Ankle Symptoms Research Articles

Effect of Tibiotalar Joint Arthrodesis on Adjacent Tarsal Joint Pressure in a Cadaver Model

Tibiotalar arthrodesis is the most common treatment of end-stage symptomatic ankle arthritis, but concerns exist about late findings of adjacent tarsal joint osteoarthritis. The purpose of this study was to evaluate the changes of pressure in the talonavicular, subtalar, and calcaneocuboid joints before and after rigid tibiotalar joint immobilization and at different levels of tibiopedal dorsiflexion. Twelve cadaver foot specimens were cyclically loaded on a servohydraulic test frame to 700 N. Joint contact pressure, peak pressure, and contact area in the three tarsal joints were measured before and after tibiotalar joint immobilization with three 6.5-mm screws to simulate ankle arthrodesis. Measurements were obtained at tibiopedal dorsiflexion angles of 0, 10, 20, and 30 degrees in normal ankle joints and at dorsiflexion angles of 0, 10, and 20 degrees in fixed tibiotalar joints. Paired Student's t-tests and one-way ANOVA with repeated measures were used to analyze the data. Joint contact pressures did not show any statistically significant difference for the talonavicular and calcaneocuboid joints in the intact ankle. Contact pressures in the talonavicular and calcaneocuboid joints showed significant differences between 0 and 10 degrees and between 0 and 20 degrees of dorsiflexion (p<0.05) in the fused ankle specimens. Comparison of the contact pressure of the talonavicular and the calcaneocuboid joints between the intact and the fused ankle specimens showed a significant difference at 10 and 20 degrees of dorsiflexion (p<0.05). Subtalar joint contact pressure in the intact ankle showed a significant difference between 0 and 30 degrees of dorsiflexion (p<0.05). These changes in joint pressures and contact area are consistent with findings of transverse tarsal joint arthritis seen in clinical studies. The current findings suggest that a substantial pressure increase in the talonavicular and calcaneocuboid joints at tibiopedal dorsiflexion levels simulating a late stance phase of the gait cycle may be responsible for the secondary tarsal joint degeneration occurring in late ankle arthrodesis.

Incidence and MR imaging features of fractures of the anterior process of calcaneus in a consecutive patient population with ankle and foot symptoms

To determine the incidence, appearances and associated injuries of fractures affecting the anterior process of calcaneus from a general population with foot and ankle symptoms. A retrospective review of foot and ankle MR imaging procedures was performed for detection of cases with a fracture affecting the anterior process of calcaneus over a four year period. Radiographs, MR imaging studies, radiology reports, medical records, and operative notes were reviewed. Imaging analysis included fracture pattern, displacement, associated fractures, and presence of tendon and ligamentous injuries. The incidence of anterior process of calcaneus fracture on MR imaging was 0.5% (14/2577). Fractures were more common in female subjects (71%, 10/14). Fracture orientation was predominantly vertical (93%, 13/14). No comminuted fractures were seen and only three fractures were displaced. Three of the eight MR imaging evident fractures of anterior process of calcaneus were seen on radiographs. Associated fractures of the talus (n=5), navicular bone (n=3), cuboid (n=2), and calcaneal body (n=1) were noted. Associated injuries to the anterior talofibular ligament (n=3) and tears of the peroneus brevis (n=3) and peroneus longus (n=1) tendons were present. All fractures were treated non-operatively. Two patients had subtalar joint steroid injection for symptomatic relief. Fractures of the anterior process of the calcaneus are uncommon in MR examinations of a general population of patients with foot and ankle symptoms. Although anterior process of calcaneus fractures are rare, there was a moderately high incidence of associated bone and soft-tissue injuries.

