Distal Ankle Research Articles

Nerve Complications with Regional Anesthesia in Foot and Ankle Surgery Avoiding the Popliteal Fossa

Category: Other Introduction/Purpose: Popliteal nerve blocks are often used to aid intraoperative general anesthesia and provide post-operative pain control for many foot and ankle surgeries. Unfortunately, there is conflicting data regarding complication rates from popliteal nerve blocks, specifically when comparing studies from (the) orthopedic and anesthesia literature. Orthopedic literature notes long term effects (foot drop/sensation deficits) whereas anesthesia literature focuses on immediate post-operative pain control. An approach to block more distal nerves and avoid the popliteal fossa altogether may provide equal anesthetic and pain relief with fewer motor and sensory complications. Our study seeks to address such complications by utilizing an alternative anesthetic approach that targets sensory distributions of nerves that may be affected during the procedure while avoiding major motor neve contributions within the popliteal fossa. Methods: We conducted a retrospective chart review between 2019 and 2023, analyzing complications associated with regional anesthesia achieved via a distal ankle block rather than a popliteal nerve block. Two hundred thirty-seven patients who underwent a variety of foot and ankle procedures (e.g., ankle arthroscopy, ankle fracture repair, cavovarus foot reconstruction, hallux valgus arthrodesis, lateral ankle stabilization, calf tendon revision, midfoot fusion, metatarsal arthrodesis) were included in this study. Results: Out of 237 patients who received a distal ankle block, only three patients were found to have superficial peroneal neuropathy confirmed with EMG, yielding a complication rate of 1.3%. Additionally, six patients required post-operative rescue block for pain control. The remaining 234 patients recovered without complications caused by the distal nerve block approach. Conclusion: The low rate of complications, specifically motor complications, from the distal nerve blocks demonstrate a beneficial alternative to the popliteal nerve blocks for various foot and ankle orthopedic surgeries. This finding is important to consider when choosing an appropriate approach to augment intraoperative general anesthesia accompanying foot and ankle surgeries in the outpatient setting.

Defining the landscape of TIA1 and SQSTM1 digenic myopathy

TIA1/SQSTM1 myopathy is one of the few digenic myopathies. We describe four new French adult male patients carrying the TIA1 p.Asn357Ser and SQSTM1 p.Pro392Leu variant and review the literature to include 20 additional cases to define the spectrum of the disease. These twenty-four patients (75% males) had late-onset (52,6 ± 10,1 years), mainly asymmetric, distal ankle and hand finger extension weakness (75%), mild CK elevation (82.4%) and myopathic EMG. Two of the four French patients had sensorimotor axonal polyneuropathy and an additional one had neurogenic changes in muscle biopsy. Muscle biopsy showed rimmed vacuoles (44.4%), myofibrillar disorganization (16.7%) or both (38.9%), with P62/TDP43 aggregates. The TIA1 p.Asn357Ser variant was present in all patients and the SQSTM1 p.Pro392Leu was the most frequent (71%) of the four reported SQSTM1 variants. We reviewed the distal myopathy gene panels of Pitié-Salpêtrière's hospital cohort finding a prevalence of 11/414=2.7% of the TIA1 p.Asn357Ser variant, with two patients having an alternative diagnosis (TTN and MYH7) with atypical phenotypes, resembling some of the features seen in TIA1/SQSTM1 myopathy. Overall, TIA1/SQSTM1 myopathy has a homogenous phenotype reinforcing the pathogenicity of its digenic variants. We confirm an increased burden of the TIA1 p.Asn357Ser variant in distal myopathy patients which could act as a genetic modifier.

