Ankle Pain Research Articles

Transfibular Total Ankle Arthroplasty: Clinical, Functional, and Radiographic Outcomes and Complications at a Minimum of 5-Year Follow-up

Background: The Trabecular Metal Total Ankle Implant differs from other newer-generation implants in the transfibular approach, multiplanar external frame for alignment, tantalum trabecular metal interfaces, curved geometry, and shallow resection depths. The primary aim of this study was to report midterm clinical and radiographic results, as well as survivorship and adverse events at a minimum of 5-year follow-up. Methods: A total of 83 ankles (81 patients, average age 60.6 years old, 50.6% females) with average 6.3 years’ (range, 5.0-10.1) follow-up were included. Postoperative patient-reported outcome measures (PROMs) included SF-12 physical (PCS) and mental component summary (MCS) scores, Ankle Osteoarthritis Scale (AOS), pain visual analog scale (VAS). Radiographic outcomes included postoperative range of motion (ROM) and coronal/sagittal alignment. Adverse events were reported using the Canadian Orthopaedic Foot and Ankle Society Reoperation Coding System (CROCS). Results: Preoperative tibiotalar coronal deformity included 27 valgus (10 degrees, range 2-20 degrees) and 25 varus ankles (−9 degrees, range −2 to −25 degrees), corrected to neutral postoperatively. Postoperative tibiopedal ROM was 17.8 degrees dorsiflexion and 21.8 degrees plantarflexion. Adverse events occurred at average 28.7 months, most commonly gutter debridement (n = 17, 16.7%) and subsequent operative treatment unrelated to metal components (n = 10, 12.0%). There were 2 cases (2.4%) of acute deep infection treated with irrigation and debridement, polyethylene exchange, and retention of metal components without recurrence of infection. There were no cases of fibular nonunion, septic or aseptic loosening, or implant subsidence. Postoperative PROMS included SF-12 PCS: 40.4; SF-12 MCS: 56.0; VAS: 2.3; AOS Pain: 17.0; and AOS Disability: 24.9. Overall implant survival, defined by retention of the metal components, was 100% at final follow-up. Conclusion: At a minimum of 5 years, patients who underwent TM TAA reported minimal ankle pain and regained neutral ankle alignment and mobility, without septic or aseptic implant loosening. Although having certain limitations, this study suggests that TM TAA is a viable option for the treatment of end-stage ankle arthritis.

Gout or Deep Vein Thrombosis: Expanding Differential Diagnosis and Avoiding Anchoring Bias

Diagnostic reasoning is a critical skill for a nurse practitioner. Cognitive biases influence nurse practitioner decision making, and anchoring bias is the most common cognitive error. Cognitive error is a systematic deviation from optimal decision making or errors in thinking from reliance on mental shortcuts known as heuristics. Anchoring bias is when initial information dominates decision making, neglecting alternative diagnoses. This case describes a patient with pain, redness, and swelling in the left ankle, attributing it to a gout flare-up. To avoid anchoring on this diagnosis, reflective practice considered alternatives such as deep vein thrombosis. Reflective practice involves examining one’s experiences and adopting a critical perspective toward one’s own methods and practice. The patient was referred to the emergency department where a diagnosis of deep vein thrombosis was confirmed. This case underscores the importance of acknowledging cognitive biases and implementing debiasing strategies.

P23 A case of visceral leishmaniasis presenting as seropositive erosive rheumatoid arthritis in an immunocompromised patient

