Feng, Zhibin; Mi, Kun; Wei, Renzhi; Liu, Wu; Wang, Bin
To study the operative procedure and the effectiveness of arthroscopic therapy for ankle joint impingement syndrome after operation of ankle joint fracture dislocation. Between March 2008 and April 2010, 38 patients with ankle joint impingement syndrome after operation of ankle joint fracture dislocation were treated. Among them, there were 28 males and 10 females with an average age of 28 years (range, 18 to 42 years). The time from internal fixation to admission was 12-16 months (mean, 13.8 months). There were pressing pain in anterolateral and anterior ankle. The dorsal extension ranged from -20 to -5 degrees (mean, -10.6 degrees), and the palmar flexion was 30-40 degrees (mean, 35.5 degrees). The total score was 48.32 +/- 9.24 and the pain score was 7.26 +/- 1.22 before operation according to American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system. The X-ray films showed osteophyte formation in anterior tibia and talus; MRI showed cartilage injury in 22 cases. Arthroscopic intervention included removing osteophytes, debriding fabric scars and synovial membrane tissues, and removing osteochondral fragments. Arthroscopic microfracture technique was used in 22 patients with cartilage injury. All incisions healed primarily. Thirty-eight cases were followed up 10-26 months (mean, 16 months). At last follow-up, 26 patients had normal range of motion (ROM); the dorsal extension was 15-25 degrees (mean, 19.6 degrees) and the palmar flexion was 35-45 degrees (mean, 40.7 degrees). Eight patients had mild limited ROM; the dorsal extension was 5-15 degrees (mean, 7.2 degrees) and the palmar flexion was 35-45 degrees (mean, 39.5 degrees). Four patients had mild limited ROM and pain in posterior portion of the ankle after a long walking (3-4 hours); the dorsal extension was 0-5 degrees (mean, 2.6 degrees) and the palmar flexion was 35-40 degrees (mean, 37.5 degrees). The total score was 89.45 +/- 9.55 and the pain score was 1.42 +/- 1.26 after
Schoepp, C; Rixen, D
Arthroscopic fracture management of the ankle and calcaneus requires a differentiated approach. The aim is to minimize surgical soft tissue damage and to visualize anatomical fracture reduction arthroscopically. Moreover, additional cartilage damage can be detected and treated. The arthroscopic approach is limited by deep impressions of the joint surface needing cancellous bone grafting, by multiple fracture lines on the articular side and by high-grade soft tissue damage. An alternative to the minimally invasive arthroscopic approach is open arthroscopic reduction in conventional osteosynthesis. This facilitates correct assessment of surgical reduction of complex calcaneal fractures, otherwise remaining non-anatomical reduction might not be fluoroscopically detected during surgery.
Lui, T H
Late complications after calcaneal fracture usually resulted in lateral heel pain. Malunion of joint depressed type calcaneal fracture can result in posterior ankle impingement pain. This is caused by the posterior calcaneal bone spike formed just behind the posterior calcaneal facet. We describe a technique to resect the offending posterior calcaneal bone spike to relieve the posterior ankle impingement pain.
Nosewicz, Tomasz L; Beerekamp, M Suzan H; De Muinck Keizer, Robert-Jan O; Schepers, Tim; Maas, Mario; Niek van Dijk, C; Goslings, J Carel
Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome. 100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year. OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs. Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS. Level IV, observational study. © The Author(s) 2016.
Gourineni, Prasad; Gupta, Asheesh
Tillaux and Triplane fractures occur in children predominantly from external rotation mechanism. We hypothesized that in displaced fractures, the talus would shift laterally along with the distal fibula and the distal tibial epiphyseal fragment increasing the medial joint space. Consecutive cases evaluated retrospectively. Level I and Level II centers. Twenty-two skeletally immature patients with 14 displaced Triplane fractures and eight displaced Tillaux fractures were evaluated for medial joint space widening. Measurement of fracture displacement and medial joint space widening before and after intervention. Thirteen Triplane and six Tillaux fractures (86%) showed medial space widening of 1 to 9 mm and equal to the amount of fracture displacement. Reduction of the fracture reduced the medial space to normal. There were no known complications. Medial space widening of the ankle may be a sign of ankle fracture displacement. Anatomic reduction of the fracture reduces the medial space and may improve the results in Tillaux and Triplane fractures.
Antoci, Valentin; Patel, Shaun P; Weaver, Michael J; Kwon, John Y
Routinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries. One thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture. Adjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays. The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays. Level IV. Copyright © 2016 Elsevier Ltd. All rights reserved.
Jubel, A; Faymonville, C; Andermahr, J; Boxberg, S; Schiffer, G
Background: Ankle fractures are extremely common in the elderly, with an incidence of up to 39 fractures per 100,000 persons per year. We found a discrepancy between intraoperative findings and preoperative X-ray findings. It was suggested that many relevant lesions of the ankle joint in the elderly cannot be detected with plain X-rays. Methods: Complete data sets and preoperative X-rays of 84 patients aged above 60 years with ankle fractures were analysed retrospectively. There were 59 women and 25 men, with a mean age of 69.9 years. Operation reports and preoperative X-rays were analysed with respect to four relevant lesions: multifragmentary fracture pattern of the lateral malleolus, involvement of the medial malleolus, posterior malleolar fractures and bony avulsion of anterior syndesmosis. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and prevalence were calculated. Results: The prevalence of specific ankle lesions in the analyzed cohort was 24 % for the multifragmentary fracture pattern of the lateral malleolus, 38 % for fractures of the medial malleolus, 25 % for posterior malleolar fractures and 22.6 % for bony avulsions of the anterior syndesmosis. Multifragmentary fracture patterns of the lateral malleolus (sensitivity 0 %) and bony avulsions of the anterior syndesmosis (sensitivity 5 %) could not be detected in plain X-rays of the ankle joint at all. Fractures of the medial malleolus and involvement of the dorsal tibial facet were detected with a sensitivity of 96.8 % and 76.2 %, respectively, and specificity of 100 % in both cases. Conclusions: This study confirms that complex fracture patterns, such as multifragmentary involvement of the lateral malleolus, additional fracture of the medial malleolus, involvement of the dorsal tibial facet or bony avulsion of the anterior syndesmosis are common in ankle fractures of the elderly. Therefore, CT scans should be routinely considered for primary
Malleolar fracture; Tri-malleolar; Bi-malleolar; Distal tibia fracture; Distal fibula fracture; Malleolus fracture ... Some ankle fractures may require surgery when: The ends of the bone are out of line with each other (displaced). The ...
Budescu, E.; Merticaru, E.; Chirazi, M.
The paper presents a biomechanical model of the ankle joint, in order to determine the force and the torque of reaction into the articulation, through inverse dynamic analysis, in various stages of the gait. Thus, knowing the acceleration of the foot and the reaction force between foot and ground during the gait, determined by experimental measurement, there was calculated, for five different positions of the foot, the joint reaction forces, on the basis of dynamic balance equations. The values numerically determined were compared with the admissible forces appearing in the technical systems of osteosynthesis of tibia malleolus fracture, in order to emphasize the motion restrictions during bone healing.
Yin, Qingwei; Jiang, Yi; Xiao, Lianping; Li, Xiaodong; Fu, Jiaxin; Tian, Yonggang; Han, Liqiang; Liu, Zhi
To summarize the technique and effect of the therapy for severe fracture and dislocation of ankle joint by operation. From March 2003 to February 2006, 76 cases were treated with primary open restoration and internal fixation for dislocated ankle joint fracture, with 47 males and 29 females, with the average age of 36.4 years (ranging from 18 years to 65 years). According to AO criterion, these fresh fractures were classified into 13 cases for type C3-1, 45 cases for type C3-2 and 18 cases for type C3-3. Based on the Gustilo-Anderson standard, 23 open fractures were classified into 17 cases for type II and 6 cases for type III A. The operation was delayed from 1 hours to 24 hours after the injury. All incisions healed at the first stage except 4 cases which delayed union because of simple infection by revision with ointment. A total of 72 cases were followed up, with the average time of 18.5 months (from 12 months to 35 months). The time of bone union was from 12 weeks to 24 weeks. The screws of fixation for lower tibia-fibula joint were found to be ruptured in 2 cases when further consultation was performed in the 16th and 20th week after the operation, respectively, and were broken within 1 year after the operation. These screws were taken out 12 weeks postoperative in 28 cases, while the whole internal fixations of the rest cases were taken out 1 year after the operation. The postoperative function of malleolus extended from 21.7 degrees to 26.8 degrees and flection from 38.5 degrees to 44.7 degrees. Assessed by the American Orthopaedic Foot and Ankle Society Clinical Rating Scales, 23 cases were excellent, 36 good, 13 fair, and the choiceness rate reached 81.94%. These procedures, together with reduction by twist after hospital, open and internal fixation in time, and parenchyma managed with internal fixation, are important to attain satisfactory effect for the treatment of severe fracture and dislocation of ankle joint.
Gehr, Jonas; Friedl, Wilhelm
Reconstruction of the anatomy of the ankle joint while protecting the soft tissue, and osteosynthesis to maintain stability for function and weight bearing. Distal fractures of the fibula, bimalleolar fractures, and isolated fractures of the medial malleolus. Very small (< 5 mm) distal fragments (if fixation of the fragments is not possible using a small XXS nail) and very narrow (< 2.5 mm) medullary cavity (conversion to plate fixation). With displaced fibula fractures, open reduction should be performed with fracture retention using wide-armed reduction forceps, insertion of a central guide wire into the medullary cavity, use of a cannulated drill bit, introduction of the nail using an aiming arm and locked fixation with threaded wire. After checking the position using X-ray, the wire should be shortened using the bolt cutters. POSTOPERATIVE MANAGEMENT (Depending on the Weber classification): Full weight bearing for all isolated distal fractures of the fibula (Weber types A and B) and isolated fractures of the medial malleolus. For distal fractures of the fibula (Weber types A and B) with additional fracture of the medial malleolus or involvement of the medial ligament partial weight bearing of 20 kp for 4 weeks, followed by full weight bearing. For all Weber C fractures and/or additional Volkmann fracture only 10 kp of partial weight bearing with a rocker-sole orthosis should be allowed for 6 weeks followed by full weight bearing. No weight bearing for 6 weeks until the screws are removed is only recommended, if positioning screws have been used for Weber C fractures. In the period from 05/2000 to 01/2002, 194 ankle fractures were treated with the IP-XS-Nail((R)). Follow-up examinations were conducted on 162 patients with an average age of 51.2 years after an average of 15 months. 62 Weber B fractures (38.3%) and 45 Weber C fractures (27.7%) were evaluated. There were bimalleolar fractures in 55 cases (34.0%). According to the Olerud Score (clinical and
Lötscher, P; Lang, T H; Zwicky, L; Hintermann, B; Knupp, M
Injuries of the ankle joint have a high incidence in daily life and sports, thus, playing an important socioeconomic role. Therefore, proper diagnosis and adequate treatment are mandatory. While most of the ligament injuries around the ankle joint are treated conservatively, great controversy exists on how to treat deltoid ligament injuries in ankle fractures. Missed injuries and inadequate treatment of the medial ankle lead to inferior outcome with instability, progressive deformity, and ankle joint osteoarthritis.
Ankle arthritis results in a stiff and painful ankle and can be a major cause of disability. For people with end-stage ankle arthritis, arthrodesis (ankle fusion) is effective at reducing pain in the shorter term, but results in a fixed joint, and over time the loss of mobility places stress on other joints in the foot that may lead to arthritis, pain and dysfunction. Another option is to perform a total ankle joint replacement, with the aim of giving the patient a mobile and pain-free ankle. In this article we review the efficacy of this procedure, including how it compares to ankle arthrodesis, and consider the indications and complications.
Zhang, Song-Tu; Lin, Yi-Rong; Chen, Lian-Yuan
To compare the clinical efficacy of grade III, IV supination-eversion fractures-dislocations of ankle joint between manipulative treatment and operative treatment. From September 2007 to December 2008, the clinical data of 60 patients with grade III, IV supination-eversion fractures-dislocations of ankle joint were retrospectively analyzed. There were 32 males and 28 females, ranging in age from 18 to 70 years with an average age of 38.17 years. All patients were respectively treated with manipulative treatment (conservative group, 30 cases) and operative treatment (operative group, 30 cases). The joint function was compared with Mazur standard; the reduction and shifting of fractures were observed with X-ray; the hospitalization day and the therapeutic cost were compared between two groups. All patients were followed up with an average of 15.27 months (ranged, 6 to 25 months). In conservative group, 16 cases got excellent result in joint function, 10 good, 3 fair, 1 poor; in operative group, 20 cases got excellent result, 8 good, 2 fair, 0 poor. In conservative group in the X-ray showed 25 cases obtained excellent and good reduction, 4 fair, 1 poor; and in operative group in the X-ray showed 28 cases obtained excellent and good reduction, 2 fair, 0 poor. There was no significant difference at the joint function and X-ray film after treatment between two groups (P > 0.05). The hospital day was respectively (7.87 +/- 3.34), (17.37 +/- 4.64) d in conservative group and operative group; and the therapeutic cost was respectively (2 506.67 +/- 649.10), (11 473.33 +/- 1 564.90) yuan. There was significant difference at hospital day and therapeutic cost between two groups (P < 0.05). Conservative treatment and operative treatment can both reach a very good result in treating grade III, IV supination-eversion fractures and dislocations of ankle joint. However, conservative treatment has advantage of high safety factor, low therapeutic cost, can reduce medical costs for
Lee, Kyoung Min; Chung, Chin Youb; Sung, Ki Hyuk; Lee, SeungYeol; Kim, Tae Gyun; Choi, Young; Jung, Ki Jin; Kim, Yeon Ho; Koo, Seung Bum; Park, Moon Seok
Injury mechanism and the amount of force are important factors determining whether a fracture or sprain occurs at the time of an ankle inversion injury. However, the anatomical differences between the ankle fracture and sprain have not been investigated sufficiently. This study was performed to investigate whether an anatomical predisposition of the ankle joint results in a lateral malleolar fracture or lateral ankle sprain. Two groups of consecutive patients, one with lateral malleolar fracture (274 patients, mean age 49.0 years) and the other with lateral ankle sprain (400 patients, mean age 38.4 years), were evaluated. Ankle radiographs were examined for 7 measures: distal tibial articular surface (DTAS) angle, bimalleolar tilt (BT), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), anterior inclination of tibia (AI), and fibular position (FP). After an interobserver reliability test, the radiographic measurements were compared between the 2 groups. Linear regression analysis was performed to correct for age and sex effects between the groups. The fracture group and the sprain group showed significant differences in BT (P = .001), MMSA (P < .001), AI (P = .023), and FP (P < .001). In multiple regression analysis, after adjusting for age and sex effects, fracture and sprain groups showed a significant difference in BT (P = .001), MMRL (P < .001), MMSA (P < .001), and FP (P < .001). The lateral malleolar fracture group tended to show more bony constraint than that of the lateral ankle sprain group. Further 3-dimensional assessment of the bony structure and subsequent biomechanical studies are needed to elucidate the mechanism of injury according to the various types of ankle fractures and ankle sprain. Level III, retrospective comparative study. © The Author(s) 2014.
Zhou, Yifei; Cai, Leyi; Lu, Xiaolang; Yu, Yang; Hong, Jianjun
To analyze the relationship between imaging findings and postoperative curative effect by measuring the morphology of the ankle mortise in patients with the Ruedi-Allgouer type III Pilon fractures. Forty-seven patients with Ruedi-Allgouer type III Pilon fractures who underwent surgical treatment from January 2011 to January 2015 were retrospectively analyzed. At the last follow-up, x-rays of the affected ankle and the healthy side were measured. According to the Kitaoka score of ankle joint function at the last follow-up. All patients were followed up for 18-24 months (mean 21 months). This study demonstrated that compared with the healthy side, the index of the width, depth, and coronal/sagittal angles of the ankle mortise were significantly different (P < 0.05) in the 47 patients except for the index of height (P > 0.05). According to the Kitaoka score, the difference between the affected and the healthy sides of each index of the ankle mortise was compared between the 3 groups. That is, the intraoperative treatment of the width and depth of the ankle mortise as well as the coronal and sagittal angles of the ankle mortise were significantly correlated with the postoperative curative effect. The intraoperative treatment of ankle mortise width, depth, and ankle coronal/sagittal angle in patients with severe Pilon fractures has a significant impact on postoperative efficacy. In order to prevent the occurrence of traumatic arthritis, the anatomical morphology of the ankle should be restored as much as possible in the course of surgery. Copyright © 2017. Published by Elsevier Ltd.
Zhang, P; Dong, Q R; Wang, Z Y; Chen, B; Wan, J H; Wang, L
Objective: To explore the manual operation skills of operative treatment of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws, and to study the clinical results. Method: From Jan 2009 to Dec 2014, the clinical data of 13 patients with ipsilateral Hawkins Ⅲ talus neck and ankle joint fractres via internal and lateral approaches with Herbert screws were retrospectively analyzed in our department.There were 10 males and 3 female, ranging in age from 20 to 60 years with an average age of 31.5 years.The fractures occurred on the right side in 9 patients and on the left side in 4 patients.Three cases had the complication of medial malleolar fracture.Ten cases had the complication of medial and lateral malleolar fracture. Totally 11 cases were made calcaneal skeletal traction, and all the were made CT with three-dimensional image reconstruction.Two cases were treated with emergency operation.Eleven cases were treated with selective operation.The operation time was 5 hours-10 days after injury. The functional results were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS). Result: The average duration of follow-up was 22.6 months (range, 14-65 months). There was skin necrosis in one cases, no incision infection, malunion and nonunion of the fractures and loss of reduction. At final follow-up, AOFAS ankle score was 75.2 (range, 42 to 93), higher than preoperative 39.2 (range, 23 to 60), the difference was statistically significant (P=0.023). The result was excellent in 4 cases, good in 5 cases, fair in 3 cases and 1 cases in poor, and the overall excellent or good rate was 69.2%. Avascular necrosis occurred in 3 cases (23.1%, 3/13). Traumatic arthritis was found in 5 cases (38.5%, 5/13), involved tibial astragaloid joint in 2 cases, involved subtalar joint in 1 case, involved tibial astragaloid joint and subtalar joint in 2 cases. Conclusion: The effect of surgical treatment for ipsilateral
Veerappa, Lokesh A; Gopalkrishna, Chetan
A rare case of talar neck fracture with intact ankle and subtalar joint is presented. The talar head fragment is dislocated dorsally with the fractured surface of the head facing plantarward. Only two such cases were reported in the literature. The mechanism of injury described in the yesteryears for talar neck fractures does not explain this variety of injury. A possible mechanism of injury has been described. This rare fracture has been successfully treated without any complications after a follow-up of 2 and 1/2 years. Copyright (c) 2009 Elsevier Ltd. All rights reserved.
Beytemür, Ozan; Albay, Cem; Adanır, Oktay; Yüksel, Serdar; Güleç, Mehmet Akif
This study aims to evaluate the functional and radiographic results and treatment complications of AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) type 43C1 and C2 fractures treated with intramedullary nailing. We retrospectively evaluated 35 AO/OTA type 43C1 and C2 patients (26 males, 9 females; mean age 39.8±16.9 years; range 19 to 82 years) treated with intramedullary nailing. Two interfragmentary screws out of nail were applied in 10 patients (29%), while one interfragmentary screw out of nail was applied in 17 patients (49%). Intramedullary nailing was applied in eight patients (23%) without external screws. Fracture union, union time, alignment problems, and complications were evaluated. Clinical evaluation of patients was conducted using the Olerud and Molander score and by measuring the ankle joint range of motion. Union was achieved in all 35 patients. Mean union time was 16.5±2.8 weeks (range 12 to 24 weeks) and mean Olerud and Molander score was 88±8.24. Varus deformity was detected in one patient, valgus deformity was detected in two patients, and rotation deformity was detected in one patient. Superficial infection was detected in three patients (9%). Deep infection was not detected in any patient. Intramedullary nailing is not contraindicated for simple intra-articular distal tibial fractures. In these fractures, intramedullary nailing performed in accordance with its technique, with an additional percutaneous screw if necessary, is a successful treatment option with high fracture union rates, high functional results, and low complication rates.
Wang, Chien-Shun; Tzeng, Yun-Hsuan; Lin, Chun-Cheng; Huang, Ching-Kuei; Chang, Ming-Chau; Chiang, Chao-Ching
The aim of this prospective study was to evaluate the influence of sectioning the calcaneofibular ligament (CFL) during an extensile lateral approach during open reduction and internal fixation (ORIF) of calcaneal fractures on ankle joint stability. Forty-two patients with calcaneal fractures that received ORIF were included. Talar tilt stress and anterior drawer radiographs were performed on the operative and contralateral ankles 6 months postoperatively. The average degree of talar tilt on stress radiographs was 3.4 degrees (range, 0-12 degrees) on the operative side and 3.2 degrees (range, 0-14 degrees) on the contralateral side. The mean anterior drawer on stress radiographs of the CFL incised ankle was 6.1 mm (range, 2.4-11.8 mm) and on the contralateral ankle was 5.7 mm (range, 2.6-8.6 mm). There was no statistically significant difference of talar tilt and anterior drawer between the CFL incised side and the contralateral side (P = .658 and .302, respectively). The results suggest that sectioning of the CFL without any repair during ORIF of a calcaneal fracture does not have a negative effect on stability of the ankle. Repair of the CFL is, thus, probably not necessary following extended lateral approach for ORIF of calcaneal fractures. Level II, comparative study. © The Author(s) 2016.
Azarkane, Mohamed; Boussakri, Hassan; Alayyoubi, Abdelghani; Bachiri, Mohamed; Elibrahimi, Abdelhalim; Elmrini, Abdelemejid
Total subtalar dislocation without fracture of the ankle is a rare clinical entity; it is usually due to a traumatic high-energy mechanism. Standard treatment is successful closed reduction under general anesthesia followed by non-weight bearing and ankle immobilization with a below-knee cast for 6 weeks. We present the case of a 30-year-old Moroccan woman who was involved in a road traffic accident. She subsequently received a radiological assessment that objectified a total subtalar dislocation without fracture of her ankle. She was immediately admitted to the operating theater where an immediate reduction was performed under sedation, and immobilization in a plaster boot was adopted for 8 weeks. The management of this traumatic lesion is discussed in the light of the literature. Medial subtalar dislocation is a rare dislocation and is not commonly seen as a sports injury because it requires transfer of a large amount of kinetic energy. The weaker talocalcaneal and talonavicular ligaments often bear the brunt of the energy and are more commonly disrupted, compared to the relatively stronger calcaneonavicular ligament. Urgent reduction is important, and closed reduction under general anesthesia is usually successful, often facilitated by keeping the knee in flexion to relax the gastrocnemius muscle. Long-term sequelae include talar avascular necrosis and osteochondral fracture, as well as chronic instability and pain.
Kern, Andrew M.; Anderson, Donald D.
Acute injury severity, altered joint kinematics, and joint incongruity are three important mechanical factors linked to post-traumatic osteoarthritis (PTOA). Finite element analysis (FEA) was previously used to assess the influence of increased contact stress due to joint incongruity on PTOA development. While promising agreement with PTOA development was seen, the inherent complexities of contact FEA limited the numbers of subjects that could be analyzed. Discrete element analysis (DEA) is a simplified methodology for contact stress computation, which idealizes contact surfaces as a bed of independent linear springs. In this study, DEA was explored as an expedited alternative to FEA contact stress exposure computation. DEA was compared to FEA using results from a previously completed validation study of two cadaveric human ankles, as well as a previous study of post-operative contact stress exposure in 11 patients with tibial plafond fracture. DEA-computed maximum contact stresses were within 19% of those experimentally measured, with 90% of the contact area having computed contact stress values within 1 MPa of those measured. In the 11 fractured ankles, maximum contact stress and contact area differences between DEA and FEA were 0.85±0.64 MPa and 22.5±11.5 mm2. As a predictive measure for PTOA development, both DEA and FEA had 100% concordance with presence of OA (KL grade ≥ 2) and >95% concordance with KL grade at 2 years. These results support DEA as a reasonable alternative to FEA for computing contact stress exposures following surgical reduction of a tibial plafond fracture. PMID:26105660
Kern, Andrew M; Anderson, Donald D
Acute injury severity, altered joint kinematics, and joint incongruity are three important mechanical factors linked to post-traumatic osteoarthritis (PTOA). Finite element analysis (FEA) was previously used to assess the influence of increased contact stress due to joint incongruity on PTOA development. While promising agreement with PTOA development was seen, the inherent complexities of contact FEA limited the numbers of subjects that could be analyzed. Discrete element analysis (DEA) is a simplified methodology for contact stress computation, which idealizes contact surfaces as a bed of independent linear springs. In this study, DEA was explored as an expedited alternative to FEA contact stress exposure computation. DEA was compared to FEA using results from a previously completed validation study of two cadaveric human ankles, as well as a previous study of post-operative contact stress exposure in 11 patients with tibial plafond fracture. DEA-computed maximum contact stresses were within 19% of those experimentally measured, with 90% of the contact area having computed contact stress values within 1MPa of those measured. In the 11 fractured ankles, maximum contact stress and contact area differences between DEA and FEA were 0.85 ± 0.64 MPa and 22.5 ± 11.5mm(2). As a predictive measure for PTOA development, both DEA and FEA had 100% concordance with presence of OA (KL grade ≥ 2) and >95% concordance with KL grade at 2 years. These results support DEA as a reasonable alternative to FEA for computing contact stress exposures following surgical reduction of a tibial plafond fracture. Copyright © 2015 Elsevier Ltd. All rights reserved.
Qi, Yue-Feng; Chen, Fa-Lin; Bao, Shu-Ren; Li, Cheng-Huan; Zhao, Xing-Wei; Liu, Shi-Ming; Chen, Wen-Xue; Li, Ye; Wang, Peng
To explore therapeutic effects of bone setting manipulation for the treatment of over degree II supination-eversion fractures of ankle,and analyze manipulative reduction mechanism. From 2005 to 2008, 95 patients with over degree II supination-eversion fractures of ankle were treated respectively by manipulation and operation. There were 43 cases [11 males and 32 females with an average age of (44.95 +/- 12.65) years] in manipulation group, and 2 cases were degree II, 11 cases were degree III, and 30 cases were degree IV. There were 52 cases [21 males and 31 females with an average age of (39.96 +/- 13.28) years] in operative group,and 6 cases were degree II, 18 cases were degree III, and 28 cases were degree IV. Bone setting manipulation and hard splint external fixation were applied to manipulative group. Operative reduction internal fixation was performed in operative group. X-ray was used to evaluate reduction of fracture before and after treatment, 2 months after treatment. Ankle joint function was evaluated according to Olerud-Molander scoring system after 6 months treatment. All patients were followed up with good reduction. Three cases occurred wound complication in operative group, but not in manipulative group. In manipulation group, 19 cases got excellent results, 20 cases good and 4 cases fair; while in operative group, 30 cases got excellent results, 20 cases good and 2 cases poor. There were no significant differences in fracture reduction and ankle joint function recovery between two groups (P > 0.05). Efficacy of operative treatment was better than that of manipulative treatment at degree IV fracture (P < 0.05). Bone setting manipulation is a good method for treating supination-eversion ankle joint fractures, which has advantages of simple and safe operation, reliable efficacy. For ankle join fracture at degree IV, manipulative reduction should be adopted earlier, and operative treatment also necessary
Su, Alvin W.; Larson, A. Noelle
Synopsis Current clinical concepts are reviewed regarding the epidemiology, anatomy, evaluation and treatment of pediatric ankle fractures. Correct diagnosis and management relies on appropriate exam, imaging, and knowledge of fracture patterns specific to children. Treatment is guided by patient history, physical examination, plain film radiographs and, in some instances, CT. Treatment goals are to restore acceptable limb alignment, physeal anatomy, and joint congruency. For high risk physeal fractures, patients should be monitored for growth disturbance as needed until skeletal maturity. PMID:26589088
Young, Ki Won; Kim, Jin-su; Cho, Jae Ho; Kim, Hyung Seuk; Cho, Hun Ki; Lee, Kyung Tai
We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to
Young, Ki Won; Cho, Jae Ho; Kim, Hyung Seuk; Cho, Hun Ki; Lee, Kyung Tai
Background We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. Methods Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. Results The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. Conclusions Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were
Lee, K M; Chung, C Y; Kwon, S S; Won, S H; Lee, S Y; Chung, M K; Park, M S
We report the bone attenuation of ankle joint measured on computed tomography (CT) and the cause of injury in patients with ankle fractures. The results showed age- and gender-dependent low bone attenuation and low-energy trauma in elderly females, which suggest the osteoporotic features of ankle fractures. This study was performed to investigate the osteoporotic features of ankle fracture in terms of bone attenuation and cause of injury. One hundred ninety-four patients (mean age 51.0 years, standard deviation 15.8 years; 98 males and 96 females) with ankle fracture were included. All patients underwent CT examination, and causes of injury (high/low-energy trauma) were recorded. Mean bone attenuations of the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis were measured on CT images. Patients were divided into younger age (<50 years) and older age (≥50 years) groups, and mean bone attenuation and causes of injury were compared between the two groups in each gender. Proportion of low-energy trauma was higher in the older age group than in the younger age group, but the difference was only significant in female gender (p = 0.011). The older age group showed significantly lower bone attenuation in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis than the younger age group in both genders. The older age group showed more complex pattern of fractures than the younger age group. With increasing age, bone attenuations tended to decrease and the difference of bone attenuation between the genders tended to increase in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis. Ankle fracture had features of osteoporotic fracture that is characterized by age- and gender-dependent low bone attenuation. Ankle fracture should not be excluded from the clinical and research interest as well as from the benefit of osteoporosis management.
Braunstein, M; Baumbach, S F; Böcker, W; Mutschler, W; Polzer, H
Acute ankle fractures are one of the most common fractures in adults with an incidence of 0.1-0.2 % per year. Operative treatment by open reduction and internal fixation (ORIF) is the standard method of treatment for unstable or dislocated fractures. The main goal of the operation is the anatomical realignment of the joint and restoration of ankle stability; nevertheless, anatomical reduction does not automatically lead to favorable clinical results. According to several studies the mid-term and in particular the long-term outcome following operative treatment is often poor with residual symptoms including chronic pain, stiffness, recurrent swelling and ankle instability. There is growing evidence that this poor outcome might be related to occult intra-articular injuries involving cartilage and soft tissues. In recent studies the frequency of fracture-related osteochondral lesions was reported to be approximately 64 %. By physical examination, standard radiography or even computed tomography (CT), these intra-articular pathologies cannot be reliably diagnosed; therefore, many authors emphasize the value of ankle arthroscopy in acute fracture treatment as it has become a safe and effective diagnostic and therapeutic procedure. Arthroscopically assisted open reduction and internal fixation (AORIF) allows control of the reduction as well examination of all intra-articular structures. If necessary, intra-articular pathologies can be addressed by removing ruptured ligaments and loose bodies, performing chondroplasty or microfracturing. So far there is no evidence that supplementary ankle arthroscopy increases the complication rate. On the other hand, the positive effect of AORIF has also not been clearly documented; nevertheless, there are clear indications that arthroscopically assisted fracture treatment is beneficial, especially in complex fractures.
Lui, Tun Hing
Adhesive capsulitis of the ankle is also known as frozen ankle and results in marked fibrosis and contracture of the ankle capsule. Arthroscopic capsular release is indicated for symptomatic frozen ankle that is resistant to conservative treatment. It is contraindicated for ankle stiffness due to degenerative joint disease, intra-articular malunion, or adhesion of the extensors of the ankle. The procedure consists of endoscopic posterior ankle capsulectomy and arthroscopic anterior ankle capsulotomy. It has the advantages of being minimally invasive surgery and allowing early postoperative vigorous mobilization of the ankle joint.
Denning, Jaime R
Ankle fractures account for 5% and foot fractures account for approximately 8% of fractures in children. Some complications are evident early in the treatment or natural history of foot and ankle fractures. Other complications do not become apparent until weeks, months, or years after the original fracture. The incidence of long-term sequelae like posttraumatic arthritis from childhood foot and ankle fractures is poorly studied because decades or lifelong follow-up has frequently not been accomplished. This article discusses a variety of complications associated with foot and ankle fractures in children or the treatment of these injuries.
Salzmann, Gian M.; Niemeyer, Philipp; Guo, Renfeng
Cytokine regulation possibly influences long term outcome following ankle fractures, but little is known about synovial fracture biochemistry. Eight patients with an ankle dislocation fracture were included in a prospective case series and matched with patients suffering from grade 2 osteochondritis dissecans (OCD) of the ankle. All fractures needed external fixation during which joint effusions were collected. Fluid analysis was done by ELISA measuring aggrecan, bFGF, IL-1β, IGF-1, and the complement components C3a, C5a, and C5b-9. The time periods between occurrence of fracture and collection of effusion were only significantly associated with synovial aggrecan and C5b-9 levels (P < 0.001). Furthermore, synovial expressions of both proteins correlated with each other (P < 0.001). Although IL-1β expression was relatively low, intra-articular levels correlated with C5a (P < 0.01) and serological C-reactive protein concentrations 2 days after surgery (P < 0.05). Joint effusions were initially dominated by neutrophils, but the portion of monocytes constantly increased reaching 50% at day 6 after fracture (P < 0.02). Whereas aggrecan and IL-1β concentrations were not different in fracture and OCD patients, bFGF, IGF-1, and all complement components were significantly higher concentrated in ankle joints with fractures (P < 0.01). Complement activation and inflammatory cell infiltration characterize the joint biology following acute ankle fractures. PMID:24967368
Giannini, Sandro; Chiarello, Eugenio; Persiani, Valentina; Luciani, Deianira; Cadossi, Matteo; Tedesco, Giuseppe
The incidence of ankle fractures (AFs) in the elderly is rising due to the increase in life expectancy. Rather than directly related to osteoporosis, AFs are a predictor of osteoporotic fractures in other sites. In women AFs are associated with weight and BMI. AFs are difficult to categorize; therapeutic options are non-operative treatment with plaster casts or surgical treatment with Kirschner's wires, plates and screws. The choice of treatment should be based not only on the fracture type but also on the local and general comorbidity of the patient. Considering the new evidence that postmenopausal women with AFs have disrupted microarchitecture and decreased stiffness of the bone compared with women with no fracture history, in our opinion low-trauma AFs should be considered in a similar way to the other classical osteoporotic fractures.
Thomason, Katherine; Ramesh, Ashwanth; McGoldrick, Niall; Cove, Richard; Walsh, James C; Stephens, Michael M
Primary ankle arthrodesis used to treat a neglected open ankle fracture dislocation is a unique decision. A 63-year-old man presented to the emergency department with a 5-day-old open fracture dislocation of his right ankle. After thorough soft tissue debridement, primary arthrodesis of the tibiotalar joint was performed using initial Kirschner wire fixation and an external fixator. Definitive soft tissue coverage was later achieved using a latissimus dorsi free flap. The fusion was consolidated to salvage the limb from amputation. The use of primary arthrodesis to treat a compound ankle fracture dislocation has not been previously described. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Bjørslev, Naja; Ebskov, Lars; Lind, Marianne; Mersø, Camilla
The purpose of this study was to determine the quality and re-operation rate of the surgical treatment of ankle fractures at a large university hospital. X-rays and patient records of 137 patients surgically treated for ankle fractures were analyzed for: 1) correct classification according to Lauge-Hansen, 2) if congruity of the ankle joint was achieved, 3) selection and placement of the hardware, and 4) the surgeon's level of education. Totally 32 of 137 did not receive an optimal treatment, 11 were re-operated. There was no clear correlation between incorrect operation and the surgeon's level of education.
Kakkar, Rahul; Siddique, M S
The ankle is a highly congruent joint with a surface area of 11-13 cm(2). Total ankle replacements have been attempted since the early 1970s and design has continually evolved as the early designs were a failure. This was because the stresses involved and the mutiaxial motion of the ankle has not been understood until recently. It has been shown that the talus slides as well as rolls during the ankle arc of motion from plantarflexion to dorsiflexion. Furthermore, the articular surfaces and the calcaneofibular and tibiocalcaneal ligaments have been shown to form a four bar linkage dictating ankle motion. A new design ankle replacement has been suggested recently which allows multiaxial motion at the ankle while maintaining congruency throughout the arc of motion. The early results of this ankle replacement have been encouraging without any reported failures due to mechanical loosening.
... foot and ankle surgeons. All Fellows of the College are board certified by the American Board of Foot and Ankle Surgery. Copyright © 2017 American College of Foot and Ankle Surgeons (ACFAS), All Rights ...
Chan, Kwok Bill; Lui, Tun Hing
To report the operative findings of ankle arthroscopy during open reduction and internal fixation of acute ankle fractures. This was a retrospective review of 254 consecutive patients with acute ankle fractures who were treated with open reduction and internal fixation of the fractures, and ankle arthroscopy was performed at the same time. The accuracy of fracture reduction, the presence of syndesmosis disruption and its reduction, and the presence of ligamentous injuries and osteochondral lesions were documented. Second-look ankle arthroscopy was performed during syndesmosis screw removal 6 weeks after the key operation. There were 6 patients with Weber A, 177 patients with Weber B, 51 patients with Weber C, and 20 patients with isolated medial malleolar fractures. Syndesmosis disruption was present in 0% of patients with Weber A fracture, 52% of patients with Weber B fracture, 92% of patients with Weber C fracture, and 20% of the patients with isolated medial malleolar fracture. Three patients with Weber B and one patient with Weber C fracture have occult syndesmosis instability after screw removal. Osteochondral lesion was present in no patient with Weber A fracture, 26% of the Weber B cases, 24% of the Weber C cases, and 20% of isolated medial malleolar fracture cases. The association between the presence of deep deltoid ligament tear and syndesmosis disruption (warranting syndesmosis screw fixation) in Weber B cases was statistically significant but not in Weber C cases. There was no statistically significant association between the presence of posterior malleolar fracture and syndesmosis instability that warrant screw fixation. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. Direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, syndesmosis disruption, and associated osteochondral lesions and ligamentous injuries. Level IV, case series
Stankowski, Tomasz; Aboul-Hassan, Sleiman Sebastian; Stępiński, Piotr; Szymańska, Anna; Marczak, Jakub; Cichoń, Romuald
A 55-year-old patient was admitted to the Department of Orthopedics due to an open fracture in the right ankle joint. On the seventh day of hospitalization the patient experienced a transient ischemic attack. During the next day, dyspnea, chest pain and a 'rider' type pulmonary embolism in the pulmonary trunk occluding both pulmonary arteries and its branches were diagnosed. The patient was transferred to the Department of Cardiac Surgery. He underwent pulmonary embolectomy for massive pulmonary, right and left atrial embolism, and left ventricular embolism. ASD II was closed during this procedure. Ultrasonography with Doppler was performed 6 days after the surgery and revealed deep vein thrombosis, so the patient was transferred to the Department of Vascular Surgery for temporary inferior vena cava filter placement at the time of orthopedic surgery. The next day after implantation of the filter, the lower limb was operated on, and 14 days after orthopedic surgery, the vena cava filter was removed.
Tellisi, Nazzar; Deland, Jonathan T; Rozbruch, S Robert
With the advances in trauma care, chronic fracture dislocation of the ankle is not a condition commonly seen in modern clinical practice. When encountered, it can be difficult to preserve the ankle joint. We present a case of a 65-year-old female, with a chronic fracture dislocation of the ankle. The ankle joint was subluxated with posterior translation of the talus, displacement of the posterior malleolus fragment, and a distal fibula fracture. A minimally traumatic approach was devised to treat this complex fracture dislocation which included gradual reduction of the ankle with a Taylor spatial frame, followed by stabilization with internal fixation and removal of the frame. Bony union and restoration of the ankle joint congruency was achieved.
Suckel, Andreas; Muller, Otto; Wachter, Nikolaus; Kluba, Torsten
Ankle joint affections and injuries are common problems in sports traumatology and in the daily routine of arthroscopic surgeons. However, there is little knowledge regarding intraarticular loads. Pressures on the ankle were determined in a dynamic model on 8 cadaver specimens, applying forces to tendons of the foot over the stance phase under vertical loading. A characteristic course of loading in the tibiotalar joint with a rapid increase upon heel contact was observed. It increased gradually to reach a maximum after 70% of the stance phase, during the push-off phase. The major torque in the ankle joint is located anterolaterally. A dynamic loading curve of the ankle joint can be demonstrated. These observations explain phenomena such as the appearance of osteophytes on the anterior tibia in the case of ankle osteoarthritis and the relatively low incidence of posterior tibial edge fragments in the case of trimalleolar ankle fracture. Furthermore, the medial side of the talus is less loaded compared to the lateral side, which appears relevant to the treatment of osteochondrosis dissecans.
Greaser, Michael C
The incidence of stress fractures in the general athletic population is less than 1%, but may be as high as 15% in runners. Stress fractures of the foot and ankle account for almost half of bone stress injuries in athletes. These injuries occur because of repetitive submaximal stresses on the bone resulting in microfractures, which may coalesce to form complete fractures. Advanced imaging such as MRI and triple-phase bone scans is used to evaluate patients with suspected stress fracture. Low-risk stress fractures are typically treated with rest and protected weight bearing. High-stress fractures more often require surgical treatment. Copyright © 2016 Elsevier Inc. All rights reserved.
Koczy, Bogdan; Pyda, Michał; Stołtny, Tomasz; Mielnik, Michał; Pajak, Jan; Hermanson, Jacek; Pasek, Jarosław; Widuchowski, Jerzy
Anterolateral soft tissue impingement of the ankle joint is a common consequence of ankle sprain due to excessive supination and adduction of the foot, injuries to the tibiofibular syndesmosis and lateral malleolus fractures. Twenty-two arthroscopic procedures to treat anterolateral soft tissue impingement of the ankle joint were performed at the Independent Public Regional Hospital of Trauma Surgery in Piekary Slaskie between 2006 and 2007. The study group included male patients at the mean age of 34 (17 to 55) years. Medical histories revealed ankle sprain in 13 patients, lateral malleolus fracture in 7, and isolated tibiofibular syndesmotic disruption in 2. The mean time from the injury to the arthroscopic treatment was 5 years (range 2 to 8 years). All patients that underwent arthroscopy were evaluated according to the AOFAS score at baseline (before surgery), and at 3 and 12 months after the treatment. The procedure consisted in the removal of hypertrophic, inflamed and scarred soft tissue from the lateral recess. The mean preoperative AOFAS score was 75.4 points. Post-operatively, the AOFAS functional scores increased to 90.6 and 92 points in the third and twelfth month after the procedure respectively. One patient showed temporary neurapraxia of the dorsal intermediate nerve and the ramus cutaneus branch of the superficial peroneal nerve. These results show that arthroscopic treatment of anterolateral soft tissue impingement of the ankle joint produces satisfactory early outcomes.
Ellitsgaard, N; Warburg, F
The parachutist injured in a dramatic accident often describes the injury in an incomplete and biased way and evaluation of materials based solely upon subjective information of this kind can be misleading and of no value for recommendations. As the relation between the mechanical factors of the injury and the lesion in ankle fractures is well documented, an investigation of clinical, radiological and operative findings in 46 parachutists with ankle fractures was conducted. Classification was possible in 44 of 46 fractures. The description of the cause of the trauma in 21 supination-eversion fractures and in 13 pronation-eversion fractures was most frequently faulty landing position or obstacles. The cause of seven supination fractures was oscillation of the parachutist whilst descending with sudden impact against the lateral aspect of the foot. For prophylaxis we recommend improvement of landing and steering techniques and the support of semi-calf boots. PMID:2730996
Jung, Hong-Geun; Kim, Jin-Il; Park, Jae-Yong; Park, Jong-Tae; Eom, Joon-Sang; Lee, Dong-Oh
The indications and clinical necessity for routine hardware removal after treating ankle or distal tibia fracture with open reduction and internal fixation are disputed even when hardware-related pain is insignificant. Thus, we determined the clinical effects of routine hardware removal irrespective of the degree of hardware-related pain, especially in the perspective of patients' daily activities. This study was conducted on 80 consecutive cases (78 patients) treated by surgery and hardware removal after bony union. There were 56 ankle and 24 distal tibia fractures. The hardware-related pain, ankle joint stiffness, discomfort on ambulation, and patient satisfaction were evaluated before and at least 6 months after hardware removal. Pain score before hardware removal was 3.4 (range 0 to 6) and decreased to 1.3 (range 0 to 6) after removal. 58 (72.5%) patients experienced improved ankle stiffness and 65 (81.3%) less discomfort while walking on uneven ground and 63 (80.8%) patients were satisfied with hardware removal. These results suggest that routine hardware removal after ankle or distal tibia fracture could ameliorate hardware-related pain and improves daily activities and patient satisfaction even when the hardware-related pain is minimal.
Jung, Hong-Geun; Kim, Jin-Il; Park, Jae-Yong; Park, Jong-Tae; Eom, Joon-Sang
The indications and clinical necessity for routine hardware removal after treating ankle or distal tibia fracture with open reduction and internal fixation are disputed even when hardware-related pain is insignificant. Thus, we determined the clinical effects of routine hardware removal irrespective of the degree of hardware-related pain, especially in the perspective of patients' daily activities. This study was conducted on 80 consecutive cases (78 patients) treated by surgery and hardware removal after bony union. There were 56 ankle and 24 distal tibia fractures. The hardware-related pain, ankle joint stiffness, discomfort on ambulation, and patient satisfaction were evaluated before and at least 6 months after hardware removal. Pain score before hardware removal was 3.4 (range 0 to 6) and decreased to 1.3 (range 0 to 6) after removal. 58 (72.5%) patients experienced improved ankle stiffness and 65 (81.3%) less discomfort while walking on uneven ground and 63 (80.8%) patients were satisfied with hardware removal. These results suggest that routine hardware removal after ankle or distal tibia fracture could ameliorate hardware-related pain and improves daily activities and patient satisfaction even when the hardware-related pain is minimal. PMID:27819005
Lin, Che-Yu; Kang, Jiunn-Horng; Wang, Chung-Li; Shau, Yio-Wha
Measurement of viscosity of the ankle joint complex is a novel method to assess mechanical ankle instability. In order to further investigate the clinical significance of the method, this study intended to investigate the relationship between ankle viscosity and severity of functional ankle instability. Cross-sectional study. 15 participants with unilateral inversion ankle sprain and 15 controls were recruited. Their ankles were further classified into stable and unstable ankles. Ankle viscosity was measured by an instrumental anterior drawer test. Severity of functional ankle instability was measured by the Cumberland Ankle Instability Tool. Unstable ankles were compared with stable ankles. Injured ankles were compared with uninjured ankles of both groups. The spearman's rank correlation coefficient was applied to determine the relationship between ankle viscosity and severity of functional ankle instability in unstable ankles. There was a moderate relationship between ankle viscosity and severity of functional ankle instability (r=-0.64, p<0.0001). Unstable ankles exhibited significantly lower viscosity (p<0.005) and more severe functional ankle instability (p<0.0001) than stable ankles. Injured ankles exhibited significantly lower viscosity and more severe functional ankle instability than uninjured ankles (p<0.0001). There was a moderate relationship between ankle viscosity and severity of functional ankle instability. This finding suggested that, severity of functional ankle instability may be partially attributed to mechanical insufficiencies such as the degenerative changes in ankle viscosity following the inversion ankle sprain. In clinical application, measurement of ankle viscosity could be a useful tool to evaluate severity of chronic ankle instability. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Rand, T; Trattnig, S; Breitenseher, M; Kreuzer, S; Wagesreither, S; Imhof, H
The etiology of chronic diseases of the ankle joint comprises a wide spectrum including chronic inflammatory processes and chronic degenerative, tumorous and neuropathic processes, as well as some specific syndromes based on chronic changes of the ankle joint. Of the inflammatory processes, chronic juvenile arthritis (JVC) is the most common disease. However, also Reiter disease, psoriasis or chronic monoarthritid diseases such as gout, as well as granulomatous diseases (tuberculosis, sarcoidosis) and fungal infections, may affect the ankle joint in a chronic course. Chronic degenerative changes are usually secondary due to abnormal positioning of the joint constituents or repetitive trauma. Neuropathic changes, as frequently seen in the course of diabetes, present with massive osseous destruction and malposition of the articular constituents. Chronic osseous as well as cartilaginous and synovial changes are seen in hemophilic patients. Chronic traumatic changes are represented by pigmented villonodular synovitis (PVNS), and chondromatosis, both with a predilection for the ankle joint. Due to the possibilities of magnetic resonance imaging (MRI), diagnosis of chronic ankle changes includes chronic ligamentous, tendinous and soft tissue changes. With the use of MRI, specific syndromes can be defined which particularly affect the ankle joint in a chronic way, such as the os trigonum syndrome, the anterolateral impingement syndrome and the sinus tarsi syndrome. Nevertheless, plain film radiographs are still the basic element of any investigation. MRI, however, can be potentially used as a second investigation, saving an unnecessary cascade of investigations with ultrasound and CT. The latter investigations are used only with very specific indications, for instance CT for subtle bone structures and sonography for a limited investigation of tendons or evaluation of fluid. Particularly due to the possibilities of MRI and the development of special gradient-echo imaging
Harrasser, N; Eichelberg, K; Pohlig, F; Waizy, H; Toepfer, A; von Eisenhart-Rothe, R
Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.
Shimamura, Yoshio; Kaneko, Kazuo; Kume, Kazuhiko; Maeda, Mutsuhiro; Iwase, Hideaki
Previous studies have demonstrated the safe passive range of ankle motion for inter-bone stiffness after internal fixation under load but there is a lack of information about the safe range of ankle motion for early rehabilitation in the absence of loading. The present study was designed to assess the effect of ankle movement on inter-bone displacement characteristics of medial malleolus fractures following three types of internal fixation to determine the safe range of motion. Five lower legs obtained during autopsy were used to assess three types of internal fixation (two with Kirschner-wires alone; two with Kirschner-wires plus tension band wiring; and, one with an AO/ASIF malleolar screw alone). Following a simulated fracture by sawing through the medial malleolus the displacement between the fractured bone ends was measured during a passive range of movement with continuous monitoring using omega (Omega) shaped transducers and a biaxial flexible goniometer. Statistical analysis was performed with repeated measures analysis of variance. Inter-bone displacement was not proportional to the magnitude of movement throughout the range of ankle motion as, when separation exceeded 25 microm, there was increasingly wide separation as plantar-flexion or dorsal-flexion was increased. There was no statistical significant difference between the small amount of inter-bone displacement observed with three types of fixation within the safe range of dorsal-flexion and plantar-flexion for early rehabilitation. However the inter-bone separation when fixation utilized two Kirschner-wires alone tended to be greater than when using the other two types of fixation during dorsal-flexion and eversion. The present study revealed a reproducible range of ankle motion for early rehabilitation which was estimated to be within the range of 20 degrees of dorsal-flexion and 10 degrees of plantar-flexion without eversion. Also, internal fixation with two Kirschner-wires alone does not seem to
Uri, Ofir; Haim, Amir
Ankle joint arthritis causes functional limitation and affects the quality of life many patients. It follows traumatic injuries, inflammatory joint arthritis, primary osteoarthritis, hemochromatosis and infections. Understanding the unique anatomy and biomechanics of the ankle is important for diagnosis and treatment of ankle joint pathology. The treatment of ankle joint arthritis has advanced considerably in recent years and it is still a surgical challenge. Total ankle replacement seems to be a promising form of treatment, even though current data does not demonstrate advantages over ankle joint arthrodesis.
Brock, Amanda K; Tan, Eric W; Shafiq, Babar
Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Nester, Christopher J; Findlow, Andrew F; Bowker, Peter; Bowden, Peter D
The ankle is often considered to have little or no capacity to move in the transverse plane. This is clear in the persistent concept that it is the role of the subtalar joint to accommodate the transverse plane motion of the leg while the foot remains in a fixed transverse plane position on the floor. We present data from noninvasive in vivo study of the ankle subtalar complex during standing internal and external rotation of the leg and study of the ankle subtalar complex during walking. These data reinforce the results of cadaver study and invasive in vivo study of the ankle/subtalar complex. We suggest that the ankle is capable of considerable movement in the transverse plane (generally greater than 15 degrees) and that its role in the mechanism that allows the foot to remain in a fixed transverse plane position on the floor while the leg rotates in the transverse plane, is not simply the transfer of the transverse plane moment to the subtalar joint, but is accommodation of some of the necessary movement.
Vannini, Francesca; Buda, Roberto; Ruffilli, Alberto; Cavallo, Marco; Giannini, Sandro
Purpose: The aim of this systematic review is to report about the clinical use of partial and total fresh osteochondral allograft in the ankle joint. The state of the art of allografts with regard to basic science, procurement and storage methods, immunogenicity, generally accepted indications and contraindications, and the rationale of the allografting procedure have been described. Methods: All studies published in PubMed from 2000 to January 2012 addressing fresh osteochondral allograft procedures in the ankle joint were identified, including those that fulfilled the following criteria: (a) level I-IV evidence addressing the areas of interest outlined above; (b) measures of functional, clinical, or imaging outcome; and (c) outcome related to ankle cartilage lesions or ankle arthritis treated by allografts. Results: The analysis showed a progressively increasing number of articles from 2000. The number of selected articles was 14; 9 of those focused on limited dimension allografts (plugs, partial) and 5 on bipolar fresh osteochondral allografts. The evaluation of evidence level showed 14 case series and no randomized studies. Conclusions: Fresh osteochondral allografts are now a versatile and suitable option for the treatment of different degrees of osteochondral disease in the ankle joint and may even be used as total joint replacement. Fresh osteochondral allografts used for total joint replacement are still experimental and might be considered as a salvage procedure in otherwise unsolvable situations. A proper selection of the patients is therefore a key point. Moreover, the patients should be adequately informed about the possible risks, benefits, and alternatives to the allograft procedure. PMID:26069666
Bartoníček, J; Rammelt, S; Tuček, M; Naňka, O
Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.
Ross, Adrianne; Catanzariti, Alan R; Mendicino, Robert W
Management of a dislocated ankle fracture can be challenging because of instability of the ankle mortise, a compromised soft tissue envelope, and the potential neurovascular compromise. Every effort should be made to quickly and efficiently relocate the disrupted ankle joint. Within the emergency department setting, narcotics and benzodiazepines can be used to sedate the patient before attempting closed reduction. The combination of narcotics and benzodiazepines provides relief of pain and muscle guarding; however, it conveys a risk of seizure as well as respiratory arrest. An alternative to conscious sedation is the hematoma block, or an intra-articular local anesthetic injection in the ankle joint and the associated fracture hematoma. The hematoma block offers a comparable amount of analgesia to conscious sedation without the additional cardiovascular risk, hospital cost, and procedure time. Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
van den Bekerom, Michel P J; Haverkamp, Daniel; Kerkhoffs, Gino M M J; van Dijk, C Niek
Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19-80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Simondson, David; Brock, Kim; Cotton, Susan
This study aimed to determine the reliability and the smallest real difference of the Ankle Lunge test in an ankle fracture patient population. In the post immobilisation stage of ankle fracture, ankle dorsiflexion is an important measure of progress and outcome. The Ankle Lunge test measures weight bearing dorsiflexion, resulting in negative scores (knee to wall distance) and positive scores (toe to wall distance), for which the latter has proven reliability in normal subjects only. A consecutive sample of ankle fracture patients with permission to commence weight bearing, were recruited to the study. Three measurements of the Ankle Lunge Test were performed each by two raters, one senior and one junior physiotherapist. These occurred prior to therapy sessions in the second week after plaster removal. A standardised testing station was utilised and allowed for both knee to wall distance and toe to wall distance measurement. Data was collected from 10 individuals with ankle fracture, with an average age of 36 years (SD 14.8). Seventy seven percent of observations were negative. Intra and inter-rater reliability yielded intra class correlations at or above 0.97, p < .001. There was a significant systematic bias towards improved scores during repeated measurement for one rater (p = .01). The smallest real difference was calculated as 13.8mm. The Ankle Lunge test is a practical and reliable tool for measuring weightbearing dorsiflexion post ankle fracture. Copyright © 2011 Elsevier Ltd. All rights reserved.
Warner, Stephen J; Garner, Matthew R; Schottel, Patrick C; Hinds, Richard M; Loftus, Michael L; Lorich, Dean G
Reduction and stabilization of the syndesmosis in unstable ankle fractures is important for ankle mortise congruity and restoration of normal tibiotalar contact forces. Of the syndesmotic ligaments, the posterior inferior tibiofibular ligament (PITFL) provides the most strength for maintaining syndesmotic stability, and previous work has demonstrated the significance of restoring PITFL function when it remains attached to a posterior malleolus fracture fragment. However, little is known regarding the nature of a PITFL injury in the absence of a posterior malleolus fracture. The goal of this study was to describe the PITFL injury pattern based on magnetic resonance imaging (MRI) and intraoperative observation. A prospective database of all operatively treated ankle fractures by a single surgeon was used to identify all supination-external rotation (SER) types III and IV ankle fracture patients with complete preoperative orthogonal ankle radiographs and MRI. All patients with a posterior malleolus fracture were excluded. Using a combination of preoperative imaging and intraoperative findings, we analyzed the nature of injuries to the PITFL. In total, 185 SER III and IV operatively treated ankle fractures with complete imaging were initially identified. Analysis of the preoperative imaging and operative reports revealed 34% (63/185) had a posterior malleolus fracture and were excluded. From the remaining 122 ankle fractures, the PITFL was delaminated from the posterior malleolus in 97% (119/122) of cases. A smaller proportion (3%; 3/122) had an intrasubstance PITFL rupture. Accurate and stable syndesmotic reduction is a significant component of restoring the ankle mortise after unstable ankle fractures. In our large cohort of rotationally unstable ankle fractures without posterior malleolus fractures, we found that most PITFL injuries occur as a delamination off the posterior malleolus. This predictable PITFL injury pattern may be used to guide new methods for
Hak, David J; Egol, Kenneth A; Gardner, Michael J; Haskell, Andrew
Ankle fractures are among the most common injuries managed by orthopaedic surgeons. Many ankle fractures are simple, with straightforward management leading to successful outcomes. Some fractures, however, are challenging, and debate arises regarding the best treatment to achieve an optimal outcome. Some patients have medical comorbidities that increase the risk for complications or may require modifications to standard surgical techniques and fixation methods. Several recent investigations have highlighted the pitfalls in accurately reducing syndesmotic injuries. Controversy remains regarding the number and diameter of screws, the duration of weight-bearing limitations, and the need or timing of screw removal. Open reduction may allow more accurate reduction than standard closed methods. Direct fixation of associated posterior malleolus fractures may provide improved syndesmotic stability. Posterior malleolus fractures vary in size and can be classified based on the orientation of the fracture line. As the size of the posterior malleolus fracture fragment increases, the load pattern in the ankle is altered. Direct or indirect reduction and surgical fixation may be required to prevent posterior talar subluxation and restore articular congruency. The supination-adduction fracture pattern is also important to recognize. Articular depression of the medial tibial plafond may require reduction and bone grafting. Optimal fixation requires directing screws parallel to the ankle joint or using a buttress plate. Identifying ankle fractures that may present additional treatment challenges is essential to achieving a successful outcome. A careful review of radiographs and CT scans, a thorough patient assessment, and detailed preoperative planning are needed to improve patient outcomes.
