Bilateral gait asymmetry associated with tibiotalocalcaneal arthrodesis versus ankle arthrodesis.

BACKGROUND: Gait asymmetries have been reported following ankle arthrodesis. However, similar reports do not exist for tibiotalocalaneal arthrodesis (TTCA), which involves further articular fusion. This study aimed to assess the extent of gait asymmetry following TTCA when compared to ankle arthrodesis. METHOD: Gait assessment was performed on 36 participants, including 12 ankle arthrodesis, 12 TTCA and 12 controls - using 3-D inertial sensors and pressure insoles. 48 gait parameters were monitored on both operated and non-operated sides. Questionnaires including AOFAS, FAAM, EQ-5D were used to assess both operative groups, comparatively. RESULTS: Both operative groups reported significantly smaller stride, slower walking speed, altered stance phase with longer loading and shorter push-off compared to controls. Joint range of motion was significantly reduced on the operated side of both operative groups at hindfoot, forefoot and toe intersegments. However, the ankle arthrodesis group reported a significantly higher alteration compared to controls in maximum contact force and pressure distribution. Furthermore, bilateral comparison showed extended gait asymmetry in the ankle arthrodesis group with 29 out of 48 parameters being significantly different between the two sides, whereas only 16 out of 48 gait parameters showed bilateral difference in the TTCA group. CONCLUSION: Both ankle salvage operations led to significant gait alteration and bilateral asymmetry. However, extended joint restriction in TTCA does not seem to worsen the gait outcomes. Further investigation is needed to understand the long-term impact of altered gait, on neighboring joints, following TTCA.

Preoperative gait asymmetry in end-stage unilateral ankle osteoarthrosis patients.

BACKGROUND: Gait asymmetries following unilateral ankle surgeries have been reported in published literature. Preoperative compensatory gait patterns are usually assumed to be the cause; however, this hypothesis is not backed by objective data. This study aims to assess gait symmetry in patients with unilateral ankle osteoarthrosis (AOA). METHOD: 20 participants, including 10 controls and 10 AOA patients, were assessed using 3-D inertial sensors and pressure insoles. 46 gait parameters and foot sub-region relative motions were studied. RESULTS: Compared with the controls, significant differences were reported in 23 parameters on the affected side and 20 on the unaffected side. AOA bilateral comparison reported differences in 14 parameters, mostly in the toe region. Asymmetries were also found in forefoot relative motion. CONCLUSION: Gait alterations are reported in AOA. One-third of measured parameters and forefoot relative motion reported marked gait asymmetries. Clarification of the origin of postoperative gait imbalances is likely to help clinicians optimize rehabilitation programs.

Sleep Apnea Research in Animals. Past, Present, and Future.

Obstructive sleep apnea (OSA) is a common disorder that describes recurrent collapse of the upper airway during sleep. Animal models have been pivotal to the understanding of OSA pathogenesis, consequences, and treatment. In this review, we highlight the history of OSA research in animals and include the discovery of animals with spontaneous OSA, the induction of OSA in animals, and the emulation of OSA using exposures to intermittent hypoxia and sleep fragmentation.

Critical evaluation of outcome scales assessment of lateral ankle ligament reconstruction.

BACKGROUND: Outcome following foot and ankle surgery can be assessed by disease- and region-specific scores. Many scoring systems exist, making comparison among studies difficult. The present study focused on outcome measures for a common foot and ankle abnormality and compared the results obtained by 2 disease-specific and 2 body region-specific scores. METHODS: We reviewed 41 patients who underwent lateral ankle ligament reconstruction. Four outcome scales were administered simultaneously: the Cumberland Ankle Instability Tool (CAIT) and the Chronic Ankle Instability Scale (CAIS), which are disease specific, and the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot scale and the Foot and Ankle Ability Measure (FAAM), which are both body region-specific. The degree of correlation between scores was assessed by Pearson's correlation coefficient. Nonparametric tests, the Kruskal-Wallis and the Mann-Whitney test for pairwise comparison of the scores, were performed. RESULTS: A significant difference (P < .005) was observed between the CAIS and the AOFAS score (P = .0002), between the CAIS and the FAAM 1 (P = .0001), and between the CAIT and the AOFAS score (P = .0003). CONCLUSIONS: This study compared the performances of 4 disease- and body region-specific scoring systems. We demonstrated a correlation between the 4 administered scoring systems and notable differences between the results given by each of them. Disease-specific scores appeared more accurate than body region-specific scores. A strong correlation between the AOFAS score and the other scales was observed. The FAAM seemed a good compromise because it offered the possibility to evaluate the patient according to his or her own functional demand. CLINICAL RELEVANCE: The present study contributes to the development of more critical and accurate outcome assesment methods in foot and ankle surgery.