An Unusual Case Of A Calcaneal Stress Fracture

HISTORY: A 56-year-old healthy female presented to clinic with several weeks of left heel pain. No inciting injury, patient is generally active but had not done any recent strenuous activity, however after the onset of the pain any slight bump of the heel produced severe pain. She also had mild swelling around the distal ankle, without any warmth or erythema. The pain gradually worsened to the point the patient started using crutches due to the pain she experienced with weight-bearing. She denied any radiation of the pain as well as any numbness, tingling, or weakness of the foot. PHYSICAL EXAMINATION: Examination revealed mild swelling over the lateral calcaneus, without erythema or induration. Patient had severe tenderness to palpation of the lateral aspect of the calcaneal tuberosity. No tenderness was noted over either malleolus or the Achilles tendon. Range of motion revealed normal inversion, eversion, and plantar flexion but dorsiflexion limited to 10 degrees due to pain. Sensation was intact and strength testing was normal. Talar tilt testing and squeeze test of the calcaneus were negative. DIFFERENTIAL DIAGNOSIS:1. Septic arthritis2. Calcaneal fracture3. GoutTEST AND RESULTS:Labs:-Normal WBC, ESR, CRP, RF, ANA, uric acid, and Lyme and anaplasma titersImaging:-Left ankle radiographs: no acute osseous abnormality-Left ankle MRI without contrast:1.Nondisplaced fracture along the posterior dorsal surface of the calcaneus2.Trace ankle joint effusion3. Mild tibialis posterior tenosynovitis FINAL DIAGNOSIS:Nondisplaced stress fracture of posterior calcaneus TREATMENT AND OUTCOMES:1. Patient was referred to Infectious Disease (ruled out infectious origin including tick-borne infection) and Orthopedics.2. Initial treatment consisted of limited weight-bearing with walking boot, however pain worsened in the boot and she developed numbness of her foot with symptoms suggestive of tarsal tunnel syndrome.3. Patient transitioned to non-weight bearing status without boot, and after approximately two months of slow improvement progressed to limited weight-bearing and physical therapy.5. Due to prolonged recovery, patient still undergoing work-up for less common risk factors for stress fractures and bone infections, including Celiac disease, Bartonella, and Rickettsia testing.

Nerve Complications after Regional Anesthesia in Foot and Ankle Surgery Avoiding the Popliteal Fossa

Category:Ankle; Arthroscopy; Hindfoot; Lesser Toes; Midfoot/Forefoot; OtherIntroduction/Purpose:Popliteal nerve blocks are a common procedure employed by anesthesiologists to augment intraoperative anesthesia as well as provide postoperative pain control. Unfortunately, these can be associated with unintended complications. These complications may be sensory or motor including pain, numbness, and foot drop, sometimes without clear resolution. Studies suggest complications higher than previously reported, Lauf (2020). Our study looked to address the complication rates from an alternative anesthetic procedure, a distal ankle nerve block which involves anesthesia to the five nerve(s) more intimately involved in the surgical procedure. This alternative technique may provide equivalent anesthetic properties and pain relief as the popliteal blocks, with less motor and sensory complications for many patients across various demographics.Methods:We retrospectively reviewed patient charts and messaging from 2019 to 2021 that received a distal ankle field block for various surgical procedures including ankle arthroscopy, ankle fractures, and lateral ankle stabilizations. The five nerves anesthetized in the distal ankle nerve block included the tibial, superficial and deep peroneal, sural, and saphenous. Thus far, 90 surgeries have been reviewed and analyzed for neuropathic complications and confirmed via EMG.Results:Of the 90 patients analyzed, 3 patients were found to have a superficial peroneal neuropathy that included dorsal numbness as a result of the distal ankle block, resulting in a 3.33% complication rate. 1 patient required a rescue block to be performed post-operatively for pain. The remaining 87 patients recovered appropriately and without complications. No motor complications have been found from patients receiving distal ankle nerve blocks, as performed by the senior author.Conclusion:With the absence of motor complications and markedly reduced incidence of sensory complications, distal ankle nerve blocks may be a beneficial alternative to popliteal nerve blocks for various foot and ankle orthopedic surgeries. As motor complications can result in life altering disability, an anesthetic procedure with reduced negative motor outcomes can improve surgery and recovery prognosis. Future directions for this study include adding more patients to increase the sample size, as well as continuing to follow current patients, monitoring symptoms or complications.