Delahunt, Eamonn; Cusack, Kim; Wilson, Laura; Doherty, Cailbhe
The objective of this study is to examine the acute effect of ankle joint mobilizations akin to those performed in everyday clinical practice on sagittal plane ankle joint kinematics during a single-leg drop landing in participants with chronic ankle instability (CAI). Fifteen participants with self-reported CAI (defined as <24 on the Cumberland Ankle Instability Tool) performed three single-leg drop landings under two different conditions: 1) premobilization and, 2) immediately, postmobilization. The mobilizations performed included Mulligan talocrural joint dorsiflexion mobilization with movement, Mulligan inferior tibiofibular joint mobilization, and Maitland anteroposterior talocrural joint mobilization. Three CODA cx1 units (Charnwood Dynamics Ltd., Leicestershire, UK) were used to provide information on ankle joint sagittal plane angular displacement. The dependent variable under investigation was the angle of ankle joint plantarflexion at the point of initial contact during the drop landing. There was a statistically significant acute decrease in the angle of ankle joint plantarflexion from premobilization (34.89° ± 4.18°) to postmobilization (31.90° ± 5.89°), t(14) = 2.62, P < 0.05 (two-tailed). The mean decrease in the angle of ankle joint plantarflexion as a result of the ankle joint mobilization was 2.98° with a 95% confidence interval ranging from 0.54 to 5.43. The eta squared statistic (0.32) indicated a large effect size. These results indicate that mobilization acted to acutely reduce the angle of ankle joint plantarflexion at initial contact during a single-leg drop landing. Mobilization applied to participants with CAI has a mechanical effect on the ankle joint, thus facilitating a more favorable positioning of the ankle joint when landing from a jump.
Ercin, Ersin; Bilgili, Mustafa Gokhan; Gamsizkan, Mehmet; Avsar, Serdar
Osteochondromas are the most common benign bone tumors. They are usually asymptomatic and found incidentally. When symptomatic, the symptoms are usually due to its location and size. Fracture of an osteochondroma presenting as posterior ankle impingement is a rare condition. We describe a 22-year-old man with solitary exostosis who presented with a posterior ankle mass and posterior ankle impingement with 2 years of follow-up. Surgical intervention was the treatment of choice in this patient, and histologic examination revealed a benign osteochondroma. Osteochondromas found in the posterior aspect of the talus can be complicated by fracture due to persistent motion of the ankle. Talar osteochondroma should be included in the differential diagnosis of posterior ankle impingement causes. Posterior talar osteochondromas, especially when a stalk is present, should be treated surgically before it is more complicated by a fracture and posterior ankle impingement.
Nakamura, Yukio; Uchiyama, Shigeharu; Kamimura, Mikio; Komatsu, Masatoshi; Ikegami, Shota; Kato, Hiroyuki
The etiology of ankle osteoarthritis (OA) is largely unknown. We analyzed 24 ankle OA of 21 patients diagnosed by plain radiographs using magnetic resonance imaging (MRI). Ankle joint pain disappeared in 22 out of 24 joints by conservative treatment. MRI bone signal changes in and around the ankle joints were observed in 22 of 24 joints. Bone signal changes along the joint line were seen in 10 of 11 joints as a Kellgren-Lawrence (KL) grade of II to IV. Such signal changes were witnessed in only 4 of 13 joints with KL grade 0 or I. In the talocrural joint, bone alterations occurred in both tibia and talus bones through the joint line in cases of KL grade III or IV, while focal bone alterations were present in the talus only in KL grade I or II cases. Sixteen of 24 joints exhibited intraosseous bone signal changes, which tended to correspond to joint pain of any ankle OA stage. Our results suggest that bone alterations around the ankle joint might be one of the etiologies of OA and associated with ankle joint pain. PMID:26776564
Large defects of the talus, i.e. due to tumors, large areas of osteolysis in total ankle replacement (TAR) and posttraumatic talus body necrosis are difficult to manage. The gold standard in these circumstances is still tibiocalcaneal arthrodesis with all the negative aspects of a completely rigid hindfoot. We started 10 years ago to replace the talus by a custom-made, all cobalt-chrome implant (laser sintering). The first patient with a giant cell tumor did very well but the following patients showed all subsidence of the metal talus into the tibia due to missing bony edges. Therefore, we constructed a custom-made talus (mirrored from the healthy side) and combined it with a well functioning total ankle prosthesis (Hintegra). So far we have implanted this custom-made implant into 3 patients: the first had a chondrosarcoma of the talus (1 year follow-up), the second had massive osteolysis/necrosis of unknown origin (6 months follow-up) and the third massive osteolysis following a correct TAR (2 months follow-up). The results are very encouraging as all of the patients are practically pain free and have a good range of movement (ROM): D-P flexion 15°-0-20° but less motion in the lower ankle joint: ROM P-S 5°-0-5°. No subsidence was detected in the tibia or the calcaneus. The custom-made talus combined with the Hintegra total ankle replacement will probably be an interesting alternative to a tibiocalcaneal arthrodesis in selected cases with massive defects of the talus.
Kołodziej, Łukasz; Boczar, Tomasz; Bohatyrewicz, Andrzej; Zietek, Paweł
Ankle fractures are among the most common musculoskeletal injures. These fractures occur with an overall age- and sex-adjusted incidence rate around 180 per 100 000 person-years. The most frequent mechanism is considered to be supination-external rotation (60 to 80% of all ankle fractures) consisting of pathologic external rotation of the foot initially placed in some degree of supination. According to Lauge-Hansen classification, ankle joint structures are damaged in a sequence where the final, stage IV injuries, represents transverse fracture of the medial malleolus or its equivalent-rupture of the deltoid ligament. The aim of this study is to compare the results of two subtypes of supination-external rotation stage IV fractures. 43 patients treated surgically in 2006 to 2007 at Authors institution because of stage IV supination-external rotation ankle fracture were submitted to retrospective analysis. There were 25 patients with bimalleolar fracture (type 1) and in 18 patients with lateral malleolar fracture with accompanying rupture of the deltoid ligament (type 2). The mean age was 46 years (from 20 to 82 years). Average follow up period was 37 months (from 24 to 46 months). For the evaluation of treatment AOFAS hind-foot score (American Orthopedic Foot and Ankle Society) was used. The mean AOFAS score scale for Type 1 fractures was 85 points and for type 2 was significantly higher and amounted to 91 points (p < 0.05). Supination-external rotation stage IV ankle fractures with medial malleolar fracture, requires the implementation of additional diagnostic and therapeutic strategies and procedures in order to improve the outcome of results.
Tan, Eric W; Sirisreetreerux, Norachart; Paez, Adrian G; Parks, Brent G; Schon, Lew C; Hasenboehler, Erik A
No consensus exists regarding the timing of weightbearing after surgical fixation of unstable traumatic ankle fractures. We evaluated fracture displacement and timing of displacement with simulated early weightbearing in a cadaveric model. Twenty-four fresh-frozen lower extremities were assigned to Group 1, bimalleolar ankle fracture (n=6); Group 2, trimalleolar ankle fracture with unfixed small posterior malleolar fracture (n=9); or Group 3, trimalleolar ankle fracture with fixed large posterior malleolar fracture (n=9) and tested with axial compressive load at 3 Hz from 0 to 1000 N for 250 000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. The average motion at all fracture sites in all groups was significantly less than 1 mm (P < .05). Group 1 displacement of the lateral and medial malleolus fracture was 0.1±0.1 mm and 0.4±0.4 mm, respectively. Group 2 displacement of the lateral, medial, and posterior malleolar fracture was 0.6±0.4 mm, 0.5±0.4 mm, and 0.5±0.6 mm, respectively. Group 3 displacement of the lateral, medial, and posterior malleolar fracture was 0.1±0.1 mm, 0.5±0.7 mm, and 0.5±0.4 mm, respectively. The majority of displacement (64.0% to 92.3%) occurred in the first 50 000 cycles. There was no correlation between fracture displacement and bone mineral density. No significant fracture displacement, no hardware failure, and no new fractures occurred in a cadaveric model of early weightbearing in unstable ankle fracture after open reduction and internal fixation. This study supports further investigation of early weightbearing postoperative protocols after fixation of unstable ankle fractures. © The Author(s) 2016.
Zhao, Yong; Wang, Gang
Ankle sprains are orthopedic clinical common disease, accounting for joint ligament sprain of the first place. If treatment is not timely or appropriate, the joint pain and instability maybe develop, and even bone arthritis maybe develop. The mechanism of injury of ankle joint, anatomical basis has been fully study at present, and the diagnostic problem is very clear. Along with the development of science and technology, biological modeling and three-dimensional finite element, three-dimensional motion capture system,digital technology study, electromyographic signal study were used for the basic research of sprain of ankle. Biomechanical and kinematic study of ankle sprain has received adequate attention, combined with the mechanism research of ankle sprain,and to explore the the biomechanics and kinematics research progress of the sprain of ankle joint.
Michael, Junitha M; Golshani, Ashkahn; Gargac, Shawn; Goswami, Tarun
Until the 1970s ankle arthrodesis was considered to be the "gold-standard" to treat arthritis. But the low fusion rate of ankle arthrodeses along with the inability to achieve normal range of motion led to the growing interest in the development of total ankle replacements. Though the short-term outcomes were good, their long-term outcomes were not as promising. To date, most models do not exactly mimic the anatomical functionality of a natural ankle joint. Therefore, research is being conducted worldwide to either enhance the existing models or develop new models while understanding the intricacies of the joint more precisely. This paper reviews the anatomical and biomechanical aspects of the ankle joint. Also, the evolution and comparison of clinical outcomes of various total ankle replacements are presented.
Walther, M; Kriegelstein, S; Altenberger, S; Volkering, C; Röser, A; Wölfel, R
Lateral ligament injuries are the most common sports injury and have a high incidence even in non-sportive activities. Although lateral ligament injuries are very common there is still a controversial debate on the best management. The diagnosis is based on clinical examination and X-ray images help to rule out fractures. Further imaging, especially magnetic resonance imaging (MRI) is used to diagnose associated injuries. According to the recommendations of the various scientific societies the primary therapy of lateral ligament injuries is conservative. Chronic ankle instability develops in 10-20 % of patients and the instability can be a result of sensomotoric deficits or insufficient healing of the lateral ligament complex. If the patient does not respond to an intensive rehabilitation program an operative reconstruction of the lateral ligaments has to be considered. Most of the procedures currently performed are anatomical reconstructions due to better long-term results compared to tenodesis procedures.
Wang, L C; Love, M B
This case report describes a patient with posteromedial dislocation of the ankle without fracture and without disruption of the tibiofibular syndesmosis. The pathogenesis of this uncommon lesion is discussed.
Marvan, J; Džupa, V; Bartoška, R; Kachlík, D; Krbec, M; Báča, V
PURPOSE OF THE STUDY The aim of the study was to assess treatment outcomes in patients undergoing K-wire transfixation of unstable ankle fractures and compare the results with those of patients in whom it was possible to perform primary one-stage osteosynthesis. MATERIAL AND METHODS Between 2009 and 2012, a total of 358 patients (191 women and 167 men) had surgery for unstable ankle fracture. At 1-year follow-up, their subjective feelings, objective findings and ankle radiographs were evaluated. The fractures were categorised according to the Weber classification. A patient group treated by one-stage osteosynthesis, a group with definitive transfixation and a group of patients in whom temporary transfixation was converted to definitive osteosynthesis were assessed and compared. RESULTS The group treated by one-stage osteosynthesis included 278 patients with an average age of 47 years; the group of 20 patients with definitive transfixation had an average age of 67 years, and the group of 60 patients who had temporary transfixation with subsequent conversion to internal osteosynthesis were 55 years on average. In the group with one-stage osteosynthesis, 223 (80%) ankle fractures on post-injury radiographs were associated with minor joint dislocations and 55 (20%) with major dislocations. On the other hand, the radiographs of the patients treated by temporary transfixation and delayed open reduction with internal fixation showed major dislocations in 38 (63%) and minor dislocations in the rest of the patients (37%); the difference between the two groups was statistically significant (p<0.001). Posterior malleolar fractures were most frequent in the group with temporary transfixation (60%) and least frequent in the group with primary osteosynthesis (44%); also this difference was statistically significant (p=0.032). At one-year follow-up, in the group with one-stage osteosynthesis, 220 patients (79%) had no radiographic signs of posttraumatic ankle osteoarthritis while
Adams, Samuel B; Setton, Lori A; Bell, Richard D; Easley, Mark E; Huebner, Janet L; Stabler, Thomas; Kraus, Virginia B; Leimer, Elizabeth M; Olson, Steven A; Nettles, Dana L
Posttraumatic osteoarthritis (PTOA) can occur after intra-articular fracture despite anatomic fracture reduction. It has been hypothesized that an early inflammatory response after intra-articular injury could lead to irreversible cartilage damage that progresses to PTOA. Therefore, in addition to meticulous fracture reduction, it would be ideal to prevent this initial inflammatory response but little is known about the composition of the synovial environment after intra-articular fracture. The purpose of this work was to characterize the inflammatory cytokine and matrix metalloproteinase (MMP) composition in the synovial fluid (SF) of patients with acute intra-articular ankle fractures. Twenty-one patients with an intra-articular ankle fracture were included in this study. All patients had a contralateral ankle joint that was pain free, had no radiographic evidence of arthritis, and no history of trauma. The uninjured ankle served as a matched control. SF was obtained from bilateral ankles at the time of surgery which occurred at a mean of 17 days post-fracture (range 8-40). The SF was analyzed for granulocyte macrophage colony-stimulating factor (GM-CSF), interferon-gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-10, IL-12p70, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, CTXII, sGAG, and bilirubin/biliverdin (markers of hemearthrosis) using either multiplex assay or ELISA using commercially available kits. Mean concentrations of each factor were compared between SF from fractured and control ankles, and correlation analysis was done to determine potential relationships between levels of cytokines and time from fracture and age at fracture. Twelve of 18 measured factors including GM-CSF, IL-10, IL-1β, IL-6, IL-8, TNF-α, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, and bilirubin/biliverdin were found to be significantly higher in the fractured ankles. Mean concentrations of ECM degradation markers (sGAG and CTXII) were not found to
Vaudreuil, Nicholas J; Fourman, Mitchell S; Wukich, Dane K
Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population. This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months. The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures. This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations. Level III, retrospective case series.
Wang, Jia; Zhang, Yun-Tong; Zhang, Chun-Cai; Tang, Yang
To analyze causes of missed diagnosis of hiding post-malleolar fractures in treating ankle joint fractures of pronation-external rotation type according to Lauge-Hansen classification and assess its medium-term outcomes. Among 103 patients with ankle joint fracture of pronation-external rotation type treated from March 2002 to June 2010,9 patients were missed diagnosis,including 6 males and 3 females,with a mean age of 35.2 years old (ranged, 18 to 55 years old) . Four patients were diagnosed during operation, 2 patients were diagnosed 2 or 3 days after first surgery and 3 patients came from other hospital. All the patients were treated remedially with lag screws and lock plates internal fixation. After operation,ankle joint function was evaluated according to American Orthopaedic Foot and Ankle Society (AOFAS). All the 9 patients were followed up, and the duration ranged from 14 to 30 months (averaged, 17 months). No incision infection was found, and all incision healed at the first stage. At the latest follow-up, AOFAS was 83.0 +/- 4.4, the score of 4 patients diagnosed during operation was 85.0 +/- 2.9, and the score of 5 patients treated by secondary operation was 81.0 +/- 5.3. All the patients got fracture union observed by X-ray at a mean time of 2.2 months after operation. There were no complications such as internal fixation loosing, broken and vascular or nerve injuries. Ankle joint fracture of pronation-external rotation type may be combined with hiding post-malleolar fractures. So to patients with ankle joint fracture of pronation-external rotation type, lateral X-ray should be read carefully, and if necessary, CT or MRI examination should be performed. If adding lateral X-ray examination after reduction of exterior and interior ankle joint fixation, the missed diagnosis may be avoided.
Veen, Egbert J D; Zuurmond, Rutger G
This study investigated the effect of short term removal of syndesmotic screws on the ankle function after 6 years, as there still exists controversy on the duration of screw stabilization. Patients with an ankle fracture who received surgery between 1998 and 2004 were reviewed. One group was composed of patients with an ankle fracture needing a syndesmotic repair with screws. The second was composed of operated patients that did not need syndesmotic repair. The primary scoring used was the Olerud-Molander Ankle Score (OMAS). A total of 59 patients were studied with comparable characteristics, with no significant difference on the OMAS after 6 years between the repair group (81.9) and the non-repair group (90.4). On additional clinical scoring groups remained the same. Joint degeneration was seen in both groups (86.7% vs. 55.5%). Patients with ankle fractures using syndesmotic repair and screw removal after 8 weeks and operated patients without syndesmotic injury have comparable results after 6 years. Copyright © 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Eechaute, Christophe; Vaes, Peter; Duquet, William; Van Gheluwe, Bart
Context: Sudden ankle inversion tests have been used to investigate whether the onset of peroneal muscle activity is delayed in patients with chronically unstable ankle joints. Before interpreting test results of latency times in patients with chronic ankle instability and healthy subjects, the reliability of these measures must be first demonstrated. Objective: To investigate the test-retest reliability of variables measured during a sudden ankle inversion movement in standing subjects with healthy ankle joints. Design: Validation study. Setting: Research laboratory. Patients or Other Participants: 15 subjects with healthy ankle joints (30 ankles). Intervention(s): Subjects stood on an ankle inversion platform with both feet tightly fixed to independently moveable trapdoors. An unexpected sudden ankle inversion of 50° was imposed. Main Outcome Measure(s): We measured latency and motor response times and electromechanical delay of the peroneus longus muscle, along with the time and angular position of the first and second decelerating moments, the mean and maximum inversion speed, and the total inversion time. Correlation coefficients and standard error of measurements were calculated. Results: Intraclass correlation coefficients ranged from 0.17 for the electromechanical delay of the peroneus longus muscle (standard error of measurement = 2.7 milliseconds) to 0.89 for the maximum inversion speed (standard error of measurement = 34.8 milliseconds). Conclusions: The reliability of the latency and motor response times of the peroneus longus muscle, the time of the first and second decelerating moments, and the mean and maximum inversion speed was acceptable in subjects with healthy ankle joints and supports the investigation of the reliability of these measures in subjects with chronic ankle instability. The lower reliability of the electromechanical delay of the peroneus longus muscle and the angular positions of both decelerating moments calls the use of these
Tao, Xu; Tang, Kanglai; Zhou, Jianbo
To analyse the clinical outcomes of the Z-osteotomy of the distal fibula to correct widened mortice of the ankle after fracture. Between September 2009 and February 2011, 5 patients (5 feet) with widened ankle mortice after fracture underwent Z-osteotomy. There were 4 males and 1 female, aged from 23 to 58 years (mean, 38 years). At 3 months after operation of internal fixation when function exercises were done, patients got pains. The interval between trauma and operation ranged from 5 to 36 months (mean, 13.2 months). Lateral pressure test showed positive in 2 cases and negative in 3 cases. American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 50.2 +/- 17.3. Primary healing of incision was achieved in all cases. Five patients were followed up 9 to 24 months (mean, 15.6 months). Mild to moderate swelling of the affected limb and anterolateral skin numbness of the ipsilateral dorsal foot occurred, and gradually improved. The clinical exam and radiology showed bone union at 12-15 weeks (mean, 13.5 weeks). Postoperative range of motion of ankle had no significant improvement. AOFAS ankle-hindfoot scores were 76.8 +/- 11.2 at 6 months after operation, and 85.4 +/- 3.2 at last follow-up, showing significant differences when compared with preoperative score (P < 0.05). Shortened fibula is the main cause of widened ankle mortice after fracture; Z-osteotomy can effectively reduce the width of the ankle mortice, increase the stability of ankle joint, and decrease the complication rate.
Kobayashi, Takumi; Suzuki, Eiichi; Yamazaki, Naohito; Suzukawa, Makoto; Akaike, Atsushi; Shimizu, Kuniaki; Gamada, Kazuyoshi
Functional ankle instability (FAI) may involve abnormal kinematics and contact mechanics during ankle internal rotation. Understanding of these abnormalities is important to prevent secondary problems in patients with FAI. However, there are no in vivo studies that have investigated talocrural joint contact mechanics during weightbearing ankle internal rotation. The objective of this study to determine talocrural contact mechanics during weightbearing ankle internal rotation in patients with FAI. Twelve male subjects with unilateral FAI (age range, 18-26 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities were obtained during weightbearing passive ankle joint complex rotation. Three-dimensional bone models created from the computed tomographic images were matched to the fluoroscopic images to compute 6 degrees of freedom for talocrural joint kinematics. The closest contact area in the talocrural joint in ankle neutral rotation and maximum internal rotation during either dorsiflexion or plantar flexion was determined using geometric bone models and talocrural joint kinematics data. The closest contact area in the talus shifted anteromedially during ankle dorsiflexion-internal rotation, whereas it shifted posteromedially during ankle plantar flexion-internal rotation. The closest contact area in FAI joints was significantly more medial than that in healthy joints during maximum ankle internal rotation and was associated with excessive talocrural internal rotation or inversion. This study demonstrated abnormal talocrural kinematics and contact mechanics in FAI subjects. Such abnormal kinematics may contribute to abnormal contact mechanics and may increase cartilage stress in FAI joints. Therapeutic, Level IV: cross-sectional case-control study. © 2015 The Author(s).
Leimer, Elizabeth M; Pappan, Kirk L; Nettles, Dana L; Bell, Richard D; Easley, Mark E; Olson, Steven A; Setton, Lori A; Adams, Samuel B
This study characterizes the metabolic profile of synovial fluid after intra-articular ankle fracture with an emphasis on changes in the lipid profile. Bilateral ankle synovial fluid from 19 patients with unilateral intra-articular ankle fracture was submitted for metabolic profiling. Contralateral ankle synovial fluid from each patient served as a matched control. Seven patients participated in a second bilateral synovial fluid collection after 6 months. Random forest classification, matched pairs t-tests (α < 0.01), repeated measures ANOVA with post-test contrasts (α < 0.01), correlation to cytokines and matrix metalloproteinases, and fracture and injury classification analyses yielded key lipid biomarkers in synovial fluid following intra-articular fracture. Free fatty acids, sphingomyelins, and lysolipids demonstrated significant elevation in fractured ankles at baseline. Fatty acids and sphingomyelins showed a significant decrease 6 months post-surgery. Random forest analysis showed predominantly fatty acids differentiating between groups. Significant correlations included fatty acids, sphingomyelins, and lysolipids with inflammatory cytokines and matrix metalloproteinases. Fracture classification showed increased fatty acids, lysolipids, and inositol metabolites as fracture severity increased. Fatty acid and sn-1 lysolipid elevation could be detrimental to the joint, as these strongly correlated with matrix metalloproteinases and TNF-α. This elevation also suggests involvement of phospholipase A2 , a potential target for therapeutic intervention. Together with elevated 2-hydroxyl fatty acids, these findings suggest elevated sn-1 lysolipids, sphingomyelins, and subsequent lipid metabolites in synovial fluid as biomarkers of ankle injury. Reversal of this signature after 6 months suggests temporary involvement of these metabolites in disease progression, although they may activate signaling pathways which drive progression to osteoarthritis. © 2016
Kim, Hak Jun; Yeo, Eui Dong; Rhyu, Im Joo; Lee, Soon-Hyuck; Lee, Yeon Soo; Lee, Young Koo
Malalignment of the ankle joint has been found after trauma, by neurological disorders, genetic predisposition and other unidentified factors, and results in asymmetrical joint loading. For a medial open wedge supramalleolar osteotomy(SMO), there are some debates as to whether concurrent fibular osteotomy should be performed. We assessed the changes in motion of ankle joint and plantar pressure after supramalleolar osteotomy without fibular osteotomy. Ten lower leg specimens below the knee were prepared from fresh-frozen human cadavers. They were harvested from five males (10 ankles)whose average age was 70 years. We assessed the motion of ankle joint as well as plantar pressure for SS(supra-syndesmotic) SMO and IS(intra-syndesmotic) SMO. After the osteotomy, each specimen was subjected to axial compression from 20 N preload to 350 N representing half-body weight. For the measurement of the motion of ankle joint, the changes in gap and point, angles in ankle joint were measured. The plantar pressure were also recorded using TekScan sensors. The changes in the various gap, point, and angles movements on SS-SMO and IS-SMO showed no statistically significant differences between the two groups. Regarding the shift of plantar center of force (COF) were noted in the anterolateral direction, but not statistically significant. SS-SMO and IS-SMO with intact fibula showed similar biomechanical effect on the ankle joint. We propose that IS-SMO should be considered carefully for the treatment of osteoarthrosis when fibular osteotomy is not performed because lateral cortex fracture was less likely using the intrasyndesmosis plane because of soft tissue support.
Bible, Jesse E; Sivasubramaniam, Priya G; Jahangir, A Alex; Evans, Jason M; Mir, Hassan R
To describe and investigate the injury pattern and outcomes of high-energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries, in which the talus is axially wedged into the tibiofibular joint. Prospective Cohort Study. Level 1 trauma center. Prospective evaluation of 23 high-energy transsyndesmotic ankle fracture dislocations (OTA 44-B). Operative fixation. Radiographs, clinical examination, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, Short Musculoskeletal Function Assessment. Fracture characteristics included 52% open fractures (all medial) and syndesmotic widening of 30.7 ± 11.9 mm. The tibial plafond was involved in 11 (48%) of 23 injuries, with 5 (22%) Chaput, 5 (22%) posterior malleolar fragments, and 6 (26%) with articular impaction. A fibula fracture occurred in all but 1 patient, on average 64.2 ± 40.0 mm above the distal tip. All patients had fixation of their fibular and medial malleolar fractures, 21 of 23 patients had syndesmotic screws, and 8 of 23 had tibial plafond fixation. Anatomic alignment (within <= 2 mm) was obtained in 21 (87%) of 23 injuries. Mean follow-up was 20.6 ± 6.2 months. Sixteen (70%) of 23 patients had radiographic evidence of posttraumatic ankle arthritis. Dorsiflexion and plantarflexion at final follow-up were 6.9 ± 9.6 and 35.6 ± 12.1 degrees, respectively. Complications included a 17% infection and 17% nonunion rate. Average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 67.0 ± 26.8, whereas Short Musculoskeletal Function Assessment Dysfunction index was 32.9 ± 28.6 and Bother index 34.5 ± 29.5. Transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries, represent an exceptional pattern of high-energy fractures with significant syndesmotic disruption, potential soft tissue compromise, and possible associated plafond injuries. Careful attention to radiographic findings can identify unique fracture characteristics relative to operative
Porter, David A; May, Benjamin D; Berney, Timothy
No reports describe the outcome for distal fibula and tibia fractures in athletes, although 10 to 15% of all athletic injuries occur around the ankle joint. Forty-seven competitive or recreational athletes with ankle fractures underwent open reduction and internal fixation (ORIF). Thirty-six met the inclusion criteria, of which 27 returned for clinical and radiographic exams and also completed validated surveys and a subjective questionnaire. Nineteen of the 27 were male. The average age of all patients was 18.1 +/- 5.9 years. The final evaluations occurred 12 months to 3.7 years after surgery. Injuries occurred in 13 different sports, of which football had the most (n = 10). Bimalleolar fractures were the most prevalent (n = 10) followed by isolated lateral malleolar fractures (n = 6), syndesmosis injury (n = 4), Salter-Harris (n = 4), medial malleolar fracture (n = 2) and pilon fracture (n = 1). The patients with isolated lateral malleolar fractures returned to competition soonest (6.8 +/- 2.4 weeks) while patients with isolated medial malleolus fractures took the longest to return at a mean of 17.0 +/- 9.9 weeks. Scores for function and pain on the Lower Limb Core Module and for pain on the Foot and Ankle module were all greater than 90. Athletes who undergo ORIF followed by early motion and early weightbearing are able to return to their pre-injury level of competition within 2 to 4 months with minimal functional morbidity or pain.
Sakaki, Marcos Hideyo; Matsumura, Bruno Akio Rodrigues; Dotta, Thiago De Angelis Guerra; Pontin, Pedro Augusto; Dos Santos, Alexandre Leme Godoy; Fernandes, Tulio Diniz
To evaluate the epidemiology of ankle fractures surgically treated at the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo. Medical records of patients admitted with foot and ankle fractures between 2006 and 2011 were revised. Seventy three ankle fractures that underwent surgical treatment were identified. The parameters analyzed included age, gender, injured side, AO and Gustilo & Anderson classification, associated injuries, exposure, need to urgent treatment, time to definitive treatment and early post-operative complications. retrospective epidemiological study. Male gender was predominant among subjects and the mean age was 27.5 years old. Thirty nine fractures resulted from traffic accidents and type B fracture according to AO classification was the most common. Twenty one were open fractures and 22 patients had associated injuries. The average time to definitive treatment was 6.5 days. Early post-operative complications were found in 21.3% of patients. Ankle fractures treated in a tertiary hospital of a large city in Brazil affect young people victims of high-energy accidents and present significant rates of associated injuries and post-operative complications. Level of Evidence IV, Cases Series.
Sakaki, Marcos Hideyo; Matsumura, Bruno Akio Rodrigues; Dotta, Thiago De Angelis Guerra; Pontin, Pedro Augusto; dos Santos, Alexandre Leme Godoy; Fernandes, Tulio Diniz
OBJECTIVES: To evaluate the epidemiology of ankle fractures surgically treated at the Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo. METHODS: Medical records of patients admitted with foot and ankle fractures between 2006 and 2011 were revised. Seventy three ankle fractures that underwent surgical treatment were identified. The parameters analyzed included age, gender, injured side, AO and Gustilo & Anderson classification, associated injuries, exposure, need to urgent treatment, time to definitive treatment and early post-operative complications. Study design: retrospective epidemiological study. RESULTS: Male gender was predominant among subjects and the mean age was 27.5 years old. Thirty nine fractures resulted from traffic accidents and type B fracture according to AO classification was the most common. Twenty one were open fractures and 22 patients had associated injuries. The average time to definitive treatment was 6.5 days. Early post-operative complications were found in 21.3% of patients. CONCLUSIONS: Ankle fractures treated in a tertiary hospital of a large city in Brazil affect young people victims of high-energy accidents and present significant rates of associated injuries and post-operative complications. Level of Evidence IV, Cases Series. PMID:24868187
Hassan, Al-Husseiny Moustafa
Impingement syndromes of the ankle joint are among the most common intraarticular ankle lesions. Soft tissue impingement lesions of the ankle usually occur as a result of synovial, or capsular irritation secondary to traumatic injuries, usually ankle sprains, leading to chronic ankle pain. The aim of this prospective study was to evaluate arthroscopic debridement of an anterolateral soft tissue impingement of the ankle. During the period between October 2000 and February 2004, 23 patients with residual complaints after an ankle sprain were diagnosed as anterolateral impingement of the ankle, and were treated by arthroscopic debridement. At a minimum of 6 months follow up, patients were asked to complete an American orthopaedic foot and ankle society (AOFAS) ankle and hind foot score. The average follow-up was 25 months (range 12-38). The average pre-operative patient assessed AOFAS score was 34 (range 4-57). At the end of follow-up the mean AOFAS score was 89 (range 60-100). In terms of patient satisfaction 22 patients said they would accept the same arthroscopic procedure again for the same complaints. At the end of follow-up, 7 patients had excellent results, and 14 patients had good results while two patients had fair results. We believe that arthroscopic debridement of the anterolateral impingement soft tissues are a good, and effective method of treatment.
Warner, Stephen J; Schottel, Patrick C; Hinds, Richard M; Helfet, David L; Lorich, Dean G
Pronation external rotation (PER) ankle fractures are relatively uncommon but serious ankle injuries. Although recent studies have demonstrated good outcomes of PER IV fractures after operative treatment, the effect of dislocation on functional outcomes has not yet been evaluated. The objective of this study was to compare short-term functional outcomes in PER IV ankle fractures with and without dislocation. Our database of ankle fractures surgically treated using an anatomic fixation approach by the senior author from 2003 to 2013 was reviewed. All PER IV ankle fracture patients older than 18 years with a minimum of 12 months of follow-up, including Foot and Ankle Outcome Score (FAOS), were included for analysis. Patient demographics, injury characteristics, FAOS, ankle range of motion (ROM), and rate of postoperative complications were compared in PER IV fractures with and without dislocation. Of the 47 PER IV fractures included for analysis, 20 (43%) were fracture-dislocations and 27 (57%) had no dislocation. Mean age of the study cohort was 49 years (range, 24-91 years). The fracture-dislocation cohort demonstrated significantly poorer FAOS (symptoms, 46 vs 70, P = .002; pain, 56 vs 82, P < .001; activities of daily living, 61 vs 84, P = .002; sports, 37 vs 59, P = .036; quality of life, 25 vs 59, P < .001) than the nondislocation cohort. Articular malreduction (33% vs 14%, P = .147) was also more common in the PER IV dislocation group. Rates of syndesmotic malreduction (44% vs 48%, P = .951) were similar between PER IV fractures with and without dislocation. PER IV fracture-dislocations had higher rates of articular malreduction and demonstrated statistically poorer functional outcomes than PER IV fractures with no dislocation. Dislocation in this select subset of ankle fracture patients likely represents a higher energy injury resulting in substantial articular damage and should spur appropriate preoperative patient counseling by the orthopaedic surgeon
Background Neuropathic deformities impair foot and ankle joint mobility, often leading to abnormal stresses and impact forces. The purpose of our study was to determine differences in radiographic measures of hind foot alignment and ankle joint and subtalar joint motion in participants with and without neuropathic midfoot deformities and to determine the relationships between radiographic measures of hind foot alignment to ankle and subtalar joint motion in participants with and without neuropathic midfoot deformities. Methods Sixty participants were studied in three groups. Forty participants had diabetes mellitus (DM) and peripheral neuropathy (PN) with 20 participants having neuropathic midfoot deformity due to Charcot neuroarthropathy (CN), while 20 participants did not have deformity. Participants with diabetes and neuropathy with and without deformity were compared to 20 young control participants without DM, PN or deformity. Talar declination and calcaneal inclination angles were assessed on lateral view weight bearing radiograph. Ankle dorsiflexion, plantar flexion and subtalar inversion and eversion were assessed by goniometry. Results Talar declination angle averaged 34±9, 26±4 and 23±3 degrees in participants with deformity, without deformity and young control participants, respectively (p< 0.010). Calcaneal inclination angle averaged 11±10, 18±9 and 21±4 degrees, respectively (p< 0.010). Ankle plantar flexion motion averaged 23±11, 38±10 and 47±7 degrees (p<0.010). The association between talar declination and calcaneal inclination angles with ankle plantar flexion range of motion is strongest in participants with neuropathic midfoot deformity. Participants with talonavicular and calcaneocuboid dislocations result in the most severe restrictions in ankle joint plantar flexion and subtalar joint inversion motions. Conclusions An increasing talar declination angle and decreasing calcaneal inclination angle is associated with decreases in ankle
Sinacore, David R; Gutekunst, David J; Hastings, Mary K; Strube, Michael J; Bohnert, Kathryn L; Prior, Fred W; Johnson, Jeffrey E
Neuropathic deformities impair foot and ankle joint mobility, often leading to abnormal stresses and impact forces. The purpose of our study was to determine differences in radiographic measures of hind foot alignment and ankle joint and subtalar joint motion in participants with and without neuropathic midfoot deformities and to determine the relationships between radiographic measures of hind foot alignment to ankle and subtalar joint motion in participants with and without neuropathic midfoot deformities. Sixty participants were studied in three groups. Forty participants had diabetes mellitus (DM) and peripheral neuropathy (PN) with 20 participants having neuropathic midfoot deformity due to Charcot neuroarthropathy (CN), while 20 participants did not have deformity. Participants with diabetes and neuropathy with and without deformity were compared to 20 young control participants without DM, PN or deformity. Talar declination and calcaneal inclination angles were assessed on lateral view weight bearing radiograph. Ankle dorsiflexion, plantar flexion and subtalar inversion and eversion were assessed by goniometry. Talar declination angle averaged 34±9, 26±4 and 23±3 degrees in participants with deformity, without deformity and young control participants, respectively (p< 0.010). Calcaneal inclination angle averaged 11±10, 18±9 and 21±4 degrees, respectively (p< 0.010). Ankle plantar flexion motion averaged 23±11, 38±10 and 47±7 degrees (p<0.010). The association between talar declination and calcaneal inclination angles with ankle plantar flexion range of motion is strongest in participants with neuropathic midfoot deformity. Participants with talonavicular and calcaneocuboid dislocations result in the most severe restrictions in ankle joint plantar flexion and subtalar joint inversion motions. An increasing talar declination angle and decreasing calcaneal inclination angle is associated with decreases in ankle joint plantar flexion motion in
Beaman, Douglas N; Gellman, Richard
Posttraumatic arthritis and prolonged recovery are typical after a severely comminuted tibial pilon fracture, and ankle arthrodesis is a common salvage procedure. However, few reports discuss the option of immediate arthrodesis, which may be a potentially viable approach to accelerate overall recovery in patients with severe fracture patterns. (1) How long does it take the fracture to heal and the arthrodesis to fuse when primary ankle arthrodesis is a component of initial fracture management? (2) How do these patients fare clinically in terms of modified American Orthopaedic Foot and Ankle Society (AOFAS) scores and activity levels after this treatment? (3) Does primary ankle arthrodesis heal in an acceptable position when anterior ankle arthrodesis plates are used? During a 2-year period, we performed open fracture reduction and internal fixation in 63 patients. Eleven patients (12 ankles) with severely comminuted high-energy tibial pilon fractures were retrospectively reviewed after surgical treatment with primary ankle arthrodesis and fracture reduction. Average patient age was 58 years, and minimum followup was 6 months (average, 14 months; range, 6-22 months). Anatomically designed anterior ankle arthrodesis plates were used in 10 ankles. Ring external fixation was used in nine ankles with concomitant tibia fracture or in instances requiring additional fixation. Clinical evaluation included chart review, interview, the AOFAS ankle-hindfoot score, and radiographic evaluation. All of the ankle arthrodeses healed at an average of 4.4 months (range, 3-5 months). One patient had a nonunion at the metaphyseal fracture, which healed with revision surgery. The average AOFAS ankle-hindfoot score was 83 with 88% having an excellent or good result. Radiographic and clinical analysis confirmed a plantigrade foot without malalignment. No patients required revision surgery for malunion. Primary ankle arthrodesis combined with fracture reduction for the severely comminuted
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Ankle joint metal/polymer semi-constrained... Ankle joint metal/polymer semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer semi-constrained cemented prosthesis is a device intended to be implanted to replace an ankle...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Ankle joint metal/polymer semi-constrained... Ankle joint metal/polymer semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer semi-constrained cemented prosthesis is a device intended to be implanted to replace an ankle...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Ankle joint metal/polymer semi-constrained... Ankle joint metal/polymer semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer semi-constrained cemented prosthesis is a device intended to be implanted to replace an ankle...
Thomas, Sarina; Schnetzke, Marc; Brehler, Michael; Swartman, Benedict; Vetter, Sven; Franke, Jochen; Grützner, Paul A.; Meinzer, Hans-Peter; Nolden, Marco
Intraoperative mobile C-arm fluoroscopy is widely used for interventional verification in trauma surgery, high flexibility combined with low cost being the main advantages of the method. However, the lack of global device-to- patient orientation is challenging, when comparing the acquired data to other intrapatient datasets. In upper ankle joint fracture reduction accompanied with an unstable syndesmosis, a comparison to the unfractured contralateral site is helpful for verification of the reduction result. To reduce dose and operation time, our approach aims at the comparison of single projections of the unfractured ankle with volumetric images of the reduced fracture. For precise assessment, a pre-alignment of both datasets is a crucial step. We propose a contour extraction pipeline to estimate the joint space location for a prealignment of fluoroscopic C-arm projections containing the upper ankle joint. A quadtree-based hierarchical variance comparison extracts potential feature points and a Hough transform is applied to identify bone shaft lines together with the tibiotalar joint space. By using this information we can define the coarse orientation of the projections independent from the ankle pose during acquisition in order to align those images to the volume of the fractured ankle. The proposed method was evaluated on thirteen cadaveric datasets consisting of 100 projections each with manually adjusted image planes by three trauma surgeons. The results show that the method can be used to detect the joint space orientation. The correlation between angle deviation and anatomical projection direction gives valuable input on the acquisition direction for future clinical experiments.
The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The
Yeoh, Ching Sing; Tan, Gek Meng Jeffrey
Bosworth fracture-dislocation of the ankle is a rare injury in which the proximal fibular fragment is entrapped behind the tibia. Closed reduction is extremely difficult to achieve. Early open reduction and internal fixation enables a better outcome by minimising soft-tissue damage. We report on a 36-year-old man who underwent open reduction and internal fixation for a Bosworth fracture-dislocation of the ankle complicated by severe soft-tissue swelling and an impending risk of skin necrosis after failed closed reduction.
Bae, Ji Yong; Park, Kyung Soon; Seon, Jong Keun; Jeon, Insu
To show the causal relationship between normal walking after various lateral ankle ligament (LAL) injuries caused by acute inversion ankle sprains and alterations in ankle joint contact characteristics, finite element simulations of normal walking were carried out using an intact ankle joint model and LAL injury models. A walking experiment using a volunteer with a normal ankle joint was performed to obtain the boundary conditions for the simulations and to support the appropriateness of the simulation results. Contact pressure and strain on the talus articular cartilage and anteroposterior and mediolateral translations of the talus were calculated. Ankles with ruptured anterior talofibular ligaments (ATFLs) had a higher likelihood of experiencing increased ankle joint contact pressures, strains and translations than ATFL-deficient ankles. In particular, ankles with ruptured ATFL + calcaneofibular ligaments and all ruptured ankles had a similar likelihood as the ATFL-ruptured ankles. The push off stance phase was the most likely situation for increased ankle joint contact pressures, strains and translations in LAL-injured ankles.
Choi, Young; Kwon, Soon-Sun; Chung, Chin Youb; Park, Moon Seok; Lee, Seung Yeol; Lee, Kyoung Min
The Lauge-Hansen classification system does not provide sufficient data related to syndesmotic injuries in supination-external rotation (SER)-type ankle fractures. The aim of the present study was to investigate factors helpful for the preoperative detection of syndesmotic injuries in SER-type ankle fractures using radiographs and computed tomography (CT). A cohort of 191 consecutive patients (104 male and eighty-seven female patients with a mean age [and standard deviation] of 50.7 ± 16.4 years) with SER-type ankle fractures who had undergone operative treatment were included. Preoperative ankle radiographs and CT imaging scans were made for all patients, and clinical data, including age, sex, and mechanism of injury (high or low-energy trauma), were collected. Patients were divided into two groups: the stable syndesmotic group and the unstable syndesmotic group, with a positive intraoperative lateral stress test leading to syndesmotic screw fixation. Fracture height, fracture length, medial joint space, extent of fracture, and bone attenuation were measured on radiographs and CT images and were compared between the groups. Binary logistic regression analysis was performed to identify the factors that significantly contributed to unstable syndesmotic injuries. Receiver operating characteristic curves were calculated, and cutoff values were suggested to predict unstable syndesmotic injuries on preoperative imaging measurements. Of the 191 patents with a SER-type ankle fracture, thirty-eight (19.9%) had a concurrent unstable syndesmotic injury. Age, sex, mechanism of injury, fracture height, medial joint space, and bone attenuation were significantly different between the two groups. In the binary logistic analysis, fracture height, medial joint space, and bone attenuation were found to be significant factors contributing to unstable syndesmotic injuries. The cutoff values for predicting unstable syndesmotic injuries were a fracture height of >3 mm and a medial
Hopper, D; Whittington, D; Davies, J; Chartier, J D
The purpose of this study was to determine whether a fifteen minute ice immersion treatment influenced the normal ankle joint position sense at 40% and 80% range of inversion and to establish the length of treatment effect through monitoring the rewarming process. Forty nine healthy volunteers between the ages of 17 and 28 were tested. Subjects were screened to exclude those with a history of ankle injuries. The subject's skin temperature over antero-lateral aspect of the ankle was measured using a thermocouple device during the fifteen minutes ice intervention and thirty minutes post-intervention. Testing of ankle joint position sense using the pedal goniometer was performed before and after a clinical application of ice immersion. The testing required the subject to actively reposition their ankle at 40% and 80% of their total range of inversion. The majority of subjects experienced numbness of the foot and ankle by the fifth or sixth minute during ice immersion. One minute after immersion skin temperatures averaged 15 degrees C + 1.7 degrees C. Skin temperature was seen to rise relatively rapidly for the first ten minutes and then slowed considerably. Subjects had not returned to the pre-test skin temperatures by thirty minutes. A significant difference in ankle joint position sense (p < 0.0499) following fifteen minutes of ice immersion was found. However, the magnitude of this difference (0.5 degree) would not be deemed significant in clinical practice. The research found no significant difference in joint position sense between 40% and 80% of the range of inversion both before and after cryotherapy. These findings suggest that the clinical application of cryotherapy is not deleterious to joint position sense and assuming normal joint integrity patients may resume exercise without increased risk of injury.
Ramanujam, Crystal L; Sagray, Bryan; Zgonis, Thomas
Intraarticular fractures of the calcaneus are a common injury to the hindfoot leading to posttraumatic arthrosis of the subtalar joint. Operative treatment with reduction and internal fixation at the time of initial presentation and once the soft tissue envelope is deemed suitable has become the standard of care for the surgical management of calcaneal fractures. However, numerous complications have been associated with calcaneal fractures, most notably subtalar joint arthrosis and calcaneal malunion. The authors describe a method of a delayed subtalar joint arthrodesis, ankle joint arthrodiastasis, and talar resurfacing with positive results for the management of painful posttraumatic concomitant arthrosis of the subtalar and ankle joints. Copyright (c) 2010 Elsevier Inc. All rights reserved.
Hintermann, B; Barg, A; Knupp, M
In the last 20 years total ankle replacement has become a viable alternative to arthrodesis for end-stage osteoarthritis of the ankle. Numerous ankle prosthesis designs have appeared on the market in the past and attracted by the encouraging intermediate results reported in the literature, many surgeons have started to perform this procedure. With increased availability on the market the indications for total ankle replacement have also increased in recent years. In particular, total ankle replacement may now be considered even in younger patients. Therefore, despite progress in total ankle arthroplasty the number of failures may increase. Up to now, arthrodesis was considered to be the gold standard for salvage of failed ankle prostheses. Because of extensive bone loss on the talar side, in most instances tibiocalcaneal fusion is the only reliable solution. An alternative to such extended hindfoot fusions would be revision arthroplasty. To date, however, there are no reported results of revision arthroplasty for salvage of a failed ankle replacement.Based on our experience prosthetic components with a flat undersurface are most likely to be able to find solid support on remaining bone stock. The first 83 cases (79 patients, 46 males, 33 females, average age 58.9 years, range 30.6-80.7 years) with a average follow-up of 5.4 years (range 2-11 years) showed excellent to good results in 69 cases (83%), a satisfactory result in 12 cases (15%) and a fair result in 2 cases (2%) and 47 patients (56%) were pain free. Primary loosening was noted in three cases and of these two cases were successfully revised by another total ankle replacement and in one case with arthrodesis. Another case with hematogenous infection was also revised by arthrodesis. At the last follow-up control two components were considered to be loose and the overall loosening rate was thus 6%.This series has proven that revision arthroplasty can be a promising option for patients with failed total
Al-Ashhab, Mohamed E
Management of severely comminuted, complete articular tibial pilon fractures (Rüedi and Allgöwer type III) remains a challenge, with few treatment options providing good clinical outcomes. Twenty patients with severely comminuted tibial pilon fractures underwent primary ankle arthrodesis with a retrograde calcaneal nail and autogenous fibular bone graft. The fusion rate was 100% and the varus malunion rate was 10%. Fracture union occurred at a mean of 16 weeks (range, 13-18 weeks) postoperatively. Primary ankle arthrodesis is a successful method for treating highly comminuted tibial pilon fractures, having a low complication rate and a high satisfaction score. [Orthopedics. 2017; 40(2):e378-e381.]. Copyright 2016, SLACK Incorporated.
Barg, Alexej; Pagenstert, Geert I; Horisberger, Monika; Paul, Jochen; Gloyer, Marcel; Henninger, Heath B; Valderrabano, Victor
Patients with varus or valgus hindfoot deformities usually present with asymmetric ankle osteoarthritis. In-vitro biomechanical studies have shown that varus or valgus hindfoot deformity may lead to altered load distribution in the tibiotalar joint which may result in medial (varus) or lateral (valgus) tibiotalar joint degeneration in the short or medium term. The treatment of asymmetric ankle osteoarthritis remains challenging, because more than half of the tibiotalar joint surface is usually preserved. Therefore, joint-sacrificing procedures like total ankle replacement or ankle arthrodesis may not be the most appropriate treatment options. The shortand midterm results following realignment surgery, are very promising with substantial pain relief and functional improvement observed post-operatively. In this review article we describe the indications, surgical techniques, and results from of realignment surgery of the ankle joint in the current literature.
Leyes, Manuel; Torres, Raúl; Guillén, Pedro
This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.
Gee, Christopher W; Dahal, Luna; Rogers, Benedict A; Harry, Lorraine E
Ankle fractures in the elderly are a complex under-recognized burden which require a multidisciplinary approach to management. This article discusses the holistic approach required, including the up-to-date surgical management options and the areas for future development.
Basques, Bryce A; Miller, Christopher P; Golinvaux, Nicholas S; Bohl, Daniel D; Grauer, Jonathan N
We conducted a retrospective national-cohort study to determine the incidence of and independent risk factors for venous thromboembolic events (VTEs) after open reduction and internal fixation (ORIF) of ankle fractures. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent ORIF for ankle fracture between 2005 and 2012. VTE was defined as the occurrence of a deep vein thrombosis or a pulmonary embolism within the first 30 postoperative days. Of the 4412 ankle fracture patients who met the inclusion criteria, 33 (0.8%) had a VTE. Multivariate analysis revealed that body mass index (BMI) of 30 to 35 kg/m2 (odds ratio [OR], 4.77; 95% confidence interval [CI], 1.05-21.72; P = .044), BMI of 35 kg/m2 or higher (OR, 4.71; 95% CI, 1.03-21.68; P = .046), heart disease (OR, 3.28; 95% CI, 1.20-8.97; P = .020), and dependent functional status (OR, 2.59; 95% CI, 1.11-6.04; P = .028) were independently associated with occurrence of VTE after ankle fracture ORIF. Patients with higher BMI and patients with heart disease or dependent functional status may be considered for VTE prophylaxis.
Goulart, Megan; O'Malley, Martin J; Hodgkins, Christopher W; Charlton, Timothy P
Fractures in the dance population are common. Radiography, CT, MRI, and bone scan should be used as necessary to arrive at the correct diagnosis after meticulous physical examination. Treatment should address the fracture itself and any surrounding problems such as nutritional/hormonal issues and training/performance techniques and regimens. Compliance issues in this population are a concern, so treatment strategies should be tailored accordingly. Stress fractures in particular can present difficulties to the treating physician and may require prolonged treatment periods. This article addresses stress fractures of the fibula, calcaneus, navicular, and second metatarsal; fractures of the fifth metatarsal, sesamoids, and phalanges; and dislocation of toes.
Tang, Yang; Zhang, Chun-Cai; Zhang, Yun-Tong; Li, Shi-Huo; Zhang, Xin; Fu, Qing-ge
To evaluate the indications, surgical techniques and clinical effects of the fixation of posterior malleolus in complicated external rotation ankle fractures and illuminate the importance of anatomical reduction and rigid internal fixation of posterior malleolar fracture. From July 2007 to June 2009, 32 patients were treated with open reduction and internal fixation,involving 21 males and 11 females with an average age of 36 years old (ranged from 19 to 68 years old). According to Lauge-Hansen classification: 13 cases of pronation-external rotation type (IV), 7 and 12 cases of supination-external rotation type (III and IV). Postoperative functional exercise and regular follow-up were done and outcomes were assessed. All the patients were followed up,and the duration ranged from 7 to 20 months,with an average of 14.5 months. According to Ankle Hindfoot Clinical Rating System of the American Orthopaedic Foot & Ankle Society (AOFAS), 23 patients got an excellent result, 7 good, 2 fair, 0 poor. Anatomical reduction and rigid internal fixation of posterior malleolar fracture as well as early functional exercise have significance in restoring ankle joint function and reducing the incidence of traumatic arthritis.
Mayer, Stephanie W.; Joyner, Patrick W.; Almekinders, Louis C.; Parekh, Selene G.
Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient. PMID:25364480
Kim, Seyoung; Son, Youngsu; Choi, Sangkyu; Ham, Sangyong; Park, Cheolhoon
In this study, a passive-elastic ankle exoskeleton (PEAX) with a one-way clutch mechanism was developed and then pilot-tested with vertical jumping to determine whether the PEAX is sufficiently lightweight and comfortable to be used in further biomechanical studies. The PEAX was designed to supplement the function of the Achilles tendon and ligaments as they passively support the ankle torque with their inherent stiffness. The main frame of the PEAX consists of upper and lower parts connected to each other by tension springs (N = 3) and lubricated hinge joints. The upper part has an offset angle of 5° with respect to the vertical line when the springs are in their resting state. Each spring has a slack length of 8 cm and connects the upper part to the tailrod of the lower part in the neutral position. The tailrod freely rotates with low friction but has a limited range of motion due to the stop pin working as a one-way clutch. Because of the one-way clutch system, the tension springs store the elastic energy only due to an ankle dorsiflexion when triggered by the stop pin. This clutch mechanism also has the advantage of preventing any inconvenience during ankle plantarflexion because it does not limit the ankle joint motion during the plantarflexion phase. In pilot jumping tests, all of the subjects reported that the PEAX was comfortable for jumping due to its lightweight (approximately 1 kg) and compact (firmly integrated with shoes) design, and subjects were able to nearly reach their maximum vertical jump heights while wearing the PEAX. During the countermovement jump, elastic energy was stored during dorsiflexion by spring extension and released during plantarflexion by spring restoration, indicating that the passive spring torque (i.e., supportive torque) generated by the ankle exoskeleton partially supported the ankle joint torque throughout the process.
Berkes, Marschall B; Little, Milton T M; Lazaro, Lionel E; Pardee, Nadine C; Schottel, Patrick C; Helfet, David L; Lorich, Dean G
With regard to supination-external rotation type-IV (SER IV) ankle fractures, there is no consensus regarding which patient, injury, and treatment variables most strongly influence clinical outcome. The purpose of this investigation was to examine the impact of articular surface congruity on the functional outcomes of operatively treatment of SER IV ankle fractures. A prospectively generated database consisting of operatively treated SER IV ankle fractures was reviewed. Postoperative computed tomography (CT) scans were used to assess ankle joint congruity. Ankles were considered incongruent in the presence of >2 mm of articular step-off, intra-articular loose bodies, or an articular surface gap of >2 mm (despite an otherwise anatomic reduction) due to joint impaction and comminution. Patients with at least one year of clinical follow-up were eligible for analysis. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and ankle motion. One hundred and eight SER IV fractures met our inclusion criteria. The average duration of follow-up was twenty-one months. Seventy-two patients (67%) had a congruent ankle joint, and thirty-six (33%) had elements of articular surface incongruity on postoperative CT scanning. These two groups were similar with regard to comorbidities and injury and treatment variables. At the time of the final follow-up, the group with articular incongruity had a significantly worse FAOS with regard to symptoms (p = 0.012), pain (p = 0.004), and activities of daily living (p = 0.038). Those with articular incongruity had worse average scores in the FAOS sport domain as well. No significant differences in ankle motion were found between the two groups. In this population of patients with an operatively treated SER IV ankle fracture, the presence of postoperative articular incongruity correlated with inferior early clinical outcomes. Orthopaedic surgeons should scrutinize ankle fracture reductions and strive for
Davidovitch, Roy I; Egol, Kenneth A
Ankle stability in ankle fractures is dependent on multiple factors. The medial malleolus and the associated deltoid ligament provide for ankle stability on the medial side. Over the years, the relative importance of this medial malleolar osteoligamentous complex (MMOLC) has been debated. This review will describe the evolution of ankle fracture surgery from the perspective of the contribution of the MMOLC to re-establishing ankle stability. Also discussed are the surgical and nonsurgical treatment options, various presentations of medial sided injuries in ankle fractures, and, finally, current recommendations for fixation.
Ju, Sung-Bum; Park, Gi Duck
[Purpose] This study was conducted to investigate the effects of ankle functional rehabilitation exercise on ankle joint functional movement screen results and isokinetic muscular function in patients with chronic ankle sprain patients. [Subjects and Methods] In this study, 16 patients with chronic ankle sprain were randomized to an ankle functional rehabilitation exercise group (n=8) and a control group (n=8). The ankle functional rehabilitation exercise centered on a proprioceptive sense exercise program, which was applied 12 times for 2 weeks. To verify changes after the application, ankle joint functional movement screen scores and isokinetic muscular function were measured and analyzed. [Results] The ankle functional rehabilitation exercise group showed significant improvements in all items of the ankle joint functional movement screen and in isokinetic muscular function after the exercise, whereas the control group showed no difference after the application. [Conclusion] The ankle functional rehabilitation exercise program can be effectively applied in patients with chronic ankle sprain for the improvement of ankle joint functional movement screen score and isokinetic muscular function. PMID:28265157
Ju, Sung-Bum; Park, Gi Duck
[Purpose] This study was conducted to investigate the effects of ankle functional rehabilitation exercise on ankle joint functional movement screen results and isokinetic muscular function in patients with chronic ankle sprain patients. [Subjects and Methods] In this study, 16 patients with chronic ankle sprain were randomized to an ankle functional rehabilitation exercise group (n=8) and a control group (n=8). The ankle functional rehabilitation exercise centered on a proprioceptive sense exercise program, which was applied 12 times for 2 weeks. To verify changes after the application, ankle joint functional movement screen scores and isokinetic muscular function were measured and analyzed. [Results] The ankle functional rehabilitation exercise group showed significant improvements in all items of the ankle joint functional movement screen and in isokinetic muscular function after the exercise, whereas the control group showed no difference after the application. [Conclusion] The ankle functional rehabilitation exercise program can be effectively applied in patients with chronic ankle sprain for the improvement of ankle joint functional movement screen score and isokinetic muscular function.