Evaluation of a modified Broström-Gould procedure for treatment of chronic lateral ankle instability: A retrospective study with critical analysis of outcome scoring.

BACKGROUND: Chronic lateral ankle instability accounts for 20% of the ankle injuries. This study evaluates functional outcome of the modified Broström-Gould technique using suture anchors, with 4 different clinical scores. METHODS: A consecutive series of 41 patients were included with a minimum follow-up of one year. The function was assessed using 4 clinical scores including: the AOFAS for hind foot; the FAAM; the CAIT and the CAIS. RESULTS: Out of 41 patients; 27 patients were very satisfied, 11 satisfied and 3 were not satisfied. Ankle mobility returned to normal in 93% of patients. At follow-up the AOFAS was 89/100 (37-100), the FAAM 85/100% (35-100%), the CAIT 20/30 (5-30), and the CAIS 74/100% (27-100%). CONCLUSION: Outcome of modified Broström-Gould procedure is good with high satisfaction rate in terms of ankle mobility. The disparity in outcome of scores, signals towards the need of a standard evaluation system.

Outcome of bracing vs. surgical treatment in adolescents with idiopathic scoliosis based on device measured daily physical activity: a prospective pilot study.

Adolescent idiopathic scoliosis (AIS) can be treated with bracing or surgery, which may affect patient's physical activity (PA). However, there are limited objective assessments of PA in patients with AIS. This study aims to compare the outcome of spinal bracing vs. surgery in patients with AIS based on a device that measured daily PA. In total 24 patients with AIS participated, including 12 patients treated with bracing and 12 with spinal surgery. Daily PA was measured throughout 4 consecutive days using four tri-axial accelerometers and patient-reported functional status was reported using the SRS-22 questionnaire. The participants were assessed both before the treatment and after treatment at a 12-month follow-up. Patients with AIS had no significant change in their PA levels at the 12-month follow-up after surgical correction. On the contrary, patients with AIS following a year-long bracing treatment had significantly reduced time spent active ( P = 0.04) with an average reduction in walking steps by 2137 steps/day ( P = 0.005). There was no significant difference in function, pain, self-image and mental health domains following both treatments, as reported by the SRS-22. There was a significant improvement in satisfaction for both treatment groups ( P ≤ 0.02). Significantly reduced PA and increased sedentary time are reported in patients with AIS following bracing treatment. An objective PA assessment is recommended to track the effect of scoliosis treatment on PA. Patients with AIS should be actively encouraged to achieve and maintain their recommended daily PA levels irrespective of the type of treatment. Level of evidence: Level II.

Home-Based Health Care Interventions for People Aged 75 Years and Above With Chronic, Noninflammatory Musculoskeletal Pain: A Scoping Review.