Analysis of Complications Following Distal Ankle Nerve Blocks for Foot and Ankle Procedures

Category:Ankle; Arthroscopy; Bunion; Hindfoot; Midfoot/Forefoot; OtherIntroduction/Purpose:Popliteal nerve blocks are a common procedure employed by anesthesiologists to augment intraoperative anesthesia and provide postoperative pain control. Unfortunately, these can be associated with unintended complications including pain, numbness, and foot drop, sometimes without clear resolution. Studies from Kahn (2017), Anderson (2015), Park (2018), Lauf (2020) suggest complications higher than previously reported with Lauf (2020) finding short-term complication rates of 10.1% and 4.1% long-term as confirmed by EMG. Our study looked to address the complication rates from an alternative anesthetic procedure, a distal ankle nerve block involving anesthesia to the five nerve(s) more intimately involved in the surgical procedure. This alternative technique may provide equivalent anesthetic properties and pain relief as popliteal blocks, with fewer complications for many patients across various demographics.Methods:We retrospectively reviewed patient charts and messaging from 2019 to 2021 that received a distal ankle field block for various surgical procedures including ankle arthroscopy, ankle fractures, and lateral ankle stabilizations. The five nerves anesthetized in the distal ankle nerve block included the tibial, superficial and deep peroneal, sural, and saphenous. Thus far, 61 surgeries have been reviewed and analyzed for neuropathic complications and confirmed via EMG.Results:Of the 61 patients analyzed, 3 patients were found to have a superficial peroneal neuropathy that included dorsal numbness as a result of the distal ankle block, resulting in a 4.92% complication rate. 1 patient required a rescue block to be performed postoperatively for pain. The remaining 57 patients recovered appropriately and without complications. No motor complications have been found from patients receiving distal ankle nerve blocks, as performed by the senior author.Conclusion:With the absence of motor complications and markedly reduced incidence of sensory complications, distal ankle nerve blocks may be a beneficial alternative to popliteal nerve blocks for various foot and ankle orthopedic surgeries. As motor complications can result in life-altering disability, an anesthetic procedure with reduced negative motor outcomes can improve surgery and recovery prognosis. Future directions for this study include adding more patients to increase the sample size, as well as continuing to follow current patients, monitoring symptoms or complications.

L4-to-L4 nerve root transfer for hindlimb hemiplegia after hypertensive intracerebral hemorrhage.

There is no effective treatment for hemiplegia after hypertensive intracerebral hemorrhage. Considering that the branches of L4 nerve roots in the lumbar plexus root control the movement of the lower extremity anterior and posterior muscles, we investigated a potential method of nerve repair using the L4 nerve roots. Rat models of hindlimb hemiplegia after a hypertensive intracerebral hemorrhage were established by injecting autogenous blood into the posterior limb of internal capsule. The L4 nerve root on the healthy side of model rats was transferred and then anastomosed with the L4 nerve root on the affected side to drive the extensor and flexor muscles of the hindlimbs. We investigated whether this method can restore the flexible movement of the hindlimbs of paralyzed rats after hypertensive intracerebral hemorrhage. In a beam-walking test and ladder rung walking task, model rats exhibited an initial high number of slips, but improved in accuracy on the paretic side over time. At 17 weeks after surgery, rats gained approximately 58.2% accuracy from baseline performance and performed ankle motions on the paretic side. At 9 weeks after surgery, a retrograde tracing test showed a large number of fluoro-gold-labeled motoneurons in the left anterior horn of the spinal cord that supports the L4-to-L4 nerve roots. In addition, histological and ultramicrostructural findings showed axon regeneration of motoneurons in the anterior horn of the spinal cord. Electromyography and paw print analysis showed that denervated hindlimb muscles regained reliable innervation and walking coordination improved. These findings suggest that the L4-to-L4 nerve root transfer method for the treatment of hindlimb hemiplegia after hypertensive intracerebral hemorrhage can improve the locomotion of hindlimb major joints, particularly of the distal ankle. Findings from study support that the L4-to-L4 nerve root transfer method can effectively repair the hindlimb hemiplegia after hypertensive intracerebral hemorrhage. All animal experiments were approved by the Animal Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (No. IACUC-1906009) in June 2019.