Kempson, G E; Freeman, M A; Tuke, M A
A prothesis has been designed to replace the articulating surfaces of the human ankle joint. The prothesis is in two parts, each forming a segment of a right circular cylinder with a single axis of rotation. The concave tibial component is manufactured from ultra-high molecular weight polyethylene and the talar component is manufactured from medical grade stainless steel. It is likely, however, that the talar component will be commercially manufactured from cobalt chrome alloy (Vitallium or Vinertia). The two components are secured to the cancellous bone by polymethylmethacrylate bone cement and laboratory tests have indicated that the bond should be strong enough to withstand the loads encountered at the ankle joint in vivo. The tests have also shown that the stability and strength of the ankle are not seriously reduced by implantation of the prosthesis. Laboratory wear tests and clinical experience over the last two years encourage optimism over the long term performance of the prothesis.
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... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Ankle joint metal/polymer semi-constrained... Ankle joint metal/polymer semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer semi-constrained cemented prosthesis is a device intended to be implanted to replace an...
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Ankle joint metal/polymer non-constrained cemented... metal/polymer non-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer non... December 26, 1996 for any ankle joint metal/polymer non-constrained cemented prosthesis that was...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Ankle joint metal/composite semi-constrained... Ankle joint metal/composite semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/composite semi-constrained cemented prosthesis is a device intended to be implanted to replace...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Ankle joint metal/polymer non-constrained cemented... metal/polymer non-constrained cemented prosthesis. (a) Identification. An ankle joint metal/polymer non... December 26, 1996 for any ankle joint metal/polymer non-constrained cemented prosthesis that was in...
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Chronic ankle joint instability often necessitates operative treatment. Operative treatment methods are classified into non-anatomical tenodesis, anatomical reconstruction and direct repair. In addition to open approaches, arthroscopic techniques are increasingly becoming established. This article describes the various operative treatment procedures, their advantages and disadvantages and in particular the arthroscopic feasibility.
Michelson, J D; Varner, K E; Checcone, M
In the lateral malleolar ankle fracture without talar shift there is much uncertainty regarding the diagnosis of deltoid ligament injury severe enough to require surgical treatment. The current study evaluated the mechanical integrity of the ankle using a novel gravity-stress mortise radiographic view, which is practical for clinical use. Eight cadaveric lower extremities were tested under the following conditions: (1) intact ankle, (2) distal fibular oblique osteotomy, (3) plated fibula after osteotomy, (4) transection of the superficial deltoid with fibula osteotomized or plated, and (5) all possible combinations of deep deltoid transection with superficial deltoid transected or repaired and fibula osteotomized or plated. For each condition, a mortise radiograph was taken of the specimen while it was mounted horizontally, lateral side down. Fibular osteotomy with or without transection of the superficial deltoid did not alter the mortise radiograph appearance of the ankles. With combined deep and superficial deltoid transection and fibular osteotomy, the talus always (eight of eight specimens) showed a lateral shift of 2 mm or greater and a valgus tilt of 15 degrees or more. The gravity stress view of the ankle was found to reproducibly document destabilizing deltoid ligament damage.
An accurate clinical diagnosis of foot and ankle pain can be made by a history, physical examination and routine X-rays of the affected part. Each problem has a specific treatment; however, fractures and dislocations around the foot and ankle can be thought of in an organized fashion by proper physical examination and then the appropriate treatment. Fractures and soft tissue injuries can be treated rationally by understanding the mechanism of injury and the possibility of subsequent deformity. This article classifies specific injuries as a group and indicates a treatment program for each problem. ImagesFig. 1Fig. 2Fig. 3Fig. 4Fig. 5Fig. 6Fig. 7aFig. 7bFig. 8Fig. 9Fig. 10 PMID:21274230
Hopkins, J Ty; Hunter, Iain; McLoda, Todd
While cryotherapy has direct physiological effects on contractile tissues, the extent to which joint cooling affects the neuromuscular system is not well understood. The purpose of the study was to detect changes in ankle dynamic restraint (peroneal short latency response and muscle activity amplitude) during inversion perturbation following ankle joint cryotherapy. A 2x3 factorial design was used to compare reaction time and EMG amplitude data of treatment conditions (cryotherapy and control) across time (pre-treatment, post-treatment, and 30 min post-treatment). Thirteen healthy volunteers (age 23 ± 4 yrs, ht 1.76 ± 0.09 m, mass 78.8 ± 16.6 kg), with no history of lower extremity joint injury participated in this study. Surface EMG was collected from the peroneus longus (PL) of the dominant leg during an ankle inversion perturbation triggered while walking. Subjects walked the length of a 6.1 m runway 30 times. A trap door mechanism, inducing inversion perturbation, was released at heel contact during six randomly selected trials for each leg. Following baseline measurements, a 1.5 L bag of crushed ice was applied to the lateral ankle of subjects in the treatment group with an elastic wrap. A bag similar in weight and consistency was applied to the lateral ankle of subjects in the control group. A repeated measures ANOVA was used to compare treatment conditions across time (p < 0.05). Maximum inversion range of motion was 28.4 ± 1.8° for all subjects. No overall condition by time difference was detected (p > 0.05) for PL reaction time. Average RMS EMG, normalized to an isometric reference position, increased in the cryotherapy group at the 30 min post-treatment interval relative to the control group (p < 0.05). Joint cooling does not result in deficiencies in reaction time or immediate muscle activation following inversion perturbation compared to a control. Key PointsJoint cooling is used as a treatment intervention prior to activity. Whether ankle cooling
Maeda, Manabu; Maeda, Nana; Takaoka, Takanori; Tanaka, Yasuhito
In this series, we aimed to describe the sonographic findings of chondral avulsion fractures that develop concomitant with lateral ankle ligament injury in children. We performed stress sonography during a manual anterior drawer stress procedure of the ankle in 9 skeletally immature patients who had recently had a lateral ankle sprain. Echo videos were obtained through the course of treatment, and all videos were reviewed. We elucidated the common features of chondral avulsion fractures of the lateral ankle ligaments in the children. The features of avulsion fractures on conventional sonography included absence of a fracture with hyperechoic spots (sonographic occult fracture type), cortical discontinuity with hyperechoic spots (cortical disruption fracture type), fracture line in the cortical bone (double-line fracture type), and a step-off deformity of the cortical bone with cartilage (displaced fracture type). In contrast, the features of chondral fractures on stress sonography included abnormal motion of the chondral lesions and mobility/fluidity of hyperechoic spots along the chondral fracture site. The presence of hyperechoic spots around the chondral lesion is an important sonographic sign for diagnosing chondral fractures concomitant with ankle lateral ligament injury. Hence, we believe that stress sonography should be considered for the detection of chondral fractures concomitant with radiographically negative ankle lateral ligament injuries in skeletally immature patients with lateral ankle pain and ankle sprains, if hyperechoic spots are present in the cartilage of the distal fibula. © 2017 by the American Institute of Ultrasound in Medicine.
Jelinek, J Adam; Porter, David A
Athletes with unstable ankle injuries treated with rigid and anatomic internal fixation with concomitant repair of indicated ligaments followed by an accelerated rehabilitation program consisting of early weight bearing and near-immediate range of motion (ROM) can obtain excellent outcomes. Early ROM and weight bearing, if indicated depending on the specific injury pattern, can be effective with low morbidity. Return to sports can be expected as early as 4 weeks after rigid fixation of an isolated fibula fracture and up to 8 to 10 weeks after stabilization of a bimalleolar equivalent fracture with deltoid repair. Syndesmosis fixation can take up to 4 to 6 months before successful return to sport.
Furman, Bridgette D.; Kimmerling, Kelly A.; Zura, Robert D.; Reilly, Rachel M.; Zlowodzki, Michal P.; Huebner, Janet L.; Kraus, Virginia B.; Guilak, Farshid; Olson, Steven A.
Objective The inflammatory response following an articular fracture is thought to play a role in the development of posttraumatic arthritis (PTA) but has not been well characterized. The objective of this study was to characterize the acute inflammatory response, both locally and systemically, in joint synovium, synovial fluid (SF), and serum following articular fracture of the ankle. We hypothesized that intraarticular fracture would alter the synovial environment and lead to increased local and systemic inflammation. Methods Synovial tissue biopsy specimens, SF samples, and serum samples were collected from patients with an acute articular ankle fracture (n = 6). Additional samples (normal, ankle osteoarthritis [OA], and knee OA [n = 6 per group]) were included for comparative analyses. Synovial tissue was assessed for synovitis and macrophage count. SF and serum were assessed for cytokines (interferon-γ [IFNγ], interleukin-1β [IL-1β], IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor α) and chemokines (eotaxin, eotaxin 3, IFNγ-inducible 10-kd protein, monocyte chemotactic protein 1 [MCP-1], MCP-4, macrophage-derived chemokine, macrophage inflammatory protein 1β, and thymus and activation–regulated chemokine). Results Synovitis scores were significantly higher in ankle fracture tissue compared with normal ankle tissue (P = 0.007), and there was a trend toward an increased abundance of CD68+ macrophages in ankle fracture synovium compared with normal knee synovium (P = 0.06). The concentrations of all cytokines and chemokines were elevated in the SF of patients with ankle fracture compared with those in SF from OA patients with no history of trauma. Only the concentration of IL-6 was significantly increased in the serum of patients with ankle fracture compared with normal serum (P = 0.027). Conclusion Articular fracture of the ankle increased acute local inflammation, as indicated by increased synovitis, increased macrophage infiltration into
Ankle fractures in the osteoporotic patient are challenging injuries to manage, due to a combination of poor soft tissue, peripheral vascular disease and increased bone fragility, often resulting in more complex fracture patterns. I aim to audit current practice and introduce change by producing recommendations to help improve longer-term functional outcomes. A retrospective 3-week audit was conducted reviewing results of ankle fracture management in 50 patients aged between 50 and 80 years. Patients admitted for either manipulation under anaesthesia (MUA)/application of cast or open-reduction and internal fixation (ORIF) were considered. Medical notes, including discharge summaries, were used for data extraction. From the 50 patients included within the cohort, forty-two patients (84%) underwent surgical intervention, with eight patients (16%) managed non-operatively. Malunion (63%) and failed fracture fixation (25%) were more commonly reported in patients managed non-operatively. Surgery performed by trainee surgeons was unlikely to prolong theatre time with no statistical significance observed with the consultant led cohort (p = 0.380). However, incidence of fracture malunion and failed fixation were significantly higher following surgery without consultant supervision in the junior trainee group (p = 0.043). Poor bone quality and associated co-morbidity can present technical difficulties when managing patients surgically. However, our results have shown considerably improved anatomical reduction rates following internal fixation in eligible patients, irrespective of age or gender.
Runge, C. F.; Shupert, C. L.; Horak, F. B.; Zajac, F. E.; Peterson, B. W. (Principal Investigator)
Previous studies have identified two discrete strategies for the control of posture in the sagittal plane based on EMG activations, body kinematics, and ground reaction forces. The ankle strategy was characterized by body sway resembling a single-segment-inverted pendulum and was elicited on flat support surfaces. In contrast, the hip strategy was characterized by body sway resembling a double-segment inverted pendulum divided at the hip and was elicited on short or compliant support surfaces. However, biomechanical optimization models have suggested that hip strategy should be observed in response to fast translations on a flat surface also, provided the feet are constrained to remain in contact with the floor and the knee is constrained to remain straight. The purpose of this study was to examine the experimental evidence for hip strategy in postural responses to backward translations of a flat support surface and to determine whether analyses of joint torques would provide evidence for two separate postural strategies. Normal subjects standing on a flat support surface were translated backward with a range of velocities from fast (55 cm/s) to slow (5 cm/s). EMG activations and joint kinematics showed pattern changes consistent with previous experimental descriptions of mixed hip and ankle strategy with increasing platform velocity. Joint torque analyses revealed the addition of a hip flexor torque to the ankle plantarflexor torque during fast translations. This finding indicates the addition of hip strategy to ankle strategy to produce a continuum of postural responses. Hip torque without accompanying ankle torque (pure hip strategy) was not observed. Although postural control strategies have previously been defined by how the body moves, we conclude that joint torques, which indicate how body movements are produced, are useful in defining postural control strategies. These results also illustrate how the biomechanics of the body can transform discrete control
Runge, C. F.; Shupert, C. L.; Horak, F. B.; Zajac, F. E.; Peterson, B. W. (Principal Investigator)
Previous studies have identified two discrete strategies for the control of posture in the sagittal plane based on EMG activations, body kinematics, and ground reaction forces. The ankle strategy was characterized by body sway resembling a single-segment-inverted pendulum and was elicited on flat support surfaces. In contrast, the hip strategy was characterized by body sway resembling a double-segment inverted pendulum divided at the hip and was elicited on short or compliant support surfaces. However, biomechanical optimization models have suggested that hip strategy should be observed in response to fast translations on a flat surface also, provided the feet are constrained to remain in contact with the floor and the knee is constrained to remain straight. The purpose of this study was to examine the experimental evidence for hip strategy in postural responses to backward translations of a flat support surface and to determine whether analyses of joint torques would provide evidence for two separate postural strategies. Normal subjects standing on a flat support surface were translated backward with a range of velocities from fast (55 cm/s) to slow (5 cm/s). EMG activations and joint kinematics showed pattern changes consistent with previous experimental descriptions of mixed hip and ankle strategy with increasing platform velocity. Joint torque analyses revealed the addition of a hip flexor torque to the ankle plantarflexor torque during fast translations. This finding indicates the addition of hip strategy to ankle strategy to produce a continuum of postural responses. Hip torque without accompanying ankle torque (pure hip strategy) was not observed. Although postural control strategies have previously been defined by how the body moves, we conclude that joint torques, which indicate how body movements are produced, are useful in defining postural control strategies. These results also illustrate how the biomechanics of the body can transform discrete control
Chen, Chuan-Mu; Su, Alvin W; Chiu, Fang-Yao; Chen, Tain-Hsiung
Managing refractory osteomyelitis around the ankle joint has been challenging. Destruction of both the ankle and the subtalar joints was common in cases of open fracture. For those who already had multiple surgeries, it would be tough to salvage the limb. Our goal was to set up a staged surgical protocol aiming in treating the aforementioned clinical issue. Twelve male patients underwent our protocol since year 2000. All patients presented refractory osteomyelitis, ankle and subtalar joint destruction, and poor soft tissue condition. All cases had internal fixation for open fractures followed by multiple debridement surgery before. The mean age was 50.8 years (range, 37-71 years), and the median follow-up time was 61 months (range, 48-96 months). The surgical protocol consisted of radical debridement, distraction osteogenesis for segmental bone transport, and tibia lengthening to avoid leg length discrepancy followed by intramedullary nailing for tibio-talo-calcaneal arthrodesis. The external fixation period averaged 24.7 weeks (range, 12-36 weeks). The mean duration to solid union of the arthrodesis and the bridging callus was 18.3 weeks (range, 16-20 weeks). Mild surgical site infection occurred in four cases but all subsided after removal of the nail and oral antibiotics use. At latest follow-up, all patients were infection free and could walk with plantigrade feet. The mean American Orthopaedic Foot and Ankle Society hindfoot score rising from 21.5 points (range 20-24 points) preoperatively to 65.5 points (range, 60-72). This study has shown our staged surgical protocol may be effective in solving complicated osteomyelitis around the ankle, although salvaging the limb with successful ankle arthrodesis and minimized limb length inequality, yet improving the patients' ambulation level.
In general, for the treatment of end-stage osteoarthritis of the ankle joint arthrodesis is considered to be the gold standard based on its versatility and eligibility for numerous indications. Nowadays, total ankle arthroplasty represents a viable alternative to ankle arthrodesis taking into account distinct premises as both procedures provide a calculable reduction of the preoperative pain level and a comparable functional gain. Furthermore, current 10-year-survival rates of total ankle replacement are reported to range between 76 % and 89 %. Revision rates of up to 10 % for both techniques have been reported with manifest differences within the respective spectrum of complications. Due to the fact that more than two thirds of patients suffer from post-traumatic osteoarthritis with a relatively low average of age concomitant malalignment, soft tissue damage or instability may frequently occur. A restoration of anatomic axes and an adequate centering of the talus under the tibia appear to be crucial for the outcome as well as an adequate soft tissue balancing, in particular in total ankle replacement. Thus, the selection of the correct indication and the right choice of treatment on the basis of complete preoperative diagnostics considering necessary additive surgical measures are of paramount importance for the final outcome.
Cong, Pei-Jun; Liu, Bai-Hong; Wang, Ji-Ping; Qiao, Yong-Ping
To explore the operative methods and curative effects of the deltoid ligament injuries. From 2002 to 2008, all 61 patients with ankle fractures complicated with deltoid ligament injuries were treated with open reduction and firm internal fixation. Among the patients, 39 patients were male and 22 patients were female, ranging in age from 14 to 71 years, with an average of 41 years. During the operation, the deltoid ligament was reconstructed to restore the medial and lateral stability of ankle joint. All the patients were followed up ranged from 5 to 30 months, with an average of 17 months. Fifty-nine patients had incision healed at the first stage; 2 patients had superficial infections at lateral malleolus, and healed at the 3rd week after changing dressings. The incisions at the internal medial malleolus were all healed at the first stage. According to Qi evaluation criteria, 35 patients got an excellent result, 13 good and 13 fair. The deltoid ligament should be treated properly in the treatment of ankle joint fractures when open reduction and firm internal fixation were emphasized.
Kynsburg, A; Pánics, G; Halasi, T
Preventive effect of proprioceptive training is proven by decreasing injury incidence, but its proprioceptive mechanism is not. Major hypothesis: the training has a positive long-term effect on ankle joint position sense in athletes of a high-risk sport (handball). Ten elite-level female handball-players represented the intervention group (training-group), 10 healthy athletes of other sports formed the control-group. Proprioceptive training was incorporated into the regular training regimen of the training-group. Ankle joint position sense function was measured with the "slope-box" test, first described by Robbins et al. Testing was performed one day before the intervention and 20 months later. Mean absolute estimate errors were processed for statistical analysis. Proprioceptive sensory function improved regarding all four directions with a high significance (p<0.0001; avg. mean estimate error improvement: 1.77 degrees). This was also highly significant (p< or =0.0002) in each single directions, with avg. mean estimate error improvement between 1.59 degrees (posterior) and 2.03 degrees (anterior). Mean absolute estimate errors at follow-up (2.24 degrees +/-0.88 degrees) were significantly lower than in uninjured controls (3.29 degrees +/-1.15 degrees) (p<0.0001). Long-term neuromuscular training has improved ankle joint position sense function in the investigated athletes. This joint position sense improvement can be one of the explanations for injury rate reduction effect of neuromuscular training.
Mäenpää, Heikki; Lehto, Matti U K; Belt, Eero A
Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.
Sculco, Peter K; Lazaro, Lionel E; Little, Milton M; Berkes, Marschall B; Warner, Stephen J; Helfet, David L; Lorich, Dean G
Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients. From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively. 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM. The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.
Tomiak, Michał; Czubak, Jarosław
Tibia ankle fractures and traumatic injuries of the ankle-tibia joint area are one of the most intractable problems in orthopedic and traumatic surgery. Because of the displacement of these fractures they require precise opening of the joint surface area to undertake the early repositioning in order to gain eficient walk. The objective of this paper was to evaluate and compare the final results of nonoperative and operative treament methods, specificlly the two most common prognosis values of tibia ankle fracture clasifications by Danis-Weber and Lauge-Hansen. This is the prognositic marking in the range of functional and radiological results dependant upon the method beeing applied. The repetetiveness and accordance of these two classifications has been evaluated as well. This research was conducted on the retrospective evalutaion based on the X-rays of 61 patients (28 women and 33 men) between the ages of 20-76 making the average age 49.5. The definition of accordance and repetitivenes was conducted by three doctors, who evaluated the x-rays from the standard fornt, back, and side projection of relaxed joint ankle.
The human ankle joint complex plays a fundamental role in gait and other activities of daily living. At the same time, it is a very complicated anatomical system but the large literature of experimental and modelling studies has not fully described the coupled joint motion, position and orientation of the joint axis of rotation, stress and strain in the ligaments and their role in guiding and stabilizing joint motion, conformity and congruence of the articular surfaces, patterns of contact at the articular surfaces, patterns of rolling and sliding at the joint surfaces, and muscle lever arm lengths. The present review article addresses these issues as described in the literature, reporting the most recent relevant findings. PMID:24499639
Rajagopalan, S; Lloyd, J; Upadhyay, Vishal; Sangar, A; Taylor, H P
Posttraumatic osteonecrosis of the distal tibia is a rare but recognized complication of Weber C ankle fractures. To our knowledge, we report the first documented case managed with early percutaneous drilling of the defect. The patient noticed an improvement in symptoms, and magnetic resonance imaging confirmed resolution of the avascular area. The previously reported complication of secondary periarticular collapse and subsequent osteoarthritis was avoided. We advocate that a high index of suspicion, early detection, and drilling can encourage neovascularisation and prevent secondary joint destruction.
Ellapparadja, Pregash; Husami, Yaya; McLeod, Ian
The posterolateral approach to ankle joint is well suited for ORIF of posterior malleolar fractures. There are no major neurovascular structures endangering this approach other than the sural nerve. The sural nerve is often used as an autologous peripheral nerve graft and provides sensation to the lateral aspect of the foot. The aim of this paper is to measure the precise distance of the sural nerve from surrounding soft tissue structures so as to enable safe placement of skin incision in posterolateral approach. This is a retrospective image review study involving 64 MRI scans. All measurements were made from Axial T1 slices. The key findings of the paper is the safety window for the sural nerve from the lateral border of tendoachilles (TA) is 7 mm, 1.3 cm and 2 cm at 3 cm above ankle joint, at the ankle joint and at the distal tip of fibula respectively. Our study demonstrates the close relationship of the nerve in relation to TA and fibula in terms of exact measurements. The safety margins established in this study should enable the surgeon in preventing endangerment of the sural nerve encountered in this approach.
Holm, Janson L; Laxson, Steven E; Schuberth, John M
Severely comminuted intra-articular calcaneal fractures often culminate in subtalar arthrosis and stiffness even after operative reduction. In some instances, subtalar arthrodesis is necessary to reduce the symptoms. Primary subtalar arthrodesis for these fractures has gained acceptance in recent years. However, few definite predictors of functional outcome after primary fusion have been found. A series of 17 patients with highly comminuted fractures were studied to determine which radiographic parameters were predictive of functional outcome. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score was obtained at an average of 34 (range 12 to 157) months after arthrodesis. Radiographic measurements included the talocalcaneal, calcaneal inclination, talo-first metatarsal, and Böhler's angles, and the height of the tibial plafond, width of the calcaneus, and the presence of a medial step-off on the injured and uninjured foot. The mean Ankle-Hindfoot scale score was 78 (range 56 to 92), and the mean visual analog score was 1.9 (0 to 4). Statistically significant associations were noted between greater postoperative function and increasing age (p = .028), the quality of restoration of Böhler's angle (p = .038), and the talocalcaneal angle (p = .049). No patient had nonunion. The results of the present study suggest that the outcomes after primary arthrodesis of the subtalar joint are favorable, in particular, when the radiographic relationships of the hindfoot have been restored. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Ackermann, Jakob; Fraser, Ethan J; Murawski, Christopher D; Desai, Payal; Vig, Khushdeep; Kennedy, John G
The purpose of this study was to report trends associated with concurrent ankle arthroscopy at the time of operative treatment of ankle fracture. The current procedural terminology (CPT) billing codes were used to search the PearlDiver Patient Record Database and identify all patients who were treated for acute ankle fracture in the United States. The Medicare Standard Analytic Files were searchable between 2005 and 2011 and the United Healthcare Orthopedic Dataset from 2007 to 2011. Annual trends were expressed only between 2007 and 2011, as it was the common time period among both databases. Demographic factors were identified for all procedures as well as the cost aspect using the Medicare data set. In total, 32 307 patients underwent open reduction internal fixation (ORIF) of an ankle fracture, of whom 313 (1.0%) had an ankle arthroscopy performed simultaneously. Of those 313 cases, 70 (22.4%) patients received microfracture treatment. Between 2005 and 2011, 85 203 patients were treated for an ankle fracture whether via ORIF or closed treatment. Of these, a total of 566 patients underwent arthroscopic treatment within 7 years. The prevalence of arthroscopy after ankle fracture decreased significantly by 45% from 2007 to 2011 (P< .0001). When ORIF and microfracture were performed concurrently, the total average charge for both procedures drops to $4253.00 and average reimbursement to $818.00 compared with approximately $4964.00 and $1069.00, respectively, when they were performed subsequently. Despite good evidence in favor of arthroscopy at the time of ankle fracture treatment, it appears that only a small proportion of surgeons in the United States perform these procedures concurrently. Therapeutic, Level IV: Retrospective. © 2015 The Author(s).
Halai, Mansur; Jamal, Bilal; Rea, Paul; Qureshi, Mobeen; Pillai, Anand
Injuries around the foot and ankle are challenging. There is a paucity of literature, outside that of specialist orthopedic journals, that focuses on this subject in the pediatric population. In this review, we outline pediatric foot and ankle fractures in an anatomically oriented manner from the current literature. Our aim is to aid the emergency department doctor to manage these challenging injuries more effectively in the acute setting. These injuries require a detailed history and examination to aid the diagnosis. Often, plain radiographs are sufficient, but more complex injuries require the use of magnetic resonance imaging. Treatment is dependent on the proximity to skeletal maturity and the degree of displacement of fracture. Children have a marked ability to remodel after fractures and therefore mainstay treatment is immobilization by a cast or splint. Operative fixation, although uncommon in this population, may be necessary with adolescents, certain unstable injuries or in cases with displaced articular surface. In the setting of severe foot trauma, skin compromise and compartment syndrome of the foot must be excluded. The integrity of the physis, articular surface and soft tissues are all equally important in treating these injuries.
Najaf-Zadeh, Abolfazl; Nectoux, Eric; Dubos, François; Happiette, Laurent; Demondion, Xavier; Gnansounou, Magloire; Herbaux, Bernard; Martinot, Alain
Background and purpose Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures. Methods We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics. Results 9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18–31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08. Interpretation A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative. PMID:24875057
Nimick, Craig J; Collman, David R; Lagaay, Pieter
Accurate reduction of the syndesmosis has been shown to be an important prognostic factor for functional outcome in ankle injuries that disrupt the syndesmosis. The purpose of the present case series was to assess the fixation orientation and the position of the fibula within the tibial incisura after open reduction and internal fixation of ankle fractures with syndesmosis injury. Computed tomography was used to assess the accuracy of the reduction. Twelve patients were included in the present case series. A ratio representing the relationship between the tibia and fibula and the orientation of the syndesmotic fixation was measured preoperatively and postoperatively and compared with the uninjured contralateral ankle, representing the patient's normal anatomy. The measurements were accomplished electronically to one tenth of 1 mm using Stentor Intelligent Informatics, I-site, version 3.3.1 (Phillips Electronics; Andover, MA). Posteriorly oriented syndesmotic fixation caused posterior translation of the fibula with respect to the tibia and anteriorly oriented syndesmotic fixation caused anterior translation. Copyright © 2013. Published by Elsevier Inc.
Thilmann, A F; Fellows, S J; Ross, H F
The resistance of the relaxed ankle to slow displacement over the joint movement range was measured on both sides of a group of hemiparetic stroke patients, in whom spasticity had been established for at least one year and who showed no clinical signs of contractures. The ankle joints of the age-matched normal subjects were flexible over most of the movement range, showing dramatically increasing stiffness only when the foot was dorsiflexed beyond 70 degrees, with a neutral range between 90-100 degrees, and a less dramatic increase in stiffness during plantarflexion. Hemiparetic patients showed identical curves to the normal subjects on the "healthy" side, ipsilateral to the causative cerebral lesion, but were significantly stiffer in dorsiflexion on the contralateral side, without change in the minimum stiffness range or during plantarflexion. Therefore significant changes in passive biomechanical properties occur at the affected ankle of hemiparetic subjects, predominantly as the result of a loss of compliance in the Achilles tendon, although an increase in the passive stiffness of the triceps surae may also occur. The contribution of these changes to the locomotor disability of hemiparetic patients is discussed. PMID:2019838
Feibel, Robert J; Uhthoff, Hans K
Ankle arthrodesis in a plantigrade position. In high-energy open injuries with segmental bone loss: proximal tibial metaphyseal corticotomy with distal Ilizarov bone transport for compensation of leg length discrepancy. Posttraumatic loss of the tibial plafond, usually resulting from open fracture type IIIC. Ipsilateral foot injuries impairing ambulation after fusion. Severe injury to the posterior tibial nerve with absent plantar sensation. Soft-tissue injury not manageable surgically. Inadequate patient compliance. Advanced age. Severe osteoporosis. Acute infection. Standard technique: anteromedial longitudinal incision. Removal of remaining articular cartilage. Passing of Ilizarov wires through the distal fibula, talar neck and body. Placement of 5-mm half-pins through stab incisions, perpendicular to the medial face of the tibial shaft. A lateral to medial 1.8-mm Ilizarov wire in the proximal tibial metaphysis is optional. Callus distraction/Ilizarov bone transport: exposure through an anteromedial incision or transverse traumatic wound. Removal of small residual segment of tibial plafond blocking transport. Retain small vascularized bone fragments not blocking transport. For Ilizarov external fixation, two rings in the proximal tibial region. Drill osteoclasis of the tibial metaphysis 1 cm distal to the tibial tuberosity and complete with Ilizarov osteotome. Secure the Ilizarov threaded rods or clickers. Weight bearing as tolerated. Begin distraction 14 days after corticotomy at a rate of 0.5-1 mm per day depending on patient's age. After docking: Ilizarov ankle arthrodesis. Between January 1993 and September 1996, four patients (two men, two women) with severe, nonreconstructable fractures of the tibial plafond were treated. Callus distraction and Ilizarov bone transport in three patients. Age range 19-68 years (average age 45.7 years). Mean follow-up 6.6 years (4 years 9 months to 7 years 4 months). Average duration of the entire treatment in external
Lundberg, A; Svensson, O K; Németh, G; Selvik, G
The axis of the talo-crural joint was analysed by roentgen stereophotogrammetry in eight healthy volunteers. Examinations were performed at 10 degrees increments of flexion and pronation/supination of the foot as well as medial and lateral rotation of the leg. Results indicate that the talo-crural joint axis changes continuously throughout the range of movement. In dorsiflexion it tended to be oblique downward and laterally. In rotation of the leg, the axis took varying inclinations between horizontal and vertical. All axes in each subject lay close to the midpoint of a line between the tips of the malleoli. Our study indicates that the talo-crural joint axis may alter considerably during the arc of motion and differ significantly between individuals. This prompts caution in the use of hinge axes in orthoses and prostheses for the ankle.
Al-Nammari, S S; Dawson-Bowling, S; Amin, A; Nielsen, D
Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices. ©2014 The British Editorial Society of Bone & Joint Surgery.
Yao, Z; Chen, X; Qiang, M
Ten Ti6Al4V joint prostheses, including 8 hips and 2 knees, were fractured after 1 to 13 years in vivo service following the primary arthroplasty. The metallographs and electronic microscopies, taken from the retrieved components, demonstrated that there are typical characteristics of stress corrosion fatigue. The excessive chemical content of raw material, the presence of interior defects, such as inclosures and porosities, incorrect design features, which violate biomechanic principles, the overheating and improper surface finishing of the parts, and the clinical varus positioning of the hip stem contribute to the device failure. Policies are proposed to overcome this problem. Among them are drawing national mandatory standards on surgical implants, taking strigent administration measures to ensure the quality of joint prostheses and the establishment of training centers for arthroplasty.
Lewis, O J
Evidence is presented to suggest that the eutherian ankle joint has been derived from a meniscus-containing joint such as that found in extant arboreal marsupials. Probable morphological derivatives of this meniscus are identifiable in the Eutheria. The form and function of the joint are described in sub-human Primates and the adaptations which characterize the joint in bipedal man are noted. These morphological findings permit some speculation about the palaeocology of the earliest mammals with particular reference to the emergence of the order Primates. PMID:7410197
Zgonis, Thomas; Stapleton, John J; Roukis, Thomas S
The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, with potentially promising long-term results.
Vanwanseele, Benedicte; Stuelcken, Max; Greene, Andrew; Smith, Richard
External ankle support has been successfully used to prevent ankle sprains. However, some recent studies have indicated that reducing ankle range of motion can place larger loads on the knee. The aim of this study was to investigate the effect of external ankle support (braces and high-top shoes) on the ankle and knee joint loading during a netball specific landing task. A repeated measure design. High performance netball players with no previously diagnosed severe ankle or knee injury (n=11) were recruited from NSW Institute of Sport netball programme. The kinematic and kinetic data were collected simultaneously using a 3-D Motion Analysis System and one Kistler force plate to measure ground reaction forces. Players performed a single leg landing whilst receiving a pass while wearing a standard netball shoe, the same shoe with a lace-up brace and a high-top shoe. Only the brace condition significantly reduced the ankle range of motion in the frontal plane (in/eversion) by 3.95 ± 3.74 degrees compared to the standard condition. No changes were found for the knee joint loading in the brace condition. The high-top shoes acted to increase the peak knee internal rotation moment by 15%. Both the brace and high-top conditions brought about increases in the peak ankle plantar flexion moment during the landing phase. Lace-up braces can be used by netball players to restrict ankle range of motion during a single leg landing while receiving a pass without increasing the load on the knee joint. Copyright © 2013 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Mehta, Saurabh Sagar; Rees, Kishan; Cutler, Lucy; Mangwani, Jitendra
Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries. PMID:25298549
Jain, Tarang Kumar; Wauneka, Clayton N.; Liu, Wen
Background Balance training has been shown to be effective in preventing ankle sprain recurrences in subjects with chronic ankle instability (CAI) but the biomechanical pathways underlying the clinical outcomes are still unknown. This study was conducted to determine if a 4-week balance training intervention can alter the mechanical characteristics in ankles with CAI. Methods Twenty-two recreationally active subjects with unilateral CAI were randomized to either a control (n = 11, 35.1 ± 9.3 years) or intervention (n = 11, 33.5 ± 6.6 years) group. Subjects in the intervention group were trained on the affected limb with static and dynamic components using a Biodex balance stability system for 4-weeks. The ankle joint stiffness and neutral zone in inversion and eversion directions on the involved and uninvolved limbs was measured at baseline and post-intervention using a dynamometer. Results At baseline, the mean values of the inversion stiffness (0.69 ± 0.37 Nm/degree) in the involved ankle was significantly lower (p < 0.011, 95% CI [0.563, 0.544]) than that of uninvolved contralateral ankle (0.99 ± 0.41 Nm/degree). With the available sample size, the eversion stiffness, inversion neutral zone, and eversion neutral zone were not found to be significantly different between the involved and uninvolved contralateral ankles. The 4-week balance training intervention failed to show any significant effect on the passive ankle stiffness and neutral zones in inversion and eversion. Conclusion Decreased inversion stiffness in the involved chronic unstable ankle was found that of uninvolved contralateral ankle. The 4-week balance training program intervention was ineffective in altering the mechanical characteristics of ankles with CAI. Level of evidence Randomized controlled clinical trial; Level of evidence, 1. PMID:27642647
Kobayashi, Takumi; Saka, Masayuki; Suzuki, Eiichi; Yamazaki, Naohito; Suzukawa, Makoto; Akaike, Atsushi; Shimizu, Kuniaki; Gamada, Kazuyoshi
Chronic ankle instability (CAI) results in abnormal ankle kinematics, but there exists limited quantitative data characterizing these alterations. This study was undertaken to investigate kinematic alterations of the talocrural and subtalar joints in CAI. A total of 14 male patients with unilateral CAI (mean age = 21.1 ± 2.5 years) were enrolled. Computed tomography and fluoroscopic imaging of both lower extremities during weightbearing passive ankle joint complex (AJC) rotation were obtained. Three-dimensional bone models created from the computed tomography images were matched with the fluoroscopic images to compute the 6 degrees-of-freedom talocrural, subtalar, and AJC kinematics. In 20° plantarflexion, ankles with CAI demonstrated significantly increased anterior translation of the talocrural joint during AJC internal rotation from 5° to 7° and significantly decreased talocrural internal rotation within an AJC arc of motion from -1° to 5°. CAI joints demonstrated significantly increased internal rotation of the subtalar joint within an AJC arc of motion from -1° to 3°. In CAI, altered subtalar internal rotation occurs with increased talocrural anterior translation and reduced talocrural internal rotation during weightbearing ankle internal rotation in plantarflexion. These results suggest that altered subtalar mechanics may contribute to CAI symptoms.
... cemented prosthesis. 888.3100 Section 888.3100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF... Ankle joint metal/composite semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/composite semi-constrained cemented prosthesis is a device intended to be implanted to replace an...
... cemented prosthesis. 888.3100 Section 888.3100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF... Ankle joint metal/composite semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/composite semi-constrained cemented prosthesis is a device intended to be implanted to replace an...
... cemented prosthesis. 888.3100 Section 888.3100 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF... Ankle joint metal/composite semi-constrained cemented prosthesis. (a) Identification. An ankle joint metal/composite semi-constrained cemented prosthesis is a device intended to be implanted to replace an...
van den Bekerom, Michel P J; Mutsaerts, Eduard L A R; van Dijk, C Niek
Review the literature concerning modalities to evaluate the integrity of the deltoid ligament in patients with supination external rotation ankle fractures. The electronic databases Pubmed/Medline, CINAHL and Embase were searched from 1987 to November 2007 to identify all published original studies concerning diagnostic modalities to evaluate the integrity of the deltoid ligament in adult ankle fractures. This review included nine studies involving 423 ankle fractures. Three trails investigated medial tenderness; two studies, ecchymosis; two studies, swelling; one study, an injury radiograph; six studies, a type of radiographic stress view; one study, the Lauge-Hansen classification; one study, MRI; and one article studied arthroscopy in the evaluation of the deltoid ligament integrity. Swelling, ecchymosis, medial tenderness, initial injury radiographs and the Lauge-Hansen classification are less adequate predictors of the integrity of the deltoid ligament. Manual or the less painful variant, the gravity external rotation stress radiographs are considered the gold standard. The amount of medial clear space widening indicative of a positive external rotation stress test has been somewhat variable in the literature but > or =5 mm is generally regarded as most reliable. Achieving adequate external rotation of the foot when obtaining stress radiographs is more important than positioning the ankle in the appropriate degree of ankle flexion. The amount of applied force necessary when performing an external rotation stress radiograph is not well defined and mainly determined by the patient's pain level. The indication for surgery should not be based on the absolute value of one parameter but on the combination of several parameters. If nonoperative treatment is chosen despite a positive stress radiograph, close follow-up is critical because subluxation of the ankle joint is still possible. MRI could be useful in individual cases.
Young, Ki-Won; Kim, Jin-Su; Cho, Hun-Ki; Choo, Ho-Sik; Park, Jang-Ho
Background The talus has a very complex anatomical morphology and is mainly fractured by a major force caused by a fall or a traffic accident. Therefore, a talus fracture is not common. However, many recent reports have shown that minor injuries, such as sprains and slips during sports activities, can induce a talar fracture especially in the lateral or posterior process. Still, fractures to the main parts of the talus (neck and body) after ankle sprains have not been reported as occult fractures. Methods Of the total 102 cases from January 2005 to December 2012, 7 patients had confirmed cases of missed/delayed diagnosis of a talus body or neck fracture and were included in the study population. If available, medical records, X-rays, computed tomography scans, and magnetic resonance imaging of the confirmed cases were retrospectively reviewed and analyzed. Results In the 7-patient population, there were 3 talar neck fractures and 4 talar body fractures (coronal shearing type). The mechanisms of injuries were all low energy trauma episodes. The causes of the injuries included twisting of the ankle during climbing (n = 2), jumping to the ground from a 1-m high wall (n = 2), and twisting of the ankle during daily activities (n = 3). Conclusions A talar body fracture and a talar neck fracture should be considered in the differential diagnosis of patients with acute and chronic ankle pain after a minor ankle injury. PMID:27583114
Moore, M. R.; Garfin, S. R.; Hargens, A. R.
A 26-year-old man presented with ipsilateral femur and ankle fractures. The patient was treated with interlocking nail of his femur fracture, followed by open reduction and internal fixation of his ankle fracture under tourniquet control. Postoperatively, the patient developed compartment syndrome of his thigh with elevated pressures, requiring decompressive fasciotomies. This case illustrates the possible complication of treating a femur fracture with intramedullary nailing and then immediately applying a tourniquet to treat an ipsilateral extremity fracture. Because of the complication with this patient, we feel the procedure should be staged, or a tourniquet should be avoided if possible.
Olsen, L L; Møller, A M; Brorson, S; Hasselager, R B; Sort, R
Lifestyle risk factors are thought to increase the risk of infection after acute orthopaedic surgery but the evidence is scarce. We aimed to investigate whether smoking, obesity and alcohol overuse are risk factors for the development of infections after surgery for a fracture of the ankle. We retrospectively reviewed all patients who underwent internal fixation of a fracture of the ankle between 2008 and 2013. The primary outcome was the rate of deep infection and the secondary outcome was any surgical site infection (SSI). Associations with the risk factors and possible confounding variables were analysed univariably and multivariably with backwards elimination. A total of 1043 patients were included; 64 (6.1%) had a deep infection and 146 (14.0%) had SSI. Obesity was strongly associated with both outcomes (odds ratio (OR) 2.21, p = 0.017 and OR 1.68, p = 0.032) in all analyses. Alcohol overuse was similarly associated, though significant only in unadjusted analyses. Surprisingly, smoking did not yield statistically significant associations with infections. These findings suggest that obesity and possibly alcohol overuse are independent risk factors for the development of infection following surgery for a fracture of the ankle. This large study brings new evidence concerning these common risk factors; although prospective studies are needed to confirm causality. Cite this article: Bone Joint J 2017;99-B:225-30. ©2017 The British Editorial Society of Bone & Joint Surgery.
Thomas, M; Jordan, M; Hamborg-Petersen, E
Ankle sprains are the most relevant injuries of the lower extremities and can lead to damage to ligaments and osteochondral lesions. Up to 50 % of patients with a sprained ankle later develop a lesion of the cartilage in the ankle joint or an osteochondral lesion of the talus. This can lead to osteoarthritis of the injured ankle joint. Spontaneous healing is possible in all age groups in cases of a bone bruise in the subchondral bone but in isolated chondral injuries is only useful in pediatric patients. In many cases chondral and osteochondral injuries lead to increasing demarcation of the affected area and can result in progressive degeneration of the joint if not recognized in time. There also exist a certain number of osteochondral changes of the articular surface of the talus without any history of relevant trauma, which are collectively grouped under the term osteochondrosis dissecans. Perfusion disorders are discussed as one of many possible causes of these alterations. Nowadays, chondral and osteochondral defects can be treated earlier due to detection using very sensitive magnetic resonance imaging (MRI) and computed tomography (CT) techniques. The use of conservative treatment only has a chance of healing in pediatric patients. Conservative measures for adults should only be considered as adjuvant treatment to surgery.Based on a comprehensive analysis of the current literature, this article gives an overview and critical analysis of the current concepts for treatment of chondral and osteochondral injuries and lesions of the talus. With arthroscopic therapy curettage and microfracture of talar lesions are the predominant approaches or retrograde drilling of the defect is another option when the chondral coating is retained. Implantation of autologous chondral cells or homologous juvenile cartilage tissue is also possible with arthroscopic techniques. Osteochondral fractures (flake fracture) are usually performed as a mini-open procedure supported by
Seo, Hyun-Do; Kim, Min-Young; Choi, Jung-Eun; Lim, Ga-Hee; Jung, Seong-In; Park, So-Hyun; Cheon, Song-Hee; Lee, Hae-Yong
[Purpose] The purpose of this study was to examine the effect of Kinesio taping on the joint position sense of the ankle. [Subjects and Methods] The subjects of this study were 26 nomal adults who had experienced ankle sprain. Kinesio taping was applied over the ankle medial ligament and ankle lateral ligament with eight pattern reinforcement taping. Joint position sense was measured using isokinetic equipment (Biodex System 4 pro dynamometer, Biodex Medical systems Inc., USA) during dorsiflexion/plantarflexion and inversion/eversion, before and after taping. Statistical analyses were performed using SPSS 21.0 for Windows. [Results] Joint position sense after Kinesio taping was improved in the dorsiflexion and inversion positions. [Conclusion] According to the results of this study, Kinesio taping of the ankle is effective for the prevention of ankle sprain. PMID:27190446
Pfeifer, Christian G; Grechenig, Stephan; Frankewycz, Borys; Ernstberger, Antonio; Nerlich, Michael; Krutsch, Werner
Fractures of the ankle, hind- and midfoot are amongst the five most common fractures. Besides initial operative or non-operative treatment, rehabilitation of the patients plays a crucial role for fracture union and long term functional outcome. Limited evidence is available with regard to what a rehabilitation regimen should include and what guidelines should be in place for the initial clinical course of these patients. This study therefore investigated the current rehabilitation concepts after fractures of the ankle, hind- and midfoot. Written rehabilitation protocols provided by orthopedic and trauma surgery institutions in terms of recommendations for weight bearing, range of motion (ROM), physiotherapy and choice of orthosis were screened and analysed. All protocols for lateral ankle fractures type AO 44A1, AO 44B1 and AO 44C1, for calcaneal fractures and fractures of the metatarsal as well as other not specific were included. Descriptive analysis was carried out and statistical analysis applied where appropriate. 209 rehabilitation protocols for ankle fractures type AO 44B1 and AO 44C1, 98 for AO 44A1, 193 for metatarsal fractures, 142 for calcaneal fractures, 107 for 5(th) metatarsal base fractures and 70 for 5(th) metatarsal Jones fractures were evaluated. The mean time recommended for orthosis treatment was 6.04 (SD 0.04) weeks. While the majority of protocols showed a trend towards increased weight bearing and increased ROM over time, the best consensus was noted for weight bearing recommendations. Our study shows that there exists a huge variability in rehabilitation of fractures of the ankle-, hind- and midfoot. This may be contributed to a lack of consensus (e.g. missing publication of guidelines), individualized patient care (e.g. in fragility fractures) or lack of specialization. This study might serve as basis for prospective randomized controlled trials in order to optimize rehabilitation for these common fractures. Copyright © 2015 Elsevier Ltd
Dekker, Travis J; Hamid, Kamran S; Easley, Mark E; DeOrio, James K; Nunley, James A; Adams, Samuel B
This study attempted to identify where motion occurs after total ankle replacement, the difference in range-of-motion contributions between fixed-bearing and mobile-bearing total ankle replacements, and the contribution of abnormal peritalar motion. We hypothesized that sagittal plane radiographic assessment would demonstrate that actual ankle motion through the prosthesis is less than the total arc of ankle motion that may be observed clinically secondary to contributions from adjacent joints. Patients underwent routine standardized weight-bearing maximum dorsiflexion and plantar flexion sagittal radiographs. Sagittal plane ankle and foot measurements were performed on each dorsiflexion and plantar flexion radiograph to determine the total arc of ankle motion, actual ankle motion through the prosthesis, motion through the subtalar and talonavicular joints, and midfoot motion. Motion radiographs were routinely made at 1 year postoperatively and at the time of the most recent follow-up. A minimum follow-up of 2 years was required of all patients. There were 197 patients who met the inclusion criteria (75 INBONE, 52 Salto Talaris, and 70 STAR prostheses). The mean time to the latest radiographs (and standard deviation) was 42.9 ± 18.8 months. The mean actual ankle motion through the prosthesis was 25.9° ± 12.2°, which was significantly less (p < 0.001) than the mean total motion arc of 37.6° ± 12.0°. The motion of the ankle accounted for 68% of total range of motion, and motion of the peritalar joints accounted for 32%. There was no significant difference (p > 0.05) among the 3 prostheses or when comparing fixed and mobile-bearing designs for both ranges of motion. This study demonstrates that actual ankle motion after total ankle replacement is approximately 12° less than the total arc of motion that might be observed clinically because of increased midfoot and subtalar motion. Therapeutic Level IV. See Instructions for Authors for a complete description of
Falsig, J; Hvid, I; Jensen, N C
A three-dimensional finite element stress analysis was employed to calculate stresses in a distal tibia modelled with three simple total ankle joint replacement tibial components. The bone was modelled as a composite structure consisting of cortical and trabecular bone in which the trabecular bone was either homogeneous with a constant modulus of elasticity or heterogenous with experimentally determined heterogeneity. The results were sensitive to variations in trabecular bone material property distributions, with lower stresses being calculated in the heterogeneous model. An anterolateral application of load, which proved the least favourable, was used in comparing the prosthetic variants. Normal and shear stresses at the trabecular bone-cement interface and supporting trabecular bone were slightly reduced by addition of metal backing to the polyethylene articular surface, and a further reduction to very low values was obtained by addition of a long intramedullary peg bypassing stresses to the cortical bone.
Background Ankle fractures are one of the more commonly occurring forms of trauma managed by orthopaedic teams worldwide. The impacts of these injuries are not restricted to pain and disability caused at the time of the incident, but may also result in long term physical, psychological, and social consequences. There are currently no ankle fracture specific patient-reported outcome measures with a robust content foundation. This investigation aimed to develop a thematic conceptual framework of life impacts following ankle fracture from the experiences of people who have suffered ankle fractures as well as the health professionals who treat them. Methods A qualitative investigation was undertaken using in-depth semi-structured interviews with people (n=12) who had previously sustained an ankle fracture (patients) and health professionals (n=6) that treat people with ankle fractures. Interviews were audio-recorded and transcribed. Each phrase was individually coded and grouped in categories and aligned under emerging themes by two independent researchers. Results Saturation occurred after 10 in-depth patient interviews. Time since injury for patients ranged from 6 weeks to more than 2 years. Experience of health professionals ranged from 1 year to 16 years working with people with ankle fractures. Health professionals included an Orthopaedic surgeon (1), physiotherapists (3), a podiatrist (1) and an occupational therapist (1). The emerging framework derived from patient data included eight themes (Physical, Psychological, Daily Living, Social, Occupational and Domestic, Financial, Aesthetic and Medication Taking). Health professional responses did not reveal any additional themes, but tended to focus on physical and occupational themes. Conclusions The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. The findings from this research have provided an empirically derived framework from which a
Starr, Adam M.; Swan, Kenneth G.; Swan, Kenneth G.
Compartment syndrome after an ankle fracture is an extremely rare and potentially devastating event. The authors report a case of an isolated anterior compartment syndrome in a college student athlete who suffered a bimalle olar ankle fracture dislocation. A review of the literature highlights the importance of vigilance when the sports medicine physician and the community orthopaedist are treating these seemingly basic orthopaedic injuries. PMID:23016060
Liu, Zhongyu; Xin, Jingyi; Liang, Jun
To explore the methods in the diagnosis and treatment of ankle fracture with Wagsaffe fragment. Among 1 201 patients, there were 18 cases of concurrent Wagstaffe fractures at our hospital between January 2009 to January 2012. There were 11 males and 7 females with an average of 37.4 (17-54) years. The causes of injuries were fall (n = 10), sports-related injury (n = 4), traffic injury (n = 3) and high-altitude fall (n = 1). All of them had lateral malleolar fracture. Other injuries included internal malleolar fracture (n = 16), posterior malleolar fracture (n = 8) and disruption of medial deltoid ligament (n = 3). According to the Lauge-Hansen system, all fractures were of supination-external rotation type. The fractures of fibula and Wagstaffe were explored through an anterolateral approach. The lateral malleolar fracture was fixed with plate While Wagstaffe fragment secured with lag screw or thread. Disrupted anterior tibiofibular ligament was restored. Other treatments included open reduction and internal fixation of medial and posterior malleolus, repair of medial deltoid ligament and screw fixation of disrupted tibiofibular syndesmosis. Ankle function was evaluated by the Baird-Jackson criteria. Wagstaffe fracture occurred at a rate of 1.5% in ankle fractures. Wagstaffe fracture was found in 4.4% of ankle fracture of supination-external rotation type. Seventeen patients were followed up over an average follow-up period of 16.8 (12-25) months. All radiographs showed union of all fractures and normal mortise. Baird-Jackson ankle functional score was from 81 to 99. In all 17 patients, 9 were rated as excellent, 5 as good and 3 as fair. The excellent and good rate was 87.4%. At the latest follow-up, 14 patients resumed their preinjury activities. As an easily misdiagnosed condition, Wagstaffe fracture is associated with ankle diastase and prone to occur in ankle fracture of supination-external rotation type. Accurate reduction and stable fixation facilitate the
Lu, Jike; Maruo Holledge, Masumi
A 59-year-old man fell off a 60-cm-high step, with his ankle in a twisted position, and sustained a closed fracture of the medial malleolus, with an ipsilateral complete Achilles tendon (TA) rupture. The TA rupture was initially missed but diagnosed by ultrasound examination, 2 weeks post-operatively. The ankle fracture was diagnosed from routine radiographs. Such a combination of injuries has been reported infrequently in the literature, but significant similarities have been described in the mechanism of injury and fracture patterns. Nevertheless, three of five reported cases with combined medial malleolus fractures were initially misdiagnosed. PMID:27141047
Aurich, Matthias; Hofmann, Gunther O; Rolauffs, Bernd
We analysed hyaline cartilage of human knee and ankle joints for collagen and proteoglycan turnover in order to find differences in the metabolism and biochemical content of the extracellular matrix that could explain the higher prevalence of osteoarthritis (OA) in the knee joint, compared to the ankle joint. Cartilage tissue from ankle and knee joints of OA patients were assessed for total collagen and proteoglycan content. For turnover, the aggrecan 846-epitope (CS 846), the type II collagen C-propeptide (CP2) and the collagenase-generated intrahelical cleavage neoepitope (C2C) were quantified. Molecular analyses showed that type II collagen turnover (CP2 and C2C) was significantly elevated in the ankle, whereas aggrecan turnover (CS 846), total proteoglycan and total collagen were comparable between both joints. Analysis of the inter-relationships in the components of cartilage matrix turnover showed a significant positive correlation of C2C vs CP2. The data suggest an increased type II collagen turnover in ankle vs knee OA cartilage but a comparable aggrecan turnover and comparable contents of type II collagen and proteoglycan. These findings point towards a focused attempt in advanced OA cartilage to structurally repair the collagen network that was more pronounced in the ankle joint and may explain in part the higher prevalence of OA in the knee as compared to the ankle joint.
Tian, Jing; Xie, Bing; Xiang, Liangbi; Zhao, Yong; Zhou, Dapeng
The ankle injuries create great pain to a great number of patients worldwide. Past studies have focused on the development of practical treatments to relieve pain and improve recovery, but the molecular mechanisms underlying the ankle injuries, especially the local inflammation in the damaged ankle joint, have been rarely studied. Moreover, although reduction of production and secretion of pro-inflammatory cytokines may reduce the pain and promote the recovery, a practical approach is currently lacking. Here, we detected significantly higher levels of placental growth factor (PLGF) and pro-inflammatory cytokines in the joint fluid from the patients of acute ankle joint injury (AAJI). Interestingly, the levels of PLGF and pro-inflammatory cytokines in the joint fluid strongly correlated. In order to examine whether PLGF may regulate the production and secretion of pro-inflammatory cytokines in the injured joint, we used a rat carrageenan-induced ankle injury model for AAJI in humans. We injected soluble Flt-1 (sFlt-1) into the articular cavity of the injured ankle joint to block PLGF signaling and found that injection of sFlt-1 significantly improved the rat behavior in activity wheels test, which appeared to result from reduced secretion of the pro-inflammatory cytokines in the ankle joint. Thus, our study suggests that blocking PLGF signaling may be a novel therapeutic approach for treating AAJI in humans. PMID:27904694
Choisne, Julie; Hoch, Matthew C; Bawab, Sebastian; Alexander, Ian; Ringleb, Stacie I
Subtalar joint instability is hypothesized to occur after injuries to the calcaneofibular ligament (CFL) in isolation or in combination with the cervical and the talocalcaneal interosseous ligaments. A common treatment for hindfoot instability is the application of an ankle brace. However, the ability of an ankle brace to promote subtalar joint stability is not well established. We assessed the kinematics of the subtalar joint, ankle, and hindfoot in the presence of isolated subtalar instability, investigated the effect of bracing in a CFL deficient foot and with a total rupture of the intrinsic ligaments, and evaluated how maximum inversion range of motion is affected by the position of the ankle in the sagittal plane. Kinematics from nine cadaveric feet were collected with the foot placed in neutral, dorsiflexion, and plantar flexion. Motion was applied with and without a brace on an intact foot and after sequentially sectioning the CFL and the intrinsic ligaments. Isolated CFL sectioning increased ankle joint inversion, while sectioning the CFL and intrinsic ligaments affected subtalar joint stability. The brace limited inversion at the subtalar and ankle joints. Additionally, examining the foot in dorsiflexion reduced ankle and subtalar joint motion.
Kim, Sooyoung; Jung, Daeun; Han, Jintae; Jung, Jaemin
[Purpose] To investigate the effects of different ankle weights on knee joint repositioning sense in elderly individuals. [Subjects and Methods] Twenty-one subjects were divided for assessment as follows: young (20-30 years, n=10) and elderly (60-70 years, n=11). Knee joint repositioning error was measured by asking the subjects to reposition the target angle of their knee joints while wearing different ankle weights (0%, 0.5%, 1%, and 1.5%) in an open kinetic chain. The Hawk Digital System (60 Hz; Motion Analysis, Santa Rosa, CA, USA) was used to measure knee joint repositioning error. Differences in knee joint repositioning error between the young and elderly groups according to ankle weight load were examined by using two-way mixed repeated-measures analysis of variance. [Results] The knee joint repositioning error was lower with than without ankle weights in both groups. The error value was lowest with the 1.0% weight, though not significantly. Knee joint repositioning error was significantly higher in the elderly under all the ankle weight conditions. [Conclusion] Knee joint repositioning sense can be improved in elderly individuals by wearing proper ankle weights. However, weights that are too heavy might disturb knee joint positioning sense.
