissected, the distances between the saphenous vein and the landmarks were measured. RESULTS: We found that the small saphenous vein was often unique. The origin of this small saphenous vein projected, on average, to 4.40 cm from the horizontal passing through the tip of the lateral malleolus and 1.2 cm from the lateral edge of the calcaneal tendon. CONCLUSION: These two measurements constitute the orthogonal coordinates for the situation of the small saphenous vein origin.

Detection of Increased Vascular Signal in Arthritis-Prone Rats Without Joint Swelling Using Superb Microvascular Imaging Ultrasonography.

This study aimed to determine whether ultrasonography (US) can detect increased vascular signal in the synovial tissue before overt synovitis in rheumatoid arthritis (RA). Env-pX rats that spontaneously develop RA-like synovitis were used. Ankle joints of 15 pre-morbid env-pX rats were observed with power Doppler and superb microvascular imaging (SMI) using an ultrahigh-frequency (8-24 MHz) probe. Signal values were counted as the number of pixels. The total number of vessels and vessel area in the synovial tissue were histologically evaluated. Dilated vessels were determined from the mean value of synovial vessels in three wild-type rats. In all env-pX rats, apparent synovial proliferation was not observed. However, vasodilation was evident. Only SMI values were significantly correlated with the number of dilated vessels (r = 0.585, p = 0.022) but not with the total number of vessels. US with SMI using ultrahigh-frequency probe can detect increased vascular signal in the synovial tissue of arthritis-prone rats.

Examination of the Origin and Branching Direction of the Anterior Medial Malleolar Artery From the Anterior Tibial Artery: A Cadaveric Study.

BACKGROUND: This study characterized the anterior medial malleolar artery (AMMA) branching from the anterior tibial artery (ATA) to identify problems in anterior ankle arthroscopy possibly contributing to injury to the AMMA. METHODS: Barium was injected into 12 adult cadaveric feet via the external iliac artery and the origin and branching direction of the AMMA were identified on computed tomography. RESULTS: The AMMA originated from the level of the ankle joint and below and above the ankle joint line (AJL) in 4 (33.3%), 6 (50.0%), and 1 (8.3%) specimen, respectively. Mean distance from the AJL to the branching point of the AMMA on the sagittal plane was 2.5 mm distal to the AJL. Mean angle between the distal longitudinal axis of the ATA and AMMA was 83.2°. CONCLUSIONS: This study established the origin and branching of the AMMA from the ATA. The AMMA should be examined carefully during ankle arthroscopy. LEVELS OF EVIDENCE: Level IV: Cadaveric study.

Classification system of the tibiofibular syndesmosis blood supply and its clinical relevance.

Due to the lack of anatomical studies concerning complexity of the tibiofibular syndesmosis blood supply, density of blood vessels with further organization of syndesmotic vascular variations is presented in clinically relevant classification system. The material for the study was obtained from cadaveric dissections. We dissected 50 human ankles observing different types of arterial blood supply. Our classification system is based on the vascular variations of the anterior aspect of tibiofibular syndesmosis and corresponds with vascular density. According to our study the mean vascular density of tibiofibular syndesmosis is relatively low (4.4%) and depends on the type of blood supply. The highest density was observed among ankles with complete vasculature and the lowest when lateral anterior malleolar artery was absent (5.8% vs. 3.5%, respectively). Awareness of various types of tibiofibular syndesmosis arterial blood supply is essential for orthopedic surgeons who operate in the ankle region and radiologists for the anatomic evaluation of this area. Knowledge about possible variations along with relatively low density of vessels may contribute to modification of treatment approach by the increase of the recommended time of syndesmotic screw stabilization in order to prevent healing complications.

Neurovascular and tendon injuries due to ankle arthroscopy portals: a meta-analysis of interventional cadaveric studies.