What Happened with Muscle Force, Dynamic Stability And Falls? A 10-Year Longitudinal Follow-Up in Adults with Myotonic Dystrophy Type 1.

Background:Individuals with myotonic dystrophy type 1 (DM1) are known to stumble and fall, but knowledge is scarce regarding dynamic stability in this disorder.Objective:To describe disease progress regarding muscle force, dynamic stability and patient reported unintentional falls during a ten-year period, in individuals with DM1.Methods:Quantification of isometric muscle force in four leg muscle groups and assessment of Timed 10-meter-walk in maximum speed (T10max), Timed Up&Go (TUG) and Step test (STEP) were performed at three occasions in a DM1 cohort, together with self-reported falls.Results:Thirty-four people (m/f:11/23, age: 50.2 + /–9.4) participated. The muscle force loss after ten years was large in the distal ankle muscles. A steeper force decrease was seen in most muscles between year five and ten compared to the former five-year period. Males reported more falls than females, 91% vs 35% had fallen last year. A positive correlation, ρ= 0.633, p < 0.001, was shown between walking time (T10max) and number of falls. Frequent fallers were only seen among those with slower walk (T10max > 10seconds), and fewer steps in the STEP test (STEP≤5 steps).Conclusions:A diminishing leg muscle strength and worse dynamic stability were seen in the group, with a steeper decrease in the latter five years. Weak ankle dorsiflexors, a slower walk and difficulties to lift the forefoot were related to frequent falls.

145 Mind the App: A Guide for the Orthopaedic Senior House Officer on Call

Abstract Aim Many senior house officers (SHOs) have little experience in Trauma and Orthopaedics. While junior doctors are encouraged to seek help from the registrar during on call shifts, they are also dependent on a variety of guidelines to assist in the management of common orthopaedic presentations to the Emergency Department. The main issue is that site-specific guidance is not readily accessible on a single platform. Method Smartphone and web-based applications were designed summarising the initial management for such conditions for the SHO on-call to use as a quick reference tool. The efficacy of this was evaluated with questionnaires specific to the rating of the application and by two closed loop audits of BOAST standards for the management of distal radius and ankle fractures. Results Pre-app implementation questionnaire ratings revealed a mediocre confidence levels and high stress during an on-call shift. Post-app implementation questionnaires demonstrated the app was useful. Future use was recommended use for new SHOs. All responders felt that this would improve stress levels on call. Closed-loop audits for BOAST guidelines for ankle and distal radius fracture management were completed. Improvements were evident for obtaining appropriate radiographs ankle fractures (50.0% vs 77.8%) and positions of manipulated distal radius fractures (80% vs 100%). Conclusions This application proved a useful reference tool for junior staff to aid and initiate the management of common orthopaedic presentations to the emergency department. This tool could be used to improve confidence and ensure timely management of patients from the take.

Developmental evolution of the distal ankle in the dinosaur-bird transition.

The adult ankle of early reptiles had five distal tarsal (dt) bones, but in Dinosauria, these were reduced to only two: dt3 and dt4, articulated to metatarsals (mt) mt3 and mt4. Birds have a single distal tarsal ossification center that fuses to the proximal metatarsals to form a new adult skeletal structure: the composite tarsometatarsus. This ossification center develops within a single large embryonic cartilage, but it is unclear if this cartilage results from fusion of earlier cartilages. We studied embryos in species from four different bird orders, an alligatorid, and an iguanid. In all embryos, cartilages dt2, dt3, and dt4 are formed. In the alligatorid and the iguanid, dt2 failed to ossify: only dt3 and dt4 develop into adult bones. In birds, dt2, dt3, and dt4 fuse to form the large distal tarsal cartilage; the ossification center then develops above mt3, in cartilage presumably derived from dt3. During the entire dinosaur-bird transition, a dt2 embryonic cartilage was always formed, as inferred from the embryology of extant birds and crocodilians. We propose that in the evolution of the avian ankle, fusion of cartilages dt3 and dt2 allowed ossification from dt3 to progress into dt2, which began to contribute bone medially, while fusion of dt3 to dt4 enabled the evolutionary loss of the dt4 ossification center. As a result, a single ossification center expands into a plate-like unit covering the proximal ends of the metatarsals, that is key to the development of an integrated tarsometatarsus.