BACKGROUND AND PURPOSE: Chronic, noninflammatory musculoskeletal pain is common in the aged population and management can be challenging for older people due to multimorbidity, social isolation, and physical frailty. The aim of this scoping review is to summarize and discuss the evidence related to home-based health care interventions for older adults, with chronic, musculoskeletal pain. METHODS: A review of the literature using 8 electronic databases (Embase, MEDLINE, CINAHL, PubMed, Cochrane Library, Physiotherapy Evidence Database [PEDro], Scopus, and Web of Science) was performed, following the PRISMA-ScR guidelines. English language published studies that assessed home-based health care intervention/s, in men and women 75 years and older, with chronic, noninflammatory musculoskeletal pain where included. Two authors independently reviewed the articles and extracted data into a preformulated chart. RESULTS AND DISCUSSION: The database search identified 4722 studies of which 7 studies met the inclusion criteria. Six of the 7 studies were randomized controlled trials and 5 studies focused on a single-site pain. The type of home-based interventions in the included studies was physical therapy (n = 2), psychotherapy (n = 3), and multimodal therapy (combination of multiple therapies) (n = 2). Participation completion rate was more than 74% in 6 out of 7 studies. Most studies used pain and/or physical function as their primary outcome (n = 6). Music therapy showed a statistically significant reduction in visual analog scale score for pain, and there was a trend toward improvement of pain and function in the physical therapy studies. No significant differences in outcomes between intervention and control groups were observed in the multimodal studies. CONCLUSION: This review highlights the scarcity of evidence related to home-based health interventions in older people 75 years and older, living with chronic, noninflammatory musculoskeletal pain. The findings were that physical, psychotherapeutic, and multimodal interventions are usually well tolerated and can be delivered as a safe self-management option. There remains a substantial need for more high-quality research with wider range of home-based interventions and comprehensive assessment of outcomes for this age group.

Optimal positioning of right internal jugular venous catheter: A randomised study comparing modified Peres' height formula and distance between insertion point and right third intercostal space.

Background and Aims: The position of the tip of the central venous catheter (CVC) is important to minimise complications. The aim of our study was to compare modified Peres' height formula and landmark method using distance between puncture site and right third intercostal space (PS-RTICS) and to develop a reliable formula for correct positioning of tip of the CVC. Methods: This prospective, randomised study was conducted on 400 patients of either gender, of age 18 years and older, scheduled to undergo right internal jugular venous cannulation. Depending on the technique used for deciding the length of CVC to be inserted, the patients were randomly allocated into two groups: Group A, using modified Peres' height formula, that is, height of patient (cm)/10-2 and Group B, using distance between PS-RTICS and subtracting one from it, that is (PS-RTICS)-1. The carina was taken as the landmark for optimum insertion of CVC, which was confirmed on postprocedure chest X-ray. Data so obtained were tabulated and analysed. P<.05 was considered statistically significant for correlation and regression coefficients. Results: In group A, the mean length of catheter inserted was 15.18 ± 0.73 cm and the catheter tip was found to be 2.41 ± 0.85 cm distal to carina (P =0.001). Over-insertion was found in 98.45% patients in group A. In group B, the mean length of catheter inserted was 14.12 ± 0.85 cm and the catheter tip was found to be 0.20 ± 1.18 cm distal to carina. Conclusion: Though both landmark and modified Peres' height formula has low accuracy, landmark technique is superior in predicting correct depth of right internal jugular venous cannulation catheter.

Differences in Physical Activity and Sedentary Behavior Patterns of Postmenopausal Women With Normal vs. Low Total Hip Bone Mineral Density.

Purpose: Recent evidence suggests that sedentary behavior (SB) may be associated with bone health. This study compares free-living physical activity (PA) and SB distribution patterns of postmenopausal women with normal vs. low total hip bone mineral density (BMD). Methods: Sixty nine post-menopausal women [mean (min-max) age: 61 (46-79) years] wore ActiGraph GT3X+ activity monitors on the bilateral ankles for 7 days in free-living. Participants were split into two groups: those with normal hip BMD (T-scores ≥-1.0; N = 34) and those with low hip BMD (T-scores <-1.0; N = 35) as defined by the World Health Organization. Daily active time, step counts, sedentary time, sedentary break number, and median sedentary bout length were estimated from ankle acceleration data. The distribution and accumulation patterns of time spent in sedentary bouts, sedentary breaks, and stepping bouts, and sedentary break and stepping bout lengths' variability were also investigated. Group differences were assessed using two-sampled t-tests and Mann-Whitney U-tests with significance levels of 0.5. Results: Significant between group differences (p < 0.05) were in total daily active time [median (IQR): 257 (209-326) vs. 249 (199-299) min], step count [14,188 (10,938-18,646) vs. 13,204 (10,337-16,630) steps], sedentary time [669 (584-731) vs. 687 (615-753) min], and sedentary break number [93 (68-129) breaks vs. 88 (64-113) breaks], as well as median sedentary bout length [15.1 (11.9-22.1) vs. 15.8 (12.1-24.9) min]. Participants' sedentary bouts were found to be power law distributed with 52% of sedentary time occurring in bouts ≥20 min for the normal BMD group, and 58% for the low BMD group. Significant differences were observed between groups in sedentary bouts' and sedentary breaks' power distribution exponents (p < 0.0001) and patterns of sedentary and stepping time accumulation using the Gini index (p ≤ 0.0014). Variability was significantly lower for sedentary break and stepping bout lengths for the low BMD group (p ≤ 0.0001). Participants with lower hip BMD have longer sedentary bouts with shorter and less complex activity bouts compared to participants with normal hip BMD. Conclusion: The results suggest healthier hip BMD may be associated with PA distributed more evenly throughout the day with shorter sedentary bouts. PA distribution should be considered in exercise-based bone health management programs.