Neurovascular and tendon structures are considered at risk when performing ankle arthroscopy. Injury rate and distance from portals to such structures varied in the literature. The aim of this meta-analysis is to evaluate the injury risk of these structures in terms of proximity and injury prevalence. Thirteen studies including 184 cadaveric ankle arthroscopy procedures met the inclusion criteria. The antero-central portal exhibited the highest frequencies of nerve/vessel proximity and nerve/vessel missed injuries. Weighted mean distances were as follows: 2.76 ± 2.37 mm for the superficial fibular nerve (SFN) to the antero-lateral portal, 8.13 ± 2.45 mm for the saphenous nerve to the antero-medial portal, 2.1 ± 1.7 mm for the dorsalis pedis artery (DPA) to the antero-central (AC) portal, 6.84 ± 2.59 mm for the sural nerve to the postero-lateral portal. Distances to the postero-medial portal were 7.82 ± 2.98 and 11.03 ± 3.2 mm for the posterior tibial nerve and the posterior tibial artery, respectively. A total of 14 (10.3%) nerve injuries and 17 (12.5%) missed nerve injuries with a cumulative frequency of 22.8% of nerve structure at high risk. The SFN was the most vulnerable (10.3% of injury/missed injury), and it was the closest nerve to a portal. Vascular involvement consisted of 2 (1.5%) injuries and 12 (8.8%) missed injuries with the DPA being the most vulnerable (20%) through the AC portal. Tendon injuries were found in 8.7% procedure acts. The injury rates of extra-articular structures were found to be higher than previously reported in clinical literature. Apart from clinical studies, distance to portals and missed injuries of these structures could be evaluated. This cadaveric meta-analysis yielded more accurate results over the proximity and potential injury risk of ankle noble structure and should incite surgeons for more attention during portal placement. Such anatomical meta-analyses could offer an excellent statistical model of evidence synthesis when assessing injury risk in mini-invasive surgeries.

Allgöwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography.

OBJECTIVE: The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. DESIGN: Prospective, randomized. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. MAIN OUTCOME MEASUREMENTS: Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. RESULTS: Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. CONCLUSIONS: The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The cardiovascular response to passive movement is joint dependent.

The cardiovascular responses to passive limb movement (PLM) at the knee are well established, however, responses to PLM at other joints involving smaller muscle volume are unknown. To compare the cardiovascular responses to passive movement at other joints, 10 participants underwent a PLM protocol in which the wrist, elbow, ankle, and knee joints were passively extended and flexed at 1 Hz for 1 min. Heart rate (HR), mean arterial blood pressure (MAP), and arterial blood flow to that limb segment (BF) were measured and vascular conductance (VC) was calculated for a 30-sec baseline period and for 3-sec intervals throughout PLM protocols. PLM of the knee and elbow resulted in significant increases in BF and VC from baseline values with peak values 180% (P < 0.001) greater than baseline. PLM of the elbow resulted in significant increases in BF and VC from baseline values with peak values 109% and 115% (P < 0.001) greater than baseline, respectively. No changes in BF and VC were observed in the ankle and wrist. Furthermore, the greater increase in blood flow per limb segment volume in the thigh and upper arm (62.8 ± 36.5 and 55.5 ± 30.3 mL min(-1) L(-1), respectively) compared to the forearm and lower leg (23.6 ± 16.7 and 19.1 ± 10.3 mL min(-1) L(-1), respectively) indicates the limb volume is not solely responsible for the differences in the hyperemic responses. These data indicate that the use of PLM to assess vascular function or as a rehabilitation modality to maintain vascular health may be most appropriate for the muscles that span the elbow and knee.

Arterial Anatomy of the Posterior Tibial Nerve in the Tarsal Tunnel.