Kim, Sooyoung; Jung, Daeun; Han, Jintae; Jung, Jaemin
[Purpose] To investigate the effects of different ankle weights on knee joint repositioning sense in elderly individuals. [Subjects and Methods] Twenty-one subjects were divided for assessment as follows: young (20–30 years, n=10) and elderly (60–70 years, n=11). Knee joint repositioning error was measured by asking the subjects to reposition the target angle of their knee joints while wearing different ankle weights (0%, 0.5%, 1%, and 1.5%) in an open kinetic chain. The Hawk Digital System (60 Hz; Motion Analysis, Santa Rosa, CA, USA) was used to measure knee joint repositioning error. Differences in knee joint repositioning error between the young and elderly groups according to ankle weight load were examined by using two-way mixed repeated-measures analysis of variance. [Results] The knee joint repositioning error was lower with than without ankle weights in both groups. The error value was lowest with the 1.0% weight, though not significantly. Knee joint repositioning error was significantly higher in the elderly under all the ankle weight conditions. [Conclusion] Knee joint repositioning sense can be improved in elderly individuals by wearing proper ankle weights. However, weights that are too heavy might disturb knee joint positioning sense. PMID:27799664
Kim, Kyung-Min; Hart, Joseph M; Saliba, Susan A; Hertel, Jay
Application of cryotherapy over an injured joint has been shown to improve muscle function, yet it is unknown how ankle cryotherapy affects postural control. Our purpose was to determine the effects of a 20-min focal ankle joint cooling on unipedal static stance in individuals with and without chronic ankle instability (CAI). Fifteen young subjects with CAI (9 males, 6 females) and 15 healthy gender-matched controls participated. All subjects underwent two intervention sessions on different days in which they had a 1.5L plastic bag filled with either crushed ice (active treatment) or candy corn (sham) applied to the ankle. Unipedal stance with eyes closed for 10s were assessed with a forceplate before and after each intervention. Center of pressure (COP) data were used to compute 10 specific dependent measures including velocity, area, standard deviation (SD), and percent range of COP excursions, and mean and SD of time-to-boundary (TTB) minima in the anterior-posterior (AP) and mediolateral directions. For each measure a three-way (Group-Intervention-Time) repeated ANOVAs found no significant interactions and main effects involving intervention (all Ps > 0.05). There were group main effects found for mean velocity (F(1,28) = 6.46, P = .017), area (F(1,28) = 12.83, P = .001), and mean of TTB minima in the AP direction (F(1,28) = 5.19, P = .031) indicating that the CAI group demonstrated greater postural instability compared to the healthy group. Postural control of unipedal stance was not significantly altered following focal ankle joint cooling in groups both with and without CAI. Ankle joint cryotherapy was neither beneficial nor harmful to single leg balance.
Witchalls, Jeremy; Waddington, Gordon; Blanch, Peter; Adams, Roger
Individuals with and without functional ankle instability have been tested for deficits in lower limb proprioception with varied results. To determine whether a new protocol for testing participants' joint position sense during stepping is reliable and can detect differences between participants with unstable and stable ankles. Descriptive laboratory study. University clinical laboratory. Sample of convenience involving 21 young adult university students and staff. Ankle stability was categorized by score on the Cumberland Ankle Instability Tool; 13 had functional ankle instability, 8 had healthy ankles. Test-retest of ankle joint position sense when stepping onto and across the Active Movement Extent Discrimination Apparatus twice, separated by an interim test, standing still on the apparatus and moving only 1 ankle into inversion. Difference in scores between groups with stable and unstable ankles and between test repeats. Participants with unstable ankles were worse at differentiating between inversion angles underfoot in both testing protocols. On repeated testing with the stepping protocol, performance of the group with unstable ankles was improved (Cohen d = 1.06, P = .006), whereas scores in the stable ankle group did not change in the second test (Cohen d = 0.04, P = .899). Despite this improvement, the unstable group remained worse at differentiating inversion angles on the stepping retest (Cohen d = 0.99, P = .020). The deficits on proprioceptive tests shown by individuals with functional ankle instability improved with repeated exposure to the test situation. The learning effect may be the result of systematic exposure to ankle-angle variation that led to movement-specific learning or increased confidence when stepping across the apparatus.
Witchalls, Jeremy; Waddington, Gordon; Blanch, Peter; Adams, Roger
Context Individuals with and without functional ankle instability have been tested for deficits in lower limb proprioception with varied results. Objective To determine whether a new protocol for testing participants' joint position sense during stepping is reliable and can detect differences between participants with unstable and stable ankles. Design Descriptive laboratory study. Setting University clinical laboratory. Patients or Other Participants Sample of convenience involving 21 young adult university students and staff. Ankle stability was categorized by score on the Cumberland Ankle Instability Tool; 13 had functional ankle instability, 8 had healthy ankles. Intervention(s) Test-retest of ankle joint position sense when stepping onto and across the Active Movement Extent Discrimination Apparatus twice, separated by an interim test, standing still on the apparatus and moving only 1 ankle into inversion. Main Outcome Measure(s) Difference in scores between groups with stable and unstable ankles and between test repeats. Results Participants with unstable ankles were worse at differentiating between inversion angles underfoot in both testing protocols. On repeated testing with the stepping protocol, performance of the group with unstable ankles was improved (Cohen d = 1.06, P = .006), whereas scores in the stable ankle group did not change in the second test (Cohen d = 0.04, P = .899). Despite this improvement, the unstable group remained worse at differentiating inversion angles on the stepping retest (Cohen d = 0.99, P = .020). Conclusions The deficits on proprioceptive tests shown by individuals with functional ankle instability improved with repeated exposure to the test situation. The learning effect may be the result of systematic exposure to ankle-angle variation that led to movement-specific learning or increased confidence when stepping across the apparatus. PMID:23182010
Nomura, Kenta; Yonezawa, Teru; Mizoguchi, Hiroshi; Takemura, Hiroshi
This paper presents a method to measure the passive stiffness of an ankle joint in three degrees of freedom (DOF) under two motion speeds (1 Hz and 5 degree/s) using a developed Stewart platform-type device. The developed device can reproduce input motions of the foot in 6 DOF by controlling six pneumatic linear motion actuators. We used the device to measure the passive stiffness of an ankle joint undergoing three kinds of motion, namely dorsi-plantar flexion, inversion-eversion, and adduction-abduction. The measured values of the passive stiffness of the ankle joint in dorsiflexion that we obtained agreed well with that obtained in a previous study, indicating that the developed device is useful for measuring the passive stiffness of ankle joint. In addition, the developed device can be used to measure the stiffness in inversion-eversion and adduction-abduction motions as well, parameters that have never been measured. The results we obtained demonstrated certain interesting features as we varied both the direction and pace of motion (e.g., there were significant differences in the stiffness not only between adduction and abduction during the faster pace, but also between these and the other motions).
Lin, Chueh-Ho; Chiang, Shang-Lin; Lu, Liang-Hsuan; Wei, Shun-Hwa; Sung, Wen-Hsu
Ankle motion and proprioception in multiple axis movements are crucial for daily activities. However, few studies have developed and used a multiple axis system for measuring ankle motion and proprioception. This study was designed to validate a novel ankle haptic interface system that measures the ankle range of motion (ROM) and joint position sense in multiple plane movements, investigating the proprioception deficits during joint position sense tasks for patients with ankle instability. Eleven healthy adults (mean ± standard deviation; age, 24.7 ± 1.9 years) and thirteen patients with ankle instability were recruited in this study. All subjects were asked to perform tests to evaluate the validity of the ankle ROM measurements and underwent tests for validating the joint position sense measurements conducted during multiple axis movements of the ankle joint. Pearson correlation was used for validating the angular position measurements obtained using the developed system; the independent t test was used to investigate the differences in joint position sense task performance for people with or without ankle instability. The ROM measurements of the device were linearly correlated with the criterion standards (r = 0.99). The ankle instability and healthy groups were significantly different in direction, absolute, and variable errors of plantar flexion, dorsiflexion, inversion, and eversion (p < 0.05). The results demonstrate that the novel ankle joint motion and position sense measurement system is valid and can be used for measuring the ankle ROM and joint position sense in multiple planes and indicate proprioception deficits for people with ankle instability. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Tsailas, P G; Wiedel, J D
There have been only a few studies in the literature that reported on the outcome of ankle arthrodesis in patients with haemophilia; furthermore, the number of patients was usually low and the operative technique has not been uniform. The aim of this study was to evaluate the outcome of surgery in haemophilic arthropathy of the ankle and subtalar joints, using internal fixation. From 1983 to 2006, 20 fusions were performed in 13 patients with advanced haemophilic arthropathy of the ankle and subtalar joints. There were 11 ankle fusions, one isolated subtalar fusion and eight combined ankle and subtalar fusions. Three of the latter had a subtalar fusion at a second operation. The mean age at operation was 38.7 years and the mean followup was 9.4 years. In the majority of the cases, the ankle fusion was achieved by two crossing screws. For the subtalar fusion, either staples were used or the tibiotalar screws were extended to the calcaneus. Arthrodesis of the ankle was successful in all but one patient, in whose case the procedure was revised and eventually his condition was progressed to fusion. There was also one case of painless non-union of the subtalar joint which was not revised. There was no recurrent bleeding, and no deep infection. Arthrodesis with cross screw fixation is an effective method for fusion of the ankle and subtalar joints in patients with haemophilia.
DeMont, Richard G.; Ryu, Keeho; Lephart, Scott M.
Objective: To assess the effects of sex, joint angle, and the gastrocnemius muscle on passive ankle joint complex stiffness (JCS). Design and Setting: A repeated-measures design was employed using sex as a between-subjects factor and joint angle and inclusion of the gastrocnemius muscle as within-subject factors. All testing was conducted in a neuromuscular research laboratory. Subjects: Twelve female and 12 male healthy, physically active subjects between the ages of 18 and 30 years volunteered for participation in this study. The dominant leg was used for testing. No subjects had a history of lower extremity musculoskeletal injury or circulatory or neurologic disorders. Measurements: We determined passive ankle JCS by measuring resistance to passive dorsiflexion (5°·s−1) from 23° plantar flexion (PF) to 13° dorsiflexion (DF). Angular position and torque data were collected from a dynamometer under 2 conditions designed to include or reduce the contribution of the gastrocnemius muscle. Separate fourth-order polynomial equations relating angular position and torque were constructed for each trial. Stiffness values (Nm·degree−1) were calculated at 10° PF, neutral (NE), and 10° DF using the slope of the line at each respective position. Results: Significant condition-by-position and sex-by-position interactions and significant main effects for sex, position, and condition were revealed by a 3-way (sex-by-position, condition-by-position) analysis of variance. Post hoc analyses of the condition-by-position interaction revealed significantly higher stiffness values under the knee-straight condition compared with the knee-bent condition at both ankle NE and 10° DF. Within each condition, stiffness values at each position were significantly higher as the ankle moved into DF. Post hoc analysis of the sex-by-position interaction revealed significantly higher stiffness values at 10° DF in the male subjects. Post hoc analysis of the position main effect revealed
Gardner, Jacob K; McCaw, Steven T; Laudner, Kevin G; Smith, Peter J; Stafford, Lindsay N
Ankle sprains are one of the most common injuries in competitive and recreational athletics. Studies have shown that the use of prophylactic ankle braces effectively reduces the frequency of ankle sprains in athletes. However, although it is generally accepted that the ankle braces are effective at reducing frontal plane motion, some researchers report that the design of the brace may also reduce ankle sagittal plane motion. The purpose of this study was to quantify lower extremity joint contributions to energy absorption during single-legged drop landings in three ankle brace conditions (no brace, boot brace, and hinged brace). Eleven physically active females experienced in landing and free of lower extremity injury (age = 22.3 ± 1.7 yr, height = 1.66 ± 0.04 m, mass = 58.43 ± 5.83 kg) performed 10 single-leg drop landings in three conditions (one unbraced, two braced) from a 0.33-m height. Measurements taken were hip, knee, and ankle joint impulse; hip, knee, ankle, and total work; and hip, knee, and ankle joint relative work. Total energy absorption remained consistent across the braced conditions (P = 0.057). Wearing the boot brace reduced relative ankle work (P = 0.04, Cohen d = 0.43) but did not change relative knee (P = 0.08, Cohen d = 0.32) or hip (P = 0.14, Cohen d = 0.20) work compared with the no-brace condition. In an ankle-braced condition, ankle, knee, and hip energetics may be altered depending on the design of the brace.
Bellringer, S F; Brogan, K; Cassidy, L; Gibbs, J
Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness. All patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken. 314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution. Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures. Level III-Retrospective Cohort Study. Copyright © 2017 Elsevier Ltd. All rights reserved.
Sekiguchi, Yusuke; Muraki, Takayuki; Kuramatsu, Yuko; Furusawa, Yoshihito; Izumi, Shin-Ichi
The role of ankle joint stiffness during gait in patients with hemiparesis has not been clarified. The purpose of this study was to determine the contribution of quasi-joint stiffness of the ankle joint to spatiotemporal and kinetic parameters regarding gait in patients with hemiparesis due to brain tumor or stroke and healthy individuals. Spatiotemporal and kinetic parameters regarding gait in twelve patients with hemiparesis due to brain tumor or stroke and nine healthy individuals were measured with a 3-dimensional motion analysis system. Quasi-joint stiffness was calculated from the slope of the linear regression of the moment-angle curve of the ankle joint during the second rocker. There was no significant difference in quasi-joint stiffness among both sides of patients and the right side of controls. Quasi-joint stiffness on the paretic side of patients with hemiparesis positively correlated with maximal ankle power (r=0.73, P<0.01) and gait speed (r=0.66, P<0.05). In contrast, quasi-joint stiffness in controls negatively correlated with maximal ankle power (r=-0.73, P<0.05) and gait speed (r=-0.76, P<0.05). Our findings suggested that ankle power during gait might be generated by increasing quasi-joint stiffness in patients with hemiparesis. In contrast, healthy individuals might decrease quasi-joint stiffness to avoid deceleration of forward tilt of the tibia. Our findings might be useful for selecting treatment for increased ankle stiffness due to contracture and spasticity in patients with hemiparesis. Copyright © 2011 Elsevier Ltd. All rights reserved.
Kim, Young Sung; Lee, Ho Min; Kim, Jong Pil; Moon, Han Sol
Fatigue stress fractures of the talus are rare and usually involve the head of the talus in military recruits. We report an uncommon cause of ankle pain due to a fatigue stress fracture of the body of the talus in a 32-year-old male social soccer player. Healing was achieved after weightbearing suppression for 6 weeks. Although rare, a stress fracture of the body of the talus should be considered in an athlete with a gradual onset of chronic ankle pain. Magnetic resonance imaging and bone scan are useful tools for early diagnosis.
Kumar, Narinder; Prasad, Manish
The Tillaux fracture of the ankle is an external rotation ankle injury resulting in an avulsion fracture of the anterolateral tibial plafond. This injury is known to occur in adolescents, although it has rarely been reported in adults. We report a case of a Tillaux fracture in an adult. A brief description of the history, mechanism of injury, required imaging, and treatment and other management options are provided in the present report. Anatomic reduction, rigid fixation, and early mobilization are emphasized to obtain a satisfactory functional outcome, shown by the long-term follow-up findings.
Daniels, Clinton J.; Welk, Aaron B.; Enix, Dennis E.
Objective The purpose of this study is to present diagnostic ultrasonography assessment of an occult fracture in a case of persistent lateral ankle pain. Clinical Features A 35-year-old woman presented to a chiropractic clinic with bruising, swelling, and pain along the distal fibula 3 days following an inversion ankle trauma. Prior radiographic examination at an urgent care facility was negative for fracture. Conservative care over the next week noted improvement in objective findings, but the pain persisted. Intervention and Outcome Diagnostic ultrasonography was ordered to assess her persistent ankle pain and showed a minimally displaced fracture of the fibula 4 cm proximal to the lateral malleolus. The patient was referred to her primary care physician and successfully managed with conservative care. Conclusion In this case, diagnostic ultrasonography was able to identify a Danis-Weber subtype B1 fracture that was missed by plain film radiography. PMID:27069430
Michelson, James D
The development of a robust treatment algorithm for ankle fractures based on well-established stability criteria has been shown to be prognostic with respect to treatment and outcomes. In parallel with the development of improved understanding of the biomechanical rationale of ankle fracture treatment has been an increased emphasis on assessing the effectiveness of medical and surgical interventions. The purpose of this study was to investigate the use of using decision analysis in the assessment of the cost effectiveness of operative treatment of ankle fractures based on the existing clinical data in the literature. Using the data obtained from a previous structured review of the ankle fracture literature, decision analysis trees were constructed using standard software. The decision nodes for the trees were based on ankle fracture stability criteria previously published. The outcomes were assessed by calculated Quality-Adjusted Life Years (QALYs) assigned to achieving normal ankle function, developing posttraumatic arthritis, or sustaining a postoperative infection. Sensitivity analysis was undertaken by varying the patient's age, incidence of arthritis, and incidence or infection. Decision analysis trees captured the essential aspects of clinical decision making in ankle fracture treatment in a clinically useful manner. In general, stable fractures yielded better outcomes with nonoperative treatment, whereas unstable fractures had better outcomes with surgery. These were consistent results over a wide range of postoperative infection rates. Varying the age of the patient did not qualitatively change the results. Between the ages of 30 and 80 years, surgery yielded higher expected QALYs than nonoperative care for unstable fractures, and generated lower QALYs than nonoperative care for stable fractures. Using local cost estimates for operative and nonoperative treatment, the incremental cost of surgery for unstable fractures was less than $40,000 per QALY (the
Cisco, R W; Shaffer, M; Kuchler, L
Exostosis formation following trauma isnot uncommon to the joints of the foot and ankle. The etiology and treatment of these boney lesions is well-documented in the literature. The following is a report of an unusual exostosis of the subtalar joint following inversion ankle injury. This case is unusual in respect to the formation of an adventitious articulation, the size of the lesion, and the pathology.
Wohlrath, B; Schweigkofler, U; Barzen, S; Heinz, S M; Schmidt-Horlohé, K; Hoffmann, R
Background: Protracted dislocation of the upper ankle joint can lead to substantial damage to the surrounding soft tissue, possibly followed by local complications and longer hospitalisation. Although reposition is usually easy to conduct, it is commonly recommended that this should only be performed by an experienced specialist, as long as there is no neurovascular restriction. There are however no exact data or studies on this problem. The aim of the present study is to examine whether early reposition is of benefit for subsequent treatment. Methods: Retrospective study of all patients in a supra-regional trauma centre during the period from January 2009 to July 2015, with either prehospital reposition of the ankle joint because of visible malposition or documented visible malposition on arrival at hospital. Patients with relevant concomitant injuries elsewhere were excluded. Data on the duration of dislocation were matched with diagnostic findings at the time of hospital admission, the kind of primary care, local complications and the time of hospitalisation, using linear regression analysis and ANOVA calculations. Results: Of a total of 391 patients with a dislocation or a fracture dislocation of the ankle joint within this period, 132 fulfilled the inclusion criteria. These patients were divided into 5 groups on the basis of the time of dislocation. Time to reposition was less than one hour for 39 patients, between one and two hours for 29 patients, between two and six hours for 41 patients, between six and 24 hours for 13 patients and more than 24 hours for 10 patients, all with a visible dislocation. The results on admission showed a significant increase in skin bruises and tension bullae with increasing time of dislocation. A longer time of dislocation was associated with more two stage surgical procedures with external fixators and a decreasing number of single stage procedures. While there was immediate definitive treatment of 79.5 % of the patients in
Ota, S; Ueda, M; Aimoto, K; Suzuki, Y; Sigward, S M
Restrictions in range of ankle dorsiflexion (DF) motion can persist following ankle injuries. Ankle DF is necessary during terminal stance of gait, and its restricted range may affect knee joint kinematics and kinetics. The purpose of this study was to investigate the acute influence of varied levels of restricted ankle DF on knee joint sagittal and frontal plane kinematics and kinetics during gait. Thirty healthy volunteers walked with a custom-designed ankle brace that restricted ankle DF. Kinematics and kinetics were collected using a 7-camera motion analysis system and two force plates. Ankle dorsiflexion was restricted in 10-degree increments, allowing for four conditions: Free, light (LR), moderate (MR) and severe restriction (SR). Knee angles and moments were measured during terminal stance. Real peak ankle DF for Free, LR, MR, and SR were 13.7±4.8°, 11.6±5.0°, 7.5±5.3°, and 4.2±7.2°, respectively. Peak knee extension angles under the same conditions were -6.7±6.7°, -5.4±6.4°, -2.5±7.5°, and 0.6±7.8°, respectively, and the peak knee varus moment was 0.48±0.17 Nm/kg, 0.47±0.17 Nm/kg, 0.53±0.20 Nm/kg, and 0.57±0.20 Nm/kg. The knee varus moment was significantly increased from MR condition with an 8-degree restriction in ankle DF. Knee joint kinematics and kinetics in the sagittal and frontal planes were affected by reduced ankle DF during terminal stance of gait. Differences were observed with restriction in ankle DF range of approximately 8°. level III. Copyright © 2014 Elsevier B.V. All rights reserved.
Introduction: The risk of growth arrest following paediatric ankle fractures type 1 A is very high. Therefore all attempts should be done to anatomically reduce this kind of fracture. The advances in ankle arthroscopy have brought the possibility to reduce these fractures under direct vision, without the need of capsulotomy. The purpose of this paper is to stress the importance of the use of arthroscopically assisted reduction of type 1 A fractures. Case Report: We describe two cases with SH type IV fractures of the distal medial tibia, one treated with open reduction and percutaneous screw fixation and the other treated with arthroscopically assisted reduction and percutaneous screw fixation. The first case ended with severe growth disturbance, while the second gave a very good result. Conclusion: The use of arthroscopically assisted reduction of type 1 A fractures should be considered to ensure anatomical reduction. PMID:27298899
Tibiotalar dislocation is rare and usually associated with a high-velocity, high-energy impact or extreme sporting injuries. I describe complete tibiotalar dislocation from an unusual mechanism. A 22-year-old mechanic was sitting under a hydraulic lift when it began to leak, lowering the engine on which he was working onto his right lower thigh. This heavy load, without rotational force or high-velocity impact, was transmitted down his foreleg. Because his foot was fixed to the ground, the talus was proximally and vertically displaced, and the distal tibia was forced to the ground, beside his foot, and was contaminated with sand and grease. The circumferential ligament complexes and capsule were completely transected, but, despite a severely disrupted dorsal and capsular blood supply, talar vasculature remained adequate. In the emergency department, gentle traction restored impaired circulation. No malleolar fractures were seen. The wound was meticulously irrigated with saline and povidone-iodine and debrided. Cefepime, 2 g, was given twice daily. In surgery, the unstable joint was transfixed with two thick Kirschner wires, passed retrograde. Interrupted sutures were placed in the anterior capsule and anterior third of the lateral ligament without additional incisions. The wound healed aseptically. The Kirschner wires were removed at 6 weeks. The joint space was only minimally reduced. He returned to work after 4 months. His ankle-hindfoot score was 90/100 at 18 months, he could jog at 24 months, and he was still asymptomatic at 36 months. The case illustrates the importance of preserving talar circulation and treatment within the "golden hour." Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Braunstein, Bjoern; Arampatzis, Adamantios; Eysel, Peer; Brüggemann, Gert-Peter
The objective of the study was to investigate the adjustment of running mechanics by wearing five different types of running shoes on tartan compared to barefoot running on grass focusing on the gearing at the ankle and knee joints. The gear ratio, defined as the ratio of the moment arm of the ground reaction force (GRF) to the moment arm of the counteracting muscle tendon unit, is considered to be an indicator of joint loading and mechanical efficiency. Lower extremity kinematics and kinetics of 14 healthy volunteers were quantified three dimensionally and compared between running in shoes on tartan and barefoot on grass. Results showed no differences for the gear ratios and resultant joint moments for the ankle and knee joints across the five different shoes, but showed that wearing running shoes affects the gearing at the ankle and knee joints due to changes in the moment arm of the GRF. During barefoot running the ankle joint showed a higher gear ratio in early stance and a lower ratio in the late stance, while the gear ratio at the knee joint was lower during midstance compared to shod running. Because the moment arms of the counteracting muscle tendon units did not change, the determinants of the gear ratios were the moment arms of the GRF's. The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.
Droog, R; Verhage, S M; Hoogendoorn, J M
In this retrospective cohort study, we analysed the incidence and functional outcome of a distal tibiofibular synostosis. Patients with an isolated AO type 44-B or C fracture of the ankle who underwent surgical treatment between 1995 and 2007 were invited for clinical and radiological review. The American Orthopaedic Foot and Ankle Society score, the American Academy of Orthopaedic Surgeons score and a visual analogue score for pain were used to assess outcome. A total of 274 patients were available; the mean follow-up was 9.7 years (8 to 18). The extent of any calcification or synostosis at the level of the distal interosseous membrane or syndesmosis on the contemporary radiographs was defined as: no or minor calcifications (group 1), severe calcification (group 2), or complete synostosis (group 3). A total of 222 (81%) patients were in group 1, 37 (14%) in group 2 and 15 (5%) in group 3. There was no significant difference in incidence between AO type 44-B and type 44-C fractures (p = 0.89). Severe calcification or synostosis occurred in 21 patients (19%) in whom a syndesmotic screw was used and in 31 (19%) in whom a syndesmotic screw was not used.(p = 0.70). No significant differences were found between the groups except for a greater reduction in mean dorsiflexion in group 2 (p = 0.004). This is the largest study on distal tibiofibular synostosis, and we found that a synostosis is a frequent complication of surgery for a fracture of the ankle. Although it theoretically impairs the range of movement of the ankle, it did not affect the outcome. Our findings suggest that synostosis of the distal tibiofibular syndesmosis in general does not warrant treatment. ©2015 The British Editorial Society of Bone & Joint Surgery.
Kang, Sang Hoon; Ren, Yupeng; Xu, Dali; Zhang, Li-Qun
Lower-limb multi-joint (knee and ankle) stiffness may play an important role in functional activities such as walking, and may be significantly altered post stroke. Thus, determination of lower-limb multi joint stiffness matrix is important for better understanding of gait and of pathological changes post stroke. In this study, using novel dynamics decomposition, the knee and ankle joint stiffness matrix including cross-coupled stiffness terms between the two joints were determined and reported ever first. The determined stiffness matrix may be useful for gait studies, and can be served as a baseline for studying pathophysiological changes post stroke.
Down, Stuart; Waddington, Gordon; Adams, Roger; Thomson, Malcolm
Background The effect on clinical safety of dampening articular mechanoreceptor feedback at the ankle is unknown. Injection of the ankle joint for pain control may result in such dampening. Athletes receiving intra‐articular local anaesthetic may therefore be at increased risk of sustaining ankle injuries, which are a common reason for missed sporting participation. Objective To determine the effect of intra‐articular local anaesthetic on movement discrimination at the ankle joint. Design Prospective, randomised, double‐blinded, placebo‐controlled, cross‐over trial. Setting Australian Institute of Sport Medical Centre, Canberra, Australia. Patients Twenty two healthy subjects (44 ankles) aged 18–26 were recruited for the three visits of the study. Interventions Subjects were tested for their initial movement discrimination scores using the active movement extent discrimination apparatus (AMEDA). They then received ultrasound‐guided intra‐articular injections of local anaesthetic (2% lignocaine hydrochloride) or normal saline, on two separate later occasions, before further AMEDA assessment. Main outcome measures Change in movement discrimination scores after intra‐articular injection of local anaesthetic or saline. Results Movement discrimination scores were not significantly different from control ankles after injection of either local anaesthetic or saline into the ankle joint. Conclusions The intra‐articular injection of neither 2 ml lignocaine nor an equivalent amount of normal saline resulted in significant effects on movement discrimination at the ankle joint. These results suggest that injections of local anaesthetic into the ankle joint are unlikely to significantly affect proprioception and thereby increase injury risk. PMID:17341587
Schottel, Patrick C; Berkes, Marschall B; Little, Milton T M; Garner, Matthew R; Fabricant, Peter D; Lazaro, Lionel E; Helfet, David L; Lorich, Dean G
A pronation external rotation (PER) ankle fracture is a relatively uncommon injury. The purpose of this study was to examine the immediate and short-term clinical outcomes of operatively treated PER IV ankle fractures and compare them with a similarly treated cohort of supination external rotation IV (SER IV) fractures. 22 PER IV and 108 SER IV fractures were identified from a single surgeon's prospectively collected database from 2004 to 2010. All patients were treated with fracture fragment and ligament specific fixation during the same time period by the same surgeon. Postoperative radiographs and bilateral ankle computed tomography (CT) scans were reviewed for articular incongruity, syndesmotic malreduction, and loss of reduction. Clinical outcome measures, including the Foot and Ankle Outcome Score (FAOS) and ankle range of motion (ROM), were collected at latest follow-up visit. There was no difference in the rate of wound complications, fracture nonunion, or loss of reduction between the PER IV and SER IV groups. There was no significant difference in the incidence of postoperative articular incongruity (19% vs 8%, P = .23); however, the PER IV cohort was found to have a significantly higher rate of syndesmotic malreduction (40% vs 18%, P = .04). No clinically or statistically significant differences were detected between the 2 groups in regard to all FAOS domains. In a cohort of operatively treated PER IV fractures, fracture fragment and ligament specific fixation resulted in good short-term outcomes that were comparable to those seen in similarly treated patients with an SER IV fracture pattern. However, a notably greater number of syndesmotic malreductions were noted in the PER IV cohort, and therefore heightened scrutiny is recommended in treating this particular injury pattern. Level III, retrospective comparative study.
Bartoníček, Jan; Rammelt, Stefan; Kostlivý, Karel; Vaněček, Václav; Klika, Daniel; Trešl, Ivo
The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19-83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.
van Wessem, K J P; Leenen, L P H
High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior. In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury. Copyright © 2016 Elsevier Ltd. All rights reserved.
Park, Jason C; McLaurin, Toni M
Ankle syndesmosis injuries frequently occur with ankle fractures, but their treatment remains controversial. Although specific clinical and radiographic diagnostic measures are generally well-accepted, there remains a lack of consensus with respect to the treatment of these injuries. Controversy arises at almost every phase of treatment including: type of fixation (screw size, type of implant), number of cortices required for fixation, and need for hardware removal. Regardless of fixation technique chosen, the most important goal should be anatomic reduction and restoration of the syndesmosis and ankle mortise as this is the only significant predictor of functional outcome.
El Ashry, Saad R; El Gamal, Tarek A; Platt, Simon R
Chronic ankle instability is a disabling condition, often occurring as a result of traumatic ankle injury. A paucity of published data is available documenting chronic ankle instability in the pediatric population. Much of the data has been confined to the adult population. We present 2 cases of chronic ankle instability, 1 in a 12-year-old and 1 in a 9-year-old patient. Unlike the typical adult etiology, the cause of instability was a dysfunctional lateral ligamentous complex as a consequence of bony avulsion of the tip of the fibula. Both patients had sustained a twisting injury to the ankle. The fractures failed to unite. The nonunion resulted in dysfunction of the anterior talofibular ligament with consequent chronic ankle instability. At the initial clinical assessment, magnetic resonance imaging was requested for both patients. In patient 1 (12 years old), the fracture was fixed with 2 headless screws and was immobilized in a plaster cast for 6 weeks. In patient 2 (9 years old), because of the small size of the avulsed fragment, fixation was not possible. A modified Gould-Broström procedure was undertaken, facilitating repair of the avulsed fragment using anchor sutures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Liu, Huaxin; Ceccarelli, Marco; Huang, Qiang
In this paper, a mechanical transmission based on cable pulley is proposed for human-like actuation in the artificial ankle joints of human-scale. The anatomy articular characteristics of the human ankle is discussed for proper biomimetic inspiration in designing an accurate, efficient, and robust motion control of artificial ankle joint devices. The design procedure is presented through the inclusion of conceptual considerations and design details for an interactive solution of the transmission system. A mechanical design is elaborated for the ankle joint angular with pitch motion. A multi-body dynamic simulation model is elaborated accordingly and evaluated numerically in the ADAMS environment. Results of the numerical simulations are discussed to evaluate the dynamic performance of the proposed design solution and to investigate the feasibility of the proposed design in future applications for humanoid robots.
Kauranen, K; Siira, P; Vanharanta, H
The purpose of this study was to examine the effect of strapping on different components of motor performance of wrist and ankle joints. The subjects were 14 healthy volunteers (12 females, two males), aged 21-33 years, with no known previous injuries of the ankle and wrist joints. The measurements were made with the HPM/BEP system and Isokinetic Lido Active Multi-joint system. First, the subjects performed the test without strapping and then, on the following day, with strapped right wrist and ankle joints. The strapping of the wrist increased the simple reaction time by 9%, choice reaction time by 9% and decreased the wrist tapping speed by 21%. Wrist strength decreased in flexion (180 degrees/s) by 14% and ulnar deviation (180 degrees/s) by 8%. The strapping of the ankle increased the simple reaction time by 12%, choice reaction time by 9% and decreased foot tapping speed by 14%. Ankle strength in plantar flexion decreased in 60 degrees/s by 22% and 180 degrees/s by 14% and in inversion in 60 degrees/s by 28% and 180 degrees/s by 15%. These results suggest the strapping of ankle and wrist joints reduces motor performance in the above-mentioned directions as measured by the following parameters: simple reaction time, choice reaction time, tapping speed, and muscle strength.
Kobayashi, Takumi; No, Yumi; Yoneta, Kei; Sadakiyo, Masashi; Gamada, Kazuyoshi
Functional ankle instability (FAI) may involve abnormal kinematics. However, reliable quantitative data for kinematics of FAI have not been reported. The objective of this study was to determine if the abnormal kinematics exist in the talocrural and subtalar joints in patients with FAI. Five male subjects with unilateral FAI (a mean age of 33.4 ± 13.2 years) were enrolled. All subjects were examined with stress radiography and found to have no mechanical ankle instability (MAI). Lateral radiography at weight-bearing ankle internal rotation of 0° and 20° was taken with the ankle at 30° dorsiflexion and 30° plantar flexion. Patients underwent computed tomography scan at 1.0 mm slice pitch spanning distal one third of the lower leg and the distal end of the calcaneus. Three-dimensional (3D) kinematics of the talocrural and subtalar joints as well as the ankle joint complex (AJC) were determined using a 3D-to-2D registration technique using a 3D-to-2D registration technique with 3D bone models and plain radiography. FAI joints in ankle dorsiflexion demonstrated significantly greater subtalar internal rotation from 0° to 20° internal rotation. No statistical differences in plantar flexion were detected in talocrural, subtalar or ankle joint complex kinematics between the FAI and contralateral healthy joints. During ankle internal rotation in dorsiflexion, FAI joints demonstrated greater subtalar internal rotation. The FAI joints without mechanical instability presented abnormal kinematics. This suggests that abnormal kinematics of the FAI joints may contribute to chronic instability. FAI joints may involve unrecognized abnormal subtalar kinematics during internal rotation in ankle dorsiflexion which may contribute to chronic instability and frequent feelings of instability.
Tsoi, Y H; Xie, S Q
The kinematics of the human ankle is commonly modeled as a biaxial hinge joint model. However, significant variations in axis orientations have been found between different individuals and also between different foot configurations. For ankle rehabilitation robots, information regarding the ankle kinematic parameters can be used to estimate the ankle and subtalar joint displacements. This can in turn be used as auxiliary variables in adaptive control schemes to allow modification of the robot stiffness and damping parameters to reduce the forces applied at stiffer foot configurations. Due to the large variations observed in the ankle kinematic parameters, an online identification algorithm is required to provide estimates of the model parameters. An online parameter estimation routine based on the recursive least-squares (RLS) algorithm was therefore developed in this research. An extension of the conventional biaxial ankle kinematic model, which allows variation in axis orientations with different foot configurations had also been developed and utilized in the estimation algorithm. Simulation results showed that use of the extended model in the online algorithm is effective in capturing the foot orientation of a biaxial ankle model with variable joint axis orientations. Experimental results had also shown that a modified RLS algorithm that penalizes a deviation of model parameters from their nominal values can be used to obtain more realistic parameter estimates while maintaining a level of estimation accuracy comparable to that of the conventional RLS routine.
Rammelt, Stefan; Godoy-Santos, Alexandre Leme; Schneiders, Wolfgang; Fitze, Guido; Zwipp, Hans
Foot and ankle fractures represent 12% of all pediatric fractures. Malleolar fractures are the most frequent injuries of the lower limbs. Hindfoot and midfoot fractures are rare, but inadequate treatment for these fractures may results in compartment syndrome, three-dimensional deformities, avascular necrosis and early post-traumatic arthritis, which have a significant impact on overall foot and ankle function. Therefore, the challenges in treating these injuries in children are to achieve adequate diagnosis and precise treatment, while avoiding complications. The objective of the treatment is to restore normal anatomy and the correct articular relationship between the bones in this region. Moreover, the treatment needs to be planned according to articular involvement, lower-limb alignment, ligament stability and age. This article provides a review on this topic and presents the scientific evidence for appropriate treatment of these lesions.
Warner, Stephen J; Garner, Matthew R; Nguyen, Joseph T; Lorich, Dean G
Hypovitaminosis D is common in patients undergoing orthopaedic trauma surgery. While previous studies have shown that vitamin D levels correlate with functional outcome after hip fracture surgery, the significance of vitamin D levels on outcomes after surgery in other orthopaedic trauma patients is unknown. The purpose of this study was to determine if vitamin D levels correlated with outcomes in ankle fracture patients. We reviewed a prospective registry of patients who underwent operative treatment for ankle fractures from 2003 to 2012. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured, and the primary and secondary outcomes included foot and ankle outcome scores (FAOS) and ankle range of motion. Data were also collected on patient comorbidities, articular malreductions, and wound complications. Included patients had at least 12 months of clinical outcome data. Ninety-eight patients operatively treated for ankle fractures met our inclusion criteria. Of these 98 patients, 36 (37%) were deficient in vitamin D (<20 ng/ml) and 31 (32%) had vitamin D insufficiency (<30 ng/ml, ≥20 mg/ml). Patients with vitamin D deficiency were similar with regard to age, gender, and comorbidities compared to patients with vitamin D levels ≥20. Univariate analysis revealed that patients with vitamin D deficiency had significantly worse FAOS with regard to symptoms (P = 0.017) and quality of life (P = 0.040) domains than patients with vitamin D levels ≥20. Multivariate regression analysis suggested that vitamin D deficiency was a factor in inferior FAOS with regard to symptoms, activities of daily living, and quality of life. In our group of patients with operative treated ankle fractures, preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up. Our study suggests that deficient vitamin D levels may result in worse outcomes in orthopaedic trauma patients recovering from fracture fixation.
Ng, Alan; Barnes, Esther S
The management of complications resulting from the open reduction and internal fixation of ankle fractures is discussed in detail. The initial radiographic findings of the most common postsurgical complications of ankle fracture reduction are briefly discussed, namely lateral, medial, and posterior malleolar malunion or nonunion, syndesmotic widening, degenerative changes, and septic arthritis with or without concomitant osteomyelitis. Emphasis is placed on the management of these complications, with a review of the treatment options proposed in the literature, a detailed discussion of the authors' recommendations, and an inclusion of different case presentations.
Phillips, Staton L; Williams, Daniel; Jeyaseelan, Luckshmana; Bryce, Elaine; Alyas, Faisal; Vemulapalli, Krishna
We present the case of a 14-year-old female who presented with unilateral pes planus 30 months after a bimalleolar ankle fracture dislocation. At surgery, the tibialis posterior tendon was encased in fracture callus within the syndesmosis and required reconstruction using flexor digitorum longus transfer. Dislocation of the tibialis posterior tendon and entrapment within the tibiofibular syndesmosis has been previously reported. To our knowledge, this is the first case report tibialis posterior tendon syndesmotic entrapment presenting with unilateral pes planus. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Barelds, Ingrid; Krijnen, Wim P; van de Leur, Johannes P; van der Schans, Cees P; Goddard, Robert J
Ankle decision rules are developed to expedite patient care and reduce the number of radiographs of the ankle and foot. Currently, only three systematic reviews have been conducted on the accuracy of the Ottawa Ankle and Foot Rules (OAFR) in adults and children. However, no systematic review has been performed to determine the most accurate ankle decision rule. The purpose of this study is to examine which clinical decision rules are the most accurate for excluding ankle fracture after acute ankle trauma. A systematic search was conducted in the databases PubMed, CINAHL, PEDro, ScienceDirect, and EMBASE. The sensitivity, specificity, likelihood ratios, and diagnostic odds ratio of the included studies were calculated. A meta-analysis was conducted if the accuracy of a decision rule was available from at least three different experimental studies. Eighteen studies satisfied the inclusion criteria. These included six ankle decision rules, specifically, the Ottawa Ankle Rules, Tuning Fork Test, Low Risk Ankle Rule, Malleolar and Midfoot Zone Algorithms, and the Bernese Ankle Rules. Meta-analysis of the Ottawa Ankle Rules (OAR), OAFR, Bernese Ankle Rules, and the Malleolar Zone Algorithm resulted in a negative likelihood ratio of 0.12, 0.14, 0.39, and 0.23, respectively. The OAR and OAFR are the most accurate decision rules for excluding fractures in the event of an acute ankle injury. Copyright © 2017 Elsevier Inc. All rights reserved.
Dagnino, Giulio; Georgilas, Ioannis; Morad, Samir; Gibbons, Peter; Tarassoli, Payam; Atkins, Roger; Dogramadzi, Sanja
Complex joint fractures often require an open surgical procedure, which is associated with extensive soft tissue damages and longer hospitalization and rehabilitation time. Percutaneous techniques can potentially mitigate these risks but their application to joint fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces involved in the fragment manipulation (due to the presence of soft tissue, e.g., muscles) which might result in fracture malreduction. Integration of robotic assistance and 3D image guidance can potentially overcome these issues. The authors propose an image-guided surgical robotic system for the percutaneous treatment of knee joint fractures, i.e., the robot-assisted fracture surgery (RAFS) system. It allows simultaneous manipulation of two bone fragments, safer robot-bone fixation system, and a traction performing robotic manipulator. This system has led to a novel clinical workflow and has been tested both in laboratory and in clinically relevant cadaveric trials. The RAFS system was tested on 9 cadaver specimens and was able to reduce 7 out of 9 distal femur fractures (T- and Y-shape 33-C1) with acceptable accuracy (≈1 mm, ≈5°), demonstrating its applicability to fix knee joint fractures. This study paved the way to develop novel technologies for percutaneous treatment of complex fractures including hip, ankle, and shoulder, thus representing a step toward minimally-invasive fracture surgeries.
Siddiqui, Noman A; Herzenberg, John E; Lamm, Bradley M
Ankle replacement systems have not been as reliable as hip replacements in providing long-term relief of pain, increased motion, and return to full activity. Supramalleolar Osteotomy is an extraarticular procedure that realigns the mechanical axis, thereby restoring ankle function. The literature discussing knee arthritis has shown that realignment osteotomies of the tibia improve function and prolong total knee replacement surgery. The success of the procedure is predicated on understanding the patient's clinical and radiographic presentation and proper preoperative assessment and planning.
Kobayashi, Toshiki; Singer, Madeline L.; Orendurff, Michael S.; Gao, Fan; Daly, Wayne K.; Foreman, K. Bo
Background The adjustment of plantarflexion resistive moment of an articulated ankle-foot orthosis is considered important in patients post stroke, but the evidence is still limited. Therefore, the aim of this study was to investigate the effect of changing the plantarflexion resistive moment of an articulated ankle-foot orthosis on ankle and knee joint angles and moments in patients post stroke. Methods Gait analysis was performed on 10 subjects post stroke under four different plantarflexion resistive moment conditions using a newly designed articulated ankle-foot orthosis. Data were recorded using a Bertec split-belt instrumented treadmill in a 3-dimensional motion analysis laboratory. Findings The ankle and knee sagittal joint angles and moments were significantly affected by the amount of plantarflexion resistive moment of the ankle-foot orthosis. Increasing the plantarflexion resistive moment of the ankle-foot orthosis induced significant decreases both in the peak ankle plantarflexion angle (P<0.01) and the peak knee extension angle (P<0.05). Also, the increase induced significant increases in the internal dorsiflexion moment of the ankle joint (P<0.01) and significantly decreased the internal flexion moment of the knee joint (P<0.01). Interpretation These results suggest an important link between the kinematic/kinetic parameters of the lower-limb joints and the plantarflexion resistive moment of an articulated ankle-foot orthosis. A future study should be performed to clarify their relationship further so that the practitioners may be able to use these parameters as objective data to determine an optimal plantarflexion resistive moment of an articulated ankle-foot orthosis for improved orthotic care in individual patients. PMID:26149007
Boutis, Kathy; Plint, Amy; Stimec, Jennifer; Miller, Elka; Babyn, Paul; Schuh, Suzanne; Brison, Robert; Lawton, Louis; Narayanan, Unni G
Lateral ankle injuries without radiographic evidence of a fracture are a common pediatric injury. These children are often presumed to have a Salter-Harris type I fracture of the distal fibula (SH1DF) and managed with immobilization and orthopedic follow-up. However, previous small studies suggest that these injuries may represent ankle sprains rather than growth plate fractures. To determine the frequency of SH1DF using magnetic resonance imaging (MRI) and compare the functional recovery of children with fractures identified by MRI vs those with isolated ligament injuries. A prospective cohort study was conducted between September 2012 and August 2014 at 2 tertiary care pediatric emergency departments. We screened 271 skeletally immature children aged 5 to 12 years with a clinically suspected SH1DF; 170 were eligible and 140 consented to participate. Children underwent MRI of both ankles within 1 week of injury. Children were managed with a removable brace and allowed to return to activities as tolerated. The proportion with MRI-confirmed SH1DF. A secondary outcome included the Activity Scale for Kids score at 1 month. Of the 135 children who underwent ankle MRI, 4 (3.0%; 95% CI, 0.1%-5.9%) demonstrated MRI-confirmed SH1DF, and 2 of these were partial growth plate injuries. Also, 108 children (80.0%) had ligament injuries and 27 (22.0%) had isolated bone contusions. Of the 108 ligament injuries, 73 (67.6%) were intermediate to high-grade injuries, 38 of which were associated with radiographically occult fibular avulsion fractures. At 1 month, the mean (SD) Activity Scale for Kids score of children with MRI-detected fibular fractures (82.0% [17.2%]) was not significantly different from those without fractures (85.8% [12.5%]) (mean difference, -3.8%; 95% CI, -1.7% to 9.2%). Salter-Harris I fractures of the distal fibula are rare in children with radiograph fracture-negative lateral ankle injuries. These children most commonly have ligament injuries (sprains
Shibuya, Naohiro; Davis, Matthew L; Jupiter, Daniel C
Understanding the epidemiology of foot and ankle trauma could be useful in health services research and for policy makers. It can also define practice patterns. Using the National Trauma Data Bank data set from 2007 to 2011, we analyzed the frequency and proportion of each fracture in the foot and ankle in major trauma hospitals in the United States. A total of 280,933 foot and/or ankle fractures or dislocations were identified. Although oversampling of more severe trauma in younger patients might have occurred owing to the nature of the data set, we found that the most common fractures in the foot and ankle were ankle fractures. Midfoot fractures were the least common among all the foot and ankle fractures when categorized by anatomic location. Approximately 20% of all foot and ankle fractures were open. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Biver, E; Durosier, C; Chevalley, T; Herrmann, F R; Ferrari, S; Rizzoli, R
In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility. Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin. In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography. Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude
Reiner, Matthew M; Sharpe, Jonathan J
While it is well known that ankle sprains are one of the most common injuries in the United States, predictive factors regarding failure of conservative treatment are not well known. There are many biomechanical and epidemiological factors that play a role in recurrence and failure of conservative treatment, but most cases are able to be treated with immobilization and/or rest, ice, elevation, physical therapy, and bracing. We propose that one important risk factor is often overlooked simply due to the fact that a vast majority of these cases resolve without the need for surgery. Accessory ossicles and avulsion fractures of the malleoli or talus may represent a predisposition or marker for ligamentous damage that may lead to the need for lateral ankle ligament repair or reconstruction in the future. We have identified 61 consecutive patients who underwent lateral ankle ligament repair or reconstruction by the primary surgeon from the years 2007 to 2017. Out of those patients who met our inclusion and exclusion criteria, 66% had the presence of osseous pathology consisting of accessory ossicles or avulsion fractures of the medial or lateral malleolus or talus. The proportion of osseous pathology seen with lateral ankle ligament repair or reconstruction was higher than what has been previously reported in both operative and nonoperative settings. This may help identify a risk factor for failure of conservative treatment in patients presenting with acute ankle sprains or ankle instability especially in the active cohort. Level IV: Case series.
Optimum friction control of the ankle joint brake is essential for realizing a stable gait when wearing an active ankle foot orthosis (AFO). An optimum friction control system using a force observer is designed and simulated. The brake friction is controlled in proportion to the observed human force of the lower limb without using force sensors. The simulated results show that the force observer performs well. The force-controlled orthosis is robust and practical because it uses no force sensors.
Fullam, Karl; Caulfield, Brian; Coughlan, Garrett F; McGroarty, Mark; Delahunt, Eamonn
Decreased postural stability is a primary risk factor for lower limb musculoskeletal injuries. During athletic competitions, cryotherapy may be applied during short breaks in play or during half-time; however, its effects on postural stability remain unclear. To investigate the acute effects of a 15-minute ankle-joint cryotherapy application on dynamic postural stability. Controlled laboratory study. University biomechanics laboratory. A total of 29 elite-level collegiate male field-sport athletes (age = 20.8 ± 1.12 years, height = 1.80 ± 0.06 m, mass = 81.89 ± 8.59 kg) participated. Participants were tested on the anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions of the Star Excursion Balance Test before and after a 15-minute ankle-joint cryotherapy application. Normalized reach distances; sagittal-plane kinematics of the hip, knee, and ankle joints; and associated mean velocity of the center-of-pressure path during performance of the ANT, PL, and PM reach directions of the Star Excursion Balance Test. We observed a decrease in reach-distance scores for the ANT, PL, and PM reach directions from precryotherapy to postcryotherapy (P < .05). No differences were observed in hip-, knee-, or ankle-joint sagittal-plane kinematics (P > .05). We noted a decrease in mean velocity of the center-of-pressure path from precryotherapy to postcryotherapy (P < .05) in all reach directions. Dynamic postural stability was adversely affected immediately after cryotherapy to the ankle joint.
Wang, Ruoli; Gutierrez-Farewik, Elena M
Excessive co-contraction causes inefficient or abnormal movement in several neuromuscular pathologies. How synergistic muscles spanning the ankle, knee and hip adapt to co-contraction of ankle muscles is not well understood. This study aimed to identify the compensation strategies required to retain normal walking with excessive antagonistic ankle muscle co-contraction. Muscle-actuated simulations of normal walking were performed to quantify compensatory mechanisms of ankle and knee muscles during stance in the presence of normal, medium and high levels of co-contraction of antagonistic pairs gastrocnemius+tibialis anterior and soleus+tibialis anterior. The study showed that if co-contraction increases, the synergistic ankle muscles can compensate; with gastrocmemius+tibialis anterior co-contraction, the soleus will increase its contribution to ankle plantarflexion acceleration. At the knee, however, almost all muscles spanning the knee and hip are involved in compensation. We also found that ankle and knee muscles alone can provide sufficient compensation at the ankle joint, but hip muscles must be involved to generate sufficient knee moment. Our findings imply that subjects with a rather high level of dorsiflexor+plantarflexor co-contraction can still perform normal walking. This also suggests that capacity of other lower limb muscles to compensate is important to retain normal walking in co-contracted persons. The compensatory mechanisms can be useful in clinical interpretation of motion analyses, when secondary muscle co-contraction or other deficits may present simultaneously in subjects with motion disorders.
Eismann, Emily A; Stephan, Zachary A; Mehlman, Charles T; Denning, Jaime; Mehlman, Tracey; Parikh, Shital N; Tamai, Junichi; Zbojniewicz, Andrew
The purpose of this study was to compare the reliability of triplane fracture classification, displacement measurement, and treatment planning with the use of radiographs with and without computed tomography. One pediatric radiologist, one musculoskeletal radiologist, and three fellowship-trained pediatric orthopaedic surgeons rated a spectrum of twenty-five triplane fractures with use of radiographs alone and then with computed tomography scans on two separate occasions (two to four weeks apart). Raters classified the fracture pattern with use of the Rapariz classification system, measured the maximum intra-articular displacement, and drew the fracture on four outlines of the distal part of the tibia: one lateral view, one anteroposterior view, one axial view above the tibial physis, and one axial view below the physis. Reliability was assessed with kappa values and intraclass correlation coefficients. The Rapariz triplane fracture classification had poor inter-rater reliability (a kappa of 0.17) and intra-rater reliability (a kappa of 0.31) with radiographs alone but moderate inter-rater reliability (a kappa of 0.41) and intra-rater reliability (a kappa of 0.54) with the addition of computed tomography. After reviewing computed tomography, raters changed the fracture pattern in 46% of ratings, the displacement from ≤2 mm to >2 mm in 39% of ratings, the treatment from nonoperative to operative in 27% of ratings, and either the orientation or number of screws in 41% of ratings. Computed tomography had a definite impact on the fracture classification, displacement, and treatment plan, supporting its use as an adjunct to radiographs for the treatment of pediatric triplane fractures. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
Jonas, S C; Young, A F; Curwen, C H; McCann, P A
Fragility fractures of the ankle are increasing in incidence. Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity. Ankle fractures in this age group are managed conservatively in plaster or by open reduction and internal fixation. Both modalities have shown high rates of failure in terms of delayed union or mal-union together with perioperative complications such as implant failure and wound breakdown. The optimal treatment of these patients remains controversial. We aimed to review the functional outcome of patients with ankle fragility fractures primarily managed using a tibio-talar-calcaneal nail (TTC). We retrospectively reviewed 31 consecutive patients primarily managed with a TCC nail for osteoporotic fragility fractures about the ankle. Data were collected via case notes, radiographic reviews and by clinical reviews at the outpatient clinic or a telephone follow-up. Information regarding patient characteristics, indication for operation, Arbeitsgemeinschaft für Osteosynthesefragen (AO) fracture classification, operative and postoperative complications, time to radiographic union and current clinical state including Olerud and Molander scores were recorded (as a measure of ankle function). Nine of 31 patients had died by the time of follow-up. Mean preoperative and postoperative Olerud and Molander scores were 56 and 45, respectively. There were no postoperative wound complications. Twenty-nine of 31 patients returned to the same level of mobility as pre-injury. There were three peri-prosthetic fractures managed successfully with nail removal and replacement or plaster cast. There were two nail failures, both in patients who mobilised using only a stick, which were managed by nail removal. Ten of 31 patients were not followed up radiographically due to either infirmity or death. Thirteen of 21 followed up radiographically had evidence of union and 8/21 had none. None, however, had clinical evidence
Sultan, M J; Zhing, T; Morris, J; Kurdy, N; McCollum, C N
In this randomised controlled trial, we evaluated the role of elastic compression using ankle injury stockings (AIS) in the management of fractures of the ankle. A total of 90 patients with a mean age of 47 years (16 to 79) were treated within 72 hours of presentation with a fracture of the ankle, 31 of whom were treated operatively and 59 conservatively, were randomised to be treated either with compression by AIS plus an Aircast boot or Tubigrip plus an Aircast boot. Male to female ratio was 36:54. The primary outcome measure was the functional Olerud-Molander ankle score (OMAS). The secondary outcome measures were; the American Orthopaedic Foot and Ankle Society score (AOFAS); the Short Form (SF)-12v2 Quality of Life score; and the frequency of deep vein thrombosis (DVT). Compression using AIS reduced swelling of the ankle at all time points and improved the mean OMAS score at six months to 98 (95% confidence interval (CI) 96 to 99) compared with a mean of 67 (95% CI 62 to 73) for the Tubigrip group (p < 0.001). The mean AOFAS and SF-12v2 scores at six months were also significantly improved by compression. Of 86 patients with duplex imaging at four weeks, five (12%) of 43 in the AIS group and ten (23%) of 43 in the Tubigrip group developed a DVT (p = 0.26). Compression improved functional outcome and quality of life following fracture of the ankle. DVTs were frequent, but a larger study would be needed to confirm that compression with AISs reduces the incidence of DVT.
Akehi, Kazuma; Long, Blaine C; Warren, Aric J; Goad, Carla L
Akehi, K, Long, BC, Warren, AJ, and Goad, CL. Ankle joint angle and lower leg musculotendinous unit responses to cryotherapy. J Strength Cond Res 30(9): 2482-2492, 2016-The use of cold application has been debated for its influence on joint range of motion (ROM) and stiffness. The purpose of this study was to determine whether a 30-minute ice bag application to the plantarflexor muscles or ankle influences passive ankle dorsiflexion ROM and lower leg musculotendinous stiffness (MTS). Thirty-five recreationally active college-aged individuals with no history of lower leg injury 6 months before data collection volunteered. On each testing day, we measured maximum passive ankle dorsiflexion ROM (°) and plantarflexor torque (N·m) on an isokinetic dynamometer to calculate the passive plantarflexor MTS (N·m per degree) at 4 joint angles before, during, and after a treatment. Surface electromyography amplitudes (μV), and skin surface and ambient air temperature (°C) were also measured. Subjects received an ice bag to the posterior lower leg, ankle joint, or nothing for 30 minutes in different days. Ice bag application to the lower leg and ankle did not influence passive ROM (F(12,396) = 0.67, p = 0.78). Passive torque increased after ice bag application to the lower leg (F(12,396) = 2.21, p = 0.011). Passive MTS at the initial joint angle increased after ice bag application to the lower leg (F(12,396) = 2.14, p = 0.014) but not at the other joint angles (p > 0.05). Surface electromyography amplitudes for gastrocnemius and soleus muscles increased after ice application to the lower leg (F(2,66) = 5.61, p = 0.006; F(12,396) = 3.60, p < 0.001). Ice bag application to the lower leg and ankle joint does not alter passive dorsiflexion ROM but increases passive ankle plantarflexor torque in addition to passive ankle plantarflexor MTS at the initial joint angle.