Accelerometer based assessment of daily physical activity and sedentary time in adolescents with idiopathic scoliosis.

BACKGROUND: Studies have shown a positive correlation between higher physical activity (PA) and health benefits. However, device-based assessment of PA and sedentary time (ST) in people with adolescent idiopathic scoliosis (AIS) has not been deeply investigated. OBJECTIVE: Analysis and comparison of weekend and weekdays PA and ST using multiple accelerometers in people with AIS with different curvature severity compared to healthy controls. METHODS: 24 participants with AIS divided into 2 groups of 12 with Cobb angles < 40° and > 40°, along with 12 age and BMI matched healthy controls. Daily PA and ST during four consecutive days were measured using four tri-axial accelerometers. Clinical functional assessment was performed using the scoliosis research society (SRS-22) questionnaire. RESULTS: The combined weekend and weekdays average daily step count was found to be 22% and 29% lower in the AIS groups with Cobb angle < 40° and > 40°, respectively, compared to the controls. The average ST was also reported to be 5% and 7% higher in the AIS groups with Cobb angle < 40° and > 40°, respectively, compared to the controls. The reported differences were significant in the AIS group with higher Cobb angle (p≤0.05). No significant differences in PA or ST were reported between the AIS groups based on curvature severity. CONCLUSIONS: Decreased PA and increased ST observed in patients with AIS may have long term health implications and may play a role in the disease process. The device-based assessment of PA to understand potential benefits in clinical practice is recommended.

Long-term evaluation of the distal transverse plantar approach for Morton's neuroma excision.

BACKGROUND: There is currently no consensus on the ideal approach for the operative treatment of Morton’s neuroma. The distal transverse plantar approach aims at optimal exposure without the scar complications associated with the longitudinal plantar approach. Long-term evaluation based on validated outcome instruments is lacking. The main purpose of this retrospective study was to evaluate the long-term clinical outcome of this approach using validated function and scar evaluation scores. METHODS: Forty-nine patients operated on at our institution were examined clinically by two independent observers using the Foot and Ankle Ability Measure (FAAM) and the Vancouver Scar Scale (VSS). Patients who underwent neurectomy alone and those who had additional foot surgery were compared. RESULTS: Assessment at a mean of 7.9 years (range 4–12) postoperatively revealed a mean FAAM score of 84.8 ± 25% and a mean VSS score of 1.57 ± 1.7. Patients who underwent neurectomy alone had higher FAAM scores at follow up. We observed no complication that required an additional procedure. CONCLUSIONS: The transverse plantar approach results in good objective outcome scores, including scar healing, in the long term. This is our preferred technique because, in our experience, it offers optimal visualisation of the nerve, does not require deep dissection and allows the exposure of two adjacent web spaces of the foot through a single incision.

Intramuscular Pressure of Human Tibialis Anterior Muscle Reflects in vivo Muscular Activity.