BACKGROUND: Both vascular and compression etiologies have been proposed as the source of neurologic symptoms in tarsal tunnel syndrome. Advancing the understanding of the arterial anatomy supplying the posterior tibial nerve (PTN) and its branches may provide insight into the cause of tarsal tunnel symptoms. The purpose of this study was to describe the arterial anatomy of the PTN and its branches. METHODS: Sixty adult cadaveric lower extremities (thirty previously frozen and thirty fresh specimens) were amputated distal to the knee. The vascular supply to the PTN and its branches was identified, measured, and described macroscopically (the thirty previously frozen specimens, prepared using a formerly described debridement technique) and microscopically (the thirty fresh specimens, processed using the Spälteholz technique). RESULTS: On both macroscopic and microscopic evaluation, the PTN and the medial and lateral plantar nerves were observed to have multiple entering vessels within the tarsal tunnel. On microscopic evaluation, a vessel was observed to enter the nerve at the bifurcation of the PTN into the medial and lateral plantar nerves in twenty-two (73%) of the thirty specimens. There was a significant difference (p < 0.05) in vascular density between the PTN and each of its branches. CONCLUSIONS: The abundant blood supply to the PTN and its branches identified in this study is consistent with observations of other peripheral nerves. This rich vascular network may render the PTN and its branches susceptible to nerve compression related to vascular congestion. The combination of vascular and structural compression may also elicit neurologic symptoms. CLINICAL RELEVANCE: Advancing the understanding of the arterial anatomy supplying the PTN and its branches may provide insight into the cause and treatment of tarsal tunnel syndrome.

An Anatomical Study of Vascular Supply of the Distally Based Sural Artery Flap: A Cadaveric Study.

Objective: In this study we conducted the vascular anatomy of sural flap to determine the peroneal artery perforator contribution relative to anatomical landmark of tip of lateral malleolus, include the first peroneal artery perforator to identify safely pivot point of the flap. Material and Method: A retrospective study of an anatomical study of Vascular supply of the Distally Based Sural Artery Flap was performed by dissection on 12 fresh adult cadavers legs. We recorded number of the perforator, location of each perforators in relationship to the tip of lateral malleolus and location of first peroneal artery perforator. Results: The anatomical of vascular supply of the distally based sural artery flap, anatomical of peroneal artery perforators was identified and measured from anatomical landmark is tip of lateral malleolus. The mean number of perforators was 3.4 (range, two to five), grouped in 5 perforators at the following average locations proximal to the tip of lateral malleolus: first, at 6.3+0.9 cm; second, at 8.5+1 cm; third, at 11.17+1.4 cm; fourth, at 12.7+1.2 cm; and fifth, at 14.6+0.2 cm proximal to the tip of the lateral malleolus. Conclusion: Complete vascularization of venoneurofasciocutaneous sural flap was accomplished by peroneal perforator, the blood supply of the distally based sural venoneurofasciocutaneous flap can be pivoted at the lowest perforators in the posterolateral region, which are about 5.4 to 7.2 cm proximal to the tip of lateral malleolus.

Ruptured Pseudoaneurysm of the Dorsalis Pedis Artery Following Ankle Arthroscopy: A Case Report.

CASE: We describe the case of a pseudoaneurysm of the dorsalis pedis artery that developed following a repeat ankle arthroscopy for persistent osseous impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the pseudoaneurysm with substantial blood loss, which required emergency vascular repair. CONCLUSION: Anterior tibial artery and dorsalis pedis artery pseudoaneurysms are relatively rare, but they are well-documented complications of ankle arthroscopy; however, their clinical importance is poorly understood. To our knowledge, this is the first reported case of a ruptured pseudoaneurysm of the dorsalis pedis artery following ankle surgery, and it highlights the need for timely diagnosis.

Managing Haemophilia for Life: 5th Haemophilia Global Summit.