Salvage arthrodesis for infected ankle fractures with segmental bone-loss using Ilizarov concepts: a prospective study.

Complex ankle fractures accompanied with infection and segmental bone loss are a worrying issue. This prospective study was conducted to explore the effectiveness of using Ilizarov concepts in achieving salvage arthrodesis and reconstructing post-debridement defects in such complicated scenarios. A total of 44 consecutive patients (mean age 35.61 ± 8.57years, 30 males, 44 feet) of post-traumatic infected ankle fractures, who met our selection criteria, were enrolled and subjected to radical debridement and salvage arthrodesis using thebifocal bone transport concepts of Ilizarov. All patients were treated between 2012 and 2017 either by acute shortening compression of the arthrodesis site with re-lengthening (ASRL) through the created proximal metaphyseal osteotomy (group I, n = 20) or by gradual bone transport (BT) through the proximal osteotomy with gradual closure of the distal ankle defect (group II, n = 24). Plain-radiographs were used for radiological assessment. Clinically, the outcomes were objectively graded according to the Hawkins criteria, while subjectively the patients reported their satisfaction on a 1-5 points acceptance scale. The mean follow-up was 37.16 ± 5.31 (30-48months). Successful fusion was achieved in 43/44 patients, with a significantly (P < 0.05) lesser needs for bone-grafting in favour of group II. The results were good in 32 cases, fair in 11, and poor in a single case with no significant difference between the two groups. The acceptance scores were significantly (P < 0.05)superior in group II (3.08 ± 1.1points) than that group I (2.25 ± 1.4 points). Bifocal bone transport is effective in salvaging troublesome infected ankle fractures with bone loss. BT is more comprehensive and acceptable than ASRL with lesser needs for bone grafting.

REVERSE SURAL ARTERY FASCIOCUTANEOUS FLAP IN SOFT TISSUE RECONSTRUCTION IN LOWER EXTREMITY

Background: Soft tissue defect around distal leg, ankle and heel region is a challenging task for an orthopaedic surgeon. Sural artery reverse fasciocutaenous flap has been widely used and is a successful method for soft tissue reconstruction in such situation. This study aimed to find out the result of sural artery distal based pedicle flap in managing soft tissue recon­struction around the ankle and distal leg. Methods: This was a retrospective study of 12 cases of sural artery based fasciocutaenous flap done between January 2015 to December 2019. Medical records were used to find the details of demographic data, operative details and post-operative status of the patients. Patients were contacted for the final follow up at minimum of 6 months after operation for assessment of the outcome. Demographic and clinical data were entered in excel chart and the clinical result was analyzed using SPSS software version 20.0. Results: There were total of 12 patients who underwent sural artery flap procedure. Among them, 10 were male and 2 females with mean age of 39 (range, 25-52) years. Eleven flaps survived with satisfactory functional outcome. One had complete flap necrosis, two had patchy margin necrosis and two had superficial infection which healed well with minor debridement and antibiotics. Conclusions: Sural artery based reverse fasciocutaenous flap is good and technically easier option for an orthopaedic surgeons for the soft tissue reconstruction around ankle, heel and distal leg in traumatic, infective or other etiology with satisfactory outcome in most of the patients.