Abstract Introduction Visceral leishmaniasis (VL) is a potentially fatal parasitic infection occurring primarily in the tropics, subtropics, and southern Europe. A strong humoral response can be observed in VL due to polyclonal activation of B-lymphocytes, and it can also result in the production of rheumatoid factor (RF), anti-CCP and anti-nuclear antibodies. We present this case here of visceral leishmaniasis presenting as seropositive RA on the background of HIV and hepatitis B infection. Case description We present a case of a 46-year-old Caucasian male with a two-year history of skin nodules, symmetrical arthralgia and weight loss. He was diagnosed with HIV a decade ago which was well controlled with bictegravir, emtricitabine and tenofovir alafenamide. He received pulmonary tuberculosis (TB) treatment in 2012 and had chronic e-antigen-positive hepatitis B. He previously resided in Ukraine and travelled frequently to Crimea and the Middle East. There was no history of Raynaud’s, chest pain, shortness of breath, sicca symptoms, mouth ulcers, genital ulcers, hair loss or photosensitivity. On examination, he was cachectic with generalised lymphadenopathy and multiple subcutaneous (1-2cm, firm, mildly tender, non-ulcerating) forearm nodules. There was synovitis on two joints but no tenosynovitis or joint deformity. Initial investigations revealed pancytopenia, hyperuricemia, proteinuria, positive RF (>200 IU/ml) and anti-CCP, positive ANA and anti-Ro antibody and erosion of proximal phalanx of the big toe bilaterally. His CD4 count was 166 (33%) with undetectable HIV viral load. Imaging showed lymphadenopathy and splenomegaly (17.5cm). A diagnosis of rheumatoid arthritis with possible connective tissue disease overlap was made and he was initiated on hydroxychloroquine. Because of systemic symptoms and atypical skin nodules, further investigation was undertaken including lymph node, bone marrow and skin biopsies, all of which confirmed a diagnosis of leishmaniasis. Blood PCR was positive for L. donovani complex, and serological analysis showed direct agglutination test and k39 Ag positivity. Treatment was initiated by the infectious diseases team initially with amphotericin B 40 mg/kg monotherapy, later on further amphotericin B 30 mg/kg and miltefisone. He responded well as evidenced by reduced splenomegaly, resolution of skin nodules and improvement in cytopenia. His joint symptoms also improved except for the recurrence of ankle pain for which he received intra-articular steroids. Discussion It has been widely reported in literature that leishmaniasis can trigger autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosis. There have also been multiple studies confirming the presence of rheumatoid factor, anti-CCP and ANA in patients with leishmaniasis without any presence of symptomatic autoimmune disease. The mechanisms involved in the pathophysiology of autoantibody productions are not yet fully understood. There is some evidence that these are related to activation of polyclonal B cells due to a decreased regulatory T cell activity. Another possible mechanism would be production of autoantigen in response to cross reaction between the parasite and the hoarse tissue antigens. There have been multiple case reports of leishmaniasis in patients with rheumatoid arthritis who were taking anti-TNF biologics. This represents the reactivation of leishmaniasis due to immunosuppression. There has been a long-known link between HIV infection and leishmaniasis. Our patient was a known case of HIV. Interestingly, not only did he have significantly positive rheumatoid factor, anti-CCP, ANA and anti-Ro antibodies, but he also had active synovitis on his joints and even erosions were seen on the X-ray. He fulfilled the criteria for rheumatoid arthritis. Our case was unique in the sense that this is a case of visceral leishmaniasis in an HIV patient who presented with rheumatoid arthritis. Skin nodules in this patient were appearing similar to rheumatoid nodules. Later on, the biopsy confirmed that these were due to leishmaniasis. It is also a challenge to manage RA in patients with HIV especially when have already an opportunistic infection like leishmaniasis. A high prevalence of hyperuricemia in HIV infection has been reported in multiple studies. Our case did have raised urate but his disease was not consistent with gout clinically. Key learning points • This is a rare case showing seropositive erosive RA coexisting with VL in an HIV patient, underscoring the link between autoimmune diseases and chronic infections. Chronic infections are always considered an important differential in inflammatory arthritis or connective tissue disease especially when they present with systemic features of fever, weight loss and organomegaly. • Although this disease is considered rare in the Western hemisphere, in the diverse, multiethnic and immigrant UK population this should be considered an important differential diagnosis. Another key element in clenching these diagnoses is detailed travel history. Multidisciplinary approach is key in managing such difficult cases. Our case was managed jointly by the rheumatology, dermatology and infectious disease teams, and the national leishmaniasis multidisciplinary team from University College London Hospitals. • It is important to do a holistic assessment for these patients and get help from other specialities especially in such challenging cases.