Hsu, Andrew R; Lareau, Craig R; Anderson, Robert B
Infolding and retraction of an avulsed deltoid complex after ankle fracture can be a source of persistent increased medial clear space, malreduction, and postoperative pain and medial instability. The purpose of this descriptive case series was to analyze the preliminary outcomes of acute superficial deltoid complex avulsion repair during ankle fracture fixation in a cohort of National Football League (NFL) players. We found that there is often complete avulsion of the superficial deltoid complex off the proximal aspect of the medial malleolus during high-energy ankle fractures in athletes. Between 2004 and 2014, the cases of 14 NFL players who underwent ankle fracture fixation with open deltoid complex repair were reviewed. Patients with chronic deltoid ligament injuries or ankle fractures more than 2 months old were excluded. Average age for all patients was 25 years and body mass index 34.4. Player positions included 1 wide receiver, 1 tight end, 1 safety, 1 running back, 1 linebacker, and 9 offensive linemen. Average time from injury to surgery was 7.5 days. Surgical treatment for all patients consisted of ankle arthroscopy and debridement, followed by fibula fixation with plate and screws, syndesmotic fixation with suture-button devices, and open deltoid complex repair with suture anchors. Patient demographics were recorded with position played, time from injury to surgery, games played before and after surgery, ability to return to play, and postoperative complications. Return to play was defined as the ability to successfully participate in at least 1 full regular-season NFL game after surgery. All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience before surgery versus after surgery. Average playing experience before surgery was 3.3 seasons, 39 games played, and 22 games started. Average playing experience after surgery was 1.6 seasons, 16 games played, and
Johanson, Marie; Baer, Jennifer; Hovermale, Holley; Phouthavong, Phouvy
Context: Gastrocnemius stretching exercises often are prescribed as part of the treatment program for patients with overuse injuries associated with limited ankle dorsiflexion. However, little is known about how the position of the subtalar joint during gastrocnemius stretching affects ankle dorsiflexion range of motion (ROM). Objective: To determine the effect of subtalar joint position during gastrocnemius stretching on ankle dorsiflexion ROM. Design: This study was a 3-way mixed-model design. The 3 factors were subtalar joint position (supinated, pronated), lower extremity (experimental, control), and time (pretest, posttest). Lower extremity and time were the repeated measures. Setting: University research laboratory. Patients or Other Participants: Thirty-three healthy volunteers (29 women, 4 men). Intervention(s): Participants performed a gastrocnemius stretching exercise 2 times daily for 3 weeks with the subtalar joint of the randomly assigned experimental side (dominant or nondominant) in the randomly assigned position (supination or pronation). The contralateral lower extremity served as the control. Main Outcome Measure(s): Before and after the 3-week gastrocnemius stretching program, we used goniometers to measure ankle dorsiflexion ROM in weight-bearing and non–weight-bearing positions with the subtalar joint positioned in anatomic 0°. Results: Ankle dorsiflexion ROM measured in weight-bearing and non–weight-bearing positions increased after the gastrocnemius stretching program (P = .034 and .003, respectively), but the increase in ROM did not differ based on subtalar joint position (P = .775 and .831, respectively). Conclusions: Subtalar joint position did not appear to influence gains in ankle dorsiflexion ROM after a gastrocnemius stretching program in healthy volunteers. PMID:18345342
Baker, Jeffrey R; Patel, Shail N; Teichman, Adam J; Bochat, Summer E S; Fleischer, Adam E; Knight, Jessica M
The initial management of ankle fracture-dislocations is the crucial step in the treatment of these emergent traumatic injuries. A stepwise approach is necessary to properly evaluate, diagnose, and treat ankle fracture-dislocations. The goal of initial management is to evaluate the vascular status of the extremity and then restore proper alignment of the talus underneath the tibia. A retrospective review was performed on 40 patients, who presented to a community-based hospital emergency room, treated by the foot and ankle service for ankle fracture-dislocation. An analysis of patient demographics, injury pattern/classification, number of reduction attempts, and immobilization method was performed and evaluated. This analysis was correlated with a review of the literature to develop an algorithm for the initial management of ankle fracture-dislocations recommending the use of a bivalved below-the-knee fiberglass cast for maintained stabilization post reduction. Therapeutic Level IV.
Barnett, Peter Leslie John; Lee, Melissa H; Oh, Luke; Cull, Greg; Babl, Franz
Pediatric ankle fractures are usually treated by immobilization with either a posterior splint, cast, or ankle brace. We set out to determine if the below-knee fiberglass posterior splint was as effective as the Air-Stirrup ankle brace in returning children with a low risk ankle fracture to their normal level of activity. This was a randomized, single-blinded, noninferiority, controlled trial at the Royal Children's Hospital, Melbourne. Children aged 5 to 15 years presenting acutely with a low-risk ankle fracture were randomized to the Air-Stirrup ankle brace or fiberglass posterior splint. A validated self-reported outcome tool, the Activities Scale for Kids performance (ASKp), was used to measure physical functioning over the 4 week period. Main outcome was ASKp scores at 2 and 4 weeks with secondary outcomes including pain, weight-bearing ability, and acceptability of device. Forty-five patients were randomized: 23 in the posterior splint group and 22 in the Air-Stirrup ankle brace. Study groups were similar in terms of age, fracture type, and baseline pain. More of the posterior splint group were non-weight bearing "at enrollment" (96%) compared with the ankle brace group (77%). The median ASKp score at 4 weeks was 91.9 in the brace group and 84.2 in the posterior splint group. Scores on the ASKp as well as ASKp differences were favorable toward the brace in the 11- to 15-year age group at 2 weeks (69.6 vs 55.6) and 4 weeks (97.5 vs 90.2) but trended toward the posterior splint in the 5- to 10-year age group (47.5 vs 56). There was no difference between the Air-Stirrup ankle brace and the fiberglass posterior splint in returning children to their normal levels of activity.
Thevendran, Gowreeson; Younger, Alastair
The management of diabetic ankle fractures is difficult given the associated wound and bone healing complications. Even with meticulous soft tissue handling and a stable construct, the fixation sometimes fails because of the poor biological environment. This study reports on 2 cases of Weber type B ankle fractures in patients with diabetes mellitus where the authors elected to treat with arthroscopy-assisted fracture reduction and percutaneous fibula nailing to reduce the risk of wound complications.
Cancienne, Jourdan M; Crosen, Matelin P; Yarboro, Seth R
Ankle fractures are one of the most common orthopedic injuries requiring operative treatment, and approximately 1 in 4 ankle fractures will have an associated distal tibiofibular syndesmosis disruption. Syndesmotic reduction is crucial to restoring ankle function and preventing the development of arthritis. The hybrid operating room provides 3-dimensional intraoperative imaging capabilities that can enable the surgeon to ensure the syndesmosis is appropriately reduced, particularly by comparing it with the contralateral ankle. By confirming the syndesmosis reduction intraoperatively, the risk of a return to the operating room for revision surgery is decreased.
Man, Hok-Sum; Leung, Aaron Kam-Lun; Cheung, Jason Tak-Man; Sterzing, Thorsten
The toe flexor muscles maintain body balance during standing and provide push-off force during walking, running, and jumping. Additionally, they are important contributing structures to maintain normal foot function. Thus, weakness of these muscles may cause poor balance, inefficient locomotion and foot deformities. The quantification of metatarsophalangeal joint (MPJ) stiffness is valuable as it is considered as a confounding factor in toe flexor muscles function. MPJ and ankle joint stiffness measurement is still largely depended on manual skills as current devices do not have good control on alignment, angular joint speed and displacement during measurement. Therefore, this study introduces an innovative dynamometer and protocol procedures for MPJ and ankle Joint torque measurement with precise and reliable foot alignment, angular joint speed and displacement control. Within-day and between-day test-retest experiments on MPJ and ankle joint torque measurement were conducted on ten and nine healthy male subjects respectively. The mean peak torques of MPJ and ankle joint of between-day and within-day measurement were 1.50±0.38Nm/deg and 1.19±0.34Nm/deg. The corresponding torques of the ankle joint were 8.24±2.20Nm/deg and 7.90±3.18Nm/deg respectively. Intraclass-correlation coefficients (ICC) of averaged peak torque of both joints of between-day and within-day test-retest experiments were ranging from 0.91 to 0.96, indicating the innovative device is systematic and reliable for the measurements and can be used for multiple scientific and clinical purposes. Copyright © 2016 Elsevier B.V. All rights reserved.
Nortunen, Simo; Lepojärvi, Sannamari; Savola, Olli; Niinimäki, Jaakko; Ohtonen, Pasi; Flinkkilä, Tapio; Lantto, Iikka; Kortekangas, Tero; Pakarinen, Harri
not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
Yi, Young; Lee, Woochun
Various types of re-alignment surgery are used to preserve the ankle joint in cases of intermediate ankle arthritis with partial joint space narrowing. The short-term and mid-term results after re-alignment surgery are promising, with substantial post-operative pain relief and functional improvement that is reflected by high rates of patient satisfaction. In this context, re-alignment surgery can preserve the joint and reduce the pathological load that acts on the affected area. Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. Cite this article: EFORT Open Rev 2017;2:324-331. DOI: 10.1302/2058-5241.2.160021 PMID:28828181
Background Human stance involves multiple segments, including the legs and trunk, and requires coordinated actions of both. A novel method was developed that reliably estimates the contribution of the left and right leg (i.e., the ankle and hip joints) to the balance control of individual subjects. Methods The method was evaluated using simulations of a double-inverted pendulum model and the applicability was demonstrated with an experiment with seven healthy and one Parkinsonian participant. Model simulations indicated that two perturbations are required to reliably estimate the dynamics of a double-inverted pendulum balance control system. In the experiment, two multisine perturbation signals were applied simultaneously. The balance control system dynamic behaviour of the participants was estimated by Frequency Response Functions (FRFs), which relate ankle and hip joint angles to joint torques, using a multivariate closed-loop system identification technique. Results In the model simulations, the FRFs were reliably estimated, also in the presence of realistic levels of noise. In the experiment, the participants responded consistently to the perturbations, indicated by low noise-to-signal ratios of the ankle angle (0.24), hip angle (0.28), ankle torque (0.07), and hip torque (0.33). The developed method could detect that the Parkinson patient controlled his balance asymmetrically, that is, the right ankle and hip joints produced more corrective torque. Conclusion The method allows for a reliable estimate of the multisegmental feedback mechanism that stabilizes stance, of individual participants and of separate legs. PMID:23433148
Göpfert, Beat; Valderrabano, Victor; Hintermann, Beat; Wirz, Dieter
This article describes an easy to use test equipment for measuring the isometric force in the ankle joints in dorsiflexion and plantar flexion. The combination of the test equipment for measuring the voluntary maximal isometric muscle force in the ankle joint, the surface electromyograms and the motion analysis of the measured leg allow an objective comparison of the strength of the muscular force between the left and right leg. It might be also used as a control setup during rehabilitation after surgical treatment or injuries.
Hoshino, C Max; Nomoto, Edward Kazuhisa; Norheim, Elizabeth P; Harris, Thomas G
A positive external rotation stress test has been used as an indication for operative treatment of fractures of the lateral malleolus. The objective of the current study was to ascertain the results of a protocol initially treating stress positive ankle fractures nonoperatively and utilizing weightbearing radiographs in surgical decision making. We performed a prospective study of lateral malleolar fractures with an associated medial ligamentous injury. All patients with fractures of the lateral malleolus with medial sided symptoms and/or signs, and an intact ankle mortise underwent an external rotation stress test to confirm injury to the deltoid ligament (stress positive). Patients with a positive stress test were placed in a short-leg walking cast and seen in 7 days where weightbearing radiographs of the ankle were obtained. If the radiographs demonstrated an intact mortise, then nonoperative treatment was continued. If the weightbearing radiographs demonstrated medial clear space widening, then the patient was offered operative treatment to restore the congruency of the ankle mortise. Patients were assessed for conversion to operative treatment, complications, and functional outcome. Thirty-eight patients were enrolled in the study. Using Lauge-Hansen classification 36 (95%) were stress positive supination-external rotation fractures and 2 (5%) were stress positive pronation-external rotation fractures. Followup assessment was performed at a minimum of 6 months and averaged 12 months. Weightbearing radiographs at the first post-injury clinic visit had an average medial clear space of 2.9 ±0.9 mm. Three (8%) patients met our criteria for medial clear space widening and underwent operative treatment. Of these three patients, two were pronation-external rotation fracture patterns. Therefore, 3% of the supination-external rotation IV fractures, and all of the pronation-external III/IV rotation fractures ultimately required operative treatment. At final followup
Aramaki, Y; Nozaki, D; Masani, K; Sato, T; Nakazawa, K; Yano, H
Human quiet standing is often modeled as a single inverted pendulum rotating around the ankle joint, under the assumption that movement around the hip joint is quite small. However, several recent studies have shown that movement around the hip joint can play a significant role in the efficient maintenance of the center of body mass (COM) above the support area. The aim of this study was to investigate how coordination between the hip and ankle joints is controlled during human quiet standing. Subjects stood quietly for 30 s with their eyes either opened (EO) or closed (EC), and we measured subtle angular displacements around the ankle (thetaa) and hip (thetah) joints using three highly sensitive CCD laser displacement sensors. Reliable data were obtained for both angular displacement and angular velocity (the first derivative of the angular displacement). Further, measurement error was not predominant, even among the angular acceleration data, which were obtained by taking the second derivative of the angular displacement. The angular displacement, velocity, and acceleration of the hip were found to be significantly greater (P<0.001) than those of the ankle, confirming that hip-joint motion cannot be ignored, even during quiet standing. We also found that a consistent reciprocal relationship exists between the angular accelerations of the hip and ankle joints, namely positive or negative angular acceleration of ankle joint is compensated for by oppositely directed angular acceleration of the hip joint. Principal component analysis revealed that this relationship can be expressed as: thetah=gammathetaa with gamma=-3.15+/-1.24 and gamma=-3.12+/-1.46 (mean +/-SD) for EO and EC, respectively, where theta is the angular acceleration. There was no significant difference in the values of y for EO and EC, and these values were in agreement with the theoretical value calculated assuming the acceleration of COM was zero. On the other hand, such a consistent relationship was
Chua, Matthew C.; Hyngstrom, Allison S.; Ng, Alexander V.; Schmit, Brian D.
Objective The purpose of this study was to quantify hip and ankle impairments contributing to movement dysfunction in multiple sclerosis (MS). Methods Volitional phasing of bilateral hip and ankle torques was assessed using a load-cell-instrumented servomotor drive system in 10 participants with MS and 10 age-matched healthy participants. The hips and ankles were separately bilaterally oscillated 180° out of phase (40° range of motion) at a frequency of 0.75 Hz while the other joints were held stationary. Participants were instructed to assist in the same direction as the robot-imposed movement. The hip and ankle torques were measured and work was calculated for each movement. Results Total negative work at the ankle was significantly different between groups (p=0.040). The participants with MS produced larger negative work during hip flexion (p=0.042) and ankle flexion (p=0.037). Negative work at the hip was significantly correlated with the Berg Balance Scores and Timed 25 Feet Walk Test, and trends demonstrated increasing negative work with increasing clinical impairment in MS. Conclusions These results suggest an increased importance of the hip in functional balance and gait in MS. Significance Rehabilitation strategies targeting ankle recovery or compensation using the hip might improve movement function in MS. PMID:24315810
Chua, Matthew C; Hyngstrom, Allison S; Ng, Alexander V; Schmit, Brian D
The purpose of this study was to quantify hip and ankle impairments contributing to movement dysfunction in multiple sclerosis (MS). Volitional phasing of bilateral hip and ankle torques was assessed using a load-cell-instrumented servomotor drive system in ten participants with MS and 10 age-matched healthy participants. The hips and ankles were separately bilaterally oscillated 180° out of phase (40° range of motion) at a frequency of 0.75 Hz while the other joints were held stationary. Participants were instructed to assist in the same direction as the robot-imposed movement. The hip and ankle torques were measured and work was calculated for each movement. Total negative work at the ankle was significantly different between groups (p=0.040). The participants with MS produced larger negative work during hip flexion (p=0.042) and ankle flexion (p=0.037). Negative work at the hip was significantly correlated with the Berg Balance Scores and Timed 25 Feet Walk Test, and trends demonstrated increasing negative work with increasing clinical impairment in MS. These results suggest an increased importance of the hip in functional balance and gait in MS. Rehabilitation strategies targeting ankle recovery or compensation using the hip might improve movement function in MS. Copyright © 2013 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.
Racu (Cazacu, C.-M.; Doroftei, I.
We propose a rehabilitation device that we intend to be low cost and easy to manufacture. The system will ensure functionality but also have a small dimensions and low mass, considering the physiological dimensions of the foot and lower leg. To avoid injure of the ankle joint, this device is equipped with a compliant joint between the motor and mechanical transmission. The torque of this joint is intended to be adjustable, according to the degree of ankle joint damage. To choose the material and the dimensions of this compliant joint, in this paper we perform the first stress simulation. The minimum torque is calculated, while the maximum torque is given by the preliminary chosen actuator.
Shanahan, Camille J; Wrigley, Tim V; Farrell, Michael J; Bennell, Kim L; Hodges, Paul W
The mechanisms for proprioceptive changes associated with knee osteoarthritis (OA) remain elusive. Observations of proprioceptive changes in both affected knees and other joints imply more generalized mechanisms for proprioceptive impairment. However, evidence for a generalized effect remains controversial. This study examined whether joint repositioning proprioceptive deficits are localized to the diseased joint (knee) or generalized across other joints (elbow and ankle) in people with knee OA. Thirty individuals with right knee OA (17 female, 66±7 [mean±SD] years) of moderate/severe radiographic disease severity and 30 healthy asymptomatic controls of comparable age (17 female, 65±8years) performed active joint repositioning tests of the knee, ankle and elbow in randomised order in supine. Participants with knee OA had a larger relative error for joint repositioning of the knee than the controls (OA: 2.7±2.1°, control: 1.6±1.7°, p=.03). Relative error did not differ between groups for the ankle (OA: 2.2±2.5°, control: 1.9±1.3°, p=.50) or elbow (OA: 2.5±3.3°, control: 2.9±2.8°, p=.58). These results are consistent with a mechanism for proprioceptive change that is localized to the knee joint. This could be mediated by problems with mechanoreceptors, processing/relay of somatosensory input to higher centers, or joint-specific interference with cognitive processes by pain.
Chen, Yan-Xi; Lu, Xiao-Ling; Bi, Gang; Yu, Xiao; Hao, Yi-Li; Zhang, Kun; Zou, Li-Ling; Mei, Jiong; Yu, Guang-Rong
As precise positioning of ankle radiography is not possible, quantitative measurement of all syndesmotic parameters on repeated ankle X-ray films may be of little value. The purpose of this study was to provide a set of scientific and objective evaluation criteria for assessing the quality of ankle fracture reduction accurately and reliably by an intelligent combining three-dimensional (3-D) computed tomography (CT) measurement model. From June 2008 to March 2011, all the thin-slice CT images of 100 cases (50 males and 50 females) with normal ankle joint scanned by 16-slice spiral CT were collected. Two-dimensional (2-D) and 3-D images of ankle joints were generated by using multiple planar reconstruction (MPR) and surface shaded display (SSD) respectively. The relevant parameters about bone structures and their relationship were measured and analyzed based on 3-D topological narrow division technique and 3-D measurement techniques combining essential elements of point, line and surface. In this study, the mean distance from lateral malleolus tip to talocrural articular surface, the tip of medial malleolus anterior colliculus to talocrural articular surface and lateral malleolus tip to the tip of medial malleolus anterior colliculus were (22.83 ± 1.12) mm, (12.84 ± 1.09) mm, and (61.18 ± 2.03) mm respectively in male group, and (20.16 ± 1.00) mm, (10.30 ± 1.05) mm and (53.00 ± 1.40) mm respectively in female group. The above three parameters were correlated with gender, height and weight (P < 0.05). However, the mean perpendicular distance from lateral malleolus tip to the plane through the tip of medial malleolus anterior colliculus, the talocrural angle, later clear space, medial clear space, and the superior clear space were (9.93 ± 0.29) mm, (10.01 ± 0.38)°, (1.94 ± 0.16) mm, (2.78 ± 0.19) mm, and (3.14 ± 0.15) mm respectively in 100 cases, were not significance correlated with gender, height and weight (P > 0.05). This study could provide a certain
Kim, Hyong-Nyun; Park, Yoo-Jung; Kim, Gab-Lae; Park, Yong-Wook
The purpose of this study was to evaluate the effectiveness of arthroscopy combined with hardware removal for chronic pain after satisfactory healing of an ankle fracture. We hypothesized that combining hardware removal with arthroscopy for the intra-articular pathology would improve residual complaints more so than hardware removal alone. The outcomes of the 53 young male patients with chronic pain after healed ankle fracture treated with two different therapeutic plans: (1) conservative treatment after hardware removal (group A) and (2) arthroscopic intervention with hardware removal (group B) were prospectively studied. Patients were reviewed preoperatively and 6 and 12 months postoperatively using American Foot and Ankle Society (AOFAS) scale. Median AOFAS scores improved from 74 (66-80) points to 76 (73-92) points in group A and from 75 (64-80) points to 85 (72-100) points in group B, and this improvement was significantly higher for patients in group B (p = 0.001). This study supports the notion that when there is a definite diagnosis such as loose body, bony impingement, or anterolateral soft-tissue impingement causing chronic pain after healed ankle fracture, arthroscopic treatment with hardware removal is a better treatment option than hardware removal and conservative treatment.
Vaillancourt, David E; Prodoehl, Janey; Sturman, Molly M; Bakay, Roy A E; Metman, Leo Verhagen; Corcos, Daniel M
We investigated the control of movement in 12 patients with Parkinson's disease (PD) after they received surgically implanted high-frequency stimulating electrodes in the subthalamic nucleus (STN). The experiment studied ankle strength, movement velocity, and the associated electromyographic patterns in PD patients, six of whom had tremor at the ankle. The patients were studied off treatment, ON STN deep brain stimulation (DBS), on medication, and on medication plus STN DBS. Twelve matched control subjects were also examined. Medication alone and STN DBS alone increased patients' ankle strength, ankle velocity, agonist muscle burst amplitude, and agonist burst duration, while reducing the number of agonist bursts during movement. These findings were similar for PD patients with and without tremor. The combination of medication plus STN DBS normalized maximal strength at the ankle joint, but ankle movement velocity and electromyographic patterns were not normalized. The findings are the first to demonstrate that STN DBS and medication increase strength and movement velocity at the ankle joint.
AIM: To report ankle fracture configurations and bone quality following arthroscopic-assisted reduction and internal-fixation (ARIF) or open reduction and internal-fixation (ORIF). METHODS: The patients of ARIF (n = 16) or ORIF (n = 29) to treat unstable ankle fracture between 2006 and 2014 were reviewed retrospectively. Baseline data, including age, sex, type of injury, immediate postoperative fracture configuration (assessed on X-rays and graded by widest gap and largest step-off of any intra-articular site), bone quality [assessed with bone mineral density (BMD) testing] and arthritic changes on X-rays following surgical treatments were recorded for each group. RESULTS: Immediate-postoperative fracture configurations did not differ significantly between the ARIF and ORIF groups. There were anatomic alignments as 8 (50%) and 8 (27.6%) patients in ARIF and ORIF groups (P = 0.539) respectively. There were acceptable alignments as 12 (75%) and 17 (58.6%) patients in ARIF and ORIF groups (P = 0.341) respectively. The arthritic changes in follow-up period as at least 16 wk following the surgeries were shown as 6 (75%) and 10 (83.3%) patients in ARIF and ORIF groups (P = 0.300) respectively. Significantly more BMD tests were performed in patients aged > 60 years (P < 0.001), ARIF patients (P = 0.021), and female patients (P = 0.029). There was no significant difference in BMD test t scores between the two groups. CONCLUSION: Ankle fracture configurations following surgeries are similar between ARIF and ORIF groups, suggesting that ARIF is not superior to ORIF in treatment of unstable ankle fractures. PMID:27114933
Tejwani, Nirmal C; Park, Ji Hae; Egol, Kenneth A
Rotational injuries are the most common and usually classified as per the Lauge Hansen classification; with the most common subgroup being the supination external rotation (SER) mechanism. Isolated fractures of the distal fibula (SE2) without associated ligamentous injury are usually treated with a splint or brace and the patient may be allowed to weight bear as tolerated. This study reports the functional outcomes following a stable, low energy, rotational ankle fracture supination external rotation (SER2) when compared to unstable SER4 fractures treated operatively. 64 patients who were diagnosed and treated nonoperatively for a stable SER2 ankle fracture were followed prospectively. In the comparison group, 93 operatively treated fibular fractures were extracted from a prospectively collected database and evaluated comparison. Baseline characteristics obtained by trained interviewers at the time of injury included: Patient demographics, short form-36, short musculoskeletal functional assessment (SMFA) and American Orthopedic Foot and Ankle Society (AOFAS) questionnaires. Patients were followed at 3, 6 and 12 months postsurgery. Additional information obtained at each followup point included any complications or evidence on fracture healing. Data were analyzed by the Student's t-test and theFisher's Exact Test to compare demographic and functional outcomes between the two cohorts. P < 0.05 was considered to be significant. The average of patients' age in the stable fracture cohort was 43 versus 45 in the SER4 group. Nearly 64% of the patient population was female when compared with 37% in the operative group. In the SER2 by 6 months all patients had returned to baseline functional status. There were 18 delayed unions (all healed by 6 months). Based on the functional outcome scores all patients had returned to preoperative level. In comparison, SE4 patients had less functional recovery at 3 and 6 months (P < 0.05) based on the SMFA scores and at 3, 6 and 12 months
Lambers, Kaj T A; van den Bekerom, Michel P J; Doornberg, Job N; Stufkens, Sjoerd A S; van Dijk, C Niek; Kloen, Peter
There is sparse information in the literature on the outcome of Maisonneuve-type pronation-external rotation ankle fractures treated with syndesmotic screws. The primary aim of this study was to determine the long-term results of such treatment of these fractures as indicated by standardized patient-based and physician-based outcome measures. The secondary aim was to identify predictors of the outcome with use of bivariate and multivariate statistical analysis. Fifty patients with pronation-external rotation (predominantly Maisonneuve) fractures were treated with open reduction and internal fixation of the syndesmosis utilizing only one or two screws. The results were evaluated at a mean of twenty-one years after the fracture utilizing three standardized outcomes instruments: (1) the Foot and Ankle Ability Measure (FAAM), (2) the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, and (3) the Center for Epidemiologic Studies-Depression (CES-D) Scale. Osteoarthritis was graded according to the van Dijk and revised Takakura radiographic scoring systems. Bivariate and multivariate analyses were performed to identify predictors of long-term outcome. Forty-four (92%) of forty-eighty patients had good or excellent AOFAS scores, and forty-four (90%) of forty-nine had good or excellent FAAM scores. Arthrodesis for severe osteoarthritis was performed in two patients. Radiographic evidence of osteoarthritis was observed in twenty-four (49%) of forty-nine patients. Multivariate analysis identified pain as the most important independent predictor of long-term ankle function as indicated by the AOFAS and FAAM scores, explaining 91% and 53% of the variation in scores, respectively. Analysis of pain as the dependent variable in bivariate analyses revealed that depression, ankle range of motion, and a subsequent surgery were significantly correlated with higher pain scores. No firm conclusions could be drawn after multivariate analysis of predictors of pain
Denegar, Craig R; Hertel, Jay; Fonseca, Jose
Retrospective study. Assess range of motion, posterior talar glide, and residual joint laxity following ankle sprain in a population of athletes who have returned to unrestricted activity. Lateral ankle sprains occur frequently in athletic populations and the reinjury rate may be as high as 80%. In an effort to better understand risk factors for reinjury, the sequelae to injury in a sample of college athletes were assessed. Twelve athletes with a history of lateral ankle sprain within the last 6 months and who had returned to sport participation were tested. Only athletes who reported never injuring the contralateral ankle were included. The injured and uninjured ankles of subjects were compared for measures of joint laxity, ankle dorsiflexion range of motion, and posterior talar glide. Friedman's test of rank order was used to analyze the laxity measures and a MANOVA was used to assess the dorsiflexion and posterior talar glide measures. Laxity was significantly greater at the talocrural and subtalar joints of the injured ankles. There were no significant differences in any of the ankle dorsiflexion measurements between injured and uninjured ankles, but posterior talar glide was significantly reduced in injured ankles as compared to uninjured ankles. In our sample of subjects, residual ligamentous laxity was commonly found following lateral ankle sprain. Dorsiflexion range of motion was restored in the population studied despite evidence of restricted posterior glide of the talocrural joint. Although restoration of physiological range of motion was achieved, residual joint dysfunction persisted. Further research is warranted to elucidate the role of altered arthrokinematics after lateral ankle sprain.
Zwipp, H; Grass, R; Rammelt, S
There are three important principles for the correction of nonunion and/or malunion of the ankle joint: (1) reorientation back to anatomic shape and to the normal biomechanical axis of the ankle and foot; (2) respect for the biology of bone by resecting all sclerotic bone and/or transplantation of autogenous bone graft; and (3) achievement of optimal biomechanical stability by using the four-screw technique, a limited-contact dynamic-compression plate or a blade plate. CT scanning is the most reliable method for detecting nonunion of the ankle joint after arthrodesis. According to Saltzman, in order to understand the pathology of malunions and nonunions and to plan their correction, weight-bearing anteroposterior radiographs with a 20 degrees internal rotation of the feet, precise lateral views, and rear views of both sides are highly recommended.
Armstrong, Miranda E.G.; Cairns, Benjamin J.; Banks, Emily; Green, Jane; Reeves, Gillian K.; Beral, Valerie
While increasing age, decreasing body mass index (BMI), and physical inactivity are known to increase hip fracture risk, whether these factors have similar effects on other common fractures is not well established. We used prospectively-collected data from a large cohort to examine the role of these factors on the risk of incident ankle, wrist and hip fractures in postmenopausal women. 1,155,304 postmenopausal participants in the Million Women Study with a mean age of 56.0 (SD 4.8) years, provided information about lifestyle, anthropometric, and reproductive factors at recruitment in 1996–2001. All participants were linked to National Health Service cause-specific hospital records for day-case or overnight admissions. During follow-up for an average of 8.3 years per woman, 6807 women had an incident ankle fracture, 9733 an incident wrist fracture, and 5267 an incident hip fracture. Adjusted absolute and relative risks (RRs) for incident ankle, wrist, and hip fractures were calculated using Cox regression models. Age-specific rates for wrist and hip fractures increased sharply with age, whereas rates for ankle fracture did not. Cumulative absolute risks from ages 50 to 84 years per 100 women were 2.5 (95%CI 2.2–2.8) for ankle fracture, 5.0 (95%CI 4.4–5.5) for wrist fracture, and 6.2 (95%CI 5.5–7.0) for hip fracture. Compared with lean women (BMI < 20 kg/m2), obese women (BMI ≥ 30 kg/m2) had a three-fold increased risk of ankle fracture (RR = 3.07; 95%CI 2.53–3.74), but a substantially reduced risk of wrist fracture and especially of hip fracture (RR = 0.57; 0.51–0.64 and 0.23; 0.21–0.27, respectively). Physical activity was associated with a reduced risk of hip fracture but was not associated with ankle or wrist fracture risk. Ankle, wrist and hip fractures are extremely common in postmenopausal women, but the associations with age, adiposity, and physical activity differ substantially between the three fracture sites. PMID:22465850
Armstrong, Miranda E G; Cairns, Benjamin J; Banks, Emily; Green, Jane; Reeves, Gillian K; Beral, Valerie
While increasing age, decreasing body mass index (BMI), and physical inactivity are known to increase hip fracture risk, whether these factors have similar effects on other common fractures is not well established. We used prospectively-collected data from a large cohort to examine the role of these factors on the risk of incident ankle, wrist and hip fractures in postmenopausal women. 1,155,304 postmenopausal participants in the Million Women Study with a mean age of 56.0 (SD 4.8) years, provided information about lifestyle, anthropometric, and reproductive factors at recruitment in 1996-2001. All participants were linked to National Health Service cause-specific hospital records for day-case or overnight admissions. During follow-up for an average of 8.3 years per woman, 6807 women had an incident ankle fracture, 9733 an incident wrist fracture, and 5267 an incident hip fracture. Adjusted absolute and relative risks (RRs) for incident ankle, wrist, and hip fractures were calculated using Cox regression models. Age-specific rates for wrist and hip fractures increased sharply with age, whereas rates for ankle fracture did not. Cumulative absolute risks from ages 50 to 84 years per 100 women were 2.5 (95%CI 2.2-2.8) for ankle fracture, 5.0 (95%CI 4.4-5.5) for wrist fracture, and 6.2 (95%CI 5.5-7.0) for hip fracture. Compared with lean women (BMI<20 kg/m(2)), obese women (BMI≥30 kg/m(2)) had a three-fold increased risk of ankle fracture (RR=3.07; 95%CI 2.53-3.74), but a substantially reduced risk of wrist fracture and especially of hip fracture (RR=0.57; 0.51-0.64 and 0.23; 0.21-0.27, respectively). Physical activity was associated with a reduced risk of hip fracture but was not associated with ankle or wrist fracture risk. Ankle, wrist and hip fractures are extremely common in postmenopausal women, but the associations with age, adiposity, and physical activity differ substantially between the three fracture sites. Copyright © 2012 Elsevier Inc. All rights
Cruz-Díaz, David; Lomas Vega, Rafael; Osuna-Pérez, Maria Catalina; Hita-Contreras, Fidel; Martínez-Amat, Antonio
To evaluate the effects of joint mobilization, in which movement is applied to the ankle's dorsiflexion range of motion, on dynamic postural control and on the self-reported instability of patients with chronic ankle instability (CAI). A double-blind, placebo-controlled, randomized trial with repeated measures and a follow-up period. Ninety patients with a history of recurrent ankle sprain, self-reported instability, and a limited dorsiflexion range of motion, were randomly assigned to either the intervention group (Joint Mobilizations, 3 weeks, two sessions per week) the placebo group (Sham Mobilizations, same duration as joint mobilization) or the control group, with a 6 months follow-up. Dorsiflexion Range of Motion (DFROM), Star Excursion Balance Test (SEBT) and CAI Tool (CAIT) were outcome measures. A separate 3 × 4 mixed model analysis of variance was performed to examine the effect of treatment conditions and time, and intention-to-treat (ITT) analysis was applied to evaluate the effect of the independent variable. The application of joint mobilization resulted in better scores of DFROM, CAIT, and SEBTs in the intervention group when compared with the placebo or the control groups (p < 0.001). The effect sizes of group-by-time interaction, measured with eta-squared, oscillated between 0.954 for DFROM and 0.288 for SEBT posteromedial distance. In within-group analysis, the manipulation group showed an improvement at 6 months follow-up in CAIT [mean = 5.23, CI 95% (4.63-5.84)], DFROM [mean = 6.77, CI 95% (6.45-7.08)], anterior SEBT [mean = 7.35, CI 95% (6.59-8.12)], posteromedial SEBT [mean = 3.32, CI 95% (0.95-5.69)], and posterolateral SEBT [mean = 2.55, CI 95% (2.20-2.89)]. Joint mobilization techniques applied to subjects suffering from CAI were able to improve ankle DFROM, postural control, and self-reported instability. These results suggest that joint mobilization could be applied to patients with recurrent ankle sprain to
Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.
Kunz, R.I.; Coradini, J.G.; Silva, L.I.; Bertolini, G.R.F.; Brancalhão, R.M.C.; Ribeiro, L.F.C.
A sprained ankle is a common musculoskeletal sports injury and it is often treated by immobilization of the joint. Despite the beneficial effects of this therapeutic measure, the high prevalence of residual symptoms affects the quality of life, and remobilization of the joint can reverse this situation. The aim of this study was to analyze the effects of immobilization and remobilization on the ankle joint of Wistar rats. Eighteen male rats had their right hindlimb immobilized for 15 days, and were divided into the following groups: G1, immobilized; G2, remobilized freely for 14 days; and G3, remobilized by swimming and jumping in water for 14 days, performed on alternate days, with progression of time and a series of exercises. The contralateral limb was the control. After the experimental period, the ankle joints were processed for microscopic analysis. Histomorphometry did not show any significant differences between the control and immobilized/remobilized groups and members, in terms of number of chondrocytes and thickness of the articular cartilage of the tibia and talus. Morphological analysis of animals from G1 showed significant degenerative lesions in the talus, such as exposure of the subchondral bone, flocculation, and cracks between the anterior and mid-regions of the articular cartilage and the synovial membrane. Remobilization by therapeutic exercise in water led to recovery in the articular cartilage and synovial membrane of the ankle joint when compared with free remobilization, and it was shown to be an effective therapeutic measure in the recovery of the ankle joint. PMID:25140815
Kadakia, Rishin J; Hsu, Raymond Y; Hayda, Roman; Lee, Yoojin; Bariteau, Jason T
The incidence of geriatric ankle fractures will undoubtedly increase as the population continues to grow. Many geriatric patients struggle to function independently after such injury and often require placement into nursing homes. The morbidity and mortality associated with nursing homes is well documented within the field of orthopaedic surgery. However, there is currently no study examining the mortality associated with nursing home placement following hospitalization for an ankle fracture. Therefore, the purpose of this study was to determine if geriatric patients admitted to nursing homes following an ankle fracture experience elevated mortality rates. Patients were identified using diagnosis codes for ankle fractures from all 2008 part A Medicare claims, and those admitted to nursing homes were identified using a Minimum Data Set (MDS). The Medicare database was also analyzed for specific variables including over-all one year mortality, length of stay, age distribution, certain demographical characteristics, incidence of medical and surgical complications within 90 days, and the presence of comorbidities. Multivariate logistic regression analysis was used to determine if patients admitted to nursing homes had elevated mortality rates. 19,648 patients with ankle fractures were identified, and 11,625 (59.0%) of these patients went to a nursing home after hospitalization. Patients who went to a nursing home had higher Elixhauser and Deyo-Charlson comorbidity scores (p<0.0001). Nursing home patients also had significantly increased rates of postoperative medical and surgical complications. One year mortality was 6.9% for patients who did not go to a nursing home and 15.4% for patients who were admitted to a nursing home (p<0.0001). However, multivariate logistic regression analysis demonstrated no significant difference in one year mortality between patients admitted to nursing homes and those who were not (OR=1.1; 95% CI 0.99-1.24, p>0.05). Although admission to
Noh, Jung Ho; Roh, Young Hak; Yang, Bo Gyu; Kim, Seong Wan; Lee, Jun Suk; Oh, Moo Kyung
Biodegradable implants for internal fixation of ankle fractures may overcome some disadvantages of metallic implants, such as imaging interference and the potential need for additional surgery to remove the implants. The purpose of this study was to evaluate the outcomes after fixation of ankle fractures with biodegradable implants compared with metallic implants. In this prospectively randomized study, 109 subjects with an ankle fracture underwent surgery with metallic (Group I) or biodegradable implants (Group II). Radiographic results were assessed by the criteria of the Klossner classification system and time to bone union. Clinical results were assessed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale, Short Musculoskeletal Function Assessment (SMFA) dysfunction index, and the SMFA bother index at three, six, and twelve months after surgery. One hundred and two subjects completed the study. At a mean of 19.7 months, there were no differences in reduction quality between the groups. The mean operative time was 30.2 minutes in Group I and 56.4 minutes in Group II (p < 0.001). The mean time to bone union was 15.8 weeks in Group I and 17.6 weeks in Group II (p = 0.002). The mean AOFAS score was 87.5 points in Group I and 84.3 points in Group II at twelve months after surgery (p = 0.004). The mean SMFA dysfunction index was 8.7 points in Group I and 10.5 points in Group II at twelve months after surgery (p = 0.060). The mean SMFA bother index averaged 3.3 points in Group I and 4.6 points in Group II at twelve months after surgery (p = 0.052). No difference existed between the groups with regard to clinical outcomes for the subjects with an isolated lateral malleolar fracture. The outcomes after fixation of bimalleolar ankle fractures with biodegradable implants were inferior to those after fixation with metallic implants in terms of the score on the AOFAS scale and time to bone union. However, the difference in the final AOFAS
Hintermann, B; Barg, A; Knupp, M
We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98). In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15). Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.
Gurgenidze, T; Mizandari, M
The aim of the research is to study sonosemiotics of ankle joint pathology by means of ultrasound in order to optimize the diagnostic process and improve the treatment. 130 patients (age ranges from 5 to 70 years) underwent the radiological study of ankle joint medial aspect. Pathology types: degenerative-dystrophic diseases - 39 (30%), inflammatory pathology - 21 (16.2%), traumatic injuries - 20 (15.2%), vascular pathologies - 26 (20%), neurogenic problems -7 (5.4%), soft tissue neoplasms - 5 (3.8%), congenital anomalies - 7 (5.4%) and vertebral pathology - 5 (4.0%). The diagnostic studies include: a) Ultrasound, performed on digital ultrasound system using high frequency (7.5-12.0 MHz) linear probe with Doppler capability (all patients); b) X-Ray filming in antero-posterior and lateral projections (6 patients- 4.5%); c) MRI - T1 and T2 weighted images in saggital and transverse planes 10 patients (10.0%) and d) CT - 2 patients (1.5%); To 2 (1.5%) patient biopsy has been performed. This study showed that ultrasound was successful in ankle joint medial aspect pathology diagnosis in 108 cases (84.0%); It was ineffective in osseous pathology definition. In final diagnosis of impingment syndrom MRI was required in 4 (3.6%) cases. It is concluded that ultrasound should be used as a Gold Standard in diagnosis of localized pain and swelling in the ankle joint.
Nortunen, Simo; Leskelä, Hannu-Ville; Haapasalo, Heidi; Flinkkilä, Tapio; Ohtonen, Pasi; Pakarinen, Harri
This study aimed to identify factors from standard radiographs that contributed to the stability of the ankle mortise in patients with isolated supination-external rotation fractures of the lateral malleolus (OTA/AO 44-B). Non-stress radiographs of the mortise and lateral views, without medial clear space widening or incongruity, were prospectively collected for 286 consecutive patients (mean age, 45 years [range, 16 to 85 years]), including 144 female patients (mean age, 50 years [range, 17 to 85 years]) and 142 male patients (mean age, 40 years [range, 16 to 84 years]) from 2 trauma centers. The radiographs were analyzed for fracture morphology by 2 orthopaedic surgeons, who were blinded to each other's measurements and to the results of external rotation stress radiographs (the reference for stability). Factors significantly associated with ankle mortise stability were tested in multiple logistic regression. Receiver operating characteristic analyses were performed for continuous variables to determine optimal thresholds. A sensitivity of >90% was used as the criterion for an optimal threshold. According to external rotation stress radiographs, 217 patients (75.9%) had a stable injury, defined as that with a medial clear space of <5 mm. Independent factors that predicted stable ankle mortise were female sex (odds ratio [OR], 2.5 [95% confidence interval (CI), 1.4 to 4.6]), a posterior diastasis of <2 mm (corresponding with a sensitivity of 0.94 and specificity of 0.39) on lateral radiographs (OR, 10.8 [95% CI, 3.7 to 31.5]), and only 2 fracture fragments (OR, 7.3 [95% CI, 2.1 to 26.3]). When the posterior diastasis was <2 mm and only 2 fracture fragments were present, the probability of a stable ankle mortise was 0.98 for 48 female patients (16.8%) and 0.94 for 37 male patients (12.9%). Patients with noncomminuted lateral malleolar fractures (85 patients [29.7%]) could be diagnosed with a stable ankle mortise without further stress testing, when the fracture
Fukui, Tsutomu; Ueda, Yasuhisa; Kamijo, Fumiko
[Purpose] Support moment was defined as the sum of ankle plantar flexion, knee and hip extension moments. There are some mechanical relationships among the 3 joints. If these relationships were understood, it might be possible to determine which joint should be strengthened to improve gait. The aims of this study were to examine the mutual relationship among kinetic variables of the 3 joints during different phases. [Subjects and Methods] Twenty-five healthy subjects volunteered for this study. They were asked to walk on a platform at a self-selected speed. Correlation coefficients between support moment and vertical ground reaction force were calculated for each subject. Pearson correlation analysis was performed among the 3 joint moments and between each joint moment and vertical ground reaction force. [Results] Knee and hip extension moments showed negative correlation throughout the stance. Ankle moment had a positive with hip but a negative correlation with knee moment except in the initial contact and pre-swing. Hip moment in the initial contact, knee moment in the loading response, and ankle moment from the terminal stance to pre-swing had a high correlation with vertical ground reaction force. [Conclusion] The results may indicate which joint should be strengthened to improve gait pattern. PMID:27821945
Berkes, M B; Little, M T M; Lazaro, L E; Sculco, P K; Cymerman, R M; Daigl, M; Helfet, D L; Lorich, D G
It has previously been suggested that among unstable ankle fractures, the presence of a malleolar fracture is associated with a worse outcome than a corresponding ligamentous injury. However, previous studies have included heterogeneous groups of injury. The purpose of this study was to determine whether any specific pattern of bony and/or ligamentous injury among a series of supination-external rotation type IV (SER IV) ankle fractures treated with anatomical fixation was associated with a worse outcome. We analysed a prospective cohort of 108 SER IV ankle fractures with a follow-up of one year. Pre-operative radiographs and MRIs were undertaken to characterise precisely the pattern of injury. Operative treatment included fixation of all malleolar fractures. Post-operative CT was used to assess reduction. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and the range of movement of the ankle. There were no clinically relevant differences between the four possible SER IV fracture pattern groups with regard to the FAOS or range of movement. In this population of strictly defined SER IV ankle injuries, the presence of a malleolar fracture was not associated with a significantly worse clinical outcome than its ligamentous injury counterpart. Other factors inherent to the injury and treatment may play a more important role in predicting outcome.
Fullam, Karl; Caulfield, Brian; Coughlan, Garrett F.; McGroarty, Mark; Delahunt, Eamonn
Context Decreased postural stability is a primary risk factor for lower limb musculoskeletal injuries. During athletic competitions, cryotherapy may be applied during short breaks in play or during half-time; however, its effects on postural stability remain unclear. Objective To investigate the acute effects of a 15-minute ankle-joint cryotherapy application on dynamic postural stability. Design Controlled laboratory study. Setting University biomechanics laboratory. Patients or Other Participants A total of 29 elite-level collegiate male field-sport athletes (age = 20.8 ± 1.12 years, height = 1.80 ± 0.06 m, mass = 81.89 ± 8.59 kg) participated. Intervention(s) Participants were tested on the anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions of the Star Excursion Balance Test before and after a 15-minute ankle-joint cryotherapy application. Main Outcome Measure(s) Normalized reach distances; sagittal-plane kinematics of the hip, knee, and ankle joints; and associated mean velocity of the center-of-pressure path during performance of the ANT, PL, and PM reach directions of the Star Excursion Balance Test. Results We observed a decrease in reach-distance scores for the ANT, PL, and PM reach directions from precryotherapy to postcryotherapy (P < .05). No differences were observed in hip-, knee-, or ankle-joint sagittal-plane kinematics (P > .05). We noted a decrease in mean velocity of the center-of-pressure path from precryotherapy to postcryotherapy (P < .05) in all reach directions. Conclusions Dynamic postural stability was adversely affected immediately after cryotherapy to the ankle joint. PMID:26285088
Forlani, Margherita; Sancisi, Nicola; Parenti-Castelli, Vincenzo
A kinetostatic model able to replicate both the natural unloaded motion of the tibiotalar (or ankle) joint and the joint behavior under external loads is presented. The model is developed as the second step of a sequential procedure, which allows the definition of a kinetostatic model as a generalization of a kinematic model of the joint defined at the first step. Specifically, this kinematic model taken as the starting point of the definition procedure is a parallel spatial mechanism which replicates the ankle unloaded motion. It features two rigid bodies (representing the tibia-fibula and the talus-calcaneus complexes) interconnected by five rigid binary links, that mimic three articular contacts and two nearly isometric fibers (IFs) of the tibiocalcaneal ligament (TiCaL) and calcaneofibular ligament (CaFiL). In the kinetostatic model, the five links are considered as compliant; moreover, further elastic structures are added to represent all the main ankle passive structures of the joint. Thanks to this definition procedure, the kinetostatic model still replicates the ankle unloaded motion with the same accuracy as the kinematic model. In addition, the model can replicate the behavior of the joint when external loads are applied. Finally, the structures that guide these motions are consistent with the anatomical evidence. The parameters of the model are identified for two specimens from both subject-specific and published data. Loads are then applied to the model in order to simulate two common clinical tests. The model-predicted ankle motion shows good agreement with results from the literature.
Background Ankle joint equinus, or restricted dorsiflexion range of motion (ROM), has been linked to a range of pathologies of relevance to clinical practitioners. This systematic review and meta-analysis investigated the effects of conservative interventions on ankle joint ROM in healthy individuals and athletic populations. Methods Keyword searches of Embase, Medline, Cochrane and CINAHL databases were performed with the final search being run in August 2013. Studies were eligible for inclusion if they assessed the effect of a non-surgical intervention on ankle joint dorsiflexion in healthy populations. Studies were quality rated using a standard quality assessment scale. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and results were pooled where study methods were homogenous. Results Twenty-three studies met eligibility criteria, with a total of 734 study participants. Results suggest that there is some evidence to support the efficacy of static stretching alone (SMDs: range 0.70 to 1.69) and static stretching in combination with ultrasound (SMDs: range 0.91 to 0.95), diathermy (SMD 1.12), diathermy and ice (SMD 1.16), heel raise exercises (SMDs: range 0.70 to 0.77), superficial moist heat (SMDs: range 0.65 to 0.84) and warm up (SMD 0.87) in improving ankle joint dorsiflexion ROM. Conclusions Some evidence exists to support the efficacy of stretching alone and stretching in combination with other therapies in increasing ankle joint ROM in healthy individuals. There is a paucity of quality evidence to support the efficacy of other non-surgical interventions, thus further research in this area is warranted. PMID:24225348
Wynkoop, Aaron; Ndubaku, Osy; Walter, Norman; Atkinson, Theresa
Previous studies have described the mechanism of ankle fractures, their seasonal variation, and fracture patterns but never in conjunction. In addition, the cohorts previously studied were either not from trauma centers or were often dominated by low-energy mechanisms. The present study aimed to describe the epidemiology of ankle fractures presenting to an urban level 1 trauma center. The records from an urban level 1 trauma center located in the Midwestern United States were retrospectively reviewed, and the injury mechanism and energy, time of injury, day of week, month, and patient characteristics (age, gender, comorbidities, smoking status) were collected. The fractures were classified using the AO (Arbeitsgemeinschaft für Osteosynthesefragen), Lauge-Hansen, and Danis-Weber systems. Of these systems, the Lauge-Hansen classification system resulted in the greatest number of "unclassifiable" cases. Most ankle fractures were due to high-energy mechanisms, with motor vehicle collisions the most common high-energy mechanism. The review found that most ankle fractures were malleolar fractures, regardless of the mechanism of injury. The ankle fracture patients had greater rates of obesity, diabetes, and smoking than present in the region where the hospital is located. The fractures were most likely to occur in the afternoon, with more fractures presenting on the weekend than earlier in the week and more fractures in the fall and winter than in the spring and summer. The temporal variation of these fractures should be considered for health services planning, in particular, in regard to resident physician staffing at urban level 1 trauma centers. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Harris, Ian A; Naylor, Justine M
Background Isolated type B ankle fractures with no injury to the medial side are the most common type of ankle fracture. Objective This study aimed to determine if surgery is superior to non-surgical management for the treatment of these fractures. Methods A pragmatic, multicentre, single-blinded, combined randomised controlled trial and observational study. Setting Participants between 18 and 65 years with a type B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants willing to be randomised were randomly allocated to undergo surgical fixation followed by mobilisation in a walking boot for 6 weeks. Those treated non-surgically were managed in a walking boot for 6 weeks. Participants not willing to be randomised formed the observational cohort. Randomisation stratified by site and using permuted variable blocks was administered centrally. Outcome assessors were blinded for the primary outcomes. Primary outcomes Patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component score (PCS) of the SF-12v2 General Health Survey at 12 months postinjury. Primary analysis was intention to treat; the randomised and observational cohorts were analysed separately. Results From August 2010 to October 2013, 160 people were randomised (80 surgical and 80 non-surgical); 139 (71 surgical and 68 non-surgical) were analysed as intention to treat. 276 formed the observational cohort (19 surgical and 257 non-surgical); 220 (18 surgical and 202 non-surgical) were analysed. The randomised cohort demonstrated that surgery was not superior to non-surgery for the FAOQ (49.8 vs 53.0; mean difference 3.2 (95% CI 0.4 to 5.9), p=0.028), or the PCS (53.7 vs 53.2; mean difference 0.6 (−2.9 to 1.8), p=0.63). 23 (32%) and 10 (14%) participants had an adverse event in the surgical and non-surgical groups, respectively. Similar results were
The dancer's foot and ankle are subjected to high forces and unusual stresses in training and performance. Injuries are common in dancers, and the foot and ankle are particularly vulnerable. Ankle sprains, ankle impingement syndromes, flexor hallucis longus tendonitis, cuboid subluxation, stress fractures, midfoot injuries, heel pain, and first metatarsophalangeal joint problems including hallux valgus, hallux rigidus, and sesamoid injuries will be reviewed. This article will discuss these common foot and ankle problems in dancers and give typical clinical presentation and diagnostic and treatment recommendations.
Lareau, Craig R.; Daniels, Alan H.; Vopat, Bryan G.; Kane, Patrick M.
Unstable ankle fractures and impacted tibial pilon fractures often benefit from provisional external fixation as a temporizing measure prior to definitive fixation. Benefits of external fixation include improved articular alignment, decreased articular impaction, and soft tissue rest. Uniplanar external fixator placement in the Emergency Department (ED ex-fix) is a reliable and safe technique for achieving ankle reduction and stability while awaiting definitive fixation. This procedure involves placing transverse proximal tibial and calcaneal traction pins and connecting the pins with two external fixator rods. This technique is particularly useful in austere environments or when the operating room is not immediately available. Additionally, this bedside intervention prevents the patient from requiring general anesthesia and may be a cost-effective strategy for decreasing valuable operating time. The ED ex-fix is an especially valuable procedure in busy trauma centers and during mass casualty events, in which resources may be limited. PMID:25709258
Background Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial. Case presentation A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications. Conclusion In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires. PMID:25103697
... ankle replacement. Your surgeon removed and reshaped damaged bones, and put in an artificial ankle joint. You received pain medicine and were shown how to treat swelling around your new ankle joint.
Butler, Daniel P; Henry, Francis P; Ghali, Shadi
Spinning is an increasingly popular form of cycle-based exercise. The workouts are often of high-intensity and participants are intermittently encouraged to achieve a high crank-set-cadence rate. We report a unique case of an open ankle fracture requiring free flap coverage, which highlights the potential perils of spinning class. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Mirmiran, Roya; Wilde, Brandon; Nielsen, Michael
Arthrodesis is a common procedure indicated for surgical treatment of end-stage degenerative joint disease of the foot and ankle. Many published studies have reviewed the union rate, focusing on specific technique or fixation. However, studies reporting on the average period required to achieve fusion, irrespective of the type of fixation or surgical method used, have been lacking. We report on the union rate and interval to fusion in patients who had undergone primary arthrodesis of various joints of the foot and ankle. A retrospective review of the medical records of 135 patients was performed. The specific joints studied were ankle, and the subtalar, triple, first tarsometatarsal, first metatarsophalangeal, and hallux interphalangeal joints. Our results showed that the average interval for complete fusion was significantly less for the joints in the forefoot, with the subtalar joint, ankle, and triple arthrodesis requiring a longer period to achieve complete fusion. The nonunion rate was also greater when the fusion involved the joints of the rearfoot. Our results have refuted the idea that 6 weeks is the minimum period required to achieve fusion in the foot and ankle. The results of our study support the need for additional education of the patients and surgeons that the interval required for recovery after foot and ankle fusion depends on the location and surface area that has been fused. Copyright © 2014 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Anđelković, Slađana Z; Vučković, Čedo Đ; Palibrk, Tomislav D; Milutinović, Suzana M; Bumbaširević, Marko Ž
The free microvascular fibula and soft tissue transfer has become a widely used method for reconstruction of different regions. Donor site morbidity for free fibula microvascular flaps has generally been reported to be low, or at least acceptable. We describe the case of a patient who underwent vascularized free fibula graft harvest for mandibular reconstruction. After 21 months, he had sustained an open dislocation of the left high ankle joint during recreational sports activity. We did not found such case in the published data. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Guarín, Diego L.; Kearney, Robert E.
Dynamic joint stiffness determines the relation between joint position and torque, and plays a vital role in the control of posture and movement. Dynamic joint stiffness can be quantified during quasi-stationary conditions using disturbance experiments, where small position perturbations are applied to the joint and the torque response is recorded. Dynamic joint stiffness is composed of intrinsic and reflex mechanisms that act and change together, so that nonlinear, mathematical models and specialized system identification techniques are necessary to estimate their relative contributions to overall joint stiffness. Quasi-stationary experiments have demonstrated that dynamic joint stiffness is heavily modulated by joint position and voluntary torque. Consequently, during movement, when joint position and torque change rapidly, dynamic joint stiffness will be Time-Varying (TV). This paper introduces a new method to quantify the TV intrinsic and reflex components of dynamic joint stiffness during movement. The algorithm combines ensemble and deterministic approaches for estimation of TV systems; and uses a TV, parallel-cascade, nonlinear system identification technique to separate overall dynamic joint stiffness into intrinsic and reflex components from position and torque records. Simulation studies of a stiffness model, whose parameters varied with time as is expected during walking, demonstrated that the new algorithm accurately tracked the changes in dynamic joint stiffness using as little as 40 gait cycles. The method was also used to estimate the intrinsic and reflex dynamic ankle stiffness from an experiment with a healthy subject during which ankle movements were imposed while the subject maintained a constant muscle contraction. The method identified TV stiffness model parameters that predicted the measured torque very well, accounting for more than 95% of its variance. Moreover, both intrinsic and reflex dynamic stiffness were heavily modulated through the
Matsui, Nobumasa; Shoji, Morio; Kitagawa, Takashi; Terada, Shigeru
[Purpose] Increased plantar pressure during walking is a risk factor for foot ulcers because of reduced range of motion at the ankle and first metatarsophalangeal joints. However, the range of motion in patients undergoing hemodialysis has not yet been determined. A cross-sectional study was performed to investigate the factors affecting the range of motion of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis who walk daily. [Subjects and Methods] Seventy feet of 35 patients receiving hemodialysis therapy were examined. Measurements included the passive range of motion of plantar flexion and dorsiflexion of the ankle joint, and flexion and extension of the first metatarsophalangeal joint. [Results] Hemodialysis duration was not associated with ankle and first metatarsophalangeal joint range of motion in patients undergoing hemodialysis. Diabetes duration was significantly associated with limited ankle joint mobility. Finally, blood hemoglobin levels, body mass index, and age were associated with first metatarsophalangeal joint range of motion. [Conclusion] The present study identified age, diabetes, and decreased physical activity, but not hemodialysis duration, to be risk factors for limited joint mobility of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis. PMID:27313371
Matsui, Nobumasa; Shoji, Morio; Kitagawa, Takashi; Terada, Shigeru
[Purpose] Increased plantar pressure during walking is a risk factor for foot ulcers because of reduced range of motion at the ankle and first metatarsophalangeal joints. However, the range of motion in patients undergoing hemodialysis has not yet been determined. A cross-sectional study was performed to investigate the factors affecting the range of motion of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis who walk daily. [Subjects and Methods] Seventy feet of 35 patients receiving hemodialysis therapy were examined. Measurements included the passive range of motion of plantar flexion and dorsiflexion of the ankle joint, and flexion and extension of the first metatarsophalangeal joint. [Results] Hemodialysis duration was not associated with ankle and first metatarsophalangeal joint range of motion in patients undergoing hemodialysis. Diabetes duration was significantly associated with limited ankle joint mobility. Finally, blood hemoglobin levels, body mass index, and age were associated with first metatarsophalangeal joint range of motion. [Conclusion] The present study identified age, diabetes, and decreased physical activity, but not hemodialysis duration, to be risk factors for limited joint mobility of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis.