The Relationship Between Tears of the Peroneus Brevis Tendon and the Distal Extent of its Muscle Belly: An MRI Study

Anomalous distal insertion of the peroneus brevis muscle belly has been implicated as a possible etiology of tears of the peroneus brevis tendon. The purpose of this study was to assess whether patients with operatively confirmed tears of the peroneus brevis tendons have a more distally located musculotendinous junction. A retrospective review was done to identify all patients in whom direct inspection of the peroneal tendons was done between 1999 and 2004. The operative reports were evaluated, and all in whom a peroneal tendon tear was confirmed were included in the study group, Group I (29 patients). Group II represented an operative control group and consisted of all patients who had operative inspection of the peroneal tendons but did not have a tear (30 patients). Group III represented a radiographic control group and consisted of patients who had MRI of the ankle for reasons unrelated to lateral ankle symptoms (30 patients). For each patient, the vertical distance from the musculotendinous junction of the peroneus brevis tendon to the tip of the fibula was measured on sagittal MRI. The role of gender also was examined. The average distance between the musculotendinous junction of the peroneus brevis tendon to the distal fibula was calculated solely for men and women in all three groups. Statistical comparison of the groups was performed using the Mann-Whitney test. Interobserver reliability was determined by calculating Cronbach's Alpha coefficient. The average distance from the musculotendinous junction to the tip of the fibula was 33.1 cm, 41.2 cm, and 46.3 cm in Groups I, II, and III, respectively. The average distance in Group I was statistically significantly lower than the average distance in both Groups II and III (p < 0.05). Interestingly, the difference in the distance between Groups II and III also was statistically significant (p < 0.05). The average distances in both men and women were statistically significantly different (p < 0.05) among the three groups. It has been hypothesized that tears of the peroneus brevis tendon result from distal insertion of the peroneus brevis muscle belly. This study provides radiographic support for this hypothesis.

Revision Lateral Ankle Reconstruction

Symptomatic lateral ankle instability is a common source of disability in an active population. While most incidences are successfully treated by conservative measures, some individuals require lateral ankle reconstruction. A commonly performed procedure is the Gould modification of the Broström lateral ankle reconstruction. Despite its success, some individuals experience recurrent instability through reinjury. Revision surgery often involves nonanatomic reconstruction using tendon grafts that may restrict normal ankle and subtalar motion and can result in persistent postoperative pain and disability. The purpose of this study was to demonstrate an equivalent success rate using a more anatomic revision lateral ankle reconstruction based on the Gould modification of the Broström concept. We retrospectively reviewed 15 consecutive patients who had a revision lateral ankle reconstruction between 1992 and 2000. All procedures were done by a single surgeon (FGL). Patients who exhibited hindfoot varus and dynamic heel rollout had a valgus calcaneal osteotomy. Patients were asked to complete a 100-point questionnaire postoperatively. All patients reported improvement in ankle function, decreased pain, and no episodes of instability compared to preoperative assessments. Excellent results were achieved in 12 of 15 patients which was consistent with published data from index Broström reconstructions. Four patients who had fixed hindfoot varus and dynamic ankle rollout had valgus calcaneal osteotomies. All patients returned to an active lifestyles including sports and military service. Our findings suggest that a revision anatomic lateral ankle reconstruction is an effective option. A thorough clinical evaluation was mandatory to assess hindfoot valgus with dynamic ankle rollout for which a valgus calcaneal osteotomy was included in the procedure. We believe that tendon sacrificing procedures can be avoided in most patients, but soft-tissue structures must be assessed intraoperatively and the surgical approach planned to allow for conversion if necessary.

Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind‐, and mid‐foot in chronic inflammatory diseases

To assess the impact of ultrasonography (US) on local corticosteroid (CS) injections of painful ankle, hindfoot, and midfoot in chronic inflammatory diseases. Consecutive patients with chronic rheumatic diseases admitted to the hospital for local CS injections of painful ankle, hindfoot, or midfoot were enrolled in this study. Clinical and radiographic evaluation was performed by the physician in charge of CS injections, and US examination was performed by an independent examiner blinded to the clinical and radiologic findings. According to a randomized weekly-periods design, the physician planned CS injections either aware (G1 group) or unaware (G2 group) of US results. In the latter case, he was nonetheless informed of US results after he had performed the injections. Impact of this information on the treatment planning was assessed in all cases. Prognostic impact of US was also evaluated by comparing the change in global assessment of efficacy of CS injections, in activity of the disease, and in the Western Ontario and McMaster Universities (WOMAC) subscales after 1 and 3 months, between G1 and G2 groups. The knowledge of US findings led the physician to change his decision of local CS injections in 56 (82%) of 68 patients studied. Among 1,131 assessed sites, by clinical, radiographic, and US evaluation, injection was cancelled in 37 (15%) of 242 proposed sites, whereas it was decided in 74 (8%) additional sites. After 1 month, there was an improvement in G1 as compared with G2 groups. The mean +/- SD change in WOMAC physical function subscale was 15.6 +/- 17.5 in G1 versus 8 +/- 13 in G2 (P = 0.0305). After 3 months, only the global assessment of efficacy of CS injections was statistically greater in G1 than in G2 group (P = 0.0170). US frequently led the physician to change his diagnosis of inflammatory lesions in painful foot, and consequently his planning of CS injections. Moreover, US could improve the response to local treatment.