P12 Post-streptococcal reactive arthritis and panniculitis in pregnancy: a case report

Abstract Introduction Reactive arthritis is an inflammatory condition that can occur following an infection, commonly caused by bacterial pathogens such as Streptococcus. Pregnancy introduces unique challenges in managing autoimmune and inflammatory conditions due to the need to balance maternal and foetal health. This case report highlights the diagnosis and management of post-streptococcal reactive arthritis and panniculitis in a 16-week pregnant patient, focusing on the use of steroids and the resulting impact on her gestational diabetes Case description A 25-year-old woman, 16 weeks pregnant with no known comorbidities, presented with bilateral ankle pain and swelling for the last two weeks, preceded by an episode of tonsillitis. Initially, the pain was localised to her right ankle and left wrist, then involved her left ankle. She was treated with antibiotics for presumed cellulitis, and a doppler ultrasound ruled out deep vein thrombosis. Examination revealed swollen, inflamed ankles with limited range of motion due to pain. The rest of the examination was unremarkable. This was her second pregnancy and had no complications in her first pregnancy. Routine investigations were done; her C-reactive protein (CRP) was 126 and erythrocyte sedimentation rate (ESR) was 56, with a normal white cell count. Autoimmune workup, including rheumatoid factor (RF), antinuclear antibodies (ANA), and HLA-B27, was negative, but her anti-streptolysin O (ASO) titer was borderline positive. She was diagnosed with post-streptococcal reactive arthritis. After discussing the risks and benefits of NSAID use in the second trimester, we started her on prednisolone 20 mg with a tapering plan. The patient showed clinical improvement, but upon tapering the steroids to 5 mg daily, she developed well-demarcated erythema with desquamation and epidermal changes over both ankles. The left ankle was tender on the medial side, but the right was non-tender. Her angiotensin-converting enzyme (ACE) levels were negative, and calcium levels were normal. Her steroid dose was increased again to 20 mg with a slow tapering plan. She also developed gestational diabetes mellitus and was started on insulin by the diabetes team. Her foetal scan was reassuring and was under obstetrician. A dermatology team reviewed her and suggested the rash was likely panniculitis, which had improved significantly with steroids, so a biopsy was not performed. With careful management, her symptoms resolved, and she successfully discontinued steroid therapy as planned. Discussion This case highlights the complex nature of managing post-streptococcal reactive arthritis and panniculitis in a pregnant patient. The initial presentation with a sore throat and subsequent development of arthritis and panniculitis, along with raised inflammatory markers and a positive ASO titer, strongly suggested reactive arthritis triggered by a recent streptococcal infection. Given the foetal risk from NSAIDs, steroid therapy was chosen for its safety profile in pregnancy. While steroid therapy provided symptomatic relief, it led to gestational diabetes, requiring careful monitoring and adjustment of the patient’s diabetic management. The emergence of panniculitis during steroid tapering added another layer of complexity, necessitating collaboration with dermatology specialists for a revised approach. The dermatological team agreed with the recommendation of slow tapering of steroids, which were crucial in managing this complication. This case highlights the importance of a multidisciplinary approach and close monitoring to ensure optimal outcomes for both the mother and the developing foetus. Key learning points • The diagnosis of post-streptococcal reactive arthritis should be considered in pregnant patients presenting with joint inflammation and a recent history of infection. Prompt recognition and appropriate treatment are essential to prevent long-term joint damage. • Careful monitoring of glycaemic control is crucial when initiating steroid therapy in pregnant patients, as it may lead to uncontrolled diabetes and can cause foetal problems. Close collaboration between obstetric and endocrine specialists is necessary to optimise diabetes management while minimising foetal risks. • Collaboration with dermatology specialists can aid in the management of complications such as panniculitis during steroid tapering in pregnant patients. A multidisciplinary approach ensures comprehensive care and improves outcomes for both the mother and the developing foetus.