The 5th Haemophilia Global Summit was held in Barcelona, Spain, in September 2014. The programme was designed by an independent Scientific Steering Committee of haemophilia experts and explored issues relevant to the practical management of haemophilia, as well as key opportunities and challenges for care in the future. The topics outlined in this supplement were selected by the Scientific Steering Committee for their relevance to improving haemophilia care globally. In this supplement from the meeting, Gerry Dolan explores pharmacokinetics and dynamics in haemophilia, and Gerry Dolan and Ian Jennings jointly address the role of the laboratory in haemophilia care. The potential benefits of low-dose prophylaxis regimens for people with haemophilia in the developing world are reviewed by Jerzy Windyga, and the question of whether 'Future haemophilia research should be undertaken in the developing world' is debated by Jerzy Windyga and Cedric Hermans. Management strategies for ankle arthropathy are discussed by Sébastien Lobet and E. Carlos Rodríguez-Merchán, and the use of ultrasound for the early detection of haemophilic arthropathy is addressed by Matteo Nicola Dario Di Minno and Víctor Jiménez-Yuste. Finally, the role of patients in the future of haemophilia care is reviewed by Brian O'Mahony.

Prognostic value of the ankle-brachial index in patients undergoing drug-eluting stent implantation.

AIM: Limited data are available regarding the prognostic value of the brachial-ankle index (ABI) in patients with a history of drug-eluting stent (DES) implantation. This study sought to determine the relationship between the ABI and coronary events in patients with DES. METHODS: A total of 322 patients who underwent both DES implantation and ABI measurement during initial hospitalization were reviewed. Cardiovascular events, including cardiac death, non-fatal acute myocardial infarction and coronary revascularization, were assessed. RESULTS: During the mean follow-up period of 298 ± 58 days, there were 32 cases of cardiovascular events (9.9%). The patients with a lower ABI had more events (2.8% in the highest tertile versus 10.3% in the middle tertile versus 16.8% in the lowest tertile, p = 0.001). According to the multiple Cox regression analysis, the ABI was independently associated with clinical events (the lowest tertile versus the highest tertile of ABI, hazard ratio: 6.35, 95% confidence interval: 1.37-29.32, p=0.018). In addition, the cumulative event rate according to the ABI tertile differed significantly in the Kaplan-Meier curves (log-rank p=0.009), whereas the receiver-operating characteristic curve analysis showed a sensitivity and specificity for predicting cardiovascular events of 62.5% and 66.2%, respectively, with an ABI of 1.057 as the best cut-off value. CONCLUSIONS: A lower ABI is associated with poorer cardiovascular outcomes in patients with DES implantation. As a simple and non-invasive parameter, the ABI has the benefit of predicting future cardiovascular events in this population.

Arterial anatomy of the tibialis posterior tendon.

BACKGROUND: Tibialis posterior tendon dysfunction is a common disorder leading to pain, deformity, and disability, although its pathogenesis is unclear. A vascular etiology has been proposed, but there is controversy regarding the existence of a hypovascular region that may render the tendon vulnerable. The purpose of this study was to provide a description of the arterial anatomy supplying the tibialis posterior tendon. METHODS: Sixty adult cadaveric lower extremities were obtained from a university-affiliated body donation program. Thirty specimens obtained within 72 hours of death were used for microscopic analysis. Thirty specimens were previously frozen and used for macroscopic analysis. The tibialis anterior, tibialis posterior, and peroneal arteries were injected with India Ink and Ward's Blue Latex. The specimens used for macroscopic analysis were debrided with sodium hypochlorite to expose the extratendinous anatomy. For the microscopic analysis, the tendon was cleared using a modified Spälteholz technique to expose the intratendinous vascular anatomy. RESULTS: Macroscopically, an average of 2.5 ± 0.7 vessels entered the tendon proximal to the navicular insertion. In all, 28/30 (93.3%) specimens had a vessel entering 4.1 ± 0.6 cm proximal to the medial malleolus and 24/30 (80.0%) specimens had a vessel entering 1.7 ± 0.9 cm distal to the medial malleolus. Microscopically, an average of 1.9 ± 0.3 vessels entered each tendon proximal to the navicular insertion. In total, 27/30 (90%) specimens had a vessel entering the tendon 4.8 ± 0.8 cm proximal to the medial malleolus and 30/30 (100%) specimens had a vessel entering the tendon 1.9 ± 0.8 cm distal to the medial malleolus. In all specimens, a hypovascular region was observed, starting 2.2 ± 0.8 cm proximal to the medial malleolus and ending 0.6 ± 0.6 cm proximal to the medial malleolus with an average length of 1.5 ± 1.0 cm. The insertion of the tendon was well vascularized both on microscopic and macroscopic specimens. CONCLUSION: The tibialis posterior tendon was supplied by 2 vessels entering the tendon approximately 4.5 cm proximal and 2.0 cm distal to the medial malleolus. A retromalleolar hypovascular region was observed. CLINICAL RELEVANCE: Improved understanding of the vascularity of the tibialis posterior tendon may be helpful in clinical practice and potentially provides a basis for further evaluation of the causative factors of tibialis posterior tendinopathy.