Long term outcomes of inversion ankle injuries

Background: Ankle sprains are common sporting injuries generally believed to be benign and self limiting. However, some studies report a significant proportion of patients with ankle sprains having persistent symptoms...

A Review of Rheumatoid Arthritis Affecting the Foot and Ankle

Rheumatoid arthritis is a systemic disease that often affects the foot and ankle. Approximately 20% of patients with rheumatoid arthritis present initially with foot and ankle symptoms, and most patients will eventually develop foot and ankle symptoms. Although early intervention includes conservative measures, operative treatment often is needed to adequately treat rheumatoid patients. Treatment of foot and ankle problems in patients with rheumatoid arthritis is directed to maintaining ambulatory capacity. This article reviews the clinical presentation, evaluation, and treatment of rheumatoid arthritis affecting the foot and ankle.

Fibular nonunion after closed rotational ankle fracture.

Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain. A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms. All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months). Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.

Sub-talar joint cyst treated by CT guided needle aspiration

We report a case of a sub-talar cyst, closely associated with the talo-calcaneal ligament in a patient with long-standing foot and ankle symptoms. Symptomatic intra-articular ganglion cysts have not to our knowledge been previously described in this location. The cyst was successfully aspirated under CT guidance. Intra- articular ganglion cysts have been reported as a cause of pain in the knee and shoulder. [Arthroscopy15 (1999) 85; Arthroscopy15 (1999) 373; Eur. Radiol. 10 (2000) 1233; Eur. Radiol. 11 (2001) 834; Dtsch Z. Chir. 186 (1924) 403; Skeletal Radiol. 30 (2001) 411; J. Bone Joint Surg. 84-A (2002) 2274] Magnetic resonance imaging has increased the detection of such lesions, allowing less invasive methods of treatment. Cysts have been treated by open or arthroscopic surgical decompression and by percutaneous aspiration of the ganglion, directed either by computed tomography [Am. J. Roentgenol. 162 (1994) 1503] or by sonography [Skeletal Radiol. 30 (2001) 411].

Surgical reconstruction for chronic lateral instability of the ankle

We have treated 56 patients (56 ankles) for symptomatic chronic lateral ankle instability by the surgical reconstruction procedure. The operation included lateral shift of the entire lateral capsule–ligament complex, suture to anterior border of fibula, and reinforcement by an elevated periosteal flap of distal fibula. These patients were reviewed at a mean period of 3.1 years (range, 9 months to 5 years) after the operation. There were 29 males and 27 females with an average age of 29 years (range, 16–49 years). The clinical results were graded according to the AOFAS Ankle-Hindfoot scales. There were 35 patients who were excellent (above 90 points), 16 who were good (between 76 and 90 points), 4 who were fair (between 60 and 75 points), and 1 who was poor (below 60 points). The excellent and good results amounted to 91.1% (51/56). Therefore, we concluded that symptomatic chronic lateral ankle instability could be successfully managed with this easy and effective surgical reconstruction method.

The initial effects of a Mulligan's mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains

Physiotherapists frequently use manipulative therapy techniques to treat dysfunction and pain resulting from ankle sprain. This study investigated whether a Mulligan's mobilization with movement (MWM) technique improves talocrural dorsiflexion, a major impairment following ankle sprain, and relieves pain in subacute populations. Fourteen subjects with subacute grade II lateral ankle sprains served as their own control in a repeated measures, double-blind randomized controlled trial that measured the initial effects of the MWM treatment on weight bearing dorsiflexion and pressure and thermal pain threshold. The subacute ankle sprain group studied displayed deficits in dorsiflexion and local pressure pain threshold in the symptomatic ankle. Significant improvements in dorsiflexion occurred initially post-MWM ( F (2,26)=7.82, P=0.002), but no significant changes in pressure or thermal pain threshold were observed after the treatment condition. Results indicate that the MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. The mechanism by which this occurs requires investigation if we are to better understand the role of manipulative therapy in ankle sprain management.