Goldstein, Rachel Y; Montero, Nicole; Jain, Sudheer K; Egol, Kenneth A; Tejwani, Nirmal C
To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. Institutional Review Board approved prospective randomized study. Metropolitan tertiary-care referral center. All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control.
Introduction We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population. Methods We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions. Results We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year. Conclusions The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies. PMID:21190571
Lin, Chou-Ching K; Ju, Ming-Shaung; Chan, Ching-Chao
The main goal of this study was to develop a new method of estimating the angle of the passively stretched ankle joint, based on structural muscle spindle models of the tibial and peroneal electroneurograms (ENG). Passive ramp-and-hold and alternating stretches of the ankle joint were performed in a rabbit. Simultaneously, two cuff electrodes were used to record the ENGs of peroneal and tibial nerves. Based on the two ENGs and the joint angle trajectory, two muscle spindle models were constructed and their inverse models were integrated to compute angle estimates. The model parameters were optimized. The performance of our approach was compared with those of the adaptive neuro-fuzzy inference system and artificial neural network model. The results revealed that our model had a better performance of estimating the ankle joint angle in large-range movements and smaller tracking errors. This study provides a new estimation algorithm to extract the joint angle from the information conveyed in a nerve.
Santos, Marcio J; McIntire, Kevin; Foecking, Joseph; Liu, Wen
The use of prophylactic ankle braces is common during athletic activities since the ankle is one of the most commonly injured joints. Past studies have focused on the effects of ankle braces on ankle movement restriction, preventing injuries, proprioception, balance and athletic performance. However, the influence of ankle restriction on other joints has not been studied. The constraint of ankle movement may lead to an increased loading on the knee joint, which could be a potential risk of knee injuries during athletic activities. The primary goal of the current study was to determine quantitatively the effect of an ankle brace on the knee axial rotation during two different trunk turning tasks. Ten healthy subjects performed trunk turning movements while standing on one leg: turning sideways to catch a ball and turning sideways to touch a target with the shoulder. The tasks were performed with and without an ankle brace worn on the supporting leg. The trunk axial rotation in reference to the floor and three dimensional joint angular motions of the ankle, knee and hip were determined. The use of an ankle brace resulted in reduced trunk axial rotation during the ball catching tasks, and increased knee axial rotation during the target touching tasks. The results of this study showed that the effect of the ankle brace on the knee axial rotation depended on the context of the tasks performed. Under situations that required forceful trunk turning movement while standing on a single leg, the ankle braces may cause an increase in the knee axial rotation indicating higher risk of knee injury.
Richards, David P; Ajemian, Stanley V; Wiley, J Preston; Brunet, Jacques A; Zernicke, Ronald F
Ankle joint complex dynamics developed during volleyball spike jumps take-offs and landings were quantified to assess potential relations between these joint dynamics and patellar tendinopathy. Three-dimensional kinematic data provided information about movements of the lower limbs, while the kinetic data permitted analysis of ground reaction forces as players took-off and landed from full-speed spike jumps. Simulated volleyball court with net in a biomechanics research laboratory. 10 members of the Canadian Men's National Volleyball Team. From history and physical examination, 3 of the 10 players had patellar tendon pain associated with activity and were diagnosed with patellar tendinopathy at the time of the study. Investigators were blinded about the injury status of the players. None. Three-dimensional kinematics and joint moments of the ankle, knee, and hip joints. Our analysis revealed that maximal external tibial rotation occurred at or near maximal dorsiflexion while maximal internal tibial rotation coincided with maximal plantarflexion. The plantarflexion moment was 3 to 10 times greater than all the other moments measured, with the maximal plantarflexor moment being calculated at 0.4 BWm (360 Nm). In blinded logistic regression analyses, we found one of the dynamics variables (inversion moment during the landing of the spike jump) was a significant predictor of patellar tendinopathy. Coupling the results of the current analysis of ankle joint complex dynamics with previously reported results of knee joint dynamics related to patellar tendinopathy suggests that a cluster of variables linked to patellar tendinopathy includes: high ankle inversion-eversion moments, high external tibial rotation and plantarflexion moments, large vertical ground reaction forces, and high rate of knee extensor moment development.
Mandell, Jacob C; Khurana, Bharti; Smith, Stacy E
Stress fractures of the foot and ankle are a commonly encountered problem among athletes and individuals participating in a wide range of activities. This illustrated review, the second of two parts, discusses site-specific etiological factors, imaging appearances, treatment options, and differential considerations of stress fractures of the foot and ankle. The imaging and clinical management of stress fractures of the foot and ankle are highly dependent on the specific location of the fracture, mechanical forces acting upon the injured site, vascular supply of the injured bone, and the proportion of trabecular to cortical bone at the site of injury. The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. In contrast, high-risk stress fractures are more prone to delayed union or nonunion and include the anterior tibial cortex, medial malleolus, navicular, base of the second metatarsal, proximal fifth metatarsal, hallux sesamoids, and the talus. Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the watershed blood supply in these locations. The radiographic differential diagnosis of stress fracture includes osteoid osteoma, malignancy, and chronic osteomyelitis.
Huang, Bingzhe; Kim, Yong Tae; Kim, Jung Uk; Shin, Jung Hoon; Park, Yong Wook; Kim, Hyong Nyun
Chronic ankle instability with generalized joint hypermobility (GJH) is considered a contraindication for the modified Broström procedure. The most widely accepted definition of GJH is a Beighton score of ≥4 on a 9-point scale. However, it is not clear whether this criterion can be applied to determine the GJH that would lead to a poor outcome after a modified Broström procedure. Some of the previous studies that report unfavorable outcomes do not specify the tests or cutoff scores used to determine the GJH, and, in fact, some of the patients with GJH in these studies had good outcomes. The modified Broström procedure results in satisfactory outcomes in patients who have chronic ankle instability with GJH if the contralateral uninjured ankle shows a normal varus talar tilt and anterior talar translation during stress tests. Case series; Level of evidence, 4. Modified Broström procedure was performed in 32 patients with chronic ankle instability with GJH if the contralateral uninjured ankle showed a normal varus talar tilt and anterior talar translation on stress tests. The mean patient age at surgery was 21.7 years, and the mean follow-up duration was 27.4 months. The Karlsson-Peterson ankle score significantly improved from a mean ± SD of 63.6 ± 7.1 preoperatively to 90.4 ± 6.7 at the final postoperative follow-up (P < .001). Sixteen patients were very satisfied with the results, 10 patients were satisfied, 3 patients rated their satisfaction as fair, and 1 patient was dissatisfied with the results. Nine patients sustained ankle sprains after the surgery, 6 of which were mild sprains. Although 3 of these 9 patients had a mechanically unstable ankle on stress radiographs, they were satisfied with the postoperative results. None of the patients required a reoperation. GJH was not a contraindication for the modified Broström procedure if the contralateral uninjured ankle showed a normal varus talar tilt and a normal anterior talar translation on stress
Little, Milton M T; Berkes, Marschall B; Schottel, Patrick C; Garner, Matthew R; Lazaro, Lionel E; Birnbaum, Jacqueline F; Helfet, David L; Lorich, Dean G
To compare radiographic and clinical outcomes of supination external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B2.1) treated with transsyndesmotic screw fixation with those treated with deltoid and posterior inferior tibiofibular ligament (PITFL) repair. Case series and single-surgeon retrospective analysis of a prospective database. Academic level I trauma center. Forty-five SER IV E ankle fractures fulfilled all inclusion/exclusion criteria with at least 12 months of radiographic follow-up. Deltoid and PITFL repair in addition to lateral malleolus fixation compared with transsyndesmotic screw fixation. Syndesmotic reduction compared with contralateral extremity on a postoperative computed tomography scan and maintenance of reduction based on final postoperative radiographs [medial clear space (MCS) and tibiofibular clear space (TCS)]. There was no significant difference in mean postoperative TCS, MCS, or change in TCS or MCS between the cohorts. The anatomic treatment group had significantly better postoperative syndesmotic reduction compared with the transsyndesmotic cohort (7.4% vs. 33.3%; P = 0.02). Fourteen patients in the transsyndesmotic screw cohort underwent removal compared with 3 patients in the anatomic cohort who required secondary procedures. The transsyndesmotic screw cohort had statistically significant better mean dorsiflexion of ankle (mean 20 vs. 17 degrees; P = 0.02). This comparison of treatment strategies for SER IV E ankle fractures has shown an improvement in immediate postoperative syndesmotic reduction and the elimination of reoperation for removal of transsyndesmotic screws in patients treated with PITFL repair. Previous research has shown a good correlation between functional outcomes and syndesmotic reduction; however, further investigation into the functional outcomes of these patients is necessary to determine the future clinical impact of this anatomic fixation strategy. Therapeutic Level III
Pakarinen, Harri J; Flinkkilä, Tapio E; Ohtonen, Pasi P; Hyvönen, Pekka H; Lakovaara, Martti T; Leppilahti, Juhana I; Ristiniemi, Jukka Y
This study was designed to assess whether transfixion of an unstable syndesmosis is necessary in supination-external rotation (Lauge-Hansen SE/Weber B)-type ankle fractures. A prospective study of 140 patients with unilateral Lauge-Hansen supination-external rotation type 4 ankle fractures was done. After bony fixation, the 7.5-Nm standardized external rotation (ER) stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. If the stress test was positive, the patient was randomized to either syndesmotic transfixion with 3.5-mm tricortical screws or no syndesmotic fixation. Clinical outcome was assessed using the Olerud-Molander scoring system, RAND 36-Item Health Survey, and Visual Analogue Scale (VAS) to measure pain and function after a minimum 1-year of followup. Twenty four (17%) of 140 patients had positive standardized 7.5-Nm ER stress tests after malleolar fixation. The stress view was positive three times on tibiotalar clear space, seven on tibiofibular clear space, and 14 times on both tibiotalar and tibiofibular clear spaces. There was no significant difference between the two randomization groups with regards to Olerud-Molander functional score, VAS scale measuring pain and function, or RAND 36-Item Health Survey pain or physical function at 1 year. Relevant syndesmotic injuries are rare in supination-external rotation ankle fractures, and syndesmotic transfixion with a screw did not influence the functional outcome or pain after the 1-year followup compared with no fixation.
Witteveen, Angelique G H; Sierevelt, Inger N; Blankevoort, Leendert; Kerkhoffs, Gino M M J; van Dijk, C Niek
To determine the efficacy, safety and dose dependency of intra-articular Orthovisc(®) hyaluronic acid injections in the ankle. A prospective single blinded study in patients with symptomatic ankle-osteoarthritis. Patients were randomly allocated to 1, 2, 3 ml, or 3 weekly injections of 1 ml (3 × 1 ml). Primary outcome was 'pain during walking' at 15 weeks measured on a 100mm VAS. Twenty-six patients (ITT) participated. The 3 × 1 ml dose group showed statistically significant decreases at week 7 for 'pain during walking' and 'pain at rest' (p=0.046). At week 15 decreases were significant for 'pain at rest' (p=0.046). There was no significant decrease of VAS-scores in any of the single dose groups. Seven patients experienced temporary local swelling and increased pain in the injected ankle. Orthovisc(®) viscosupplementation in the ankle joint is effective and well tolerated. The 3 × 1 ml dose regimen shows the best results. Copyright © 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Fuller, Joel T; Buckley, Jonathan D; Tsiros, Margarita D; Brown, Nicholas A T; Thewlis, Dominic
Minimalist shoes have been suggested as a way to alter running biomechanics to improve running performance and reduce injuries. However, to date, researchers have only considered the effect of minimalist shoes at slow running speeds. To determine if runners change foot-strike pattern and alter the distribution of mechanical work at the knee and ankle joints when running at a fast speed in minimalist shoes compared with conventional running shoes. Crossover study. Research laboratory. Twenty-six trained runners (age = 30.0 ± 7.9 years [age range, 18-40 years], height = 1.79 ± 0.06 m, mass = 75.3 ± 8.2 kg, weekly training distance = 27 ± 15 km) who ran with a habitual rearfoot foot-strike pattern and had no experience running in minimalist shoes. Participants completed overground running trials at 18 km/h in minimalist and conventional shoes. Sagittal-plane kinematics and joint work at the knee and ankle joints were computed using 3-dimensional kinematic and ground reaction force data. Foot-strike pattern was classified as rearfoot, midfoot, or forefoot strike based on strike index and ankle angle at initial contact. We observed no difference in foot-strike classification between shoes (χ(2)1 = 2.29, P = .13). Ankle angle at initial contact was less (2.46° versus 7.43°; t25 = 3.34, P = .003) and strike index was greater (35.97% versus 29.04%; t25 = 2.38, P = .03) when running in minimalist shoes compared with conventional shoes. We observed greater negative (52.87 J versus 42.46 J; t24 = 2.29, P = .03) and positive work (68.91 J versus 59.08 J; t24 = 2.65, P = .01) at the ankle but less negative (59.01 J versus 67.02 J; t24 = 2.25, P = .03) and positive work (40.37 J versus 47.09 J; t24 = 2.11, P = .046) at the knee with minimalist shoes compared with conventional shoes. Running in minimalist shoes at a fast speed caused a redistribution of work from the knee to the ankle joint. This finding suggests that runners changing from conventional to minimalist shoes
Fuller, Joel T.; Buckley, Jonathan D.; Tsiros, Margarita D.; Brown, Nicholas A. T.; Thewlis, Dominic
Context: Minimalist shoes have been suggested as a way to alter running biomechanics to improve running performance and reduce injuries. However, to date, researchers have only considered the effect of minimalist shoes at slow running speeds. Objective: To determine if runners change foot-strike pattern and alter the distribution of mechanical work at the knee and ankle joints when running at a fast speed in minimalist shoes compared with conventional running shoes. Design: Crossover study. Setting: Research laboratory. Patients or Other Participants: Twenty-six trained runners (age = 30.0 ± 7.9 years [age range, 18−40 years], height = 1.79 ± 0.06 m, mass = 75.3 ± 8.2 kg, weekly training distance = 27 ± 15 km) who ran with a habitual rearfoot foot-strike pattern and had no experience running in minimalist shoes. Intervention(s): Participants completed overground running trials at 18 km/h in minimalist and conventional shoes. Main Outcome Measure(s): Sagittal-plane kinematics and joint work at the knee and ankle joints were computed using 3-dimensional kinematic and ground reaction force data. Foot-strike pattern was classified as rearfoot, midfoot, or forefoot strike based on strike index and ankle angle at initial contact. Results: We observed no difference in foot-strike classification between shoes (χ21 = 2.29, P = .13). Ankle angle at initial contact was less (2.46° versus 7.43°; t25 = 3.34, P = .003) and strike index was greater (35.97% versus 29.04%; t25 = 2.38, P = .03) when running in minimalist shoes compared with conventional shoes. We observed greater negative (52.87 J versus 42.46 J; t24 = 2.29, P = .03) and positive work (68.91 J versus 59.08 J; t24 = 2.65, P = .01) at the ankle but less negative (59.01 J versus 67.02 J; t24 = 2.25, P = .03) and positive work (40.37 J versus 47.09 J; t24 = 2.11, P = .046) at the knee with minimalist shoes compared with conventional shoes. Conclusions: Running in minimalist shoes at a fast speed caused a
Daimaruya, M.; Fujiki, H.; Ambarita, H.
This study is concerned with the development of a fracture criterion for the impact fracture of jointed steel plates of a bolted joint used in a car body. For the accurate prediction of crash characteristics of car bodies by computer-aided engineering (CAE), it is also necessary to examine the behavior and fracture of jointed steel plates subjected to impact loads. Although the actual impact fracture of jointed steel plates of a bolted joint used in cars is complicated, for simplifying the problem it might be classified into the shear fracture and the extractive fracture of jointed steel plates. Attention is given to the extractive fracture of jointed steel plates in this study. The extractive behavior and fracture of three kinds of steel plates used for cars are examined in experiments and numerical simulations. The impact extraction test of steel plates jointed by a bolt is performed using the one-bar method, together with the static test. In order to understand the mechanism of extractive fracture process of jointed steel plates, numerical simulations by a FEM code LS-DYNA are also carried out. The obtained results suggest that a stress-based fracture criterion may be developed for the impact extractive fracture of jointed steel plates of a bolted joint used in a car body.
de David, Ana Cristina; Carpes, Felipe Pivetta; Stefanyshyn, Darren
Joint moments can be used as an indicator of joint loading and have potential application for sports performance and injury prevention. The effects of changing walking and running speeds on joint moments for the different planes of motion still are debatable. Here, we compared knee and ankle moments during walking and running at different speeds. Data were collected from 11 recreational male runners to determine knee and ankle joint moments during different conditions. Conditions include walking at a comfortable speed (self-selected pacing), fast walking (fastest speed possible), slow running (speed corresponding to 30% slower than running) and running (at 4 m · s(-1) ± 10%). A different joint moment pattern was observed between walking and running. We observed a general increase in joint load for sagittal and frontal planes as speed increased, while the effects of speed were not clear in the transverse plane moments. Although differences tend to be more pronounced when gait changed from walking to running, the peak moments, in general, increased when speed increased from comfortable walking to fast walking and from slow running to running mainly in the sagittal and frontal planes. Knee flexion moment was higher in walking than in running due to larger knee extension. Results suggest caution when recommending walking over running in an attempt to reduce knee joint loading. The different effects of speed increments during walking and running should be considered with regard to the prevention of injuries and for rehabilitation purposes.
O'Neill, Barry J; Sweeney, Laura A; Moroney, Paul J; Mulhall, Kevin J
Antiphospholipid syndrome and systemic erythematosus have been associated with metatarsal stress fractures. Stress fractures of the Lisfranc joint complex are uncommon injuries but have been reported to occur most frequently in ballet dancers. We present a case of an avulsion fracture of the Lisfranc joint complex that occurred spontaneously. We have reviewed the association between systemic conditions and metatarsal fractures and proposed a series of hypothetical pathological events that may have contributed to this unusual injury.
Kynsburg, A; Halasi, T; Tállay, A; Berkes, I
Improvement of ankle proprioception through physiotherapy (a.k.a. proprioceptive training) is a widely accepted conservative treatment modality of chronic functional lateral ankle instability. Clinical studies provided controversial data on its proprioceptive effect. Aim of this study was to gain evidence on the efficacy of proprioceptive training on ankle joint position sense. Ten patients (five males and five females, aged 23.3+/-5.4 years) were treated conservatively for chronic lateral ankle instability with a special training programme over 6 weeks. For the assessment of joint position sense we used the slope-box test, first applied and described by Robbins et al. (Br J Sports Med 29:242-247, 1995). The test was performed before the start and after the end of the training programme, measuring joint position sense on 11 different slope amplitudes in four directions (anterior, posterior, lateral and medial) in random order each on both ankles. Comparisons were made between pre- and post-training results as well as versus a control-group of ten healthy athletes. Overall the proprioceptive sensory function of the studied group has improved, but this improvement was not significant in all directions. Only two patients have shown significant improvement of joint position sense in all directions (mean estimate error improvement: 2.47 degrees ), while conservative treatment was partially successful in five others (mean estimate error improvement: 0.73 degrees ). The follow-up results of these seven patients were comparable with the values measured in the control-group. Three patients did not show any improvements (mean estimate error improvement: -0.55 degrees ) (overall difference between improving and non-improving patients: P<0.0001). Mean absolute estimate error profiles of the seven improving patients became similar to the profiles of healthy athletes, while these changes could not be observed in the case of the three non-improving participants. Proprioceptive
Carlson, Kristian J; Jashashvili, Tea; Houghton, Kimberley; Westaway, Michael C; Patel, Biren A
Joint surfaces of limb bones are loaded in compression by reaction forces generated from body weight and musculotendon complexes bridging them. In general, joints of eutherian mammals have regions of high radiodensity subchondral bone that are better at resisting compressive forces than low radiodensity subchondral bone. Identifying similar form-function relationships between subchondral radiodensity distribution and joint load distribution within the marsupial postcranium, in addition to providing a richer understanding of marsupial functional morphology, can serve as a phylogenetic control in evaluating analogous relationships within eutherian mammals. Where commonalities are established across phylogenetic borders, unifying principles in mammalian physiology, morphology, and behavior can be identified. Here, we assess subchondral radiodensity patterns in distal tibiae of several marsupial taxa characterized by different habitual activities (e.g., locomotion). Computed tomography scanning, maximum intensity projection maps, and pixel counting were used to quantify radiodensity in 41 distal tibiae of bipedal (5 species), arboreal quadrupedal (4 species), and terrestrial quadrupedal (5 species) marsupials. Bipeds (Macropus and Wallabia) exhibit more expansive areas of high radiodensity in the distal tibia than arboreal (Dendrolagus, Phascolarctos, and Trichosurus) or terrestrial quadrupeds (Sarcophilus, Thylacinus, Lasiorhinus, and Vombatus), which may reflect the former carrying body weight only through the hind limbs. Arboreal quadrupeds exhibit smallest areas of high radiodensity, though they differ non-significantly from terrestrial quadrupeds. This could indicate slightly more compliant gaits by arboreal quadrupeds compared to terrestrial quadrupeds. The observed radiodensity patterns in marsupial tibiae, though their statistical differences disappear when controlling for phylogeny, corroborate previously documented patterns in primates and xenarthrans
Carlson, Kristian J.; Jashashvili, Tea; Houghton, Kimberley; Westaway, Michael C.; Patel, Biren A.
Joint surfaces of limb bones are loaded in compression by reaction forces generated from body weight and musculotendon complexes bridging them. In general, joints of eutherian mammals have regions of high radiodensity subchondral bone that are better at resisting compressive forces than low radiodensity subchondral bone. Identifying similar form-function relationships between subchondral radiodensity distribution and joint load distribution within the marsupial postcranium, in addition to providing a richer understanding of marsupial functional morphology, can serve as a phylogenetic control in evaluating analogous relationships within eutherian mammals. Where commonalities are established across phylogenetic borders, unifying principles in mammalian physiology, morphology, and behavior can be identified. Here, we assess subchondral radiodensity patterns in distal tibiae of several marsupial taxa characterized by different habitual activities (e.g., locomotion). Computed tomography scanning, maximum intensity projection maps, and pixel counting were used to quantify radiodensity in 41 distal tibiae of bipedal (5 species), arboreal quadrupedal (4 species), and terrestrial quadrupedal (5 species) marsupials. Bipeds (Macropus and Wallabia) exhibit more expansive areas of high radiodensity in the distal tibia than arboreal (Dendrolagus, Phascolarctos, and Trichosurus) or terrestrial quadrupeds (Sarcophilus, Thylacinus, Lasiorhinus, and Vombatus), which may reflect the former carrying body weight only through the hind limbs. Arboreal quadrupeds exhibit smallest areas of high radiodensity, though they differ non-significantly from terrestrial quadrupeds. This could indicate slightly more compliant gaits by arboreal quadrupeds compared to terrestrial quadrupeds. The observed radiodensity patterns in marsupial tibiae, though their statistical differences disappear when controlling for phylogeny, corroborate previously documented patterns in primates and xenarthrans
Stufkens, S A S; Knupp, M; Lampert, C; van Dijk, C N; Hintermann, B
We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured. Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score. Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups. At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture.
Lui, Tun Hing
Chondrolysis of the ankle is a very rare condition. We report a case of chondrolysis of the ankle following ankle arthroscopy and microfracture of the osteochondral lesion of the talar dome. The patient's symptoms were relieved after articulated distraction arthroplasty. PMID:24369518
Maculan, Marco; Pizzolato, Claudio; Reggiani, Monica; Farina, Dario
This work presents an electrophysiologically and dynamically consistent musculoskeletal model to predict stiffness in the human ankle and knee joints as derived from the joints constituent biological tissues (i.e., the spanning musculotendon units). The modeling method we propose uses electromyography (EMG) recordings from 13 muscle groups to drive forward dynamic simulations of the human leg in five healthy subjects during overground walking and running. The EMG-driven musculoskeletal model estimates musculotendon and resulting joint stiffness that is consistent with experimental EMG data as well as with the experimental joint moments. This provides a framework that allows for the first time observing 1) the elastic interplay between the knee and ankle joints, 2) the individual muscle contribution to joint stiffness, and 3) the underlying co-contraction strategies. It provides a theoretical description of how stiffness modulates as a function of muscle activation, fiber contraction, and interacting tendon dynamics. Furthermore, it describes how this differs from currently available stiffness definitions, including quasi-stiffness and short-range stiffness. This work offers a theoretical and computational basis for describing and investigating the neuromuscular mechanisms underlying human locomotion. PMID:26245321
Cronin, Neil J; Prilutsky, Boris I; Lichtwark, Glen A; Maas, Huub
The main objective of this paper is to highlight the difficulties of identifying shortening and lengthening contractions based on analysis of power produced by resultant joint moments. For that purpose, we present net ankle joint powers and muscle fascicle/muscle-tendon unit (MTU) velocities for medial gastrocnemius (MG) and soleus (SO) muscles during walking in species of different size (humans and cats). For the cat, patterns of ankle joint power and MTU velocity of MG and SO during stance were similar: negative power (ankle moment×angular velocity<0), indicating absorption of mechanical energy, was associated with MTU lengthening, and positive power (generation of mechanical energy) was found during MTU shortening. This was also found for the general fascicle velocity pattern in SO. In contrast, substantial differences between ankle joint power and fascicle velocity patterns were observed for MG muscle. In humans, like cats, the patterns of ankle joint power and MTU velocity of SO and MG were similar. Unlike the cat, there were substantial differences between patterns of fascicle velocity and ankle joint power during stance in both muscles. These results indicate that during walking, only a small fraction of mechanical work of the ankle moment is either generated or absorbed by the muscle fascicles, thus confirming the contribution of in-series elastic structures and/or energy transfer via two-joint muscles. We conclude that ankle joint negative power does not necessarily indicate eccentric action of muscle fibers and that positive power cannot be exclusively attributed to muscle concentric action, especially in humans. Copyright © 2013 Elsevier Ltd. All rights reserved.
Ng, Thomas Ka-Wai; Lo, Sing-Kai; Cheing, Gladys Lai-Ying
Previous studies showed that older adults with diabetes have a worse mobility performance as compared with those without diabetes. Studies also demonstrated that older adults with diabetes have weakened ankle muscle strength, reduced joint range in ankle dorsiflexion and worsened ankle joint proprioception as compared with control population. The purpose of the present study was to examine the relationship between the physical characteristics of the ankle joint and the mobility performance in older adults with type 2 diabetes. Older adults with type 2 diabetes (n=85) were recruited, and Timed Up and Go test (TUG) for mobility assessment was performed. Active ankle joint repositioning test was used for assessing the ankle joint proprioception sense; peak torque of ankle dorsiflexors and plantar flexors were tested by using a Cybex Norm dynamometer, and weight-bearing lunge test (WBLT) was used for assessing the stiffness of ankle dorsiflexion. Our results showed that age, body mass index (BMI), normalized peak torque of plantar flexors and dorsiflexors, active ankle joint repositioning test errors and the WBLT distance were significantly correlated with the TUG (all p<0.001). These ankle characteristics, together with the demographic data of the subjects, contributed 59.9% of the variance in the TUG by multiple regression analysis. Body mass, ankle plantar flexors strength and ankle joint proprioception are important factors contributing to the physical mobility of the older adults with type 2 diabetes. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Jasqui-Remba, Salomon; Rodriguez-Corlay, Ruy Ernesto
In this case report, we present an acute rupture in the muscular tendinous junction of a posterior tibialis muscle in a bimalleolar closed ankle fracture after a high-energy trauma in a 30-year-old patient with no significant medical history. Fracture was confirmed by simple X-rays, and was treated with an open reduction in which both of the fractures were treated with osteosynthesis material and reparation of the syndesmosis. If left untreated, this uncommon finding can result in a bad postsurgical outcome; we believe this injury is more common but under-reported in the literature. The surgeon should be aware and look specifically for this type of lesion during the procedure. Finding and treating this injury requires special postoperative care, non-weight-bearing instructions and balanced physiotherapy. 2016 BMJ Publishing Group Ltd.
El-Mowafi, Hani; El-Hawary, Ahmed; Kandil, Yasser
Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgőwer classification. Follow up ranged from 10 to 37 months with a mean of 18 months. All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. level 2. Copyright © 2015 Elsevier Ltd. All rights reserved.
Wong, Duo Wai-Chi; Niu, Wenxin; Wang, Yan; Zhang, Ming
Introduction Foot and ankle impact injury is common in geriatric trauma and often leads to fracture of rearfoot, including calcaneus and talus. The objective of this study was to assess the influence of foot impact on the risk of calcaneus and talus fracture via finite element analysis. Methods A three-dimensional finite element model of foot and ankle was constructed based on magnetic resonance images of a female aged 28. The foot sustained a 7-kg passive impact through a foot plate. The simulated impact velocities were from 2.0 to 7.0 m/s with 1.0 m/s interval. Results At 5.0 m/s impact velocity, the maximum von Mises stress of the trabecular calcaneus and talus were 3.21MPa and 2.41MPa respectively, while that of the Tresca stress were 3.46MPa and 2.55MPa. About 94% and 84% of the trabecular calcaneus and talus exceeded the shear yielding stress, while 21.7% and 18.3% yielded the compressive stress. The peak stresses were distributed around the talocalcaneal articulation and the calcaneal tuberosity inferiorly, which corresponded to the common fracture sites. Conclusions The prediction in this study showed that axial compressive impact at 5.0 m/s could produce considerable yielding of trabecular bone in both calcaneus and talus, dominantly by shear and compounded with compression that predispose the rearfoot in the risk of fracture. This study suggested the injury pattern and fracture mode of high energy trauma that provides insights in injury prevention and fracture management. PMID:27119740
Springer, M A; van Binsbergen, E A; Patka, P; Bakker, F C; Haarman, H J
A prospective randomized clinical trial was performed to evaluate the use of self-reinforced absorbable composites (Biofix) in the fixation of ankle fractures. The aim of this study was to demonstrate that fixation with Biofix rods and screws is as good as the standard A.O. fixation. The benefits of Biofix rods and screws are: a reduction in costs since no secondary operation is needed, prevention of stress-shielding and thereby diminishing the risk of bone porosity. Patients aged between 16 and 75 years old with closed, non-comminuted fractures of the lateral and/or medial malleolus and dislocation of the fracture fragments greater than 2 mm were included in the study. 22 patients were treated with Biofix rods and screws and the control group of 19 patients with a standard technique. After 3, 6 and 12 months, rontgenograms were taken. At the same time functional results were evaluated following the criteria of Olerud and Molander. Two patients were withdrawn from the trial for non-medical reasons. 22 patients (12 from the Biofix group, 10 from the AO group) operated two or more years ago were contacted to see if any complications had occurred since they were last seen. In 4 cases a Biofix screw broke down just beneath the head during insertion. This did not result in an insufficient fixation of the fracture. There were no early post-operative complications. The functional and rontgenological results in both groups were equal. In three cases a sterile sinus developed at the site of screw insertion. Biofix rods and screws, made of polylactic acid, are a good alternative for the fixation of fractures of the ankle. The use of resorbable fracture fixation material has the advantage that a second operation to remove osteosynthesis material is not necessary. The long term results are good. There is, however, a possibility of development of tissue reaction to the resorbable material.
Wong, Duo Wai-Chi; Niu, Wenxin; Wang, Yan; Zhang, Ming
Foot and ankle impact injury is common in geriatric trauma and often leads to fracture of rearfoot, including calcaneus and talus. The objective of this study was to assess the influence of foot impact on the risk of calcaneus and talus fracture via finite element analysis. A three-dimensional finite element model of foot and ankle was constructed based on magnetic resonance images of a female aged 28. The foot sustained a 7-kg passive impact through a foot plate. The simulated impact velocities were from 2.0 to 7.0 m/s with 1.0 m/s interval. At 5.0 m/s impact velocity, the maximum von Mises stress of the trabecular calcaneus and talus were 3.21MPa and 2.41MPa respectively, while that of the Tresca stress were 3.46MPa and 2.55MPa. About 94% and 84% of the trabecular calcaneus and talus exceeded the shear yielding stress, while 21.7% and 18.3% yielded the compressive stress. The peak stresses were distributed around the talocalcaneal articulation and the calcaneal tuberosity inferiorly, which corresponded to the common fracture sites. The prediction in this study showed that axial compressive impact at 5.0 m/s could produce considerable yielding of trabecular bone in both calcaneus and talus, dominantly by shear and compounded with compression that predispose the rearfoot in the risk of fracture. This study suggested the injury pattern and fracture mode of high energy trauma that provides insights in injury prevention and fracture management.
Willerslev-Olsen, Maria; Lorentzen, Jakob; Nielsen, Jens Bo
Foot drop and toe walking are frequent concerns in children with cerebral palsy (CP). Increased stiffness of the ankle joint muscles may contribute to these problems. Does four weeks of daily home based treadmill training with incline reduce ankle joint stiffness and facilitate heel strike in children with CP? Seventeen children with CP (4-14 years) were recruited. Muscle stiffness and gait ability were measured twice before and twice after training with an interval of one month. Passive and reflex-mediated stiffness were measured by a dynamometer which applied stretches below and above reflex threshold. Gait kinematics were recorded by 3-D video-analysis during treadmill walking. Foot pressure was measured by force-sensitive foot soles during treadmill and over-ground walking. Children with increased passive stiffness showed a significant reduction in stiffness following training (P = 0.01). Toe lift in the swing phase (P = 0.014) and heel impact (P = 0.003) increased significantly following the training during both treadmill and over-ground walking. Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.
Tehrani, Ehsan Sobhani; Jalaleddini, Kian; Kearney, Robert E
This paper describes a novel method for the identification of time-varying ankle joint dynamic stiffness during large passive movements. The method estimates a linear parameter varying parallel-cascade (LPV-PC) model of joint stiffness consisting of two pathways: (a) an LPV impulse response function (IRF) for intrinsic mechanics and (b) an LPV Hammerstein cascade with time-varying static nonlinearity and a time-invariant linear dynamics for the reflex pathway. A subspace identification technique is used to estimate a statespace representation of the reflex stiffness dynamics. Then, an orthogonal projection decouples intrinsic from reflex response and subsequently identifies an LPV-IRF model of intrinsic stiffness. Finally, an LPV model of the reflex static nonlinearity is estimated using an iterative, separable least squares method. The LPV method was validated using experimental data from two healthy subjects where the ankle was moved passively by an actuator through its range of motion first without and then with perturbations. The identification results demonstrated that (a) the dynamic response of the intrinsic pathway changes systematically with joint position; and (b) the static nonlinearity of the reflex pathway resembles a half-wave rectifier whose threshold decreases and gain increases as ankle is moved to dorsiflexed position.
Fouré, A; Nordez, A; Guette, M; Cornu, C
This study aimed to determine simultaneously the effects of plyometric training on the passive stiffness of the ankle joint musculo-articular complex, the gastrocnemii muscle-tendon complex (MTC) and the Achilles tendon in order to assess possible local adaptations of elastic properties. Seventeen subjects were divided into a trained (TG) group and a control (CG) group. They were tested before and after 8 weeks of a plyometric training period. The ankle joint range of motion (RoM), the global musculo-articular passive stiffness of the ankle joint, the maximal passive stiffness of gastrocnemii and the stiffness of the Achilles tendon during isometric plantar flexion were determined. A significant increase in the jump performances of TG relative to CG was found (squat jumps: +17.6%, P=0.008; reactive jumps: +19.8%, P=0.001). No significant effect of plyometric training was observed in the ankle joint RoM, musculo-articular passive stiffness of the ankle joint or Achilles tendon stiffness (P>0.05). In contrast, the maximal passive stiffness of gastrocnemii of TG increased after plyometric training relative to CG (+33.3%, P=0.001). Thus, a specific adaptation of the gastrocnemii MTC occurred after plyometric training, without affecting the global passive musculo-articular stiffness of the ankle joint.
Sancisi, Nicola; Baldisserri, Benedetta; Parenti-Castelli, Vincenzo; Belvedere, Claudio; Leardini, Alberto
Mathematical modelling of mobility at the human ankle joint is essential for prosthetics and orthotic design. The scope of this study is to show that the ankle joint passive motion can be represented by a one-degree-of-freedom spherical motion. Moreover, this motion is modelled by a one-degree-of-freedom spherical parallel mechanism model, and the optimal pivot-point position is determined. Passive motion and anatomical data were taken from in vitro experiments in nine lower limb specimens. For each of these, a spherical mechanism, including the tibiofibular and talocalcaneal segments connected by a spherical pair and by the calcaneofibular and tibiocalcaneal ligament links, was defined from the corresponding experimental kinematics and geometry. An iterative procedure was used to optimize the geometry of the model, able to predict original experimental motion. The results of the simulations showed a good replication of the original natural motion, despite the numerous model assumptions and simplifications, with mean differences between experiments and predictions smaller than 1.3 mm (average 0.33 mm) for the three joint position components and smaller than 0.7° (average 0.32°) for the two out-of-sagittal plane rotations, once plotted versus the full flexion arc. The relevant pivot-point position after model optimization was found within the tibial mortise, but not exactly in a central location. The present combined experimental and modelling analysis of passive motion at the human ankle joint shows that a one degree-of-freedom spherical mechanism predicts well what is observed in real joints, although its computational complexity is comparable to the standard hinge joint model.
DeAngelis, Nicola A; Eskander, Mark S; French, Bruce G
To identify whether medial tenderness is a predictor of deep deltoid ligament incompetence in supination-external rotation ankle fractures. All Weber B lateral malleolar fractures with normal medial clear space over a 9 month period were prospectively included in the study. Fracture patterns not consistent with a supination-external rotation mechanism were excluded. High-volume tertiary care referral center and Level I trauma center. Fifty-five skeletally mature patients with a Weber B lateral malleolar fracture and normal medial clear space presenting to our institution were included. All study patients had ankle anteroposterior, lateral, and mortise radiographs. Each patient was seen and evaluated by an orthopedic specialist and the mechanism of injury was recorded. Each patient was assessed for tenderness to palpation in the region of the deltoid ligament and then had an external rotation stress mortise radiograph. Correlating medial tenderness with deep deltoid competence as measured by stress radiographs. Thirteen patients (23.6%) were tender medially and had a positive external rotation stress radiograph. Thirteen patients (23.6%) were tender medially and had a negative external rotation stress radiograph. Nineteen patients (34.5%) were nontender medially and had a negative external rotation stress radiograph. Ten patients (18.2%) were nontender medially and had a positive external rotation stress radiograph. We calculated a chi statistic of 2.37 as well as the associated P value of 0.12. Medial tenderness as a measure of deep deltoid ligament incompetence had a sensitivity of 57%, a specificity of 59%, a positive predictive value of 50%, a negative predictive value of 66%, and an accuracy of 42%. There was no statistical significance between the presence of medial tenderness and deep deltoid ligament incompetence. There is a 25% chance of the fracture in question with medial tenderness having a positive external rotation stress and a 25% chance the fracture
Kumar, A J Shyam; Gill, D S; Fairweather, C; Dykes, L
The aim of this study was to review the pattern of ankle fractures sustained by patients brought to the Emergency Department at Ysbyty Gwynedd from The Snowdonia National Park. The study group included all patients with ankle fractures on the mountain medicine database between March 2004 and December 2006. The presence of talar shift and comminution of the medial malleolus was noted. The pattern of fractures were analysed and compared with the literature. Radiographs were obtained for 20 casualties. 70% of these were injured whilst hill walking. Open fractures represented 12% of injuries. 75% of fractures required operative fixation. Weber B injuries were the commonest followed by Weber C and A. Talar shift was seen in 80% of the cases and 45% showed comminution of the medial malleolus. In our case series we observed a high proportion of open and unstable ankle fractures, with the majority treated by operative fixation. The high rate of comminution of the medial malleolus has previously not been reported in the literature and has the potential of making operative fixation technically difficult. Encouraging the use of walking poles particularly at the time of descending may help to reduce the incidence of ankle fractures in hill walkers.
Donken, Christian C M A; Verhofstad, Michael H J; Edwards, Michael J; van Laarhoven, Cees J H M
To evaluate long-term results after protocoled treatment of supination-external rotation (SER) Type II-IV ankle injuries. Retrospective cohort study. Level I trauma center. Two hundred seventy-six adult patients with an SER Type II-IV ankle fracture between January 1, 1985, and January 1, 1990. All patients were approached to participate in this study. Fractures with tibiotalar congruity were treated nonoperative and unstable fractures with joint incongruity were treated operatively. MEAN OUTCOME MEASUREMENTS: 1) a functional outcome questionnaire (Olerud score); 2) range of motion; 3) functional impairment (American Medical Association guidelines); and 4) radiologic anatomic result (medial clear space widening; osteoarthritis; Cedell score). After a median of 21 years in 54% (n = 148) of patients, follow-up was achieved. Seventy-six patients (51%) had a SER Type II injury, four patients (3%) a SER Type III injury, and 68 (46%) had sustained a SER Type IV. Excellent or good results were found in 92% (Olerud score), 97% (loaded dorsal range of motion), 92% (medial clear space widening), 97% (osteoarthritis), and 76% (Cedell score) of patients. Functional impairment expressed as percentage of whole person impairment varied between 0% and 16%. The various fracture types performed statistically equal on all outcome parameters. There was no difference between operative and nonoperative treatment. There was no correlation between the Olerud score and other parameters. The very long-term overall results of the stratified surgical treatment of SER Type II-IV ankle fractures is 'excellent' or 'good' in the majority of patients and therefore seems justified. Although additional soft tissue damage is unavoidable in case of operative treatment, it does not negatively affect outcome in the long term. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Yang, Chonglin; Xu, Xiangyang; Zhu, Yuan; Liu, Jinhao; Wei, Baofu
Subtalar arthrodesis is a common therapy for subtalar joint disorders. In this article, we evaluate the effect of subtalar arthrodesis on the ankle and hindfoot joints. Fifty patients (33 men and 17 women) underwent subtalar arthrodesis between January 1, 1996, and August 31, 2011. The 36-item Short-Form Health Survey and American Orthopaedic Foot and Ankle Society ankle hindfoot scores were used for clinical evaluation. Radiographic analysis included assessment of degenerative changes and ankle and hindfoot joint function in the frontal and sagittal planes. Thirty-seven patients (27 men and 10 women; mean age, 42.6 years) were followed up for an average of 9.2 years (range, 2-17 years). The mean ± SD 36-item Short-Form Health Survey score improved from 30.21 ± 7.19 before surgery to 78.50 ± 12.23, and the American Orthopaedic Foot and Ankle Society ankle hindfoot score increased from 50.32 ± 12.39 to 73.14 ± 15.44. Degenerative changes in the talonavicular, calcaneocuboid, metatarsocuboid, and ankle joints occurred. The talar-vertical angle was positively related to the tibial-plantar minimal angle (affected side: r = 0.56; P < .01; healthy side: r = 0.46; P < .01). The difference in hindfoot height is positively related to the difference in tibial-plantar minimal angle (r = 0.54; P < .01). Subtalar arthrodesis is effective treatment for subtalar joint disease but could induce joint degeneration and ankle joint motion limitation related to talar declination and hindfoot height.
Thorud, Jakob C; Mortensen, Spencer; Thorud, Jennifer L; Shibuya, Naohiro; Maldonado, Yolanda Munoz; Jupiter, Daniel C
As obesity has become more common, fractures in the obese population have become more frequent. Concern exists regarding alterations in bone health and healing in obese patients. A matched case-control study was performed at 1 institution to evaluate whether an association exists between nonunion and a high body mass index in metatarsal and ankle fractures. A total of 48 patients with nonunion were identified, and control patients matched 2 to 1 (n = 96) were selected. The control patients were matched for age, sex, and fracture type. No association was identified between nonunion and the continuous body mass index (p = .23) or morbid obesity, with a body mass index of ≥40 kg/m(2) (p = .51). However, the results from both univariate and multivariate analysis suggested that patients with a current alcohol problem or a history of an alcohol problem might have a greater risk of nonunion. The odds ratio of a patient with a history of alcohol use experiencing nonunion was 2.7 (95% confidence interval 1.2 to 6.2). Further studies are warranted to confirm these findings. Copyright © 2016 American College of Foot and Ankle Surgeons. All rights reserved.
Jeon, Kyoungkyu; Seo, Byoung-Do; Lee, Sang-Ho
[Purpose] To collect basic data for exercise programs designed to enhance functional knee and ankle joint stability based on isokinetic measurement and muscle strength evaluations in normal and impaired functional states. [Subjects and Methods] Twenty-four subjects were randomly assigned to the athlete group and the control group (n = 12 each). Data were collected of isokinetic knee extensor and flexor strength at 60°/sec, 180°/sec, and 240°/sec and ankle plantar and dorsiflexor strength at 30°/sec and 120°/sec. [Results] Significant intergroup differences were observed in peak torque of the right extensors at 60°/sec, 180°/sec, and 240°/sec and the right flexors at 240°/sec. Significant differences were observed in peak torque/body weight in the right extensors at 60°/sec, 180°/sec, and 240°/sec and in the right flexors at 180°/sec and 240°/sec. Significant peak torque differences were noted in the left ankle joint dorsiflexor at 30°/sec and 120°/sec, right plantar flexor at 120°/sec, left plantar flexor at 30°/sec, left dorsiflexor at 30°/sec and 120°/sec, and right dorsiflexor at 120°/sec. [Conclusion] Isokinetic evaluation stimulates muscle contraction at motion-dependent speeds and may contribute to the development of intervention programs to improve knee and ankle joint function and correct lower-extremity instability. PMID:26957768
Munteanu, Shannon E; Strawhorn, Andrea B; Landorf, Karl B; Bird, Adam R; Murley, George S
Measurement of ankle joint dorsiflexion is routinely undertaken by clinicians who manage lower limb musculoskeletal pathology. This study aimed to determine the reliability of a technique to measure ankle joint dorsiflexion in a weightbearing position with the knee extended. Four raters with varying clinical experience measured ankle joint dorsiflexion in a weightbearing position with the knee extended on 30 asymptomatic participants. Measurements occurred on two occasions, 1 week apart using (i) a digital inclinometer and (ii) a clear acrylic plate apparatus. Intraclass correlation coefficients (ICCs) and 95% limits of agreement (LOAs) were calculated. Intra-rater reliability of the experienced raters was high for both the digital inclinometer (average ICC=0.88, average 95% LOA=-6.6 degrees to 4.8 degrees ) and the clear acrylic plate apparatus (average ICC=0.89, average 95% LOA=-7.2 degrees to 4.3 degrees ). Intra-rater reliability of the inexperienced rater was good to high for both the digital inclinometer (ICC=0.77, 95% LOA=-9.1 degrees to 8.3 degrees ) and the clear acrylic plate apparatus (ICC=0.89, 95% LOA=-8.1 degrees to 4.6 degrees ). Inter-rater reliability was high for both the digital inclinometer (ICC=0.95, 95% LOA=-5.7 degrees to 5.7 degrees ) and the clear acrylic plate apparatus (ICC=0.97, 95% LOA=-4.7 degrees to 4.7 degrees ). Measurements of ankle dorsiflexion in a weightbearing position with the knee extended can be performed reliably by experienced and inexperienced raters. However, the reliability of this measurement technique needs to be interpreted in the context of the purpose for which the measurement is intended.
Jeon, Kyoungkyu; Seo, Byoung-Do; Lee, Sang-Ho
[Purpose] To collect basic data for exercise programs designed to enhance functional knee and ankle joint stability based on isokinetic measurement and muscle strength evaluations in normal and impaired functional states. [Subjects and Methods] Twenty-four subjects were randomly assigned to the athlete group and the control group (n = 12 each). Data were collected of isokinetic knee extensor and flexor strength at 60°/sec, 180°/sec, and 240°/sec and ankle plantar and dorsiflexor strength at 30°/sec and 120°/sec. [Results] Significant intergroup differences were observed in peak torque of the right extensors at 60°/sec, 180°/sec, and 240°/sec and the right flexors at 240°/sec. Significant differences were observed in peak torque/body weight in the right extensors at 60°/sec, 180°/sec, and 240°/sec and in the right flexors at 180°/sec and 240°/sec. Significant peak torque differences were noted in the left ankle joint dorsiflexor at 30°/sec and 120°/sec, right plantar flexor at 120°/sec, left plantar flexor at 30°/sec, left dorsiflexor at 30°/sec and 120°/sec, and right dorsiflexor at 120°/sec. [Conclusion] Isokinetic evaluation stimulates muscle contraction at motion-dependent speeds and may contribute to the development of intervention programs to improve knee and ankle joint function and correct lower-extremity instability.
Błażkiewicz, Michalina; Wiszomirska, Ida; Kaczmarczyk, Katarzyna; Naemi, Roozbeh; Wit, Andrzej
Muscle forces acting over the ankle joint play an important role in the forward progression of the body during gait. Yet despite the importance of ankle muscle forces, direct in-vivo measurements are neither possible nor practical. This makes musculoskeletal simulation useful as an indirect technique to quantify the muscle forces at work during locomotion. The purpose of this study was to: 1) identify the maximum peaks of individual ankle muscle forces during gait; 2) investigate the order over which the muscles are sorted based on their maximum peak force. Three-dimensional kinematics and ground reaction forces were measured during the gait of 10 healthy subjects, and the data so obtained were input into the musculoskeletal model distributed with the OpenSim software. In all 10 individuals we observed that the soleus muscle generated the greatest strength both in dynamic (1856.1N) and isometric (3549N) conditions, followed by the gastrocnemius in dynamic conditions (1232.5N). For all other muscles, however, the sequence looks different across subjects, so the k-means clustering method was used to obtain one main order over which the muscles' peak-forces are sorted. The results indicate a common theme, with some variations in the maximum peaks of ankle muscle force across subjects. Copyright © 2017. Published by Elsevier B.V.
khanmohammadi, Roya; Someh, Marjan; Ghafarinejad, Farahnaze
Purpose To determine whether a fifteen-minute water immersion treatment affects the normal ankle joint position sense (JPS) at the middle range of dorsiflexion and plantar flexion actively and passively. Methods Thirty healthy female volunteers aged between 18 and 30 years were treated by a 15-minute cryotherapy (6 ± 1°C). The subject's skin temperature over antromedial aspect of dominant ankle was measured by the Mayomed device before, immediate and 15 minutes after water immersion. Ankle JPS was tested trough the pedal goniometer at 3 stages similar to the skin temperature. ANOVA (α = 0.05) was performed on each of variables using SPSS 19.0 software. Results Skin temperature was seen to decrease after water immersion but subjects did not return to pre-test skin temperature after 15 minutes (P<0.001). The research found no significant difference in JPS at middle range of dorsiflexion and plantar flexion actively and passively before and after cryotherapy. Conclusion These findings suggest that 15-minute water immersion at 6°C dose not significantly alter the middle range of plantar flexion/ dorsiflexion JPS at the ankle and is not deleterious to JPS. PMID:22375224
Chien, Bonnie; Hofmann, Kurt; Ghorbanhoseini, Mohammad; Zurakowski, David; Rodriguez, Edward K; Appleton, Paul; Ellington, J Kent; Kwon, John Y
Determining the stability of ankle fractures, particularly Weber B fibula fractures, can be challenging. Ability to weight-bear after injury may be predictive of stability. We sought to determine whether patients' ability to weight-bear immediately after injury was an effective indicator for ankle stability following fracture. A prospective review was conducted of patients sustaining ankle fractures. Patients' ability to weight-bear after injury was elicited and correlated with ankle radiographs, which were deemed stable or unstable based on commonly used indices to assess stability. For the entire cohort (n = 121), patients who were able to weight-bear immediately after injury were over 8 times more likely to have a stable fracture than those who could not (odds ratio [OR] = 8.6, P < .001). Positive predictive value (PPV) for being able to fully weight-bear as it related to stability was 73%. Inability to weight-bear was 85% specific among patients with an unstable fracture. When analyzing patients with radiographic isolated fibula fractures (n = 67), PPV = 82%, negative predictive value [NPV] = 53%, specificity = 79%, whereas the OR was 5.0 (P = .003) for those who could weight-bear having a stable fracture. When subanalyzing patients who presented with isolated fibula fractures and anatomic mortises (n = 43), PPV = 74%, NPV = 52%, specificity = 62%, whereas the OR was 3.6 (P = .07) for those who could weight-bear having a stable fracture. Patients' ability to weight-bear immediately after injury was a specific and prognostic indicator for stability across a range of ankle fracture subtypes. Patients with an isolated fibula fracture and anatomic mortise were 3.6 times more likely to have a stable fracture if they were able to fully weight-bear at the time of injury. Although a patient's history does not preclude the need for appropriate imaging studies and clinical judgment, it may aid in the assessment of ankle stability following fracture. Level II, clinical
Adouni, M; Shirazi-Adl, A
Accurate estimation of muscle forces during daily activities such as walking is critical for a reliable evaluation of loads on the knee joint. To evaluate knee joint muscle forces, the importance of the inclusion of the hip joint alongside the knee and ankle joints when treating the equilibrium equations remains yet unknown. An iterative kinematics-driven finite element model of the knee joint that accounts for the synergy between passive structures and active musculature is employed. The knee joint muscle forces and biomechanical response are predicted and compared with our earlier results that did not account for moment equilibrium equations at the hip joint. This study indicates that inclusion of the hip joint in the optimization along the knee and ankle joints only slightly (<10%) influences total forces in quadriceps, lateral hamstrings and medial hamstrings. As a consequence, even smaller differences are found in predicted ligament forces, contact forces/areas, and cartilage stresses/strains during the stance phase of gait. The distribution of total forces between the uni- and bi-articular muscle components in quadriceps and in lateral hamstrings; however, substantially alter at different stance phases.
Weerasekara, Ishanka; Osmotherly, Peter; Snodgrass, Suzanne; Marquez, Jodie; de Zoete, Rutger; Rivett, Darren A
To assess the clinical benefits of joint mobilisation on ankle sprains. MEDLINE, MEDLINE In Process, Embase, AMED, PsycINFO, CINAHL, Cochrane library, PEDro, Scopus, SPORTDiscus and Dissertations and Thesis were searched from inception to June, 2017. Studies investigating humans with a grade I or II lateral or medial sprains of the ankle in any pathological state from acute to chronic, who had been treated with joint mobilisation were considered for inclusion. Any conservative intervention was considered as a comparator. Commonly reported clinical outcomes were considered such as ankle range of movement, pain, and function. After screening of 1530 abstracts, 56 studies were selected for full text screening, and 23 were eligible for inclusion. Eleven studies on chronic sprains reported sufficient data for meta-analysis. Data were extracted using the participants, interventions, comparison, outcomes and study design approach. Clinically relevant outcomes (dorsiflexion range, proprioception, balance, function, pain threshold, pain intensity) were assessed at immediate, short term and long term follow-up points. Methodological quality was assessed independently by two reviewers and most studies were found to be of moderate quality, with no studies rated as poor. Meta-analysis revealed significant immediate benefits of joint mobilisation compared to comparators on improving postero-medial dynamic balance (p=0.0004), but not for improving dorsiflexion range (p= 0.16), static balance (p = 0.96) or pain intensity (p= 0.45). Joint mobilisation was beneficial in the short term for improving weight-bearing dorsiflexion range (p= 0.003) compared to a control. Joint mobilisation appears to be beneficial for improving dynamic balance immediately after application and dorsiflexion range in the short term. Long term benefits have not been adequately investigated. Copyright © 2017. Published by Elsevier Inc.
Golditz, T; Steib, S; Pfeifer, K; Uder, M; Gelse, K; Janka, R; Hennig, F F; Welsch, G H
The aim of this study was to investigate, using T2-mapping, the impact of functional instability in the ankle joint on the development of early cartilage damage. Ethical approval for this study was provided. Thirty-six volunteers from the university sports program were divided into three groups according to their ankle status: functional ankle instability (FAI, initial ankle sprain with residual instability); ankle sprain Copers (initial sprain, without residual instability); and controls (without a history of ankle injuries). Quantitative T2-mapping magnetic resonance imaging (MRI) was performed at the beginning ('early-unloading') and at the end ('late-unloading') of the MR-examination, with a mean time span of 27 min. Zonal region-of-interest T2-mapping was performed on the talar and tibial cartilage in the deep and superficial layers. The inter-group comparisons of T2-values were analyzed using paired and unpaired t-tests. Statistical analysis of variance was performed. T2-values showed significant to highly significant differences in 11 of 12 regions throughout the groups. In early-unloading, the FAI-group showed a significant increase in quantitative T2-values in the medial, talar regions (P = 0.008, P = 0.027), whereas the Coper-group showed this enhancement in the central-lateral regions (P = 0.05). Especially the comparison of early-loading to late-unloading values revealed significantly decreasing T2-values over time laterally and significantly increasing T2-values medially in the FAI-group, which were not present in the Coper- or control-group. Functional instability causes unbalanced loading in the ankle joint, resulting in cartilage alterations as assessed by quantitative T2-mapping. This approach can visualize and localize early cartilage abnormalities, possibly enabling specific treatment options to prevent osteoarthritis in young athletes. Copyright © 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Uto, Yuki; Maeda, Tetsuo; Kiyama, Ryoji; Kawada, Masayuki; Tokunaga, Ken; Ohwatashi, Akihiko; Fukudome, Kiyohiro; Ohshige, Tadasu; Yoshimoto, Yoichi; Yone, Kazunori
The purpose of this study was to determine whether a lateral wedge insole reduces the external knee adduction moment during slope walking. Twenty young, healthy subjects participated in this study. Subjects walked up and down a slope using 2 different insoles: a control flat insole and a 7° lateral wedge insole. A three-dimensional motion analysis system and force plate were used to examine the knee adduction moment, the ankle valgus moment, and the moment arm of the ground reaction force to the knee joint center in the frontal plane. The lateral wedge insole significantly decreased the moment arm of the ground reaction force, resulting in a reduction of the knee adduction moment during slope walking, similar to level walking. The reduction ratio of knee adduction moment by the lateral wedge insole during the early stance of up-slope walking was larger than that of level walking. Conversely, the lateral wedge insole increased the ankle valgus moment during slope walking, especially during the early stance phase of up-slope walking. Clinicians should examine the utilization of a lateral wedge insole for knee osteoarthritis patients who perform inclined walking during daily activity, in consideration of the load on the ankle joint.