OA13 Trust your gut: it has the answer

Abstract Introduction We report the case of a 51-year-old man who presented over seven years to multiple specialities, including rheumatology on several occasions, with arthralgia, fevers and weight loss. He was found to have raised inflammatory markers, lymphadenopathy and pericardial and pleural effusions but despite extensive investigation over this time, the cause for his presentation remained elusive. After many years, he developed gastrointestinal symptoms, which led us to the unifying diagnosis of Whipple’s disease. Case description This patient initially presented to rheumatology in 2017 with left ankle pain. His only medical history was renal calculi. He was diagnosed with gout and osteoarthritis and was discharged. Two years later, he presented with fevers. Investigations revealed raised inflammatory markers, small pericardial and pleural effusions and small-volume upper abdominal lymphadenopathy. He was treated with colchicine for pericarditis with some improvement. He presented again in 2021 with chest and flank pain and breathlessness. CTPA revealed an ongoing small pericardial effusion and small-volume intrathoracic and intra-abdominal lymphadenopathy. Inflammatory markers remained raised (CRP 30-50, ESR 20-30). He had now begun to lose weight. He was referred to the cancer of unknown primary service, who monitored his lymphadenopathy. In January 2022, he underwent an open biopsy of a mesenteric lymph node, which revealed non-caseating granulomas and no evidence of malignancy. He was referred again to rheumatology due to ongoing migratory joint pains in his wrists, ankles and knees. Rheumatoid factor, anti-CCP, antinuclear antibody and serum ACE had been negative on several occasions. He underwent a PET scan that revealed persistent lymphadenopathy with low to moderate avidity, borderline splenomegaly and a slightly prominent marrow signal. He then had a bone marrow biopsy that showed no significant abnormality. In December 2023, we settled on a probable diagnosis of sarcoidosis. He was treated with a trial of steroid without much symptomatic improvement and there was a plan to initiate Methotrexate. However, he then developed nausea and vomiting and was noted to have a new iron deficiency anaemia. He was referred to gastroenterology and underwent an upper endoscopy, which was macroscopically normal, but microscopically showed findings in keeping with Whipple’s disease (WD) with PAS-positive staining. Duodenal biopsy PCR confirmed this. He is now awaiting input from the infectious diseases team and long-term antibiotic treatment. Discussion WD is caused by the bacterium Tropheryma whipplei. There are four commonly recognised manifestations of T. whipplei infections: 1) classic WD, 2) localised chronic infections, 3) acute infections and 4) asymptomatic carriage. Our patient has classic WD, and his case exemplifies the disease course and diagnostic challenges. Classic WD is a rare, chronic, multisystem infectious disease. It is reported as most often affecting middle-aged white males of European ancestry. It can be divided into an early phase with intermittent arthralgias or arthritis and fever, a middle phase with gastrointestinal symptoms and weight loss, and a late phase with predominant neurological symptoms. Arthritis is the presenting symptom in 60-70% of cases and occurs in 90% of all cases. Given this, around half of patients are initially misdiagnosed as having an inflammatory rheumatic disease. As in the case of our patient, joint manifestations do not correlate with intestinal symptoms and can precede intestinal manifestations by a mean interval of six years. Joint involvement in WD is typically a migratory oligo- or polyarthritis or arthralgia primarily involving large and medium joints, most commonly the knees, ankles and wrists. Less commonly affected joints are elbows, hips and shoulders. WD should be considered in all patients with the four cardinal symptoms of arthralgias, diarrhoea, abdominal pain, and weight loss after more common differentials have been excluded. In patients without gastrointestinal symptoms, having suspicion of the disease is more difficult; however, consideration should be made in patients with seronegative arthritis, who do not respond to immunosuppressive treatment. Other clinical syndromes in which WD should be considered include fever of unknown origin, chronic serositis, generalised lymphadenopathy, progressive central nervous system disease or early onset cognitive deficits. Although histology revealing non-caseating granulomas is the hallmark of sarcoidosis, they are non-specific and can be found in many other diseases. Key learning points • WD has a reputation as a great mimicker of many diseases and there is still often a considerable delay to diagnosis, even in typical cases, given the natural history of the disease and its rarity. WD should be considered in patients with seronegative arthritis not following a typical disease course, particularly if they develop gastrointestinal symptoms. WD is also a pertinent differential in patients with persistent constitutional upset with unexplained lymphadenopathy or serositis. It should be remembered that non-caseating granulomas can be found in many diseases and that sarcoidosis remains a diagnosis of exclusion among granulomatous disorders.