Correlation between ankle brachial index, symptoms, and health-related quality of life in patients with peripheral vascular disease

Introduction: In the absence of quality of life measurement, other measures such as ABIs and patient symptoms provide a basis for determining the need for invasive therapy for patients with peripheral vascular disease (PVD). The accuracy of these surrogates in representing HRQL is, however, untested. The purpose of this study was to determine the correlation of these measures to HRQL. Methods: 115 PVD patients (114 male:1 female; median-age 64yrs) referred for vascular evaluation, were enrolled in an IRB-approved, prospective study. All patients completed Short Form-36 (SF-36) and Walking Impairment Questionnaire (WIQ- validated, PVD specific HRQL measure). 102 patients had measurement of ABIs and all had documented PVD symptoms. Pearsons correlation and student’s t test were used to examine univariate associations. Linear regression was used to assess the significance of the association of ABIs or symptoms in explaining the variance in HRQL scores. Results: The average ABI was 0.54 (0.00–0.98). The maximal correlation between SF-36 and ABIs was Physical Component Summary score (r = 0.29, p = 0.003). WIQ scores also exhibited modest correlation with ABIs (maximal correlation noted [r = 0.30, p = 0.002] for stair climbing). Both SF-36 and WIQ exhibited a highly significant association with symptoms: in all cases patients with surgical indications (lifestyle-limiting claudication or chronic critical limb-ischemia) had reduced HRQL scores compared with non-surgical patients (non-lifestyle-limiting claudication). Multivariate analysis suggested that in each case, SF-36 and WIQ summary scores were better predicted by symptoms than ABI’s (see table). TABLE—ABSTRACT 2Summary scoresSymptoms coefficientABI coefficientSF36 Physical Component Score−5.8: p = 0.0015.3: p = 0.13WIQ Walking Distance−9.0: p = 0.0011.6: p = 0.77WIQ Walking Speed−6.3: p = 0.0046.8: p = 0.14Conclusions: HRQL in PVD patients correlates weakly with ABIs, but exhibits a closer association with vascular symptoms. This suggests that sole reliance on ABIs may not accurately reflect the impact of PVD on HRQL, or the potential benefit of vascular surgery in improving HRQL.

Paper #87 Chronic ankle instability: results with arthroscopic shrinkage with termal retraction

The appearance of new instruments based on the radiofrequency, using controlled thermal energy, opens news possibilities in arthroscopic surgery. There are many surgical applications with this type of energy, based on thermal contraction of the collagen fibbers with molecular reorganisation. Nevertheless, results of the few studies published are contradictory in literature and with short follow-up. We used this treatment in patients chronic ankle instability and symptoms not solved with conservative attitudes. We study 30 patients with chronic instability of the ankle, checked by clinical evaluation and stress X-ray (pre-op and post-op), 18 males and 12 females, with ages between 17 and 37 years, all performing sports activity, with a follow-up from 3 to 7 years. They were all operated by arthroscopy (same surgeon) using VAPR-T to retract the external ligament with a monopolar probe. The results were evaluated by the AOFAS score. In this series of 30 ankles, 29 had symptomatic and objective improvements in pain and stability and 1 maintained painful symptoms with instability (reoperated with Bronstrom modified procedure). The radiological evaluation protocol showed normal values of the external angle in 25 patients. The results of this study pointed the significant useful of radiofrequency in arthroscopic treatment of chronic instability of the ankle.

Arthroscopic Ankle Arthrodesis

Abstract Surgical options are limited for the patient who has symptomatic severe ankle joint degeneration that is unresponsive to nonoperative treatment. Arthrodesis of the tibiotalar joint is a procedure that can produce a pain-free ankle that can withstand the rigors of daily life, even in a young, high-demand, working individual. Minimally invasive orthopedic techniques have been applied to ankle arthrodesis, and arthroscopic ankle fusion has been shown to be an effective technique to achieve tibiotalar arthrodesis, with high rates of fusion and low rates of complication. This article covers indications, contraindications, and procedural techniques for arthroscopic ankle arthrodesis. Results of arthroscopic versus open ankle arthrodesis are compared.