Kiyokawa, Kensuke; Tanaka, Shinsuke; Kiduka, Yuichiro; Inoue, Yojiro; Yamauchi, Toshihiko; Tai, Yoshiaki
Soft-tissue reconstruction alone cannot obtain normal ankle function in patients with large defects in the area of the lateral malleolus. The authors report a functional reconstructive method for the lateral malleolus, utilized in a male patient whose osteosarcoma in the fibula was resected with surrounding soft tissue. In order to reconstruct the lateral malleolus, the remaining half of the fibula at the knee was removed, and the fibular head was fixed with the tibia at the ankle joint. Ligaments were reconstructed with tendon grafts. Skin and soft-tissue defects were reconstructed with a combined composite flap comprised of a latissimus dorsi myocutaneous flap and a serratus anterior muscle flap. Dead space around the bone graft was filled with the serratus anterior muscle flap that was divided into two portions. The surface was covered with the latissimus dorsi myocutaneous flap. The patient regained almost normal function of the ankle joint. This technique would be a useful functional reconstructive method for patients with large defects in the area of the lateral malleolus.
White, T O; Bugler, K E; Appleton, P; Will, E; McQueen, M M; Court-Brown, C M
The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems. A total of 100 patients (25 men, 75 women) over the age of 65 years with unstable ankle fractures were randomised to undergo standard ORIF or fibular nailing (11 men and 39 women in the ORIF group, 14 men and 36 women in the fibular nail group). The mean age was 74 years (65 to 93) and all patients had at least one medical comorbidity. Complications, patient related outcome measures and cost-effectiveness were assessed over 12 months. Significantly fewer wound infections occurred in the fibular nail group (p = 0.002). At one year, there was no evidence of difference in mean functional scores (Olerud and Molander Scores 63; 30 to 85, versus 61; 10 to 35, p = 0.61) or scar satisfaction. The overall cost of treatment in the fibular nail group was £91 less than in the ORIF group despite the higher initial cost of the implant. We conclude that the fibular nail allows accurate reduction and secure fixation of ankle fractures, with a significantly lower rate of soft-tissue complications, and is more cost-effective than ORIF. Cite this article: Bone Joint J 2016;98-B:1248-52. ©2016 The British Editorial Society of Bone & Joint Surgery.
Cordova, Mitchell L; Takahashi, Yosuke; Kress, Gregory M; Brucker, Jody B; Finch, Alfred E
To investigate the effects of external ankle support (EAS) on lower extremity joint mechanics and vertical ground-reaction forces (VGRF) during drop landings. A 1 x 3 repeated-measures, crossover design. Biomechanics research laboratory. 13 male recreationally active basketball players (age 22.3 +/- 2.2 y, height 177.5 +/- 7.5 cm, mass 72.2 +/- 11.4 kg) free from lower extremity pathology for the 12 mo before the study. Subjects performed a 1-legged drop landing from a standardized height under 3 different ankle-support conditions. Hip, knee, and ankle angular displacement along with specific temporal (TGRFz1, TGRFz2; s) and spatial (GRFz1, GRFz2; body-weight units [BW]) characteristics of the VGRF vector were measured during a drop landing. The tape condition (1.08 +/- 0.09 BW) demonstrated less GRFz1 than the control (1.28 +/- 0.16 BW) and semirigid conditions (1.28 +/- 0.21 BW; P < .0001), and GRFz2 was unaffected. For TGRFz1, no-support displayed slower time (0.017 +/- 0.004 s) than the semirigid (0.014 +/- 0.001 s) and tape conditions (0.014 +/- 0.002 s; P < .05). For TGRFz2, no-support displayed slower time (0.054 +/- 0.006 s) than the semirigid (0.050 +/- 0.006 s) and tape conditions (0.045 +/- 0.004 s; P < .05). Semirigid bracing was slower than the tape condition, as well (P < .05). Ankle-joint displacement was less in the tape (34.6 degrees +/- 7.7 degrees) and semirigid (36.8 degrees +/- 9.3 degrees) conditions than in no-support (45.7 degrees +/- 7.3 degrees; P < .05). Knee-joint displacement was larger in the no-support (45.1 degrees +/- 9.0 degrees) than in the semirigid (42.6 degrees +/- 6.8 degrees; P < .05) condition. Tape support (43.8 degrees +/- 8.7 degrees) did not differ from the semirigid condition (P > .05). Hip angular displacement was not affected by EAS (F(2,24) = 1.47, P = .25). EAS reduces ankle- and knee-joint displacement, which appear to influence the spatial and temporal characteristics of GRFz1 during drop landings.
... is surgery to replace the damaged bone and cartilage in the ankle joint. Artificial joint parts (prosthetics) ... Your surgeon will remove the damaged bone and cartilage. Your surgeon will replace the damaged part of: ...
Pires, Robinson Esteves Santos; Mauffrey, Cyril; de Andrade, Marco Antônio Percope; Figueiredo, Leonardo Brandão; Giordano, Vincenzo; Belloti, João Carlos; dos Reis, Fernando Baldy
The gold standard for the surgical management of ankle fractures is through open reduction and internal fixation. The rate of wound problems has been reported to be as high as 18%, especially in patients with poor vascular supply or in diabetics. Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been described as a potential solution for these patients. This is a prospective observational cohort study. From October 2009 to February 2010, and following ethical approval of our research, adult patients admitted at our level I trauma center with a closed lateral malleolar displaced unstable fracture (Lauge-Hansen supination-external rotation) with or without a medial-sided injury and patients with an undisplaced fracture associated with medial clear space opening on external rotation stress radiographs were recruited and managed using MIPPO technique. All patients were followed up for a minimum of 12 months post-surgery (12-20 with a mean of 16.5 months). Trauma mechanism, comorbidities, classifications, trauma-surgery interval, image intensifier duration, surgery duration, complications, and function American Orthopaedic Foot and Ankle Society (AOFAS) were analyzed. Thirty-two patients were recruited of which 20 fulfilled the inclusion criteria (16 females, 4 males) and were available for follow-up. Ten fractures (50%) were classified as 44-B1, 7 fractures (35%) as 44-B2, and 3 fractures (15%) as 44-B3 according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (100% were supination-external rotation injuries). At 8 weeks post-surgery, all fractures had healed. The duration of surgery ranged between 15 and 73 min (average 32.8) from skin incision to closure. There were 2 complications (1 malunion and 1 skin necrosis requiring implant removal). At 12-month follow-up, AOFAS average was 88.3 (72-100 standard deviation of 6.8 points). MIPPO technique proved to be a viable option for lateral malleolar fracture
Nguyentat, Annie; Camisa, William; Patel, Sandeep; Lagaay, Pieter
Previous biomechanical studies have advocated the use of locking plates for isolated distal fibula fractures in osteoporotic bone. Complex rotational ankle injuries involve an increased number of fractures, which can result in instability, potentially requiring the same fixed angle properties afforded by locking plates. However, the mechanical indication for locking plate technology has not been tested in this fracture model. The purpose of the present study was to compare the biomechanical properties of locking and conventional plate fixation for distal fibula fractures in trimalleolar ankle injuries. Fourteen (7 matched pairs) fresh-frozen cadaver leg specimens were used. The bone mineral density of each was obtained using dual x-ray absorptiometry scans. The fracture model simulated an OTA 44-B3.3 fracture. The syndesmosis was not disrupted. Each fracture was fixated in the same fashion, except for the distal fibula plate construct: locking (n = 7) and one-third tubular (n = 7). The specimens underwent axial and torsional cyclic loading, followed by torsional loading to failure. No statistically significant differences were found between the locking and conventional plate constructs during both fatigue and torque to failure testing (p > .05). Our specimen bone mineral density averages did not represent poor bone quality. The clinical implication of the present study is that distal fibular locking plates do not provide a mechanical advantage for trimalleolar ankle injuries in individuals with normal bone density and in the absence of fracture comminution.
Ryu, Dong Jin; Kim, Joon Mee; Kim, Bom Soo
Injury of the medial head of the gastrocnemius, also called "tennis leg," is known to heal uneventfully in most cases with compression and immobilization therapy. Failure to heal or long-term complications, including ongoing pain and pes equinus, have been documented in only a limited number of case reports. To the best of our knowledge, a severe concomitant contracture of the knee and ankle joint as a consequence of a maltreated gastrocnemius muscle rupture has not been previously reported in English-language reports. The purpose of the present study was to report a serious complication of neglected tennis leg with a review of the published data. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Espinosa, N; Walti, M; Favre, P; Snedeker, J G
A major cause of the limited longevity of total ankle replacements is premature polyethylene component wear, which can be induced by high joint contact pressures. We implemented a computational model to parametrically explore the hypothesis that intercomponent positioning deviating from the manufacturer's recommendations can result in pressure distributions that may predispose to wear of the polyethylene insert. We also investigated the hypothesis that a modern mobile-bearing design may be able to better compensate for imposed misalignments compared with an early two-component design. Two finite element models of total ankle replacement prostheses were built to quantify peak and average contact pressures on the polyethylene insert surfaces. Models were validated by biomechanical testing of the two implant designs with use of pressure-sensitive film. The validated models were configured to replicate three potential misalignments with the most version of the tibial component, version of the talar component, and relative component rotation of the two-component design. The misalignments were simulated with use of the computer model with physiologically relevant boundary loads. With use of the manufacturer's guidelines for positioning of the two-component design, the predicted average joint contact pressures exceeded the yield stress of polyethylene (18 to 20 MPa). Pressure magnitudes increased as implant alignment was systematically deviated from this reference position. The three-component design showed lower-magnitude contact pressures in the standard position (<10 MPa) and was generally less sensitive to misalignment. Both implant systems were sensitive to version misalignment. In the tested implants, a highly congruent mobile-bearing total ankle replacement design yields more evenly distributed and lower-magnitude joint contact pressures than a less congruent design. Although the mobile-bearing implant reduced susceptibility to aberrant joint contact
Tang, Wen-Jiang; Jiang, Chui-Gang; Chen, Li-Rong; Pang, Yong; Li, Jie; Huang, Yun
To compare the efficacy differences between acupuncture-moxibustion and physiotherapy interventions in improving proprioception of athletes with lateral collateral ligament injury of the ankle joint. Thirty patients with injured lateral collateral ligament of ankle joint were randomly divided into acupuncture group (n = 15) and physiotherapy group (n = 15). Patients of the acupuncture group were treated by acupuncture and moxibustion stimulation of Qiuxu (GB40), Kunlun (BL 60), Shenmai (BL 62), Jiexi (ST 41), and Ashi-points, etc., and those of the physiotherapy group treated with TDP irradiation of the regional lateral malleolus. The treatment of the two groups was conducted once the other day, 3 times each week, continuously for 8 weeks. Before and after the treatment, the ankle-joint's active and passive repositioning error angles were measured by using a joint angle ruler. The average error angle values of active and passive reposition tests of the injured ankle-joint were 4.98 +/- 1.11 and 4.78 +/- 1.3 before the treatment, and 3.67 +/- 0.58 and 3.51 +/- 0.64 after the treatment, respectively in the acupuncture group, being reduced significantly after the treatment (both P < 0.01). No significant changes of the average error angle values of both active and passive reposition tests of the ankle-joint were found after the treatment in the physiotherapy group (P > 0.05). Comparison between two groups showed that the average error angle, average active and passive reposition angles of the injured ankle in the acupuncture group were evidently lower than those in the physiotherapy group (P < 0.01). Acupuncture and moxibustion can effectively improve the proprioception of the injured lateral collateral ligament of the ankle joint in athletes, which is superior to conventional physiotherapy in the therapeutic effect.
Sarkalkan, Nazli; Loeve, Arjo J; van Dongen, Koen W A; Tuijthof, Gabrielle J M; Zadpoor, Amir A
(Osteo)chondral defects (OCDs) in the ankle are currently diagnosed with modalities that are not convenient to use in long-term follow-ups. Ultrasound (US) imaging, which is a cost-effective and non-invasive alternative, has limited ability to discriminate OCDs. We aim to develop a new diagnostic technique based on US wave propagation through the ankle joint. The presence of OCDs is identified when a US signal deviates from a reference signal associated with the healthy joint. The feasibility of the proposed technique is studied using experimentally-validated 2D finite-difference time-domain models of the ankle joint. The normalized maximum cross correlation of experiments and simulation was 0.97. Effects of variables relevant to the ankle joint, US transducers and OCDs were evaluated. Variations in joint space width and transducer orientation made noticeable alterations to the reference signal: normalized root mean square error ranged from 6.29% to 65.25% and from 19.59% to 8064.2%, respectively. The results suggest that the new technique could be used for detection of OCDs, if the effects of other parameters (i.e., parameters related to the ankle joint and US transducers) can be reduced.
Halasi, T; Kynsburg, A; Tallay, A; Berkes, I
Background: A search of the literature shows that the effect of surgery on ankle proprioception has been hardly investigated. Objective: To examine the effect of anatomical reconstruction of the anterolateral capsuloligamentous complex on ankle joint position sense. Methods: A prospective study using the "slope box" test. Ten consecutive patients were included in the study, and 10 healthy athletes represented the control group. Results: Similar test-retest reliability rates (overall reliability 0.92; p = 0.0013) were obtained to those of the original designers of the method. There were no significant differences with respect to side dominance (p = 0.9216). Investigation of the characteristics of mean absolute estimate errors showed that the controls tested became error prone in the range of slope altitudes 7.5–25° in every direction, compared with the range 0–5° (range of p values 0.00003–0.00072). The results of the intervention group showed that, for the two main directions of interest (anterior and lateral), preoperative differences in mean absolute estimate errors between injured (anterior 3.91 (2.81)°; lateral 4.06 (2.85)°) and healthy (anterior 2.94 (2.21)°, lateral 3.19 (2.64)°) sides (anterior, p = 0.0124; lateral, p = 0.0250) had disappeared (postoperative differences: anterior, p = 0.6906; lateral, p = 0.4491). The afflicted ankle had improved significantly after surgery in both important directions (anterior, p<0.0001; lateral, p = 0.0023). Conclusions: The study shows that differences in joint position sense between healthy and injured ankles disappeared as the result of surgery. Preoperative data show that proprioceptive malfunction is a cause of functional instability. If treatment is by means of surgery, the retensioning of the original anterolateral structures is inevitable, even if other grafting or surgical techniques are used. PMID:16244190
Simoneau, Emilie; Martin, Alain; Van Hoecke, Jacques
The aim of this study was to enquire whether older adults, who continue plantar-flexion (PF) strength training for an additional 6-month period, would achieve further improvements in neuromuscular performance, in the ankle PFs, and in the antagonist dorsi-flexors (DFs). Twenty-three healthy older volunteers (mean age 77.4 +/- 3.7 years) took part in this investigation and 12 of them followed a 1-year strength-training program. Both neural and muscular factors were examined during isometric maximal voluntary contraction (MVC) torques in ankle PF and DF pre-training, post 6 and post 12 months. The main finding was that 6 months of additional strength training of the PFs, beyond 6 months, allowed further improvements in neuromuscular performance at the ankle joint in older adults. Indeed, during the first 6 months of progressive resistance training, there was an increase in the PF MVC torque of 11.1 +/- 19.9 N m, and then of 11.1 +/- 17.9 N m in the last 6-month period. However, it was only after 1 year that there was an improvement in the evoked contraction at rest in PF (+ 8%). The strength training of the agonist PF muscles appeared to have an impact on the maximal resultant torque in DF. However, it appeared that this gain was first due to modifications occurring in the trained PFs muscles, then, it seemed that the motor drive of the DFs per se was altered. In conclusion, long-term strength training of the PFs resulted in continued improvements in neuromuscular performance at the ankle joint in older adults, beyond the initial 6 months.
Kowalczyk, Bartłomiej; Lejman, Tadeusz
We present results of treatment in 36 cases of distal tibial epiphyseolysis in 34 patients treated between 1999 and 2005 with a minimal follow up of 12 months (average 28,5, range 13-84 months). The mean age at injury was 12 years (range from 7 to 16). There were 22 cases of type II injury according to the Salter-Harris classification, 5 cases of type VII, 3 of type IV, 2 of type I and two cases of triplane fracture, one case of retrospectively recognised type V and one of type III. 12 children required open reduction and K-wire fixation, the rest of 22 children underwent closed reduction followed by percutaneus fixation in 12 cases. Concomitant fibular fracture occured in 30 cases and required open reduction and fixation in 4. There were 18 good, 14 fair and 3 bad results according to Gleizes. The mean AOFAS scale result was 92.7. One child underwent 2 weeks of intravenous antybiotic therapy to recover from superficial skin infection around percutaneus K-wires. Four cases of physeal bar formation were noted. In two of them distal tibial osteotomy to correct ankle varus was necessary and one underwent bony bridge removal followed by fatty tissue interposition. The remaining physeal bar resulted in 10 degree of ankle valgus without functional dispairement.
Cherney, Steven M.; Haynes, Jacob A.; Spraggs-Hughes, Amanda; McAndrew, Christopher M.; Ricci, William M.; Gardner, Michael J.
Objectives The goals of this study were to assess syndesmotic reductions utilizing computerized tomography (CT) scans, and to determine if malreductions were associated with certain injury types or reduction forceps. Design Prospective cohort Setting Urban Level 1 Trauma center Patients Twenty-seven patients with operatively treated syndesmotic injuries were recruited prospectively. Intervention Patients underwent postoperative bilateral CT scans of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Main outcome measurement Side-to-side differences of fibula position within the tibial incisura were measured at several anatomic points and analyzed based on injury type, the presence of posterior malleolar injury, level of fracture, and type of reduction forceps used. Results On average, operatively treated syndesmotic injuries were over-compressed (fibular medialization) by 1mm (p < .001) and externally rotated by 5° (p = .002) when compared to the uninjured extremity. The absence of a posterior malleolar injury and Weber B (OTA 44-B) fractures seemed to have a protective effect against malrotation, but not against over-compression. There was no difference in malreduction based on type of clamp used. Conclusions It is possible, and highly likely based on these data, to over-compress the syndesmosis when using a reduction forceps. Care should be taken to avoid over-compression, as this may affect ankle motion and functional outcome. This is the first in vivo series of syndesmotic over-compression to our knowledge. PMID:26295735
Bouguecha, Anas; Weigel, Nelly; Behrens, Bernd-Arno; Stukenborg-Colsman, Christina; Waizy, Hazibullah
The use of artificial endoprostheses has become a routine procedure for knee and hip joints while ankle arthritis has traditionally been treated by means of arthrodesis. Due to its advantages, the implantation of endoprostheses is constantly increasing. While finite element analyses (FEA) of strain-adaptive bone remodelling have been carried out for the hip joint in previous studies, to our knowledge there are no investigations that have considered remodelling processes of the ankle joint. In order to evaluate and optimise new generation implants of the ankle joint, as well as to gain additional knowledge regarding the biomechanics, strain-adaptive bone remodelling has been calculated separately for the tibia and the talus after providing them with an implant. FE models of the bone-implant assembly for both the tibia and the talus have been developed. Bone characteristics such as the density distribution have been applied corresponding to CT scans. A force of 5,200 N, which corresponds to the compression force during normal walking of a person with a weight of 100 kg according to Stauffer et al., has been used in the simulation. The bone adaptation law, previously developed by our research team, has been used for the calculation of the remodelling processes. A total bone mass loss of 2% in the tibia and 13% in the talus was calculated. The greater decline of density in the talus is due to its smaller size compared to the relatively large implant dimensions causing remodelling processes in the whole bone tissue. In the tibia, bone remodelling processes are only calculated in areas adjacent to the implant. Thus, a smaller bone mass loss than in the talus can be expected. There is a high agreement between the simulation results in the distal tibia and the literature regarding. In this study, strain-adaptive bone remodelling processes are simulated using the FE method. The results contribute to a better understanding of the biomechanical behaviour of the ankle joint
Pakarinen, Harri; Flinkkilä, Tapio; Ohtonen, Pasi; Hyvönen, Pekka; Lakovaara, Martti; Leppilahti, Juhana; Ristiniemi, Jukka
This study was designed to assess the sensitivity, specificity, and interobserver reliability of the hook test and the stress test for the intraoperative diagnosis of instability of the distal tibiofibular joint following fixation of ankle fractures resulting from supination-external rotation forces. We conducted a prospective study of 140 patients with an unstable unilateral ankle fracture resulting from a supination-external rotation mechanism (Lauge-Hansen SE). After internal fixation of the malleolar fracture, a hook test and an external rotation stress test under fluoroscopy were performed independently by the lead surgeon and assisting surgeon, followed by a standardized 7.5-Nm external rotation stress test of each ankle under fluoroscopy. A positive stress test result was defined as a side-to-side difference of >2 mm in the tibiotalar or the tibiofibular clear space on mortise radiographs. The sensitivity and specificity of each test were calculated with use of the standardized 7.5-Nm external rotation stress test as a reference. Twenty-four (17%) of the 140 patients had a positive standardized 7.5-Nm external rotation stress test after internal fixation of the malleolar fracture. The hook test had a sensitivity of 0.25 (95% confidence interval, 0.12 to 0.45) and a specificity of 0.98 (95% confidence interval, 0.94 to 1.0) for the detection of the same instabilities. The external rotation stress test had a sensitivity of 0.58 (95% confidence interval, 0.39 to 0.76) and a specificity of 0.96 (95% confidence interval, 0.90 to 0.98). Both tests had excellent interobserver reliability, with 99% agreement for the hook test and 98% for the stress test. Interobserver agreement for the hook test and the clinical stress test was excellent, but the sensitivity of these tests was insufficient to adequately detect instability of the syndesmosis intraoperatively.
... are held together with special screws and metal plates attached to the outer surface of the bone. ... bone fragments may be ﬁxed using screws, a plate and screws, or diﬀerent wiring techniques. (Le ) X- ...
Faizullin, I; Faizullina, E
Ankle sprain is a medical condition when ankle ligaments are totally or partially torn. The primary cause of ankle sprain is sharp movements like turning or rolling the foot . The ankle sprain needs to be treated right after the trauma, because if not treated it could lead to decreased stability of the ankle joint and lead to chronic ankle instability, which is characterized by increased risk of the ankle sprain  . We suppose that rehabilitation after the ankle sprain could significantly increase the performance of sportsmen. To investigate effects of balance exercise training on instable ankle due to the previous ankle sprain injury. In addition, the secondary aim of this systematic review was to find the effectiveness of different balance training exercises on instable ankle in order to find better opportunities for rehabilitation of sportsmen. The studies were selected from PubMed and Scopus using the library of the Friedrich-Alexander University of Erlangen-Nuremberg (further-UB FAU), we used full texts, and only texts in English were included in this review. The literature search was conducted at the end of December 2014. Texts included randomised controlled trials, which were published in the last 5 years (2009-2014). The literature was included in this review only if it was published in English and if the randomised controlled trial was conducted in the study and if the full text was available from UB FAU. The articles, which were found only in PubMed search, were excluded during Scopus search.PubMed search.First MeSH term was "Balance training for the ankle sprain" and 44 articles were found in PubMed. Then 29 articles were filtered by title and excluded from the study. Remaining 15 articles were assessed reading their abstracts, 6 of them were excluded and only 4 articles were left. The second MeSH term was "Balance training for ankle injury". Four additional articles were found by initial search. Two of them were filtered by the title and 2 were
Patikas, D A; Kotzamanidis, C; Robertson, C T; Koceja, D M
The factors that are responsible for the relationship between motoneuron excitability and muscle length may have both mechanical and/or neurophysiologic origins. The aim of the study was to investigate the changes in the level of presynaptic inhibition, as measured with a soleus H-reflex conditioning protocol, and muscle length. Ten healthy volunteers were measured at three different ankle angles: 30 degrees plantar flexion, neutral position (0 degrees) and 15 degrees dorsiflexion. At each position the soleus H-reflex and the maximum M-wave were measured while the limb was relaxed. The H-reflex was conditioned by a stimulation of the common peroneal nerve, 100 ms prior to the tibial nerve stimulation. The results revealed that the level of presynaptic inhibition was higher at the neutral position in comparison to the dorsiflexed or plantarflexed positions. Additionally, the HMAX/MMAX ratio was significantly decreased when the joint position was set at dorsiflexion. Further, there was a significant correlation, independent of ankle joint angle, between presynaptic inhibition levels and the HMAX/MMAX ratio. The above findings support the concept that peripheral feedback from passive, static modifications in the joint angle and consequently in muscle length, can modify the input/output threshold of the motoneurons on a presynaptic level.
Background Spastic paresis in cerebral palsy (CP) is characterized by increased joint stiffness that may be of neural origin, i.e. improper muscle activation caused by e.g. hyperreflexia or non-neural origin, i.e. altered tissue viscoelastic properties (clinically: “spasticity” vs. “contracture”). Differentiation between these components is hard to achieve by common manual tests. We applied an assessment instrument to obtain quantitative measures of neural and non-neural contributions to ankle joint stiffness in CP. Methods Twenty-three adolescents with CP and eleven healthy subjects were seated with their foot fixated to an electrically powered single axis footplate. Passive ramp-and-hold rotations were applied over full ankle range of motion (RoM) at low and high velocities. Subject specific tissue stiffness, viscosity and reflexive torque were estimated from ankle angle, torque and triceps surae EMG activity using a neuromuscular model. Results In CP, triceps surae reflexive torque was on average 5.7 times larger (p = .002) and tissue stiffness 2.1 times larger (p = .018) compared to controls. High tissue stiffness was associated with reduced RoM (p < .001). Ratio between neural and non-neural contributors varied substantially within adolescents with CP. Significant associations of SPAT (spasticity test) score with both tissue stiffness and reflexive torque show agreement with clinical phenotype. Conclusions Using an instrumented and model based approach, increased joint stiffness in CP could be mainly attributed to higher reflexive torque compared to control subjects. Ratios between contributors varied substantially within adolescents with CP. Quantitative differentiation of neural and non-neural stiffness contributors in CP allows for assessment of individual patient characteristics and tailoring of therapy. PMID:23880287
Madeley, Luke T; Munteanu, Shannon E; Bonanno, Daniel R
Medial tibial stress syndrome (MTSS) is a common overuse leg injury seen in athletes and can be recalcitrant to management. This cross-sectional study aimed to determine if there are differences in the isotonic endurance of the ankle joint plantar flexor muscles in athletes with MTSS compared to athletes without MTSS. The isotonic endurance of the ankle joint plantar flexors was measured in 30 participants diagnosed with MTSS, and 30 reference participants that were matched to MTSS participants on the basis of age (+/-5 years), gender, BMI (+/-5%) and type of sporting activity. The number of heel-rise repetitions of the participants in each group was compared for differences. There were no significant differences between participants with and without MTSS for age (p=0.34), height (p=0.40) or BMI (p=0.27). The mean number of heel-rise repetitions performed by participants in the MTSS group was significantly less than the reference group (mean 23, S.D. 5.6, versus mean 33, S.D. 8.6; p<0.001). These results suggest that athletes with MTSS have endurance deficits of the ankle joint plantar flexor muscles. Rehabilitation of athletes with MTSS should comprise training designed to enhance endurance of the lower limb musculature, including the ankle joint plantar flexors. It is not known whether a lack of endurance of the ankle joint plantar flexor muscles is the cause or effect of MTSS.
Acute ankle injury, a common musculoskeletal injury, can cause ankle sprains. Some evidence suggests that previous injuries or limited joint flexibility may contribute to ankle sprains. The initial assessment of an acute ankle injury should include questions about the timing and mechanism of the injury. The Ottawa Ankle and Foot Rules provide clinical guidelines for excluding a fracture in adults and children and determining if radiography is indicated at the time of injury. Reexamination three to five days after injury, when pain and swelling have improved, may help with the diagnosis. Therapy for ankle sprains focuses on controlling pain and swelling. PRICE (Protection, Rest, Ice, Compression, and Elevation) is a well-established protocol for the treatment of ankle injury. There is some evidence that applying ice and using nonsteroidal antiinflammatory drugs improves healing and speeds recovery. Functional rehabilitation (e.g., motion restoration and strengthening exercises) is preferred over immobilization. Superiority of surgical repair versus functional rehabilitation for severe lateral ligament rupture is controversial. Treatment using semirigid supports is superior to using elastic bandages. Support devices provide some protection against future ankle sprains, particularly in persons with a history of recurrent sprains. Ankle disk or proprioceptive neuromuscular facilitation exercise regimens also may be helpful, although the literature supporting this is limited.
MILNER, C. E.; SOAMES, R. W.
Compared with other joints, the ligaments of the ankle have not been studied in great detail; consequently relatively little literature exists. The positions of the 3 major bands of the lateral collateral ligament are well known and documented (Schafer et al. 1915; Sarrafian, 1983; McMinn, 1994; Palastanga et al. 1994; Williams et al. 1995). The detailed anatomy of the ligaments is, however, relatively complex with variations of the major bands and several minor additional bands being reported (Sarrafian, 1993; Burks & Morgan, 1994; Rosenberg et al. 1995). PMID:9419003
Wrazidlo, W; Karl, E L; Koch, K
We describe 114 cases based on 2020 arthrographies of the ankle joint for diagnosing fresh tears of the tibio-fibula syndesmosis without bone lesions. Comparison of the arthrographical diagnosis with the intra-operative diagnosis showed good agreement. Diagnosis of the isolated tear of the tibio-fibular syndesmosis revealed a sensitivity of 90% and a specificity of 67%. The technical procedure and the isolated tear of the tibiofibular syndesmosis in combination with other capsuleligament lesions are presented, using typical x-ray images as examples.
Vieira, Rodrigo Barreiros; Bertolini, Fabricio Melo; Vieira, Tallys Campos; Aguiar, Rodrigo Manso; Pinheiro, Guilherme Baldez; Lasmar, Rodrigo Campos Pace
Objective: Eighty-three soccer players aged between 14 and 19 years, in the basic category of a professional soccer club in the city of Belo Horizonte, were followed up during the 2009 season. Methods: A prospective observational cohort study was conducted, in which these soccer players were divided randomly into two groups. The first consisted of individuals with joint hypermobility syndrome (JHS), totaling 22 players, and the second was a control group with 61 players without this syndrome, determined through a physical examinati. Results: Both groups were studied with regard to incidence of ankle sprains. At the end of this period, the data were compiled and statistical analysis was performed. A total of 43 cases of ankle injury due to sprains were recorded, of which nine episodes were in players with JHS, thus making p = 0.106. The significance level was 5%. Conclusion: We were able to conclude that in our study there was insufficient evidence to assert that there is an association with increased incidence of ankle sprains among patients with JHS. PMID:27047888
Pittaccio, Simone; Viscuso, Stefano; Beretta, Elena; Turconi, Anna Carla; Strazzer, Sandra
NiTi is a metal alloy with unconventional functional characteristics: Shape memory and pseudoelasticity. Its use in the field of rehabilitation is very innovative. This work presents applications in lower limb orthotics. Three different devices were assembled and tested: An equinus gait dynamic splint, a compliant ankle positioning brace, and a dual-mode haptic/active exerciser for the dorsiflexors. Results are derived from technical and preclinical trials. The gait splint improves several walking parameters even better than a traditional flexible ankle-foot orthoses (AFO). In particular, it supports mid-stance and propulsion biomechanics and affects physiological activation of tibialis anterior during swing much less than posterior leaf AFO. The haptic/active exerciser, able to provide dorsiflexion through a suitable articular range, could be controlled on the basis of minimal surface electromyographic (sEMG) signals, suggesting its use as an aid for early active workouts as soon as patients start to recover voluntary control of tibialis anterior. Further evidence must be sought in future to confirm for the ankle joint the promising results obtained in repositioning applications in prior upper limb studies. The work done so far on the tested prototypes is encouraging: Material characteristics and dimensioning will be optimized so that customized NiTi devices can be prescribed to best meet individual patients' requirements.
Thakore, Rachel V; Greenberg, Sarah E; Sathiyakumar, Vasanth; Prablek, Marc A; Elmashat, David; Hinson, Julian K; Joyce, David; Obremskey, William T; Sethi, Manish K
We evaluated the operative notes for justification on the use of the 22-modifier in ankle fracture cases and compared the differences in physician billing and reimbursement. A total of 265 patients who had undergone operative management of isolated ankle fractures across a 10-year period were identified at a level I trauma center through a retrospective chart review. Of the 265 patients, 61 (23.0%) had been billed with the 22-modifier. The radiographs were reviewed by 3 surgeons to determine the complexity of the case. The amount of the professional fees and payments was obtained from the financial services department. Operative reports were reviewed for inclusion of eight 22-modifier criteria and word count. Mann-Whitney U tests of means were used to compare cases with and without the 22-modifier. From our analysis of preoperative radiographs, 37 (60%) showed evidence of a significantly complex fracture that justified the use of the 22-modifier. A review of the operative reports showed that 42 (68%) did not identify 2 or more reasons for requesting the 22-modifier in the report. Overall, the 22-modifier cases were not always reimbursed significantly greater amounts than the nonmodifier cases. No significant difference in the average word count of the operative notes was found. We have concluded that orthopedic trauma surgeons do not appropriately justify the use of the 22-modifier within their operative report. Further education on modifiers and the use of the operative report as billing documentation is required to ensure surgeons are adequately reimbursed for difficult trauma cases.
Mildren, Robyn L; Bent, Leah R
It has previously been shown that cutaneous sensory input from across a broad region of skin can influence proprioception at joints of the hand. The present experiment tested whether cutaneous input from different skin regions across the foot can influence proprioception at the ankle joint. The ability to passively match ankle joint position (17° and 7° plantar flexion and 7° dorsiflexion) was measured while cutaneous vibration was applied to the sole (heel, distal metatarsals) or dorsum of the target foot. Vibration was applied at two different frequencies to preferentially activate Meissner's corpuscles (45 Hz, 80 μm) or Pacinian corpuscles (255 Hz, 10 μm) at amplitudes ∼3 dB above mean perceptual thresholds. Results indicated that cutaneous input from all skin regions across the foot could influence joint-matching error and variability, although the strongest effects were observed with heel vibration. Furthermore, the influence of cutaneous input from each region was modulated by joint angle; in general, vibration had a limited effect on matching in dorsiflexion compared with matching in plantar flexion. Unlike previous results in the upper limb, we found no evidence that Pacinian input exerted a stronger influence on proprioception compared with Meissner input. Findings from this study suggest that fast-adapting cutaneous input from the foot modulates proprioception at the ankle joint in a passive joint-matching task. These results indicate that there is interplay between tactile and proprioceptive signals originating from the foot and ankle.
Bent, Leah R.
It has previously been shown that cutaneous sensory input from across a broad region of skin can influence proprioception at joints of the hand. The present experiment tested whether cutaneous input from different skin regions across the foot can influence proprioception at the ankle joint. The ability to passively match ankle joint position (17° and 7° plantar flexion and 7° dorsiflexion) was measured while cutaneous vibration was applied to the sole (heel, distal metatarsals) or dorsum of the target foot. Vibration was applied at two different frequencies to preferentially activate Meissner's corpuscles (45 Hz, 80 μm) or Pacinian corpuscles (255 Hz, 10 μm) at amplitudes ∼3 dB above mean perceptual thresholds. Results indicated that cutaneous input from all skin regions across the foot could influence joint-matching error and variability, although the strongest effects were observed with heel vibration. Furthermore, the influence of cutaneous input from each region was modulated by joint angle; in general, vibration had a limited effect on matching in dorsiflexion compared with matching in plantar flexion. Unlike previous results in the upper limb, we found no evidence that Pacinian input exerted a stronger influence on proprioception compared with Meissner input. Findings from this study suggest that fast-adapting cutaneous input from the foot modulates proprioception at the ankle joint in a passive joint-matching task. These results indicate that there is interplay between tactile and proprioceptive signals originating from the foot and ankle. PMID:26823342
Smith, Matthew; Medlock, Gareth; Johnstone, Alan J
We describe a minimally invasive technique to stabilise unstable ankle fractures by inserting a 100mm screw up the fibula medullary canal along with percutaneous screw fixation of the medial malleolus if required. This technique is utilised in patients with poor soft tissues and significant co-morbidities where the fracture cannot be adequately controlled by a cast alone. Retrospective review of 23 patients the average age being 70 years (29-89) and 74% had significant co-morbidities. Postoperative radiographs were examined for adequacy of reduction using the method described by Mclenna and Ungersma. Patient based functional and health questionnaires were performed, reviewed and scored. Six patients were lost during the follow-up period due to death caused by issues unrelated to the ankle fracture. There were no reported intraoperative complications, no postoperative wound infections and no non-unions. There was two complications one loss of fixation, and another required removal of the screw due to irritation. Radiographic reduction was good in 52%, fair in 44% and poor in 4%. Patient questionnaire results were 70 (20-100) for the Abbreviated Olerud and Molander score and the SF-12 physical component score was 42 and mental component was 44. With appropriate patient selection percutaneous screw fixation is an excellent technique supplementing cast immobilisation of unstable ankle fractures with poor soft tissues. Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
A short-cut review was carried out to determine whether hydrotherapy is an effective treatment to reduce pain and improve function in patients recovering from an ankle fracture. Although 12 papers were found using the reported search, no studies were relevant to this three-part question. No evidence was found to support this treatment.
Best, Raymond; Böhle, Caroline; Mauch, Frieder; Brüggemann, Peter G
To construct and evaluate an ankle arthrometer that registers inversion joint deflection at standardized inversion loads and that, moreover, allows conclusions about the mechanical strain of intact ankle joint ligaments at these loads. Twelve healthy ankles and 12 lower limb cadaver specimens were tested in a self-developed measuring device monitoring passive ankle inversion movement (Inv-ROM) at standardized application of inversion loads of 5, 10 and 15 N. To adjust in vivo and in vitro conditions, the muscular inactivity of the evertor muscles was assured by EMG in vivo. Preliminary, test-retest and trial-to-trial reliabilities were tested in vivo. To detect lateral ligament strain, the cadaveric calcaneofibular ligament was instrumented with a buckle transducer. After post-test harvesting of the ligament with its bony attachments, previously obtained resistance strain gauge results were then transferred to tensile loads, mounting the specimens with their buckle transducers into a hydraulic material testing machine. ICC reliability considering the Inv-ROM and torsional stiffness varied between 0.80 and 0.90. Inv-ROM ranged from 15.3° (±7.3°) at 5 N to 28.3° (±7.6) at 15 N. The different tests revealed a CFL tensile load of 31.9 (±14.0) N at 5 N, 51.0 (±15.8) at 10 N and 75.4 (±21.3) N at 15 N inversion load. A highly reliable arthrometer was constructed allowing not only the accurate detection of passive joint deflections at standardized inversion loads but also reveals some objective conclusions of the intact CFL properties in correlation with the individual inversion deflections. The detection of individual joint deflections at predefined loads in correlation with the knowledge of tensile ligament loads in the future could enable more individual preventive measures, e.g., in high-level athletes.
Kumar, P.; Huang, Z.; Dutta, I.; Sidhu, R.; Renavikar, M.; Mahajan, R.
A methodology to construct fracture mechanism maps for Sn-3.8%Ag-0.7%Cu (SAC387) solder joints attached to Cu substrates has been developed. The map, which delineates the operative mechanisms of fracture along with corresponding joint fracture toughness values, is plotted in a space described by two microstructure-dependent parameters, with the abscissa describing the interfacial intermetallic compound (IMC) and the ordinate representing the strain-rate-dependent solder yield strength. The plot space encompasses the three major mechanisms by which joints fail, namely (i) cohesive fracture of solder, (ii) cleavage fracture of interfacial intermetallic compounds (IMC), and (iii) fracture of the solder-IMC interface. Line contours of constant fracture toughness values, as well as constant fraction of each of the above mechanisms, are indicated on the plots. The plots are generated by experimentally quantifying the dependence of the operative fracture mechanism(s) on the two microstructure-dependent parameters (IMC geometry and solder yield strength) as functions of strain rate, reflow parameters, and post-reflow aging. Separate maps are presented for nominally mode I and equi-mixed mode loading conditions (loading angle ϕ = 0° and 45°, respectively). The maps allow rapid assessment of the operative fracture mechanism(s) along with estimation of the expected joint fracture toughness value for a given loading condition (strain rate and loading angle) and joint microstructure without conducting actual tests, and may serve as a tool for both prediction and microstructure design.
Mohammadi, Farshid; Roozdar, Arash
The high incidence of ankle sprains that occur later in matches suggests that fatigue may contribute to altered neuromuscular control of the ankle. Moreover, deficits in ankle joint position sense (JPS) were seen in patients with a history of recurrent ankle sprains. It has been hypothesized that ankle sprains may be related to altered ankle JPS as a consequence of fatigue. To evaluate if fatiguing contractions of evertor muscles alter the ankle JPS. Controlled laboratory study. Thirty-six soccer players (age, 24.7 +/- 1.3 years; height, 183.7 +/- 8.2 cm; weight, 78.9 +/- 7.9 kg) were recruited. Subjects were asked to recognize 2 positions (15 degrees of inversion and maximal active inversion minus 5 degrees ) for 2 conditions: normal and fatigue. Muscular fatigue was induced in evertor muscles of the dominant leg by using isometric contractions. The average of the absolute and variable errors of 3 trials were recorded for both fatigue and nonfatigue conditions. A matched control group of 36 soccer players (age, 23.9 +/- 0.9 years; height, 181.2 +/- 6.9 cm; weight, 77.8 +/- 6.5 kg) was asked to recognize the same positions, before a soccer match and after 45 minutes of playing, and their same scores were recorded. Finally, results of the 2 groups were compared. There was significant decrease in subjects' ability to recognize passive and active repositioning of their ankle after a fatigue protocol (P <.001). Passive and active JPS were reduced after playing (P <.001). There was no significant difference between 2 groups in the results of JPS before and after the intervention (P > .1). The acuity of the ankle JPS is reduced subsequent to a fatigue protocol and after a soccer match. Evaluation of athletes' ankle JPS before returning to physical activity may prevent further injuries.
Nyland, J A; Caborn, D N M
This study evaluated the ankle and knee electromyographic, kinematic, and kinetic differences of 20 nonimpaired females with either neutral (group 1) or coxa varus-genu valgus (group 2) alignment during crossover cutting stance phase. Two-way mixed model ANOVA (group, session) assessed mean differences ( p<0.05) and correlation analysis further delineated relationships. During impact absorption, group 2 displayed earlier peak horizontal braking (anterior-posterior) ground reaction force timing, decreased and earlier peak internal knee extension moments (eccentric function), and earlier peak internal ankle dorsiflexion moment timing (eccentric function). During the pivot phase, group 2 displayed later and eccentrically-biased peak ankle plantar flexion moments, increased peak internal knee flexion moments (eccentric function), and later peak knee internal rotation timing. Correlation analysis revealed that during impact absorption, subjects with coxa varus-genu valgus alignment (group 2) displayed a stronger relationship between knee internal rotation velocity and peak internal ankle dorsiflexion moment onset timing ( r= -0.64 vs r = -0.26) and between peak horizontal braking ground reaction forces and peak internal ankle dorsiflexion moment onset timing ( r= 0.61 vs r= 0.24). During the pivot phase these subjects displayed a stronger relationship between peak horizontal braking ground reaction forces and peak internal ankle plantar flexion moment onset timing ( r= -0.63 vs r= -0.09) and between peak horizontal braking forces and peak internal ankle plantar flexion moments ( r= -0.72 vs r= -0.26). Group differences suggest that subjects with coxa varus-genu valgus frontal-plane alignment have an increased dependence on both ankle dorsiflexor and plantar flexor muscle group function during crossover cutting. Greater dependence on ankle muscle group function during the performance of a task that requires considerable 3D dynamic knee joint control suggests a greater
Green, T; Refshauge, K; Crosbie, J; Adams, R
Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial. Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. DISCUSSION AND CONCLUSION Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.
Parikh, S; Dawe, E; Lee, C; Whitehead-Clarke, T; Smith, C; Bendall, S
Introduction Pseudoaneurysm formation following ankle arthroscopy is a rare but potentially catastrophic complication. The placement of anterior ankle portals carries inherent risk to the superficial and deep peroneal nerves, as well as to the dorsalis pedis artery. Anatomical variations in the dorsalis pedis and the presence of branches at the joint line may increase the risk of vascular injury and pseudoaneurysm formation during arthroscopy. There is limited anatomical evidence available regarding the branches of the dorsalis pedis artery, which occur at the point at which they cross the ankle joint. Objectives The objective of the study was to describe the frequency and direction of branches of the dorsalis pedis crossing the ankle joint. Materials and Methods Nineteen cadaveric feet were carefully dissected to explore the course of the dorsalis pedis artery, noting in particular the branching pattern at the joint line. Results Eleven of the nineteen feet had a branch of the dorsalis pedis artery that crossed the level of the ankle joint. Out of these, six were lateral, four medial and one bilateral. Eight of the eleven specimens had one branch at, or just before, the level of the joint. Two specimens had two branches and one had three branches crossing the ankle, which were all in the same direction, crossing laterally to the main trunk of the dorsalis pedis. Conclusions Our study demonstrated high rates of branching of the dorsalis pedis artery at the level of the ankle joint. The role of these branches in pseudoaneurysm formation during anterior hindfoot surgery remains unclear.
Kobayashi, Toshiki; Leung, Aaron K L; Akazawa, Yasushi; Hutchins, Stephen W
Ankle-foot orthoses (AFOs) are commonly prescribed to improve gait. The stiffness of an AFO is central for successful prescription; however, the recommended level of stiffness is currently based on the experience of clinicians. Therefore, the aim of this study was to design an experimental AFO (EAFO) whose stiffness was adjustable using commercially available oil-damper joints, and to demonstrate its potential capability in investigating the effects of altering AFO stiffness on gait. The influence of the EAFO stiffness on ankle joint kinematics in sagittal plane was evaluated in 10 patients with stroke by altering the stiffness of its oil-damper- type orthotic ankle joints using the four levels pre-set and defined by the manufacturer in dorsi- and plantarflexion directions independently. The mean peak plantarflexion angle was reduced by 105%, showing a change from 8.18 (3.14) degrees of plantarflexion to 0.38 (4.17) degrees of dorsiflexion, whilst the mean peak dorsiflexion angle was reduced by 44%, showing a change from 11.46 (5.57) degrees of dorsiflexion to 6.47 (5.23) degrees of dorsiflexion by altering the EAFO stiffness. The EAFO would therefore serve as a convenient tool when investigating the influence of AFO stiffness on gait in both clinical and research settings. Copyright © 2011 Elsevier B.V. All rights reserved.
Mall, S.; Kochhar, N. K.
A study was undertaken to characterize the debond growth mechanism of adhesively bonded composite joints under mode I, mixed mode I-II, and mode II static loadings. The bonded system consisted of graphite-epoxy composite adherends bonded with a toughened epoxy adhesive. The mode I, mode II and mixed mode I-II fracture energies of the tested adhesives were found to be equal to each other. The criterion for mixed mode fracture in composite bonded joints was found.
Park, Hyun-Joo; Durand, Dominique M
The flat interface nerve electrode (FINE) has demonstrated significant capability for fascicular and subfascicular stimulation selectivity. However, due to the inherent complexity of the neuromuscular skeletal systems and nerve-electrode interface, a trajectory tracking motion control algorithm of musculoskeletal systems for functional electrical stimulation using a multiple contact nerve cuff electrode such as FINE has not yet been developed. In our previous study, a control system was developed for multiple-input multiple-output (MIMO) musculoskeletal systems with little prior knowledge of the system. In this study, more realistic computational ankle/subtalar joint model including a finite element model of the sciatic nerve was developed. The control system was tested to control the motion of ankle/subtalar joint angles by modulating the pulse amplitude of each contact of a FINE placed on the sciatic nerve. The simulation results showed that the control strategy based on the separation of steady state and dynamic properties of the system resulted in small output tracking errors for different reference trajectories such as sinusoidal and filtered random signals. The proposed control method also demonstrated robustness against external disturbances and system parameter variations such as muscle fatigue. These simulation results under various circumstances indicate that it is possible to take advantage of multiple contact nerve electrodes with spatial selectivity for the control of limb motion by peripheral nerve stimulation even with limited individual muscle selectivity. This technology could be useful to restore neural function in patients with paralysis.
Castagnini, Francesco; Pellegrini, Camilla; Perazzo, Luca; Vannini, Francesca; Buda, Roberto
Ankle osteoarthritis (AOA) is a severe pathology, mostly affecting a post-traumatic young population. Arthroscopic debridement, arthrodiastasis, osteotomy are the current joint sparing procedures, but, in the available studies, controversial results were achieved, with better outcomes in case of limited degeneration. Only osteotomy in case of malalignment is universally accepted as a joint sparing procedure in case of partial AOA. Recently, the biological mechanism of osteoarthritis has been intensively studied: it is a whole joint pathology, affecting cartilage, bone and synovial membrane. In particular, the first stage is characterized by a reversible catabolic activity with a state of chondropenia. Thus, biological procedures for early AOA were proposed in order to delay or to avoid end stage procedures. Mesenchymal stem cells (MSCs) may be a good solution to prevent or reverse degeneration, due to their immunomodulatory features (able to control the catabolic joint environment) and their regenerative osteochondral capabilities (able to treat the chondral defects). In fact, MSCs may regulate the cytokine cascade and the metalloproteinases release, restoring the osteochondral tissue as well. After interesting reports of mesenchymal stem cells seeded on scaffold and applied to cartilage defects in non-degenerated joints, bone marrow derived cells transplantation appears to be a promising technique in order to control the degenerative pathway and restore the osteochondral defects.
Mandell, Jacob C; Khurana, Bharti; Smith, Stacy E
A stress fracture is a focal failure of bone induced by the summation of repetitive forces, which overwhelms the normal bone remodeling cycle. This review, the first of two parts, discusses the general principles of stress fractures of the foot and ankle. This includes bone structure, biomechanics of stress applied to bone, bone remodeling, risk factors for stress fracture, and general principles of imaging and treatment of stress fractures. Cortical bone and trabecular bone have a contrasting macrostructure, which leads to differing resistances to externally applied forces. The variable and often confusing imaging appearance of stress fractures of the foot and ankle can largely be attributed to the different imaging appearance of bony remodeling of trabecular and cortical bone. Risk factors for stress fracture can be divided into intrinsic and extrinsic factors. Stress fractures subject to compressive forces are considered low-risk and are treated with activity modification and correction of any modifiable risk factors. Stress fractures subject to tensile forces and/or located in regions of decreased vascularity are considered high risk, with additional treatment options including restricted weight-bearing or surgery.
Schottel, Patrick C; Fabricant, Peter D; Berkes, Marschall B; Garner, Matthew R; Little, Milton T M; Hentel, Keith D; Mintz, Douglas N; Helfet, David L; Lorich, Dean G
Stress ankle radiographs are routinely performed to determine deep deltoid ligament integrity in supination external rotation (SER) ankle fractures. However, variability is present in the published data regarding what medial clear space (MCS) value constitutes a positive result. The purposes of the present study were to evaluate the diagnostic accuracy of different MCS cutoff values and determine whether this clinical test could accurately discriminate between patients with and without a deep deltoid ligament disruption. MCS measurements were recorded for stress ankle injury radiographs in an SER ankle fracture cohort. Preoperative ankle magnetic resonance imaging studies, obtained for all patients, were then read independently by 2 musculoskeletal attending radiologists to determine deep deltoid ligament integrity. The MCS measurements were compared with the magnetic resonance imaging diagnosis using receiver operating characteristic analyses to determine the sensitivity, specificity, and optimal data-driven cutoff values. SER II-III patients demonstrated a mean stress MCS distance of 4.3 ± 0.98 mm compared with 5.8 ± 1.76 mm in the SER IV cohort (p < .001). An analysis of differing MCS positive cutoff thresholds revealed that a stress MCS of 5.0 mm maximized the combined sensitivity and specificity of the external rotation test: 65.8% sensitive and 76.5% specific. Using the receiver operating characteristic curve analysis of the MCS measurement, the calculated area under the curve was 0.77, indicating inadequate discriminative ability for diagnosing SER pattern fractures with or without a deep deltoid ligament tear. Judicious use of additional diagnostic testing in patients with a stress MCS result between 4.0 mm and 5.5 mm is warranted. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Lee, Jinkyu; Yoon, Yong-Jin; Shin, Choongsoo S
The purpose of this study was to investigate the effect of load carriage on the kinematics and kinetics of the ankle and knee joints during uphill walking, including joint work, range of motion (ROM), and stance time. Fourteen males walked at a self-selected speed on an uphill (15°) slope wearing military boots and carrying a rifle in hand without a backpack (control condition) and with a backpack. The results showed that the stance time significantly decreased with backpack carriage (p<.05). The mediolateral impulse significantly increased with backpack carriage (p<.05). In the ankle joints, the inversion-eversion, and dorsi-plantar flexion ROM in the ankle joints increased with backpack carriage (p<.05). The greater dorsi-plantar flexion ROM with backpack carriage suggested one strategy for obtaining high plantar flexor power during uphill walking. The result of the increased mediolateral impulse and inversion-eversion ROM in the ankle joints indicated an increase in body instability caused by an elevated center of mass with backpack carriage during uphill walking. The decreased stance time indicated that an increase in walking speed could be a compensatory mechanism for reducing the instability of the body during uphill walking while carrying a heavy backpack.
Kim, Suezie; Ward, James P; Rettig, Michael E
Galeazzi fracture dislocations are fractures of the distal one-third of the radial diaphysis with traumatic disruption of the distal radioulnar joint (DRUJ). This injury results in subluxation or dislocation of the ulnar head. We present a case of a Galeazzi fracture with a volar dislocation of the DRUJ. Open reduction of the DRUJ with Kirschner wire fixation in pronation was necessary to reduce the joint and maintain anatomic alignment. Repair of the triangular fibrocartilage complex was also necessary to maintain stability of the DRUJ.
Walker, Logan; Willis, Nigel
Tibiofibular transfixation of Weber C injuries using a diastasis screw is the current method of fixation. However, controversy remains regarding the screw size and number, number of cortices engaged, and the interval to screw removal. The present study reviewed the current practice in the Wellington Region. A retrospective audit of patients with documented Weber C injuries in the Capital & Coast District Health Board from June 2012 to December 2013 was performed. The clinical medical records and radiographs were reviewed, and the patient demographics, surgeon details, screw number, size, cortices engaged, screw removal period, and documented complications were recorded. A total of 36 operations were documented, of which 27 (75%) cases also required fibula plating. Of the 36 cases, 25 (69.44%) used a single diastasis screw, 33 (91.67%) used 4.5-mm screws, and 18 (50%) engaged 3 cortices. Surgical practice did not vary with the experience level. Of the 36 patients, 29 (80.56%) underwent routine screw removal at a median of 20 (25th to 75th quartile range 16 to 22) weeks. Also, 9 (25%) cases of screw fracture occurred, with a median documented interval to fracture of 18 (25th to 75th quartile range 15 to 20) weeks. The surgical management of Weber C injuries is consistent with current practice. The routine removal of diastasis screws by 20 weeks postoperatively was not different from the documented interval of screw removal when screw fractures had occurred. The timing of screw removal needs to be weighed against the fracture risk, patient symptoms, and the risk of secondary procedure complications. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Daimaruya, M.; Fujiki, H.; Ambarita, H.; Kobayashi, H.; Shin, H.-S.
The present study is concerned with the development of a fracture criterion for the impact fracture of jointed steel plates of bolted joints used in a car body, which contributes to crash simulations by CAE. We focus our attention on the shear fracture of the jointed steel plates of lap-bolted joints in the suspension of a car under impact load. Members of lap-bolted joints are modelled as a pair of steel plates connected by a bolt. One of the plates is a specimen subjected to plastic deformation and fracture and the other is a jig subjected to elastic deformation only. Three kinds of steel plate specimens are examined, i.e., a common steel plate with a tensile strength of 270 MPa and high tensile strength steel plates of 440 and 590 MPa used for cars. The impact shear test was performed using the split Hopkinson bar technique for tension impact, together with the static test using a universal testing machine INSTRON 5586. The behaviour of the shear stress and deformation up to rupture taking place in the joint was discussed. The obtained results suggest that a stress-based fracture criterion may be developed for the impact fracture of jointed steel plates of a lap-bolted joint.
Seidel, Angela; Krause, Fabian; Weber, Martin
Isolated lateral malleolar fractures may result from a supination-external rotation (SER) injury of the ankle. Stable fractures maintain tibiotalar congruence due to competent medial restraints and can be treated nonoperatively with excellent functional results and long-term prognosis. Stability might be assessed with either stress radiographs or weightbearing radiographs. A consecutive series of patients with closed SER fractures (presumed AO 44-B1) were prospectively enrolled from 2008 to 2015. Patients with clearly unstable fractures (medial clear space more than 7 mm) on the initial nonweightbearing radiograph were excluded and operated on. All other patients were examined with a gravity stress and a weightbearing anteroposterior radiograph. Borderline instability of the fracture was assumed when the medial clear space was 4 to 7 mm. Those were treated nonoperatively. Of 104 patients with isolated lateral malleolar fractures of the SER type, 14 patients were treated operatively because of clear instability (displacement) on the initial radiographs. Of the nonoperative patients, 44 patients demonstrated borderline instability on the gravity stress but stability on the weightbearing radiograph ("gravity borderline"); the remaining 46 were stable in both tests ("gravity stable"). At an average follow-up of 23 months, no significant differences were seen in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points gravity-borderline group vs 93 points gravity-unstable group), the Foot Functional Index score (11 vs 10 points), the Short Form 36 (SF-36) physical component (86 vs 85 points), and SF-36 mental component (84 vs 81 points). Radiographically, all fractures had healed with anatomic congruity of the ankle. Weightbearing radiographs provided a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up. Gravity
Nichols, T R; Lawrence, J H; Bonasera, S J
To study the biomechanics of the calcaneal tendon's complex insertion onto the calcaneus, we measured torque-time trajectories exerted by the triceps surae and tibialis anterior muscles in eight unanesthetized decerebrate cats using a multi-axis force-moment sensor placed at the ankle joint. The ankle was constrained to an angle of 110 degrees plantarflexion. Muscles were activated using crossed-extension (XER), flexion (FWR), and caudal cutaneous sural nerve (SNR) reflexes. Torque contributions of other muscles activated by these reflexes were eliminated by denervation or tenotomy. In two animals, miniature pressure transducers were implanted among tendon fibers from the lateral gastrocnemius (LG) muscle that insert straight into the calcaneus or among tendon fibers from the medial gastrocnemius (MG) that cross over and insert on the lateral aspect of calcaneus. Reflexively evoked torques had the following directions: FWR, dorsiflexion and adduction; SNR, plantarflexion and abduction; and XER, plantarflexion and modest abduction or adduction. The proportion of abduction torque to plantarflexion torque was always greater for SNR than XER; this difference was about 50% of the magnitude of abduction torque generated by tetanic stimulation of the peronei. During SNR, pressures were higher in regions of the calcaneal tendon originating from MG than regions originating from LG. Similarly, pressures within the MG portion of the calcaneal tendon were higher during SNR than during XER, although these two reflexes produced matched ankle plantarflexion forces. Selective tenotomies and electromyographic recordings further demonstrated that MG generated most of the torque in response to SNR, while soleus, LG, and MG all generated torques in response to XER.(ABSTRACT TRUNCATED AT 250 WORDS)
Niu, Wenxin; Wang, Yang; He, Yan; Fan, Yubo; Zhao, Qinping
A search of the literature did not reveal known gender differences in biomechanics during parachute landing. Eight male and eight female healthy adults participated in this experiment. Each individual jumped from platforms with three different heights (low: 0.32 m; medium: 0.52 m; and high: 0.72 m) and landed on flat ground in a standard half-squat parachute landing technique. The ground reaction force (GRF) normalized to bodyweight (BW), ankle joint kinematics, and the surface electromyogram (EMG) signals of the tibialis anterior (TA) and lateral gastrocnemius (LG) were measured. Two-way ANOVA was used to analyze the effects of the dropping height and gender factors. The anterior-posterior GRF (men 1.01 BW; women 0.79 BW), rate of loading (men 260 BW x s(-1); women 127 BW x s(-1)), and absolute EMG amplitude of TA (pre-landing: men 219 microv; women 129 microv; post-landing: men 573 microv; women 288 microv) in the men's group were significantly higher than in the women's group, whereas peak angular velocity of dorsiflexion in the women's group (1627 degrees x s(-1)) was significantly higher than in the men's (1188 degrees x s(-1)). Women are prone to transform the kinetic energy to the ankle motion, whereas men are more likely to transform it to friction. The co-contraction of the ankle flexor and extensor differs between genders. These factors may be associated with the higher incidence of parachute injuries among women reported by some authors.