Intramuscular pressure (IMP) is the fluid hydrostatic pressure generated within a muscle and reflects the mechanical forces produced by a muscle. By providing accurate quantification of interstitial fluid pressure, the measurement of IMP may be useful to detect changes in skeletal muscle function not identified with established techniques. However, the relationship between IMP and muscle activity has never been studied in vivo in healthy human muscles. To determine if IMP is able to evaluate electromechanical performance of muscles in vivo, we tested the following hypotheses on the human tibialis anterior (TA) muscle: (i) IMP increases in proportion to muscle activity as measured by electrical [Compound Muscle Action Potential (CMAP)] and mechanical (ankle torque) responses to activation by nerve stimulation and (ii) the onset delay of IMP (IMPD) is shorter than the ankle torque electromechanical delay (EMD). Twelve healthy adults [six females; mean (SD) = 28.1 (5.0) years old] were recruited. Ankle torque, TA IMP, and CMAP responses were collected during maximal stimulation of the fibular nerve at different intensity levels of electrical stimulation, and at different frequencies of supramaximal stimulation, i.e., at 2, 5, 10, and 20 Hz. The IMP response at different stimulation intensities was correlated with the CMAP amplitude (r 2 = 0.94). The area of the IMP response at different stimulation intensities was also significantly correlated with the area of the CMAP (r 2 = 0.93). Increasing stimulation intensity resulted in an increase of the IMP response (P < 0.001). Increasing stimulation frequency caused torque (P < 0.001) as well as the IMP (P < 0.001) to increase. The ankle torque EMD [median (interquartile range) = 41.8 (14.4) ms] was later than the IMPD [33.0 (23.6) ms]. These findings support the hypotheses and suggest that IMP captures active mechanical properties of muscle in vivo and can be used to detect muscular changes due to drugs, diseases, or aging.

Muscle activation pattern during gait and stair activities following total hip arthroplasty with a direct anterior approach: a comprehensive case study.

Muscle activation following total hip arthroplasty with a direct anterior approach has not previously been reported in the literature. This case report details the electromyography outcome of a 60-year-old male patient with unilateral direct anterior approach-total hip arthroplasty during walking and stair activities. Outcome reports the continuation of altered muscle activation 12 months postoperatively, even with a good clinical outcome.

Intramuscular Pressure of Tibialis Anterior Reflects Ankle Torque but Does Not Follow Joint Angle-Torque Relationship.

Intramuscular pressure (IMP) is the hydrostatic fluid pressure that is directly related to muscle force production. Electromechanical delay (EMD) provides a link between mechanical and electrophysiological quantities and IMP has potential to detect local electromechanical changes. The goal of this study was to assess the relationship of IMP with the mechanical and electrical characteristics of the tibialis anterior muscle (TA) activity at different ankle positions. We hypothesized that (1) the TA IMP and the surface EMG (sEMG) and fine-wire EMG (fwEMG) correlate to ankle joint torque, (2) the isometric force of TA increases at increased muscle lengths, which were imposed by a change in ankle angle and IMP follows the length-tension relationship characteristics, and (3) the electromechanical delay (EMD) is greater than the EMD of IMP during isometric contractions. Fourteen healthy adults [7 female; mean (SD) age = 26.9 (4.2) years old with 25.9 (5.5) kg/m2 body mass index] performed (i) three isometric dorsiflexion (DF) maximum voluntary contraction (MVC) and (ii) three isometric DF ramp contractions from 0 to 80% MVC at rate of 15% MVC/second at DF, Neutral, and plantarflexion (PF) positions. Ankle torque, IMP, TA fwEMG, and TA sEMG were measured simultaneously. The IMP, fwEMG, and sEMG were significantly correlated to the ankle torque during ramp contractions at each ankle position tested. This suggests that IMP captures in vivo mechanical properties of active muscles. The ankle torque changed significantly at different ankle positions however, the IMP did not reflect the change. This is explained with the opposing effects of higher compartmental pressure at DF in contrast to the increased force at PF position. Additionally, the onset of IMP activity is found to be significantly earlier than the onset of force which indicates that IMP can be designed to detect muscular changes in the course of neuromuscular diseases impairing electromechanical transmission.

Qualitative analysis of foot intersegment coordination in the sagittal plane following surgery for end-stage ankle osteoarthrosis.