A Review of Local Soft Tissue Coverage Options for Oncologic Defects of the Distal Lower Extremity

Abstract The distal third of the lower extremity has historically been a challenging anatomic region to provide durable soft tissue coverage following significant trauma or oncologic resection. This is due to the paucity of locoregional tissue. At times, wound coverage is the rate limiting factor in attempts at limb salvage, and the pendulum has swung from amputation to utilization of free tissue transfer as these techniques have developed over the years. The most recent published novel techniques in reconstruction of this area have instead utilized local tissue options rather than their free flap counterparts. The potential benefits of choosing these alternatives in the appropriate patient selection include less donor site morbidity, less operative time, ability of more healthcare facilities to provide reconstruction if not equipped for free flaps, and preservation of other sites if they are needed for in the setting of disease progression. This provides a review of the most common and reliable locoregional options for the distal leg, ankle, and foot.

Quality of life after fragility fracture in the Russian Federation: results from the Russian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (ICUROS)

SummaryChanges in health-related quality of life (QoL) due to hip, humeral, ankle, spine, and distal forearm fracture were measured in Russian adults age 50 years or more over the first 18 months after fracture. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27).IntroductionData on QoL following osteoporotic fractures in Russia are scarce. The present study evaluated the impact of hip, vertebral, proximal humerus, distal forearm, and ankle fracture up to 18 months after fracture from the Russian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study.MethodsIndividuals age ≥ 50 years with low-energy-induced humeral, hip, clinical vertebral, ankle, or distal forearm fracture were enrolled. After a recall of pre-fracture status, HRQoL was prospectively collected over 18 months of follow-up using EQ-5D-3L. Multivariate regression analysis was used to identify determinants of QALYs loss.ResultsAt 2 weeks, patients with hip fracture (n = 223) reported the lowest mean health state utility value (HSUV) compared with other fracture sites. Thereafter, utility values increased but remained significantly lower than before fracture. For spine (n = 183), humerus (n = 166), and ankle fractures (n = 214), there was a similar pattern of disutility with a nadir within 2 weeks and a progressive recovery thereafter. The accumulated mean QoL loss after hip fracture was 0.5 and significantly greater than after fracture of the distal forearm (0.13), spine (0.21), proximal humerus (0.26), and ankle (0.27). Substantial impairment in self-care and usual activities immediately after fracture were important predictors of recovery across at all fracture sites.ConclusionsFractures of the hip, vertebral, distal forearm, ankle, and proximal humerus incur substantial loss of QoL in Russia. The utility values derived from this study can be used in future economic evaluations.

Modified Anterior Tibial Artery Perforator-Pedicled Propeller Flap for Soft-Tissue Coverage of the Ankle and Heel.

The ankle and heel are challenging regions to reconstruct functionally. Here, we explored the feasibility and clinical outcomes of a modified anterior tibial artery perforator-pedicled propeller flap for the repair of soft-tissue defects of the ankle and heel. Between January 2013 and December 2015, 12 patients with soft-tissue defects of the ankle and/or heel underwent reconstructive surgery that included our flap technique. The flaps measured 20 × 8cm to 7 × 4cm. A hand-held Doppler was used to identify a proper constant perforator in the distal ankle. In each case, the base of the flap was well preserved. The flap was transposed (180° rotation) to reach and cover the defect. The average follow-up time was 13months (10-28months). We observed good texture matches and contour in all of the flaps. All patients could walk and wear normal footwear. All but one flap survived completely without complications. Partial loss was observed in one patient, and the necrotic region was healed with secondary intention. Our modified anterior tibial artery free-style perforator-pedicled propeller flap provides a novel option for functional ankle and heel reconstruction. Level IV.

Modular footwear that partially offsets downhill or uphill grades minimizes the metabolic cost of human walking.