The effect of PNF combination exercise therapy on shin splint injuries in marathon runners

Training at high intensity without proper warm-up and cool-down can cause shin splint injuries in runners. This may lead to a decline in the athlete’s performance during training and competition. This study aims to determine the effect of PNF training therapy on shin splint injuries in marathon runners. This research employs a quasi-experimental approach with a One Group Pretest-Posttest Design. Data collection methods include tests and measurements using a goniometer to assess joint range of motion (ROM) and the Visual Analogue Scale (VAS) to measure pain levels. The population in this study consisted of running athletes from the Yogyakarta running community, with a sample of 16 individuals selected based on specific criteria. The study results showed a significant average reduction in knee pain of 1.00 and ankle pain of 0.94. Additionally, an increase in knee ROM was observed: flexion increased by 7.81; extension by 7.82; adduction by 4.25; and abduction by 3.75. Ankle ROM also increased: dorsiflexion by 5.94, plantarflexion by 3.62, inversion by 3.57, and eversion by 2.68.

Progressive pseudorheumatoid dysplasia involving a novel CCN6 mutation: a case report

ObjectiveThis study aims to report a case of progressive pseudorheumatoid dysplasia (PPRD) with two kinds of cellular communication network factor 6 (CCN6) gene mutation. In this paper, the clinical profile and the process of diagnosis were analyzed, and the related literature was reviewed. A 15-year-old boy, who developed progressive ankle and hip joint pain and enlargement with spine involvement, was diagnosed with PPRD. The erythrocyte sedimentation rate and C-reactive protein (CRP) were in the normal range; rheumatoid factor and anti-cyclic citrullinated peptide antibody (ACPA) were all negative. Human leukocyte antigen 27 (HLA-B27) was also negative. Cene study discovered two kinds of mutations in CCN6 gene: c. 802T>C and c.624dup. Radiographic studies revealed spine platyspondyly and shaped beaked, osteoporosis, and bilateral symmetric bony enlargements of the interphalangeal joints. Hip shows bilateral acetabulum and femoral head bone marrow edema, which revealed hip arthritis. Gene detection, laboratory examination, and typical radiographic features are helpful for the diagnosis of PPRD. This is the first report of c. 802T>C and c.624dup mutations in patients with PPRD in our country.

Early clinical efficacy study on the efficacy of a three-stage conservative Chinese medicine external treatment for acute lateral ankle ligament injuries

To evaluate the clinical effect of a new three-phase Chinese medicine (CM) external treatment for acute lateral ankle ligament injuries. From July to December 2023, 64 patients with acute lateral ankle ligament injuries were randomly assigned to receive either the new three-phase CM external treatment combined with the POLICE(protect, optimal loading, ice, compression, elevation) treatment (observation group) or the POLICE treatment (control group), with 32 cases in each group. The observation group consisted of 17 males and 15 females, with an average age of(30.59±3.10) years old ranging from 25 to 36 years old, while the control group included 14 males and 18 females, with an average age of(30.03±3.19) years old ranging from 24 to 37 years old. Visual analogue scale (VAS) evaluation and Figure of 8 measurement were used to evaluate the degree of ankle joint pain and swelling of the subjects at the initial enrollment and after 1 week and sixth weeks of treatment. At the same time, the American Orthopaedic Foot and Ankle Society (AOFAS) and Karlsson Ankle Function Score System were used to evaluate the improvement of ankle joint function in patients at all stages. MRI imaging was employed to observe the degree of biological healing of the anterior talofibular ligament, with the signal to noise ratio(SNR) indicating the level of healing. A lower SNR suggests better ligament healing, as it represents lower water content in the ligament. All patients completed a 6-week follow-up. There was no significant difference in VAS, AOFAS score and Karlsson score between the two groups before treatment (P>0.05). After 1 week and 6 weeks of treatment, the VAS, AOFAS score and Karlsson score of the two groups were significantly improved (P<0.05). After 1 week of treatment, the VAS score of the observation group (3.21±0.87) was lower than that of the control group (4.21±1.50), and the difference was statistically significant (P<0.05). After 1 weeks of treatment, the AOFAS and Karlsson scores [(50.84±4.70) points, (49.97±4.00) points] of the observation group were higher than those [(46.91±5.56) points, (46.66±5.36) points]of the control group (P<0.05). MRI images showed that after 6 weeks of treatment, the SNR value of the observation group was significantly lower than that of the control group, and the difference was statistically significant(SNR of the observation group was 75.25±16.59, the contral gruop was 85.81±15.55), (P<0.05). Compared with the control group, the new three-phase CM external treatment is significantly effective in reducing pain and swelling, enhancing ligament repair quality, and promoting functional recovery of the ankle joint in patients with acute lateral malleolar ligament injuries.