ISOLATED GASTROCNEMIUS TIGHTNESS

Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed. This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed). With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group. On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present. These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.

Long-term outcome after tibial shaft fracture: is malunion important?

Fractures of the shaft of the tibia often heal with some angulation. Although there is biomechanical evidence that such angulation alters load transmission through the joints of the lower limb, it is not clear whether it can eventually lead to osteoarthritis. One hundred and sixty-four individuals who had sustained a tibial shaft fracture were assessed in a research clinic thirty to forty-three years after the injury. The subjects were evaluated with regard to self-reported lower limb joint pain, stiffness, and disability (assessed with the Western Ontario and McMaster Universities [WOMAC] osteoarthritis questionnaire); clinical signs of osteoarthritis; and radiographic evidence of osteophytes and joint-space narrowing in the knees, ankles, and subtalar joints. Twenty-two (15%) of the 151 subjects who reported no other knee injury reported at least moderate knee pain, and eight (6%) of the 145 subjects who reported no other ankle injury reported at least moderate ankle pain. Seventeen (13%) of the 135 subjects who reported no other knee or ankle injury reported at least moderate disability. The ipsilateral side demonstrated a higher prevalence than the contralateral side in terms of pain with passive ankle movement (nineteen versus nine subjects, p = 0.02), pain with passive subtalar movement (fifteen versus four subjects, p = 0.01), and radiographic signs of ankle joint space narrowing (twelve subjects versus one subject, p = 0.0055). Knee osteoarthritis was frequently bilateral. Forty-seven fractures (29%) healed with coronal angulation of > or = 5 degrees. Apart from an association between shortening of > or = 10 mm and self-reported knee pain (p = 0.016), there were no significant univariate associations between these malunions and the development of osteoarthritis. Seventeen (15%) of 114 eligible subjects had overall malalignment of the lower limb, defined as a hip-knee-ankle angle outside the normal range of 6.25 degrees of varus to 4.75 degrees of valgus. This malalignment was due to the fracture malunion in nine subjects and predated the fracture in eight. In limbs with varus or valgus malalignment, there was an excess of subtalar stiffness (p = 0.04) and a nonsignificant trend toward more frequent knee pain. In limbs with varus malalignment, there was a nonsignificant trend toward more frequent radiographic evidence of osteoarthritis in the medial compartment of the knee joint. Most of the subjects in whom osteoarthritis was observed had normal overall alignment of the lower limb. The thirty-year outcome after a tibial shaft fracture is usually good, although mild osteoarthritis is common. Fracture malunion is not the cause of the higher prevalence of symptomatic ankle and subtalar osteoarthritis on the side of the fracture. Although varus malalignment of the lower limb occurs occasionally and may cause osteoarthritis in the medial compartment of the knee, other factors are more important in causing osteoarthritis after a tibial shaft fracture.

Do Functional-Performance Tests Detect Impairment in Subjects with Ankle Instability?

Objective:To determine whether the triple-crossover hop and timed shuttle run are able to discriminate between injured and uninjured limbs in subjects with functional ankle instability.Design and Setting:A comparative study involving the assessment of functional performance, conducted in a university gymnasium.Participants:A volunteer sample of 16 university-age subjects with unilateral functional ankle instability.Outcome Measures:The triple-crossover hop for distance and timed shuttle run measured functional performance, with the uninjured limb acting as a control. Subjects also rated their ankle symptoms using a self-report questionnaire.Results:The triple-crossover hop and shuttle run did not detect functional deficit despite subjects’ self-report scores indicating functional impairment.Conclusions:Results of the triple-crossover hop and shuttle run used in the clinic should be interpreted with caution, because they will not necessarily identify functional impairment.