Walking on different grades becomes challenging on energetic and muscular levels compared to level walking. While it is not possible to eliminate the cost of raising or lowering the centre of mass (COM), it could be possible to minimize the cost of distal joints with shoes that offset downhill or uphill grades. We investigated the effects of shoe outsole geometry in 10 participants walking at 1 m s−1 on downhill, level and uphill grades. Level shoes minimized metabolic rate during level walking (Psecond-order effect < 0.001). However, shoes that entirely offset the (overall) treadmill grade did not minimize the metabolic rate of walking on grades: shoes with a +3° (upward) inclination minimized metabolic rate during downhill walking on a −6° grade, and shoes with a −3° (downward) inclination minimized metabolic rate during uphill walking on a +6° grade (Pinteraction effect = 0.023). Shoe inclination influenced (distal) ankle joint parameters, including soleus muscle activity, ankle moment and work rate, whereas treadmill grade influenced (whole-body) ground reaction force and COM work rate as well as (distal) ankle joint parameters including tibialis anterior and plantarflexor muscle activity, ankle moment and work rate. Similar modular footwear could be used to minimize joint loads or assist with walking on rolling terrain.

Effectiveness of Joint Stiffness and Power Alternations in Different Shoe Insole Hardness on Injury Prevention During Jump-landing

PurposeStudies on how the shoe insole hardness regulate joint stiffness and transfer energy in the lower extremity during jump landing are scarce. The current study aimed to determine the effectiveness of shoe insole changes in joint power and stiffness during landing from jumps. MethodsFifteen healthy male athletes volunteered to perform jump-landing in various shoe insole conditions. Kinematics and kinetics data were examined to calculate joint stiffness and peak negative power (absorbing power).ResultsThe shoe insole hardness significantly affected ankle joint stiffness (P≤0.05). Furthermore, enhanced shoe inserts hardness increased ankle joint stiffness. Moreover, soft insole significantly increased negative peak power, compared to the hard insole condition (P=0.01). ConclusionIncreasing the shoe insert hardness can higher affect the distal ankle joint, compared to the proximal joints. However, landing with soft shoe insoles increased the negative joint power during landing; it implied neuromuscular adaptation in response to the impact signals and elevated eccentric force by the knee extensors.

Hoverboard injuries in children and adolescents: results of a multicenter study.

With the increasing popularity of hoverboards in recent years, multiple centers have noted associated orthopaedic injuries of riders. We report the results of a multi-center study regarding hoverboard injuries in children and adolescents. who presented with extremity fractures while riding hoverboards to 12 paediatric orthopaedic centers during a 2-month period were included in the study. Circumstances of the injury, location, severity, associated injuries, and the required treatment were recorded and analysed using descriptive analysis to report the most common injuries. Between-group differences in injury location were examined using chi-squared statistics among (1) children versus adolescents and (2) males versus females. Seventy-eight patients (M/F ratio: 1.8) with average age of 11 ± 2.4 years were included in the study. Of the 78 documented injuries, upper extremity fractures were the most common (84.6%) and the most frequent fracture location overall was at the distal radius and ulna (52.6%), while ankle fractures comprised most of the lower extremity fractures (66.6%). Majority of the distal radius fractures (58.3%) and ankle fractures (62.5%) were treated with immobilization only. Seventeen displaced distal radius fractures and three displaced ankle fractures were treated with closed reduction in the majority of cases (94.1% versus 66.7%, respectively). The distal radius and ulna are the most common fracture location. Use of appropriate protective gear such as wrist guards, as well as adult supervision, may help mitigate the injuries associated with the use of this device; however, further studies are necessary to demonstrate the real effectiveness of these preventions.

A case report depicting patient\u2019s installation on the fracture table when an ankle spanning external fixator is already in place

BackgroundFractures of the proximal and diaphyseal femur are frequently internally fixed using a fracture table. Moreover, some femoral neck fractures may be treated with total hip arthroplasty using a direct anterior approach and a traction table. Fracture and traction tables both use a boot tightly fitted to the patient’s foot in order to: 1) obtain fracture reduction by traction and adequate rotation exerted on the slightly abducted or adducted extremity; or 2) adequately expose the hip joint using traction, rotation and extension to implant total hip arthroplasty components. In some instances, multiply injured patients may present with both a proximal or diaphyseal femur fracture and a diaphyseal or distal tibia or ankle fracture necessitating an ankle spanning external fixator on the same limb. Frequently, the tibia or ankle fracture has to be treated first, and standard use of the fracture or traction table may be thereafter difficult due to the external fixator construct preventing tight fitting of the boot to the patient’s foot.Case presentationIn order to address this situation, the authors describe a simple technique allowing rigid fixation of the limb with an ankle spanning external fixator to the traction or fracture table, providing accurate control of the position of the lower limb in all planes for adequate fracture reduction and fixation or total hip arthroplasty. The technique is exemplified with a clinical case.ConclusionsThis technique allows an efficient way to: 1) timely stabilize diaphyseal or distal tibia or ankle fractures; and 2) subsequently use all the advantages of a fracture or traction table to adequately reduce and fix proximal or diaphyseal femur fractures, or optimally expose femoral neck fractures for total hip arthroplasty using a direct anterior approach.