Evaluation of venous return in lower limb by passive ankle exercise performed by PHARAD.

This paper presents evaluation of venous return, i.e., blood flow volume of vein (BF), in the lower limb after passive exercise performed by our developed "parallel link type human ankle rehabilitation assistive device (PHARAD)". The PHARAD can perform complex passive exercises (plantar flexion/dorsiflexion, inversion/eversion, adduction/abduction, and combination of these motions) by reproducing input motions of a foot plate that is attached to a sole of foot. The passive exercise can be performed for not only rehabilitation but also prevention of deep vein thrombosis (DVT). In this study, we measured the concentration of Total hemoglobin (Total-Hb) using multi-channel near infra-red spectroscopy (NIRS)-based tissue oximeters and calculated a gradient of Total-Hb during a venous occlusion. We defined the gradient as BF and evaluated BF after 3 min passive exercise performed by the PHARAD comparing to BF of resting. Seven healthy young adult people were recruited for the experiment and we assessed passive exercise, active exercise, and walking. Experimental results show that BF after the passive exercises significantly increases compare to BF of resting and this indicates that passive exercises performed by the PHARAD increases BF and has a potential to prevent DVT.

The effect of ankle range of motion on venous ulcer healing rates.

Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose-finding study of an allogeneic living cell bioformulation. Two hundred twenty-seven patients were enrolled in four active treatment groups and one standard-care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.

Distribution of sensory nerve endings around the human sinus tarsi: a cadaver study.

The aim of this study was to analyse the pattern of sensory nerve endings and blood vessels around the sinus tarsi. The superficial and deep parts of the fat pads at the inferior extensor retinaculum (IER) as well as the subtalar joint capsule inside the sinus tarsi from 13 cadaver feet were dissected. The distribution of the sensory nerve endings and blood vessels were analysed in the resected specimens as the number per cm(2) after staining with haematoxylin-eosin, S100 protein, low-affinity neurotrophin receptor p75, and protein gene product 9.5 using the classification of Freeman and Wyke. Free nerve endings were the predominant sensory ending (P < 0.001). Ruffini and Golgi-like endings were rarely found and no Pacini corpuscles were seen. Significantly more free nerve endings (P < 0.001) and blood vessels (P = 0.01) were observed in the subtalar joint capsule than in the superficial part of the fat pad at the IER. The deep part of the fat pad at the IER had significantly more blood vessels than the superficial part of the fat pad at the IER (P = 0.012). Significantly more blood vessels than free nerve endings were seen in all three groups (P < 0.001). No significant differences in distribution were seen in terms of right or left side, except for free nerve endings in the superficial part of the fat pad at the IER (P = 0.003). A greater number of free nerve endings correlated with a greater number of blood vessels. The presence of sensory nerve endings between individual fat cells supports the hypothesis that the fat pad has a proprioceptive role monitoring changes and that it is a source of pain in sinus tarsi syndrome due to the abundance of free nerve endings.