A rare and misleading condition: isolated skeletal involvement of Erdheim-Chester Disease.

We are describing an unusual presentation of Erdheim-Chester Disease (ECD), a non -Langerhans histiocytosis provoked by abnormal aggregation of foamy histiocytes in several organs and systems. Our patient, already with osteoporosis, presented severe bilateral ankle pain with functional impairment, clinically mimicking "Complex Regional Pain Syndrome" (CRPS); the radiological images and subsequently the bone biopsy were fundamental for achieving the proper diagnosis. The diagnosis was challenging given the isolated bone localization which is uncommonly seen in ECD.

Comparative analysis of clinical outcomes of talocalcaneal coalition resection: subtalar joint middle and posterior facet involvement versus isolated posterior facet involvement – a retrospective cohort study

BackgroundDespite coalition resection being the preferred treatment for talocalcaneal coalition (TCC), postoperative complications, suboptimal functional recovery, and recurrence risks remain challenges. Although current TCC classification systems guide personalized surgical plans, the impact of middle and posterior facet coalitions on TCC resection surgery’s effectiveness is still poorly understood. Therefore, this study aims to compare the clinical outcomes of TCC patients with and without involvement of the subtalar joint’s (STJ) middle and posterior facets undergoing coalition resection to explore the potential impact of these coalitions on surgical outcomes.MethodsWe conducted a retrospective study on 115 patients who underwent coalition resection surgery due to symptomatic TCC between November 2009 and February 2023. According to preoperative CT scan results, patients were divided into an isolated posterior facet coalition (P-type) group and a middle-posterior facet coalition (MP-type) group. Demographic characteristics (including age, sex, body mass index (BMI), follow-up time, and medical history duration), pre-and postoperative assessments (including Visual Analog Scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Pain Interference (PI) and Physical Function (PF) scores from the Patient-Reported Outcomes Measurement Information System (PROMIS)), as well as postoperative self-assessment of efficacy (excellent, good, fair, poor) and hindfoot stiffness, were compared between the two groups. Postoperatively, TCC recurrence was evaluated through imaging follow-up examinations.Results69 patients meeting the inclusion criteria were included, with 30 patients in the P-type group and 39 in the MP-type group. There were no statistically significant differences between the two groups in demographic characteristics (P<0.05). There were also no statistically significant differences between the two groups in preoperative VAS score, AOFAS score, PI score, and PF score. However, postoperatively, there were statistically significant differences between the two groups in VAS score (1(1,1.5) vs. 2(1,2), P<0.01), AOFAS score (92.5(87,96.5) vs. 82(69.5,87), P<0.01), PI score (39(39,43) vs. 39(39,51), P = 0.014), PF score (73(61,73) vs. 55(51,73), P = 0.001), fair or poor outcome (4(13%) vs. 14(35.9%), P = 0.034), and hindfoot stiffness (3(10.3%) vs. 16(37.2%), P = 0.011). There was no statistically significant differences in the recurrence rate between the two groups postoperatively (0(0%) vs. 3(7.69%), P = 0.252).ConclusionEven with complete coalition resection during surgery and rehabilitation following standardized protocols, the surgical outcomes in MP-type TCC patients are still inferior to those in P-type patients.

Comparison of retrograde and antegrade tibial intramedullary nail in the treatment of extra-articular distal tibial fractures.