The role of MRI in therapy and follow-up after surgical treatment of osteochondrosis dissecans of the talus

Our study was designed to evaluate the use of magnetic resonance imaging (MRI) in the follow-up of surgically treated osteochondrosis dissecans (OCD) of the talus. We investigated 16 patients (18 joints) with OCD of the talus, surgically treated in our department between 1990 and 1997. All of them had preoperative MRI scans of the affected ankle. The mean follow-up was 40 months (8-82). All patients were evaluated by clinical examination, plain radiography and MRI using a standard protocol. The clinical Bray score improved significantly from 58 preoperative to 82 postoperative. Using a visual analogue scale we saw a significant reduction of the patients pain level post-op. In 72% of the patients the preoperative MRI was able to predict the accurate stage of the cartilage. Postoperative MRI showed no more lesion in 3, intact articular cartilage in 11, and disrupted cartilage in 4 joints. There was no correlation between clinical, plain radiographical, and MRI findings postoperative. Arthroscopy remains the golden standard in evaluating articular cartilage. Using our data, MRI is not the method of choice in the follow-up of surgically treated OCD lesions of the talus. Postoperative use of intravenous contrast media gave no additional information. Postoperative MRI should be reserved only for symptomatic patients to gather additional information about the actual state of the OCD. Afterwards a prompt arthroscopy of the symptomatic ankle should be performed.

EFFICACY OF CELECOXIB VS NAPROXEN IN THE TREATMENT OF ANKLE SPRAIN

Active adults commonly experience ankle sprain, resulting in pain, inflammation, ecchymosis, and swelling. Physicians often prescribe conventional nonsteroidal anti-inflammatory drugs to treat ankle sprain and accelerate return to activity. In a recent clinical trial, celecoxib, a COX-2 specific inhibitor with platelet-sparing properties, was as effective as ibuprofen and better than placebo in reducing ankle sprain signs and symptoms. We hypothesized that celecoxib would be as effective as naproxen in ankle sprain. In an 8-day, multicenter, randomized, double-blind, parallel group trial, 396 adults with first or second degree inversion ankle sprain were treated with celecoxib 200 mg BID (n = 198) or naproxen 500 mg BID (n = 198). At baseline, patients had moderate-to-severe ankle pain on weight bearing [at least 45 mm on 100-mm visual analog scale (VAS)]. Patients were mostly male (67%) with a mean age of 30 years. Injuries were sports- (54%) or non-sports-related and occurred within 48 hours of the first dose of study medication (mean duration, 23.2 hours). Covariate-adjusted analyses of the primary end points (Patient's Global Assessment and VAS) at Day 4 demonstrated that celecoxib was as effective as naproxen in improving signs and symptoms of ankle sprain. Both groups had a median of 5 days to return to normal function/activity or function improvement by at least 2 grades (5-point categorical scale).Table1Responders improved by ≥ 1 grade on 5-pt scale from 1 (very good) to 5 (very poor); †p ≥ 0.51; ‡cel vs napr within 95% CI limits for noninferiority. Celecoxib is as effective as the maximum recommended dose of naproxen in treating pain of ankle sprains. Celecoxib, with its platelet-sparing properties and superior gastrointestinal tolerability, may offer an advantage over naproxen in managing ankle sprain injuries. Sponsored by Pharmacia Corp.

Prospective Evaluation of Syndesmotic Ankle Sprains without Diastasis

Sixty consecutive collegiate athletes with "high" ankle symptoms were prospectively evaluated over a 3-year period in an effort to better define this debilitating ankle injury. All athletes included in this study had tenderness over the distal anterior tibiofibular ligament, tenderness proximally along the interosseous membrane, and functional disability. No study subject had a fracture or frank tibia-fibula diastasis. The severity of the sprain was quantified using the interosseous "tenderness length." A standard rehabilitation protocol was followed by all patients. Athletes returned to competition when they could perform all functional testing without difficulty. Time to return to full competitive activity averaged 13.4 days. The number of days missed from competition was statistically related to the interosseous tenderness length (P = 0.0001) and to positive results on the squeeze test (P = 0.03). Fifty-three of the 60 injured athletes were evaluated at least 6 months after injury. Patients rated their outcomes as good or excellent. Six of the patients experienced occasional ankle pain and stiffness, four patients reported recurrent ankle sprains, and one patient had heterotopic ossification formation.