Today, ankle joint kinematic assessment gives important information regarding the intersegment range of motion. It does not, however, provide information regarding coordination between the segments. This study aimed to determine whether or not intersegment coordination can provide valuable, otherwise missed information in relation to kinematic alterations of the ankle joint. The study consisted of 40 participants, including 12 total ankle replacement (TAR) patients, 12 ankle arthrodesis (AA) patients, and 16 controls. Gait assessment was carried out wearing 3-D inertial sensors. Intersegment coordination was determined by calculation of the continuous relative phase (CRP) between foot intersegments. CRP analysis found useful information regarding the magnitude and directionality of segment motion throughout the gait cycle, with AA patients reporting an altered coordination pattern for all three intersegments, forefoot-hindfoot, hindfoot-shank, and forefoot-shank, and TAR patients showing alterations in the hindfoot-shank intersegment. Results show that assessment of intersegment coordination can provide further information, otherwise overlooked by the general kinematic assessment, which could be used to optimize patient rehabilitation. Furthermore, the study showed that such information could be used to compare surgical outcomes. As a result, the study concludes that the inclusion of intersegment coordination assessment could be beneficial in clinical practice. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1304-1310, 2017.

Obstructive Sleep Apnea Dynamically Increases Nocturnal Plasma Free Fatty Acids, Glucose, and Cortisol During Sleep.

Context: Obstructive sleep apnea (OSA) is associated with diabetes and cardiovascular disease. This association may be related to metabolic changes that transpire during sleep in OSA. Objective: To examine the impact of OSA, elicited by cessation of continuous positive airway pressure (CPAP), on frequently sampled nocturnal metabolic markers including plasma free fatty acids (FFAs), glucose, insulin, triglycerides (TGs), cortisol, and lactate, as well as glucose production, oral glucose tolerance, blood pressure (BP), endothelial function, cholesterol, and high-sensitivity C-reactive protein (hsCRP). Design and Setting: Randomized crossover trial of CPAP vs CPAP withdrawal. Patients: Thirty-one patients with moderate to severe OSA acclimated to CPAP. Intervention: Patients underwent attended polysomnography while sleeping with therapeutic CPAP, or after CPAP withdrawal, in random order. Venous blood was sampled at ∼20-minute intervals on both nights. In 11 patients, we assessed glucose kinetics with an infusion of 6,6-[2H2]glucose. Results: CPAP withdrawal caused recurrence of OSA associated with hypoxemia, sleep disruption, and heart rate (HR) elevation. CPAP withdrawal dynamically increased nocturnal FFA (P = 0.007), glucose (P = 0.028), and cortisol (P = 0.037), in proportion to respiratory event frequency, HR elevation, or sleep fragmentation. Diabetes predisposed to glucose elevation. CPAP withdrawal also increased systolic BP (P = 0.017) and augmentation index (P = 0.008), but did not affect insulin, TGs, glucose production, oral glucose tolerance, cholesterol, or hsCRP. Conclusion: OSA recurrence during CPAP withdrawal increases FFA and glucose during sleep, associated with sympathetic and adrenocortical activation. Recurring exposure to these metabolic changes may foster diabetes and cardiovascular disease.

Sleep apnoea.

Sleep apnoea is a disorder characterised by repetitive pauses in breathing during sleep caused by airway occlusion (obstructive sleep apnoea) or altered control of breathing (central sleep apnoea). In this Clinical Year in Review, we summarise high-impact research from the past year pertaining to management, diagnosis and cardio-metabolic consequences of sleep apnoea.

Outcome of unilateral ankle arthrodesis and total ankle replacement in terms of bilateral gait mechanics.

Previous studies assessed the outcome of ankle arthrodesis (AA) and total ankle replacement (TAR) surgeries; however, the extent of postoperative recovery towards bilateral gait mechanics (BGM) is unknown. We evaluated the outcome of the two surgeries at least 2 years post rehabilitation, focusing on BGM. 36 participants, including 12 AA patients, 12 TAR patients, and 12 controls were included. Gait assessment over 50 m distance was performed utilizing pressure insoles and 3D inertial sensors, following which an intraindividual comparison was performed. Most spatiotemporal and kinematic parameters in the TAR group were indicative of good gait symmetry, while the AA group presented significant differences. Plantar pressure symmetry among the AA group was also significantly distorted. Abnormality in biomechanical behavior of the AA unoperated, contralateral foot was observed. In summary, our results indicate an altered BGM in AA patients, whereas a relatively fully recovered BGM is observed in TAR patients, despite the quantitative differences in several parameters when compared to a healthy population. Our study supports a biomechanical assessment and rehabilitation of both operated and unoperated sides after major surgeries for ankle osteoarthrosis.