The aim of this study was to compare the effectiveness of retrograde and antegrade intramedullary tibial nails (RTN and ATN) in managing extra-articular distal tibial fractures, addressing current controversies in surgical approaches. A retrospective analysis included 56 patients treated between December 2019 and August 2022 with either RTN (n = 23) or ATN (n = 33). Data on baseline characteristics, operative specifics, fluoroscopy usage, hospitalization duration, fracture healing times, time to full weight-bearing, distal tibial alignment, American Orthopedic Foot and Ankle Society (AOFAS) scores at final follow-up, and complications were evaluated and compared. Baseline characteristics were generally comparable and no significant differences except for fracture line lengths (RTN: 6.1 ± 1.9cm vs. ATN: 7.8 ± 1.6cm) were observed. Follow-up ranged from 12 to 20 months. No significant differences were observed in operative duration, hospital stays, coronal angulation of the distal tibial joint surface, or AOFAS scores at final follow-up. Intraoperative fluoroscopy was more frequent in the ATN group (9.5 ± 1.5) compared to RTN (8.3 ± 1.1) (P = 0.001). RTN showed shorter healing times (9.6 ± 1.2 weeks) and quicker return to full weight-bearing (12.9 ± 1.3 weeks) than ATN (10.6 ± 1.2 weeks and 13.9 ± 1.7 weeks, respectively). RTN complications included one delayed union, one superficial infection, and two ankle pain, while ATN complications comprised one delayed union, one superficial infection, seven anterior knee pain, and one malalignment. Despite higher complication rates with ATN, the differences were not statistically significant. For the treatment of extra-articular distal tibial fractures, both RTN and ATN are effective approaches. RTN may offer benefits such as reduced fluoroscopy use, accelerated healing, and earlier return to full weight-bearing compared to ATN.

Magnetic Resonance Imaging Findings and Potential Anatomic Risk Factors for Anterolateral Ankle Impingement in Children and Adolescents Suffering from Non-Overload Atraumatic Ankle Pain.

To assess magnetic resonance image (MRI) findings in children and adolescents with atraumatic non-overload ankle pain and to identify potential anatomic risk factors. In total, 310 MRIs of 6- to 20-year-old patients were evaluated regarding detectable ankle pathologies. A total of 147 patients (68 males; 79 females) suffered from atraumatic non-overload ankle pain. The findings were compared to a control group (163 patients: 89 males; 74 females), including patients with ankle trauma in the 4 weeks prior to MRI examination. A t-test for unpaired samples and a binary logistic regression model were used to identify significant differences between both groups and determine potential anatomic risk factors. In the group with atraumatic ankle pain, 95 patients (64.6%) showed at least one pathology. Anterolateral impingement of the upper ankle joint was found in 29 patients (19.7%). Its occurrence was significantly higher in atraumatic non-overload patients than in the control group (p = 0.043). Moreover, a significant correlation between anterolateral impingement of the upper ankle and the presence of hindfoot valgus malposition (n = 25; 17.0%) could be proven in atraumatic non-overload patients (p = 0.035). Anterolateral impingement of the upper ankle joint is frequently observed in children and adolescents suffering from atraumatic non-overload ankle pain, whereby a hindfoot valgus malposition seems to present an anatomic risk factor.

Proposed Classification of Syndesmotic Soft Tissue Impingement and Its Association With Lateral Talar Cartilage Lesions.

Syndesmotic impingement syndrome has been described to explain persistent lateral or anterolateral ankle pain. This condition is thought to often result from a rotational ankle injury. This study aimed to identify the type of syndesmotic impingement tissue according to arthroscopic and histologic findings and to analyze its association with lateral talar cartilage lesions. This retrospective study included 107 ankles in 105 patients who underwent arthroscopic surgery for syndesmotic impingement syndrome from January 2017 to August 2019. Histologic findings of biopsied impingement tissue were obtained in 59 ankles (55.1%) and compared with gross findings on arthroscopy. Cartilage lesions were evaluated using the International Cartilage Repair Society grading system. Risk factors associated with lateral talar cartilage injury were evaluated using multivariate logistic regression analysis. Based on the histologic results, the most common pathology was fibrosis (24 ankles [22.4%]), followed by fatty degeneration (23 ankles [21.5%]), synovial hyperplasia (8 ankles [7.5%]), and inflammatory synovium (4 ankles [3.7%]). Interclass correlation coefficient was 0.841 (P = .001) between histologic results and arthroscopic findings. Patients with fibrotic impingement tissue had on average a significantly longer duration of symptoms (12 vs 48 months, P = .021). A lateral talar dome cartilage lesion was detected in 25 ankles (23.4%). Fibrotic impingement tissue was the only factor significantly associated with lateral talar dome lesion on multivariate logistic regression analysis (odds ratio 10.04; 95% CI 1.84-54.9; P = .008). Syndesmotic impingement with fibrotic tissue was often associated with cartilage lesions at the lateral talar dome. Patients with prolonged anterolateral or lateral ankle pain after a rotational ankle injury warrant careful assessment for possible syndesmotic impingement by fibrotic tissue and associated lateral talar cartilage injury.