Transspinal stimulation increases motoneuron output of multiple segments in human spinal cord injury.

Targeted neuromodulation strategies that strengthen neuronal activity are in great need for restoring sensorimotor function after chronic spinal cord injury (SCI). In this study, we established changes in the motoneuron output of individuals with and without SCI after repeated noninvasive transspinal stimulation at rest over the thoracolumbar enlargement, the spinal location of leg motor circuits. Cases of motor incomplete and complete SCI were included to delineate potential differences when corticospinal motor drive is minimal. All 10 SCI and 10 healthy control subjects received daily monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at right soleus transspinal evoked potential (TEP) subthreshold and suprathreshold intensities at rest. Before and two days after cessation of transspinal stimulation, we determined changes in TEP recruitment input-output curves, TEP amplitude at stimulation frequencies of 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and TEP postactivation depression upon transspinal paired stimuli at interstimulus intervals of 60, 100, 300, and 500 ms. TEPs were recorded at rest from bilateral ankle and knee flexor/extensor muscles. Repeated transspinal stimulation increased the motoneuron output over multiple segments. In control and complete SCI subjects, motoneuron output increased for knee muscles, while in motor incomplete SCI subjects motoneuron output increased for both ankle and knee muscles. In control subjects, TEPs homosynaptic and postactivation depression were present at baseline, and were potentiated for the distal ankle or knee flexor muscles. TEPs homosynaptic and postactivation depression at baseline depended on the completeness of the SCI, with minimal changes observed after transspinal stimulation. These results indicate that repeated transspinal stimulation increases spinal motoneuron responsiveness of ankle and knee muscles in the injured human spinal cord, and thus can promote motor recovery. This noninvasive neuromodulation method is a promising modality for promoting functional neuroplasticity after SCI.

Delayed Internal Fixation of Distal Radius and Bimalleolar Ankle Fractures Does Not Increase Surgical Time

Introduction: It is commonly believed that delay in fracture fixation of more than two weeks results in increased Surgical Time (ST), due to scar and callus formation at the fracture site. Reducing ST can lower hospital costs and decrease radiation exposure. Methods and Results: A retrospective chart review was conducted to investigate whether early fracture care (up to 2 days after injury) results in decreased ST and radiation exposure compared to delayed fracture care (&gt; 14 days after injury) for distal radius and bimalleolar ankle fractures. A total of 581 radius and ankle fractures that underwent surgical fixation between 2014 and 2017 were identified from the OR registry. Cases with only a single volar locking plate for the distal radius and constructs consisting of 2 medial malleolar screws, third tubular plate, and up to 1 syndesmotic screw for the ankle were included. The mean ST for distal radius cases done up to 2 days after injury was significantly greater than ST for distal radius cases done &gt; 14 days after injury (125.78±29.75 minutes versus 105.83±24.82 minutes respectively , p=0.06). The mean ST for ankle fracture cases done less than 2 days did not differ from ST for ankle fracture cases done &gt; 14 days after injury (140.86±28.15 minutes versus 173.22±39.98 minutes respectively, p=0.06). Conclusion: There was no significant difference in radiation exposure. Delaying surgery for distal radius and bimalleolar ankle fractures &gt; 14 days after injury does not seem to significantly affect the duration of surgery or radiation exposure.