Meng, M.; Wang, Z. B.; Wang, X.; Chen, Y.
This paper analyzes two failure cases of creep-caused fracture of PbSn solder joint, including the joint between the wire and solder cup in the connector and the joint between the integrated circuit (IC) pins and the printed circuit board (PCB). The environment conditions, for the creep of PbSn solder joint is demonstrated, including the temperature and stress level. The stress origin and fracture morphology are summarized based on the failure analysis. Besides, the developing process of creep-caused fracture is explained. The paper comprehensively clarifies the creep mechanism of PbSn solder and consequently provides significant guidance for the reliable electronic assembly to avoid the creep-caused damage.
Restoration of a stable and plantigrade foot in deformities of the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joint. Deformities of the ankle and/or hindfoot and concomitant degenerative changes at the ankle and subtalar joint. Active local infection or relevant arterial insufficiency. Prone position and posterolateral approach to ankle and subtalar joint. Placement of dynamic reference bases (DRB) in the tibia and through a stab incision in the talus or calcaneus. Two-dimensional (2D) image acquisition for navigation. Definition of axes of the tibia, calcaneus, and hindfoot, and of extent of correction. Exposition of ankle and subtalar joint and removal of remaining cartilage. Computer-assisted surgery (CAS)-guided correction and transfixation of the corrected position with 2.5 mm K-wires. Three-dimensional (3D) image acquisition for analysis of the accuracy of the correction and planning of the drilling for the retrograde nail. CAS-guided drilling insertion of the nail. Insertion of locking screws in the calcaneus, talus and tibia. 3D image acquisition for analysis of the accuracy of the correction implant position. Partial weight bearing (15 kg) in an orthosis (Vacuped) for 6 weeks, followed by full weight bearing in a stable standard shoe. From 1 September 2006 to 31 August 2008, 14 correction arthrodeses were performed. The accuracy was assessed by intraoperative 3D imaging. All achieved angles/translations were within a maximum deviation of 2°/mm when compared to the planned correction. Complications that were associated with CAS were not observed. In all 14 cases completing follow-up, timely fusion was registered.
Jentzsch, Thorsten; Hasler, Anita; Renner, Niklas; Peterhans, Manuel; Sutter, Reto; Espinosa, Norman; Wirth, Stephan H
Lateral talar process fractures (LTPF) are often missed on conventional radiographs. A positive V sign is an interruption of the contour of the LTP. It has been suggested, but not proven to be pathognomonic for LTPF. The objective was to study whether the V sign is pathognomonic for LTPF and if it can be properly assessed in different ankle positions and varying fracture types. An experimental study was conducted. Two investigators assessed lateral radiographs (n = 108) of a foot and ankle model. The exposure variables were different ankle positions and fracture types. The primary outcome was the correct detection of a V sign. The secondary outcomes were the detection of the V sign depending on ankle position and fracture type as well as the uncertainty. The interobserver agreement on the V sign and type of fracture were fair (κ = 0.35, 95% CI 0.18-0.53, p < 0.001 and κ = 0.37, 95% CI 0.26-0.48, p < 0.001). The mean sensitivity, specificity, PPV, NPV, and likelihood ratio for the detection of the V sign were 77% (95% CI 67-86%), 59% (95% CI 39-78%), 85% (95% CI 75-92%), 46% (95% CI 29-63%), and 2. The mean uncertainty in the V sign detection was 38%. The V sign identification stratified by ankle position and fracture type showed significant better results with increasing inversion (p = 0.035 and p = 0.011) and type B fractures (p = 0.001 and p = 0.013). The V sign may not be pathognomonic and is not recommended as the only modality for the detection of LTPF. It is better visualized with inversion, but does not depend on plantar flexion or internal rotation. It is also better seen in type B fractures. It is difficult to detect and investigator-dependent. It may be helpful in a clinical setting to point into a direction, but a CT scan may be used if in doubt about a LTPF.
Tremblay, Francois; Karam, Siobhan
Context Physiotherapists and athletic trainers often use Kinesio Taping (KT) to prevent and treat musculoskeletal injuries in athletes, yet evidence about its effects on neuromuscular performance is conflicting. Objective To investigate the influence of a KT application directed at the ankle joint on measures of corticospinal excitability with transcranial magnetic stimulation. Design Controlled laboratory study. Setting Research laboratory. Patients or Other Participants Twelve healthy young women (age = 23.1 ± 1.9 years; range, 19–26 years). Intervention(s) Participants were tested under no-tape and KT conditions according to a random sequence order. The KT was applied to the skin overlying the dorsiflexor and plantar-flexor muscles of the ankle. Main Outcome Measure(s) We assessed changes in the amplitude of motor-evoked potentials elicited at rest and during movement and changes in the silent period and background muscle activity during movement. Results Taping conditions had no effect on motor-evoked potential amplitude at rest or during movement or on the silent-period duration and background muscle activity. Conclusions Our results concur with other recent reports, showing KT applications have little influence at the neuromuscular level. Alterations in sensory feedback ascribed to elastic taping are likely insufficient to modulate corticospinal excitability in a functionally meaningful manner. PMID:26090708
Spratford, Wayne; Hicks, Amy
The purpose of this study was to investigate the effect stride length has on ankle biomechanics of the leading leg with reference to the potential risk of injury in cricket fast bowlers. Ankle joint kinematic and kinetic data were collected from 51 male fast bowlers during the stance phase of the final delivery stride. The bowling cohort comprised national under-19, first class and international-level athletes. Bowlers were placed into either Short, Average or Long groups based on final stride length, allowing statistical differences to be measured. A multivariate analysis of variance with a Bonferroni post-hoc correction (α = 0.05) revealed significant differences between peak plantarflexion angles (Short-Long P = 0.005, Average and Long P = 0.04) and negative joint work (Average-Long P = 0.026). This study highlighted that during fast bowling the ankle joint of the leading leg experiences high forces under wide ranges of movement. As stride length increases, greater amounts of negative work and plantarflexion are experienced. These increases place greater loads on the ankle joint and move the foot into positions that make it more susceptible to injuries such as posterior impingement syndrome.
Tan, John F; Masani, Kei; Vette, Albert H; Zariffa, José; Robinson, Mark; Lynch, Cheryl; Popovic, Milos R
The restoration of arm-free standing in individuals with paraplegia can be facilitated via functional electrical stimulation (FES). In developing adequate control strategies for FES systems, it remains challenging to test the performance of a particular control scheme on human subjects. In this study, we propose a testing platform for developing effective control strategies for a closed-loop FES system for standing. The Inverted Pendulum Standing Apparatus (IPSA) is a mechanical inverted pendulum, whose angular position is determined by the subject's ankle joint angle as controlled by the FES system while having the subject's body fixed in a standing frame. This approach provides a setup that is safe, prevents falling, and enables a research and design team to rigorously test various closed-loop controlled FES systems applied to the ankle joints. To demonstrate the feasibility of using the IPSA, we conducted a case series that employed the device for studying FES closed-loop controllers for regulating ankle joint kinematics during standing. The utilized FES system stimulated, in able-bodied volunteers, the plantarflexors as they prevent toppling during standing. Four different conditions were compared, and we were able to show unique performance of each condition using the IPSA. We concluded that the IPSA is a useful tool for developing and testing closed-loop controlled FES systems for regulating ankle joint position during standing.
Tan, John F.; Masani, Kei; Vette, Albert H.; Zariffa, José; Robinson, Mark; Lynch, Cheryl; Popovic, Milos R.
The restoration of arm-free standing in individuals with paraplegia can be facilitated via functional electrical stimulation (FES). In developing adequate control strategies for FES systems, it remains challenging to test the performance of a particular control scheme on human subjects. In this study, we propose a testing platform for developing effective control strategies for a closed-loop FES system for standing. The Inverted Pendulum Standing Apparatus (IPSA) is a mechanical inverted pendulum, whose angular position is determined by the subject's ankle joint angle as controlled by the FES system while having the subject's body fixed in a standing frame. This approach provides a setup that is safe, prevents falling, and enables a research and design team to rigorously test various closed-loop controlled FES systems applied to the ankle joints. To demonstrate the feasibility of using the IPSA, we conducted a case series that employed the device for studying FES closed-loop controllers for regulating ankle joint kinematics during standing. The utilized FES system stimulated, in able-bodied volunteers, the plantarflexors as they prevent toppling during standing. Four different conditions were compared, and we were able to show unique performance of each condition using the IPSA. We concluded that the IPSA is a useful tool for developing and testing closed-loop controlled FES systems for regulating ankle joint position during standing. PMID:27350992
Knobe, M; Siebert, C H
Osteoporotic fractures of the femoral neck and trochanteric region pose an ever-expanding existential problem both for the individual and for society. Despite numerous innovations and advances regarding implant design, mortality and the systemic and mechanical complication rates remain high. Depiction of treatment options for femoral neck fractures and trochanteric femur fractures in the elderly comparing joint replacement and osteosynthesis. A search of the Medline, Embase and Cochrane databases was carried out focusing on hip fracture treatment. Randomized or quasi-randomized controlled trials, meta-analyses and reviews comparing joint replacement or fixation implants in the elderly were included. Displaced fractures of the femoral neck often require total joint arthroplasty whereas trochanteric fractures are amenable to internal fixation. Cemented total hip replacement as opposed to cementless techniques is recommended in the elderly and yields good functional results in active patients. Hemiarthroplasty is the treatment of choice in infirm patients with multiple comorbidities and cognitive impairment. Trochanteric fractures (AO/OTA types A1 and A2) can be successfully treated with intramedullary or extramedullary fixation. Adequate reduction and stable fixation are prerequisites for uneventful healing. A meticulous operative technique can prevent iatrogenic complications. In summary, there are many parameters affecting the outcome in the treatment of fragility and hip fractures. Technical features as well as surgeon characteristics play an important role and the ultimate solution has yet to be developed. Even though fracture morphology may indicate a specific treatment option, patient characteristics play an important role in decision-making. The development of centers of fragility fracture care in Germany could help to lower the complication rate and increase quality of life in hip fracture patients in the future.
Martín Lorenzo, Teresa; Albi Rodríguez, Gustavo; Rocon, Eduardo; Martínez Caballero, Ignacio; Lerma Lara, Sergio
Abstract Muscle fascicles lengthen in response to chronic passive stretch through in-series sarcomere addition in order to maintain an optimum sarcomere length. In turn, the muscles’ force generating capacity, maximum excursion, and contraction velocity is enhanced. Thus, longer fascicles suggest a greater capacity to develop joint power and work. However, static fascicle length measurements may not be taking sarcomere length differences into account. Thus, we considered relative fascicle excursions through passive ankle dorsiflexion may better correlate with the capacity to generate joint power and work than fascicle length. Therefore, the aim of the present study was to determine if medial gastrocnemius relative fascicle excursions correlate with ankle joint power and work generation during gait in typically developing children. A sample of typically developing children (n = 10) were recruited for this study and data analysis was carried out on 20 legs. Medial gastrocnemius relative fascicle excursion from resting joint angle to maximum dorsiflexion was estimated from trigonometric relations of medial gastrocnemius pennation angle and thickness obtained from B-mode real-time ultrasonography. Furthermore, a three-dimensional motion capture system was used to obtain ankle joint work and power during the stance phase of gait. Significant correlations were found between relative fascicle excursion and peak power absorption (–) r(14) = −0.61, P = .012 accounting for 31% variability, positive work r(18) = 0.56, P = .021 accounting for 31% variability, and late stance positive work r(15) = 0.51, P = .037 accounting for 26% variability. The large unexplained variance may be attributed to mechanics of neighboring structures (e.g., soleus or Achilles tendon mechanics) and proximal joint kinetics which may also contribute to ankle joint power and work performance, and were not taken into account. Further studies are encouraged to provide
Kraal, T; van der Heide, H J L; van Poppel, B J; Fiocco, M; Nelissen, R G H H; Doets, H C
Little is known about the long-term outcome of mobile-bearing total ankle replacement (TAR) in the treatment of end-stage arthritis of the ankle, and in particular for patients with inflammatory joint disease. The aim of this study was to assess the minimum ten-year outcome of TAR in this group of patients. We prospectively followed 76 patients (93 TARs) who underwent surgery between 1988 and 1999. No patients were lost to follow-up. At latest follow-up at a mean of 14.8 years (10.7 to 22.8), 30 patients (39 TARs) had died and the original TAR remained in situ in 28 patients (31 TARs). The cumulative incidence of failure at 15 years was 20% (95% confidence interval (CI) 11 to 28). The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of the surviving patients at latest follow-up was 80.4 (95% CI 72 to 88). In total, 21 patients (23 TARs) underwent subsequent surgery: three implant exchanges, three bearing exchanges and 17 arthrodeses. Neither design of TAR described in this study, the LCS and the Buechel-Pappas, remains currently available. However, based both on this study and on other reports, we believe that TAR using current mobile-bearing designs for patients with end-stage arthritis of the ankle due to inflammatory joint disease remains justified.
Prinold, Joe A I; Mazzà, Claudia; Di Marco, Roberto; Hannah, Iain; Malattia, Clara; Magni-Manzoni, Silvia; Petrarca, Maurizio; Ronchetti, Anna B; Tanturri de Horatio, Laura; van Dijkhuizen, E H Pieter; Wesarg, Stefan; Viceconti, Marco
Juvenile idiopathic arthritis (JIA) is the leading cause of childhood disability from a musculoskeletal disorder. It generally affects large joints such as the knee and the ankle, often causing structural damage. Different factors contribute to the damage onset, including altered joint loading and other mechanical factors, associated with pain and inflammation. The prediction of patients' joint loading can hence be a valuable tool in understanding the disease mechanisms involved in structural damage progression. A number of lower-limb musculoskeletal models have been proposed to analyse the hip and knee joints, but juvenile models of the foot are still lacking. This paper presents a modelling pipeline that allows the creation of juvenile patient-specific models starting from lower limb kinematics and foot and ankle MRI data. This pipeline has been applied to data from three children with JIA and the importance of patient-specific parameters and modelling assumptions has been tested in a sensitivity analysis focused on the variation of the joint reaction forces. This analysis highlighted the criticality of patient-specific definition of the ankle joint axes and location of the Achilles tendon insertions. Patient-specific detection of the Tibialis Anterior, Tibialis Posterior, and Peroneus Longus origins and insertions were also shown to be important.
Chan, Ching-Chao; Lin, Chou-Ching K; Ju, Ming-Shaung
The steady-state passive joint moment was considered as a nonlinear elasticity in the past. However, we found that it was path dependent and the estimation error could be large if the commonly used path-independent functions were adopted. The aim of this study was to develop a model to describe the movement history-dependent passive moment in the steady state. The steady-state passive ankle moments of the rabbit were measured by a series of ramp-and-hold angle changes (stairway angle trajectory). A customized discrete Preisach model was constructed and a commonly adopted double-exponential function was also implemented. Two sets of data with different angle paths (major loop and inward loop trajectories) were acquired for model validation. The performance of the two models was compared. The results showed that the proposed model could accurately estimate the steady-state passive moment for both sets of validation data. The estimated error of the proposed model was approximately 50% smaller than that of the double-exponential function approach. It is expected that this new approach, by reducing the error of estimating passive joint moment, may contribute to the active control of joint moments.
Kao, Pei-Chun; Lewis, Cara L.; Ferris, Daniel P.
During human walking, plantar flexor activation in late stance helps to generate a stable and economical gait pattern. Because plantar flexor activation is highly mediated by proprioceptive feedback, the nervous system must modulate reflex pathways to meet the mechanical requirements of gait. The purpose of this study was to quantify ankle joint mechanical output of the plantar flexor stretch reflex response during a novel unexpected gait perturbation. We used a robotic ankle exoskeleton to mechanically amplify the ankle torque output resulting from soleus muscle activation. We recorded lower-body kinematics, ground reaction forces, and electromyography during steady-state walking and during randomly perturbed steps when the exoskeleton assistance was unexpectedly turned off. We also measured soleus Hoffmann- (H-) reflexes at late stance during the two conditions. Subjects reacted to the unexpectedly decreased exoskeleton assistance by greatly increasing soleus muscle activity about 60 milliseconds after ankle angle deviated from the control condition (p<0.001). There were large differences in ankle kinematic and electromyography patterns for the perturbed and control steps, but the total ankle moment was almost identical for the two conditions (p=0.13). The ratio of soleus H-reflex amplitude to background electromyography was not significantly different between the two conditions (p=0.4). This is the first study to show that the nervous system chooses reflex responses during human walking such that invariant ankle joint moment patterns are maintained during perturbations. Our findings are particularly useful for the development of neuromusculoskeletal computer simulations of human walking that need to adjust reflex gains appropriately for biomechanical analyses. PMID:20171638
Tümer, N; Blankevoort, L; van de Giessen, M; Terra, M P; de Jong, P A; Weinans, H; Tuijthof, G J M; Zadpoor, A A
The etiology of osteochondral defects (OCDs), for which the ankle (talocrural) joint is one of the common sites, is not yet fully understood. In this study, we hypothesized that bone shape plays a role in development of OCDs. Therefore, we quantitatively compared the morphology of the talus and the distal tibia between an OCD group and a control group. The shape variations of the talus and distal tibia were described separately by constructing two statistical shape models (SSMs) based on the segmentation of the bones from ankle computed tomography (CT) scans obtained from control (i.e., 35 CT scans) and OCD (i.e., 37 CT scans) groups. The first five modes of shape variation for the SSM corresponding to each bone were statistically compared between control and OCD groups using an analysis of variance (ANOVA) corrected with the Bonferroni for multiple comparisons. The first five modes of variation in the SSMs respectively represented 49% and 40% of the total variance of talus and tibia. Less than 5% of the variance per mode was described by the higher modes. Mode 5 of the talus (P = 0.004) primarily describing changes in the vertical neck angle and Mode 1 of the tibia (P < 0.0001) representing variations at the medial malleolus, showed statistically significant difference between the control and OCD groups. Shape differences exist between control and OCD groups. This indicates that a geometry modulated biomechanical behavior of the talocrural joint may be a risk factor for OCD. Copyright © 2016. Published by Elsevier Ltd.
Siegler, S; Udupa, J K; Ringleb, S I; Imhauser, C W; Hirsch, B E; Odhner, D; Saha, P K; Okereke, E; Roach, N
A technique to study the three-dimensional (3D) mechanical characteristics of the ankle and of the subtalar joints in vivo and in vitro is described. The technique uses an MR scanner compatible 3D positioning and loading linkage to load the hindfoot with precise loads while the foot is being scanned. 3D image processing algorithms are used to derive from the acquired MR images bone morphology, hindfoot architecture, and joint kinematics. The technique was employed to study these properties both in vitro and in vivo. The ankle and subtler joint motion and the changes in architecture produced in response to an inversion load and an anterior drawer load were evaluated. The technique was shown to provide reliable measures of bone morphology. The left-to-right variations in bone morphology were less than 5%. The left-to-right variations in unloaded hindfoot architecture parameters were less than 10%, and these properties were only slightly affected by inversion and anterior drawer loads. Inversion and anterior drawer loads produced motion both at the ankle and at the subtalar joint. In addition, high degree of coupling, primarily of internal rotation with inversion, was observed both at the ankle and at the subtalar joint. The in vitro motion produced in response to inversion and anterior drawer load was greater than the in vivo motion. Finally, external motion, measured directly across the ankle complex, produced in response to load was much greater than the bone movements measured through the 3D stress MRI technique indicating the significant effect of soft tissue and skin interference.
Finsterle, S.; Edmiston, J. K.; Zhang, Y.
Natural and man-made fractures tend to significantly impact the behavior of a subsurface system - with both desirable and undesirable consequences. Thus, the description, characterization, and prediction of fractured systems requires careful conceptualization and a defensible modeling approach that is tailored to the objectives of a specific application. We review some of these approaches and the related data needs, and discuss the use of multi-physics joint inversion techniques to identify and characterize the relevant features of the fracture system. In particular, we demonstrate the potential use of a non-isothermal, multiphase flow simulator coupled to a thermo-poro-elastic model for the calculation of observable deformations during injection-production operations. This model is integrated into a joint inversion framework for the estimation of geometrical, hydrogeological, rockmechanical, thermal, and statistical parameters representing the fractured porous medium.
Fantini Pagani, Cynthia H; Willwacher, Steffen; Benker, Rita; Brüggemann, Gert-Peter
Several conservative treatments for medial knee osteoarthritis such as knee orthosis and laterally wedged insoles have been shown to reduce the load in the medial knee compartment. However, those treatments also present limitations such as patient compliance and inconsistent results regarding the treatment success. To analyze the effect of an ankle-foot orthosis on the knee adduction moment and knee joint alignment in the frontal plane in subjects with knee varus alignment. Controlled laboratory study, repeated measurements. In total, 14 healthy subjects with knee varus alignment were analyzed in five different conditions: without orthotic, with laterally wedged insoles, and with an ankle-foot orthosis in three different adjustments. Three-dimensional kinetic and kinematic data were collected during gait analysis. Significant decreases in knee adduction moment, knee lever arm, and joint alignment in the frontal plane were observed with the ankle-foot orthosis in all three different adjustments. No significant differences could be found in any parameter while using the laterally wedged insoles. The ankle-foot orthosis was effective in reducing the knee adduction moment. The decreases in this parameter seem to be achieved by changing the knee joint alignment and thereby reducing the knee lever arm in the frontal plane. This study presents a novel approach for reducing the load in the medial knee compartment, which could be developed as a new treatment option for patients with medial knee osteoarthritis. © The International Society for Prosthetics and Orthotics 2013.
Crenna, Paolo; Frigo, Carlo
Aim of this study was to provide a non-invasive assessment of the dynamic properties of the ankle joint during human locomotion, with specific focus on the effects of gender and age. Accordingly, flexion-extension angles and moments, obtained through gait analysis, were used to generate moment-angle loops at the ankle joint in 120 healthy subjects walking at a same normalized speed. Four reproducible types of loops were identified: Typical Loops, Narrow, Large and Yielding loops. No significant changes in the slopes of the main loop phases were observed as a function of gender and age, with the exception of a relative increase in the slope of the descending phase in elderly males compared to adult females. As for the ergometric parameters, the peak ankle moment, work produced and net work along the cycle were slightly, but significantly affected, with progressively decrease in the following order: Adult Males, Adult Females, Elderly Males and Elderly Females. The evidence that only few of the quantitative aspects of moment-angle loops were affected suggests that the control strategy which regulates the biomechanical properties of the ankle joint during walking is rather robust and qualitatively consistent across genders and age. Copyright © 2011 Elsevier B.V. All rights reserved.
Kang, Min-Hyeok; Oh, Jae-Seop; Kwon, Oh-Yun; Weon, Jong-Hyuk; An, Duk-Hyun; Yoo, Won-Gyu
Although gastrocnemius stretching and talocrural joint mobilization have been suggested as effective interventions to address limited ankle dorsiflexion passive range of motion (DF PROM), the effects of a combination of the two interventions have not been identified. The aim of the present study was to compare the effects of gastrocnemius stretching combined with joint mobilization and gastrocnemius stretching alone. A randomized controlled trial. In total, 24 individuals with limited ankle DF PROM were randomized to undergo gastrocnemius stretching combined with joint mobilization (12 feet in 12 individuals) or gastrocnemius stretching alone (12 feet in 12 individuals) for 5 min. Ankle kinematics during gait (time to heel-off and ankle DF before heel-off), ankle DF PROM, posterior talar glide, and displacement of the myotendinous junction (MTJ) of the gastrocnemius were assessed before and after the interventions. The groups were compared using two-way repeated measures analysis of variance. Greater increases in the time to heel-off and ankle DF before heel-off during gait and posterior talar glide were observed in the stretching combined with joint mobilization group versus the stretching alone group. Ankle DF PROM and displacement of the MTJ of the gastrocnemius were increased significantly after the interventions in both groups, with no significant difference between them. These findings suggest that gastrocnemius stretching with joint mobilization needs to be considered to improve ankle kinematics during gait. Copyright © 2015 Elsevier Ltd. All rights reserved.
The treatment of bony, osteochondral, and ligamentous injuries of the tibio-talar joint requires precise preoperative planning by radiological investigation. This is essential to a correct understanding of the underlying pathology and will allow a proper classification of the injury, which is the basis of treatment. Conventional radiography using anteroposterior and lateral X-rays with comparative views of the noninjured side and, if necessary, rotated spot views and tomography are of high value especially in osteochondral fractures of the talus. Intraoperative control images in both planes after osteosynthesis are mandatory. For evaluation of the postoperative course and severity of arthrosis formation, the classification system of Bargon has proved its worth. In addition, tomography of the tibio-talar joint in two planes is useful especially in tibial pilon fractures, some malleolar fractures, and peripheral talar fractures. In talar fracture dislocations with concomitant compartment syndrome an emergency CT scan can be helpful to determine the optimal surgical approach. In these cases a 3-D reconstruction also might be of assistance. If there is evidence of partial or total talar necrosis, magnetic resonance imaging can be extremely helpful. However, in most cases implants considerably limit the validity of the image obtained. Ultrasonography offers a noninvasive, reproducible, and very inexpensive alternative and should be performed in cases of chondral-osteochondral talar rim avulsions and juvenile osteochondral ligament ruptures. It can also be used as a dynamic method for stress examination in fibular ligament ruptures and soft tissue injuries such as dislocation of the peroneal tendons. The use of Arthrography, stress tenography, and Arthro-CT scan nowadays has become extremely limited.
Mall, S.; Kochhar, N. K.
A study was undertaken to characterize the debond growth mechanism of adhesively bonded composite joints under mode I, mixed mode I-II, and mode II static loadings. The bonded system consisted of graphite/epoxy (T300/5208) composite adherends bonded with a toughened epoxy (EC 3445) adhesive. The mode I, mode II and mixed-mode I-II fracture energies of the tested adhesive were found to be equal to each other. Furthermore, the criterion for mixed mode fracture in composite bonded joints was determined.
Hartwich, Kathleen; Lorente Gomez, Alejandro; Pyrc, Jaroslaw; Gut, Radosław; Rammelt, Stefan; Grass, René
We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP). Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05. All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair ( P = .762). The mean BMD values between feet of men (0.603 g/cm(2)) and women (0.329 g/cm(2)) were statistically different ( P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different ( P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N ( P
Ebinger, T; Kinzl, L; Mentzel, M
We present a splint system for a protected mobilization program after closed reduction of articular proximal phalangeal base fractures. This therapy consists of the periarticular soft tissue and functional anatomy. The soft-tissue around the base of the proximal phalanx leads to a circular stabilization effect. This so called Zancolli Complex (Metacarpophalangeal Retention Apparatus) can be used with the effect of a brace treatment. Treating 31 patients with articular fractures of the proximal phalanx way we found good functional results within a mean follow up period of 2 years after the accident.
Schuld, Jill C; Volker, Mark L; Anderson, Sarah A; Zwank, Michael D
Acute nondisplaced fractures (NDFs) are common in the emergency department (ED), and providers often obtain postsplinting x-rays to identify displacement that potentially occurs during the splinting process. Our objectives are to (1) determine how often x-rays are obtained after splinting of NDFs, (2) identify if postsplinting x-rays change treatment management in the ED, and (3) identify if there are medical complications at follow-up. A retrospective chart review of ED patients who were discharged with hand, wrist, ankle, or foot fractures was conducted to determine patients with definite NDFs that were verified by a radiologist, underwent splinting, and either had postsplint x-rays or not. Bone displacement during the splinting procedure was determined by the postsplint x-rays in the ED. Internal movement of bones or management change was also determined for patients who did not undergo postsplint x-rays in the ED but had obtained an x-ray at their follow-up visit (in-network providers only). Our results demonstrate that no patients required further manipulation or operative management due to the splinting that occurred in the ED. These results take into account both patients who had postsplint x-rays conducted in the ED (27 patients) and those who received x-rays in follow-up consults (179 patients). There was minimal incidence of interval movement in the latter group (14 patients), none of which resulted in management change. These data conclude that postsplinting x-rays of NDFs are unnecessary. Removal of this procedure from routine practice will help decrease patient and hospital cost, time, and radiation exposure. Copyright © 2016 Elsevier Inc. All rights reserved.
Simoneau, Emilie M; Billot, Maxime; Martin, Alain; Van Hoecke, Jacques
A recorded muscular torque at one joint is a resultant torque corresponding to the participation of both agonist and antagonist muscles. This study aimed to examine the effect of aging on the mechanical contributions of both plantar- and dorsi-flexors to the resultant maximal voluntary contraction (MVC) torques exerted at the ankle joint, in dorsi-flexion (DF) and plantar-flexion (PF). The estimation of isometric agonist and antagonist torques by means of an EMG biofeedback technique was made with nine young (mean age 24 years) and nine older (mean age 80 years) men. While there was a non-significant age-related decline in the measured resultant DF MVC torque (-15%; p=0.06), there was a clear decrease in the estimated agonist MVC torque exerted by the dorsi-flexors (-39%; p=0.001). The DF-to-PF resultant MVC torque ratio was significantly lower in young than in older men (0.25 vs. 0.31; p=0.006), whereas the DF-to-PF agonist MVC torque ratio was no longer different between the two populations (0.38 vs. 0.35; p>0.05). Thus, agonist MVC torques in PF and DF would be similarly affected by aging, which could not be deduced when only resultant torques were examined.
Wirth, S H; Klammer, G; Espinosa, N
If adequate conservative measures for the treatment of end-stage ankle osteoarthritis have failed, surgery may be taken into consideration. After exorbitant failure rates in the beginning of total ankle replacement, nowadays this kind of treatment has regained lot of interest and has become a viable alternative to ankle fusion. The correct indication and a precise explanation of the surgical procedure, outcomes and potential complications provide a solid base for future success.Currently, there is no doubt that total ankle replacement has become an important player in the treatment of symptomatic and debilitating end-stage ankle arthritis. With increasing number of patients who undergo total ankle replacement the experience with this kind of procedure increases too. As a consequence several surgeons have started to stretch indications favoring total ankle replacement. However, it must be mentioned here, despite progress in terms of improved anatomical and biomechanical understanding of the hindfoot and improved surgical techniques and instruments, total ankle replacement and ankle fusion remain challenging and difficult procedures. We provide a review article including an overview of the relevant techniques. This article should serve as rough guide for surgeons and help in decision-making regarding total ankle replacement and ankle fusion.
Cheng, Y; Cai, Y
Objective: The aim of this study was to assess the accuracy of ultrasonography in the diagnosis of chronic lateral ankle ligament injury. Methods: A total of 120 ankles in 120 patients with a clinical suspicion of chronic ankle ligament injury were examined by ultrasonography by using a 5- to 17-MHz linear array transducer before surgery. The results of ultrasonography were compared with the operative findings. Results: There were 18 sprains and 24 partial and 52 complete tears of the anterior talofibular ligament (ATFL); 26 sprains, 27 partial and 12 complete tears of the calcaneofibular ligament (CFL); and 1 complete tear of the posterior talofibular ligament (PTFL) at arthroscopy and operation. Compared with operative findings, the sensitivity, specificity and accuracy of ultrasonography were 98.9%, 96.2% and 84.2%, respectively, for injury of the ATFL and 93.8%, 90.9% and 83.3%, respectively, for injury of the CFL. The PTFL tear was identified by ultrasonography. The accuracy of identification between acute-on-chronic and subacute–chronic patients did not differ. The accuracies of diagnosing three grades of ATFL injuries were almost the same as those of diagnosing CFL injuries. Conclusion: Ultrasonography provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain. Advances in knowledge: Intraoperative findings are the reference standard. We demonstrated that ultrasonography was highly sensitive and specific in detecting chronic lateral ligments injury of the ankle joint. PMID:24352708
Conradsson, D; Fridén, C; Nilsson-Wikmar, L; Ang, B O
Skating technique in cross-country skiing is a complex multi-joint movement with kinematics comparable to those of the standing squat exercise where any restricted joint mobility in the lower extremity-chain may change the movement pattern. The aim of this pilot study was to investigate the effect of ankle mobility on trunk posture during squat exercise in cross-country skiers. Seven elite junior cross-country skiers (age range 17-19 years) performed two different standing squats, one with hands on hips and one with arms extended above the head. The squats were recorded on video and analyzed in selected positions: 90 degrees and maximal knee flexion. Segment angles for shank and trunk were calculated from anatomical references relative to vertical/horizontal orientation in space. Recordings from passive ankle dorsiflexion were correlated with 1) trunk flexion, and 2) angle index (trunk flexion relative to shank angle). Reduced ankle dorsiflexion was moderately associated with increased trunk flexion with hands on hips (r=-0.51 to -0.57), and arms above head (r=-0.61 to -0.64). Further, reduced dorsiflexion was also moderately associated with decreased angle index with hands on hip (r=0.60 to 0.67) but highly associated with decreased angle index with arms above head (r=0.75 to 0.76). The results imply that reduced ankle dorsal mobility is related to decreased angle index as well as increased trunk flexion during squat exercise, thus indicating the relevance of good ankle joint mobility for appropriate upper-body posture during squat exercise.
Venkataraman, Vivek V; Kraft, Thomas S; Desilva, Jeremy M; Dominy, Nathaniel J
The "negrito" and African "pygmy" phenotypes are predominately exhibited by hunter-gatherers living in rainforest habitats. Foraging within such habitats is associated with a unique set of locomotor behaviors, most notably habitual vertical climbing during the pursuit of honey, fruit, and game. When performed frequently, this behavior is expected to correlate with developmentally plastic skeletal morphologies that respond to mechanical loading. Using six measurements in the distal tibia and talus that discriminate nonhuman primates by vertical climbing frequency, we tested the prediction that intraspecific variation in this behavior is reflected in the morphology of the ankle joint of habitually climbing human populations. First, to explore the plasticity of climbing-linked morphologies, we made comparisons between chimpanzees, gorillas, and orangutans from wild and captive settings. The analysis revealed significant differences in two climbing-linked traits (anterior expansion of the articular surface of the distal tibia and increased degree of talar wedging), indicating that these traits are sensitive to climbing behavior. However, our analyses did not reveal any signatures of climbing behavior in the ankles of habitually climbing hunter-gatherers. These results suggest that the detection of fine-grained differences in human locomotor behaviors at the ankle joint, particularly those associated with arboreality, may be obscured by the functional demands of terrestrial bipedalism. Accordingly, it may be difficult to use population-level characteristics of ankle morphology to make inferences about the climbing behavior of hominins in the fossil record, even when facultative arborealism is associated with key fitness benefits.
In understanding the control of the ankle joint during different motor tasks, we have to investigate at least three components, namely the influence of i) the passive and intrinsic properties of the intact and active muscle system around the joint (termed the non-reflex component), ii) the mechanical importance of the stretch reflex in the stretched and unloaded muscles, and iii) the supraspinal control of the stretch reflex. This thesis is dealing with the importance of the three components in healthy and spastic persons during sitting, standing, and walking. The results are based on stretch reflex and H-reflex measurements from the ankle extensor muscles. During stretch reflex experiments the foot was mounted to a platform (portable during walking) from which the ankle joint torque and the position were measured. To elicit a stretch reflex, the ankle joint was rotated by a strong motor connected to the platform. The mechanical importance of the stretch reflex was investigated by measuring the changes in joint torque. Electrically, the stretch reflex was recorded as the compound muscle action potential through bipolar surface EMG electrodes placed over the soleus muscle. During H-reflex experiments, the tibial nerve was stimulated at the popliteal fossa and the H-reflex recorded over the soleus muscle as during stretch reflex experiments. To investigate how the contractile properties of a muscle in humans depend on the history of activation, we investigated the intrinsic stiffness of the ankle extensors in healthy subjects. At matched background contraction in sitting subjects, a prolonged contraction increased the intrinsic muscle stiffness by 49%. Muscle yielding has been considered especially important for understanding the reflex compensation. We found a general lack of muscle yield and a mechanically important non-reflex stiffness of the ankle extensors showing that non-reflex stiffness is a prominent factor in normal movements of the ankle joint. In both
Jahss, Melvin H
The mechanics, anatomy, and pathomechanics of traumatic dorsal dislocation of the first metatarsophalangeal joint are discussed. There are two basic types of dislocations. In Type I, dislocation of the hallux with the sesamoids occurs without disrupting the sesamoid mass. Such cases are usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids. In Type II, there is either associated disruption of the intersesamoid ligament (Type IIA) or a transverse fracture of one of the sesamoids (Type IIB). In Type II, the sesamoid disruption usually permits closed reduction.
Umstadt, H E; Ellers, M; Müller, H H; Austermann, K H
In a clinical and axiographic study the outcome of patients with severely displaced fractures and fracture dislocations of the mandibular condyle was evaluated. Two operation methods were compared one via an intraoral approach without joint revision and another via a preauricular approach with open reduction of the joint. In the group with joint revision, resorbable material was used for osteosynthesis. Twenty-eight patients (32 joints) treated without revision of the joint and 26 patients (29 joints) with open reduction of the joint were evaluated. The mean observation time following surgery was 3 years and 10 months (range 1-7.5 years). Clinical examination utilized the Helkimo-index, while the electronic axiographical results were evaluated by using a five point scheme of joint-mobility. Concerning clinical evaluation, 20 out of 28 patients (71%) without joint revision and 23 out of 26 (89%) patients with joint revision had none or only slight dysfunction of the stomatognathic system. When focusing on arthralgia and pain in motion (part D and E of Helkimo's-index) significantly better results were achieved by open joint revision (Helkimo D: p< or =0.007; Helkimo E: p = 0.0029). No patient exhibited severe dysfunction (group D3). In axiographic evaluation optimal results (group A1) were achieved in seven joints (24%) with revision and four joints (12%) without revision. Twelve out of 29 joints with revision (41%) and six out of 32 joints without revision (19%) were classified as group A2 with a slightly shortened condylar excursion. Revision of joints with disc reduction and reconstruction of ligaments in cases of severely displaced or dislocated fractures resulted in better mobility and less pain. This was seen clinically and in the axiographic results. Looking at the long-term outcome of patients better mobility of the joint without internal derangement due to surgical repair also protects the contralateral (nonoperated) joint. When managing severe TMJ
Jeon, Si-Nae; Choi, Jung-Hyun
[Purpose] The aim of this study was to examine the effects of visual feedback training on the balance of stroke patients performing ankle joint strategy exercises. [Subjects and Methods] In this study, 26 stroke patients were randomly and equally assigned to a visual feedback group (VFG) and a visual disuse group (VDG). They performed ankle joint strategy exercises for 30 minutes, three times per week for six weeks. The patients’ balance ability was measured before and after the exercises to compare the effects of visual feedback. To assess balance ability, the limits of stability (LOS) and the distance the center of pressure (CoP) moved were measured using a BT4 portable force platform. The Berg balance scale (BBS) and the timed up and go (TUG) test were also used to assess balance before and after the exercises. [Results] Changes in LOS were significant in the anterior, posterior, left, and right directions in each group, and the interactions between the two groups were significant in the posterior, left, and right directions. The changes in TUG and BBS results between pre-test and the post-test were statistically significant in the two groups, and also between the groups. [Conclusion] Visual feedback training had a positive effect on balance when ankle joint strategy exercises were performed by stroke patients to improve balance. PMID:26355721
Kovaleski, John E.; Heitman, Robert J.; Gurchiek, Larry R.; Hollis, J. M.; Liu, Wei; IV, Albert W. Pearsall
Context: This is part II of a 2-part series discussing stability characteristics of the ankle complex. In part I, we used a cadaver model to examine the effects of sectioning the lateral ankle ligaments on anterior and inversion motion and stiffness of the ankle complex. In part II, we wanted to build on and apply these findings to the clinical assessment of ankle-complex motion and stiffness in a group of athletes with a history of unilateral ankle sprain. Objective: To examine ankle-complex motion and stiffness in a group of athletes with reported history of lateral ankle sprain. Design: Cross-sectional study. Setting: University research laboratory. Patients or Other Participants: Twenty-five female college athletes (age = 19.4 ± 1.4 years, height = 170.2 ± 7.4 cm, mass = 67.3 ± 10.0 kg) with histories of unilateral ankle sprain. Intervention(s): All ankles underwent loading with an ankle arthrometer. Ankles were tested bilaterally. Main Outcome Measure(s): The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness. Results: Anterior displacement of the ankle complex did not differ between the uninjured and sprained ankles (P = .37), whereas ankle-complex rotation was greater for the sprained ankles (P = .03). The sprained ankles had less anterior and inversion end-range stiffness than the uninjured ankles (P < .01). Conclusions: Changes in ankle-complex laxity and end-range stiffness were detected in ankles with histories of sprain. These results indicate the presence of altered mechanical characteristics in the soft tissues of the sprained ankles. PMID:24568223
Asloum, Y; Bedin, B; Roger, T; Charissoux, J-L; Arnaud, J-P; Mabit, C
Open reduction and internal plate fixation of the fibula is the gold standard treatment for ankle fractures. The aim of this study was to perform a prospective randomized study to compare bone union, complications and functional results of two types of internal fixation of the fibula (plating and the Epifisa FH intramedullary nail). Inclusion criteria were: closed fractures, isolated displaced fractures of the lateral malleolus, inter- and supra-tubercular bimalleolar fractures, and trimalleolar fractures. This study included 71 patients (mean age 53 ± 19): plate fixation group (n=35) and intramedullary nail fixation group (n=36). In seven cases, intramedullary nailing was technically impossible and was converted to plate fixation (the analysis of this sub-group was performed independently). Two patients died and two patients were lost to follow-up. The final comparative series included 32 cases of plate fixation and 28 cases of intramedullary nail fixation. Union, postoperative complications and Kitaoka and Olerud-Molander functional scores were analyzed after one year of follow-up. There was no significant difference in the rate of union (P=0.5605) between the two types of fixation. There were significantly fewer complications (7% versus 56%) and better functional scores (96 versus 82 for the Kitaoka score; 97 versus 83 for the Olerud-Molander score) with intramedullary nailing than with plate fixation. Intramedullary nailing of the lateral malleolus in non-comminuted ankle fractures without syndesmotic injury is a reproducible technique with very few complications that provides better functional results than plate fixation. II (randomized prospective study). Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Kim, Mi-Kyoung; Yoo, Kyung-Tae
[Purpose] This study was performed to examine how the balance of lower limbs and the muscle activities of the tibialis anterior (TA), the medial gastrocnemius (GCM), and the peroneus longus (PL) are influenced by isotonic and isokinetic exercise of the ankle joint. [Subjects] The subjects of this study were healthy adults (n=20), and they were divided into two groups (isotonic=10, isokinetic=10). [Methods] Isotonic group performed 3 sets of 10 contractions at 50% of MVIC and Isokinetic group performed 3 sets of 60°/sec. Muscle activity was measured by EMG and balance was measured by one-leg standing test. [Results] For muscle activity, a main effect of group was found in the non-dominant TA, and the dominant TA, GCM and PL. For balance, a main effect of time was found in both groups for the sway area measured support was provided by the non-dominant side. [Conclusion] In terms of muscle activity, the two groups showed a significant difference, and the isokinetic group showed higher muscle activities. In terms of balance, there was a significant difference between the pre-test and the post-test. The results of this study may help in the selection of exercises for physical therapy, because they show that muscle activity and balance vary according to the type of exercise. PMID:25729181
Kim, Mi-Kyoung; Yoo, Kyung-Tae
[Purpose] This study was performed to examine how the balance of lower limbs and the muscle activities of the tibialis anterior (TA), the medial gastrocnemius (GCM), and the peroneus longus (PL) are influenced by isotonic and isokinetic exercise of the ankle joint. [Subjects] The subjects of this study were healthy adults (n=20), and they were divided into two groups (isotonic=10, isokinetic=10). [Methods] Isotonic group performed 3 sets of 10 contractions at 50% of MVIC and Isokinetic group performed 3 sets of 60°/sec. Muscle activity was measured by EMG and balance was measured by one-leg standing test. [Results] For muscle activity, a main effect of group was found in the non-dominant TA, and the dominant TA, GCM and PL. For balance, a main effect of time was found in both groups for the sway area measured support was provided by the non-dominant side. [Conclusion] In terms of muscle activity, the two groups showed a significant difference, and the isokinetic group showed higher muscle activities. In terms of balance, there was a significant difference between the pre-test and the post-test. The results of this study may help in the selection of exercises for physical therapy, because they show that muscle activity and balance vary according to the type of exercise.
Purpose The goal of the study was to survey ankle joint disorder in male senior high school and college student basketball players based on the results of an ultrasonographic medical check-up of the ankle joint. Materials and Methods The subjects were 17 senior high school student and 19 college student basketball players. Ultrasonography, evaluation of ATFL injury, and examination of the talocrural joint region were performed. The subjects were grouped based on the presence or absence of old ATFL injury, and subjects with ATFL injury were classified by the injured region: fibular insertion site, parenchyma, and talar insertion site. The talocrural joint region was evaluated based on the areas of the lateral margin, central region, and medial margin, and sites with an irregular bone contour and osteophyte were counted individually. The questionnaire asked about the patients’ history of ankle injuries. Results A questionnaire survey revealed that 70–79% of all subjects had experienced a sprain at least once and 21–29% had frequently sprained the left or right foot 10 or more times in the past. On ultrasonography, there was no significant difference in ligament injury or injured site between the senior high school and college students, but the number of osteochondral findings in the talocrural joint region was significantly higher in the college students. In addition, the number of injured sites significantly increased in those with 10 or more years of playing experience. Conclusion These results suggest that disorder of the talocrural joint region progresses with an increase in years of experience in student basketball players who do not take specific preventive measures against this injury. PMID:28603784
The goal of the study was to survey ankle joint disorder in male senior high school and college student basketball players based on the results of an ultrasonographic medical check-up of the ankle joint. The subjects were 17 senior high school student and 19 college student basketball players. Ultrasonography, evaluation of ATFL injury, and examination of the talocrural joint region were performed. The subjects were grouped based on the presence or absence of old ATFL injury, and subjects with ATFL injury were classified by the injured region: fibular insertion site, parenchyma, and talar insertion site. The talocrural joint region was evaluated based on the areas of the lateral margin, central region, and medial margin, and sites with an irregular bone contour and osteophyte were counted individually. The questionnaire asked about the patients' history of ankle injuries. A questionnaire survey revealed that 70-79% of all subjects had experienced a sprain at least once and 21-29% had frequently sprained the left or right foot 10 or more times in the past. On ultrasonography, there was no significant difference in ligament injury or injured site between the senior high school and college students, but the number of osteochondral findings in the talocrural joint region was significantly higher in the college students. In addition, the number of injured sites significantly increased in those with 10 or more years of playing experience. These results suggest that disorder of the talocrural joint region progresses with an increase in years of experience in student basketball players who do not take specific preventive measures against this injury.
Thune, Alexandra; Hagelberg, Mårten; Nåsell, Hans; Sköldenberg, Olof
For any orthopaedic surgeon working with trauma; ankle fractures are one of the most common injuries treated. The treatment of ankle fractures can be conservative, using external fixation, but more commonly the fractures are treated with open reduction and internal fixation. Residual pain and discomfort are common in patients after surgical treatment of fractures of the ankle. Sometimes it is difficult to determine whether the pain or discomfort is due to the implants left in situ or the primary injury itself. In many cases, the decision is made to remove the implants. Extraction of internal fixation material from the ankle is a common procedure in many orthopaedic clinics. There are no evidence-based guidelines or consensus regarding the effect of hardware removal from the ankle. The aim of this protocol is to describe the method that will be used to collect, describe and analyse the current evidence regarding hardware removal after fracture healing of the ankle. We will conduct a systematic review of studies that were published after 1967 regarding the benefits of hardware removal in patients with pain or discomfort after fracture healing of the ankle. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We will make a predefined search strategy and use it in several databases. We will include both randomised controlled trials (RCTs) and non-RCT studies. We will use descriptive statistics to summarise the studies collected. If more than one RCT is collected then a meta-analysis will be conducted. The quality of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation guidelines. No ethics approval is required as no primary data will be collected. Once complete, the results will be made available by peer-reviewed publication. PROSPERO registration number CRD42016039186. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article
Schulze, Christoph; Lindner, Tobias; Woitge, Sandra; Schulz, Katharina; Finze, Susanne; Mittelmeier, Wolfram; Bader, Rainer
Footwear and equipment worn by military personnel is of importance for them to be able to meet the physical demands specific to their profession daily activities. The aim of the present study was to investigate by means of gait analysis how army-provided footwear and equipment influence the range of motion of hip, knee and ankle joints as well as stride length. Thirty-two soldiers were subjected to gait analysis on a treadmill by way of video recordings and goniometric measurements. The stride length increased when military shoes are worn. We found no influence on stride length in connection to increased loading. The weight of the shoes represents the decisive factor. Neither shoes nor equipment changed the range of motion of the knee joint. Weight of equipment affected range of motion of the hip joint. The range of motion of the upper and lower ankle joints was mainly influenced by the properties of the shoes. Military footwear and weight of equipment influence stride length and range of motion of joints of the lower extremities in a specific way. Shape of material is the decisive factor.
Briet, Jan Paul; Houwert, Roderick Marijn; Smeeing, Diederik P J; Dijkgraaf, Marcel G W; Verleisdonk, Egbert Jan; Leenen, Luke P H; Hietbrink, Falco
Although fracture type and treatment options for ankle fractures are well defined, the differences between mono- and polytrauma patients and low- and high-energy trauma have not been addressed. The aim of the present study was to compare the fracture type and trauma mechanism between mono- and polytrauma and low- and high-energy trauma patients with an ankle fracture. We performed a single-center retrospective cohort study. Fractures were classified according to the Lauge-Hansen classification and a descriptive classification. High-energy trauma (HET) was defined using triage criteria. All other patients were classified as having experienced low-energy trauma (LET). The patients were divided into 2 groups according to the injury severity score (ISS). Monotrauma patients were defined as patients with an ISS of 4 to 11 with an isolated ankle fracture or an ankle fracture with a minor contusion or laceration. Polytrauma patients were defined as patients with an ISS of ≥16 with ≥2 body regions involved. Patients with an ISS from 12 to 15 were excluded. A total of 96 patients were eligible for analysis. Of the 96 patients, 62 had experienced monotrauma and 34 had experienced polytrauma. A significant difference was found between the mono- and polytrauma patients in the Lauge-Hansen classification (p < .001). Monotrauma patients had a high incidence of an isolated supination external rotation injury. Supination adduction and pronation abduction injuries were more often observed in polytrauma patients. The same pattern was observed for ankle fractures after HET compared with LET (p < .001), because all pronation abduction and supination adduction injuries were observed after a HET mechanism. The results of the present study indicate that polytrauma patients sustain different types of ankle fractures than patients with an isolated ankle fracture. This difference likely results from the high-energy transfer associated with polytrauma, because pronation abduction
Bowker, Samantha; Terada, Masafumi; Thomas, Abbey C; Pietrosimone, Brian G; Hiller, Claire E; Gribble, Phillip A
Neuromuscular and mechanical deficiencies are commonly studied in participants with chronic ankle instability (CAI). Few investigators have attempted to comprehensively consider sensorimotor and mechanical differences among people with CAI, copers who did not present with prolonged dysfunctions after an initial ankle sprain, and a healthy control group. To determine if differences exist in spinal reflex excitability and ankle laxity among participants with CAI, copers, and healthy controls. Case-control study. Research laboratory. Thirty-seven participants with CAI, 30 participants categorized as copers, and 26 healthy control participants. We assessed spinal reflex excitability of the soleus using the Hoffmann reflex protocol. Participants' ankle laxity was measured with an instrumented ankle arthrometer. The maximum Hoffmann reflex : maximal muscle response ratio was calculated. Ankle laxity was measured as the total displacement in the anterior-posterior directions (mm) and total rotation in the inversion and eversion directions (°). Spinal reflex excitability was diminished in participants with CAI compared with copers and control participants (P = .01). No differences were observed among any of the groups for ankle laxity. Changes in the spinal reflex excitability of the soleus that likely affect ankle stability were seen only in the CAI group, yet no mechanical differences were noted across the groups. These findings support the importance of finding effective ways to increase spinal reflex excitability for the purpose of treating neural excitability dysfunction in patients with CAI.
Kiene, J; Schulz, Arndt P; Hillbricht, S; Jürgens, Ch; Paech, A
The methods for ankle arthrodesis differ significantly, probably a sign that no method is clearly superior to others. In the last ten years there is a clear favour toward internal fixation. We retrospectively evaluate the technique and evaluate the clinical long term results of external fixation in a triangular frame. From 1994 to 2001 a consecutive series of 95 patients with end stage arthritis of the ankle joint were treated. Retrospectively the case notes were evaluated regarding trauma history, medical complaints, further injuries and illnesses, walking and pain status and occupational issues and the clinical examination before arthrodesis. Mean age at the index procedure was 45.4 years (18-82), 67 patients were male (70.5%). Via a bilateral approach the malleoli and the joint surfaces were resected. An AO fixator was applied with two Steinmann-nails inserted with approximately 8 cm distance in the distal tibia, one in the neck of the talus and one in the dorsal calcaneus. The fixator was removed after approximately 12 weeks. Follow up examination at mean 4.4 years included a standardised questionnaire and a clinical examination including the criteria of the AOFAS-Score and radiographs. Due to different complications, 8 (8.9%) further surgical procedures were necessary including 1 below knee amputation. In 4 patients a non-union of the ankle arthrodesis developed (4.5%). The mean AOFAS score improved from 20.8 to 69.3 points. Non-union rates and clinical results of arthrodesis by triangular external fixation of the ankle joint do not differ to internal fixation methods. The complication rate and the reduced patient comfort reserve this method mainly for infected arthritis and complicated soft tissue situations.
Pittaccio, S.; Viscuso, S.
The capacity of flexing one's ankle is an indispensible segment of gait re-learning, as imbalance, wrong compensatory use of other joints and risk of falling may depend on the so-called drop-foot. The rehabilitation of ankle dorsiflexion may be achieved through active exercising of the relevant musculature (especially tibialis anterior, TA). This can be troublesome for patients affected by weakness and flaccid paresis. Thus, as needs evolve during patient's improvements, a therapeutic device should be able to guide and sustain gradual recovery by providing commensurate aid. This includes exploiting even initial attempts at voluntary motion and turns those into effective workout. An active orthosis powered by two rotary actuators containing NiTi wire was designed to obtain ankle dorsiflexion. A computer routine that analyzes the electromyographic (sEMG) signal from TA muscle is used to control the orthosis and trigger its activation. The software also provides instructions and feed-back for the patient. Tests on the orthosis proved that it can produce strokes up to 36° against resisting torques exceeding 180 Ncm. Three healthy subjects were able to control the orthosis by modulating their TA sEMG activity. The movement produced in the preliminary tests is interesting for lower limb rehabilitation, and will be further improved by optimizing body-orthosis interface. It is hoped that this device will enhance early rehabilitation and recovery of ankle mobility in stroke patients.
Li, Mengnai; Collier, Rachel C; Hill, Brian W; Slinkard, Nathaniel; Ly, Thuan V
Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Rbia, Nadia; van der Vlies, Cornelis H; Cleffken, Berry I; Selles, Ruud W; Hovius, Steven E R; Nijhuis, Tim H J
Unstable ankle fractures require treatment with open reduction and internal fixation (ORIF). Long-term functional outcome is satisfying in most patients; however, a number of patients have persistent complaints. Superficial nerve complications following ankle surgery may be the cause of chronic pain and disability. In this observational retrospective survey, a cohort of 527 women and men, who underwent ORIF in the period from January 2007 to January 2014, were invited to an online questionnaire. Pain symptoms were assessed using the McGill Pain Questionnaire (MPQ) and the Douleur Neuropathic en 4 Questions (DN4) Questionnaire. Descriptive statistics were used to present patient characteristics; a logistic regression model was used to analyze prognostic factors of neuropathic pain. A total of 271 patients completed the questionnaire. Mean follow-up period was 5.8 years (±1.9). Persistent neuropathic pain symptoms were present in 61 of all patients, and 51 of these patients reported an impaired quality of life caused by their symptoms. In univariate analysis, the following parameters were associated with neuropathic pain: age, hypertension, a thyroid disorder, lower back pain, fracture dislocations, and late complications such as nonunion, posttraumatic arthritis, or osteochondral injury. In multivariate analysis, an age between 40 and 60 years was found to be a significant predictor of neuropathic pain. Hypertension, dislocation, and late complications were significant predictors of persistent pain without neuropathic characteristics. The present study demonstrated a prevalence of persistent neuropathic pain symptoms after ORIF for ankle fractures in 23% of the respondents, which caused an impaired health-related quality of life. We identified 4 significant predictors of chronic and neuropathic pain after ORIF. This knowledge may aid the treating surgeon to identify patients who are at increased risk of persistent postoperative neuropathic pain and may affect the
Cavallo, M; Natali, S; Ruffilli, A; Buda, R; Vannini, F; Castagnini, F; Ferranti, E; Giannini, S
The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult. From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures. In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site. The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome. Case series, Level IV.
Fisher, Beth E; Piraino, Andrew; Lee, Ya-Yun; Smith, Jo Armour; Johnson, Sean; Davenport, Todd E; Kulig, Kornelia
Study Design Controlled laboratory study. Background Joint mobilization and manipulation decrease pain and improve patient function. Yet, the processes underlying these changes are not well understood. Measures of corticospinal excitability provide insight into potential mechanisms mediated by the central nervous system. Objectives To investigate the differential effects of joint mobilization and manipulation at the talocrural joint on corticospinal excitability in individuals with resolved symptoms following ank