Medial sleeve fractures in elite-athletes: A heterogeneous group, anatomical and case-based considerations.

The purpose of this study is to provide a detailed description of the anatomy and radiology of the medial sleeve and present an approach in its management among elite athletes. Five cases of elite athletes who underwent treatment for a medial sleeve injury of which the diagnosis was confirmed through physical examination and additional magnetic resonance imaging scan are described in this study. Two patients presented with isolated medial sleeve injuries, while the other three patients suffered from concomitant ankle injuries. Non-operative treatment consisted of relative rest, soft cast immobilization and mobilization in a walking boot or kinesiotape which was successful in four of the cases with regard to the medial sleeve. One patient underwent surgery due to syndesmotic instability. Another patient presented with combined medial and lateral ankle instability which was treated surgically with an open medial and lateral ligament repair. All patients were able to return to their pre-injury sports and at the time of the last follow-up were still playing in their pre-injury level of competition. Medial sleeve injuries of the ankle in elite athletes should be considered in the differential diagnosis for athletes presenting with medial ankle pain. Inherent knowledge regarding anatomy is essential when guiding the management of these injuries which can be treated successfully with a non-operative approach consisting of relative rest, immobilization, kinesiotape and physical therapy. In case of persistent medial instability or rotational instability, surgical repair is a viable treatment option. Both modalities allow athletes to return to the pre-injury level of competition. However, early diagnosis is crucial to minimize the delay of appropriate treatment and avoid potential residual symptoms. Level IV.

Ankle Pain - Recreational Golfer

Ankle Pain - Recreational Golfer

Bilateral Ankle And Back Pain In A Traditional Chinese Lion Dancer

Bilateral Ankle And Back Pain In A Traditional Chinese Lion Dancer

Anterior Ankle Pain In A Female Recreational Runner

Anterior Ankle Pain In A Female Recreational Runner

Characteristics and Outcomes of Surgical Treatment for Anterolateral Ankle Impingement Due to the Distal Fascicle of the Anterior Inferior Tibiofibular Ligament.

The pathomechanism of anterolateral ankle impingement (ALAI) due to the distal fascicle of the anterior inferior tibiofibular ligament (DF-AITFL) has not been fully elucidated. In addition, because of its rarity, no definitive diagnostic criteria have been established for ALAI due to DF-AITFL. To document the symptom characteristics and magnetic resonance imaging (MRI) and and arthroscopic findings as well as postoperative clinical outcomes of ALAI due to DF-AITFL. Case series; Level of evidence, 4. Included were 12 patients (5 male and 7 female; mean age, 34.4 years [range, 21-76 years]) who were diagnosed with ALAI due to DF-AITFL and underwent excision of the DF-AITFL from November 2017 to August 2021. Symptom characteristics and symptom-related medical histories were evaluated, as were MRI and arthroscopic findings. Clinical outcomes were assessed using the visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot functional scale, and Foot Function Index. All 12 patients had a history of ankle sprain before symptom onset. DF-AITFL was confirmed by MRI in all patients. Bone edema of the talus was observed in 2 patients (16.7%), and cartilage abnormalities in 3 patients (25%). Arthroscopy showed that the DF-AITFL contacted the anterolateral aspect of the talar dome during range of motion in all patients and that the AITFL was bent where it contacted the anterolateral dome of the talus in 3 patients (25%). Partial tear or adhesion of the DF-AITFL was noted in 7 patients (58.3%), and cartilage deformation at the anterolateral talar dome in 4 patients (33.3%). Mean visual analog scale pain, American Orthopaedic Foot & Ankle Society, and Foot Function Index scores improved significantly from preoperatively to postoperatively. ALAI due to DF-AITFL should be considered a possible cause of anterolateral ankle pain after an ankle sprain. The diagnosis can be reliably made with a thorough clinical examination and imaging studies. Half of the patients in this series also had lateral ankle instability. Surgical resection of the DF-AITFL and ligament reconstruction, if necessary, resulted in significant symptom improvement.

Bilateral Ankle Pain - Recreational Runner

Bilateral Ankle Pain - Recreational Runner

Chronic Ankle Pain - Cross-country Athlete

Chronic Ankle Pain - Cross-country Athlete