Interosseous Membrane Research Articles

Does the inter-osseous membrane fascial dysfunction exist ? An observational study comparing palpation to ultrasound measurements

BackgroundThere is a lack of evidence to support a correspondence between osteopathic palpation and anatomical findings. The concept of dysfunction could be defined using more accurate words when describing palpatory findings if they could be explained by objective measurements. The forearm Interosseous Membrane (IOM) is a fascia often evaluated by osteopaths, searching for Fascial Dysfunction (FD). We measured IOM physical characteristics, such as elasticity and thickness, with ultrasound (US) and then compared it with osteopaths’ FD assessment. MethodsHealthy subjects were recruited and their forearms were marked every centimeter. At every mark, 3 registered osteopaths assessed the potential FD (none, moderate or strong). Assessments were compared to the IOM elasticity and thickness measured by US. A mixed effect model was used to analyse the link between thickness and FD and a chi-2 test for the link between elasticity and FD. Result41 subjects were included. Mean age was 28.1, 46% were men. The average IOM length was 13.0 cm (±1.5), the average thickness was 1.29 (±0.41). The mixed model found a strong correlation between the grade of FD and the IOM thickness for all three osteopaths (p < 0.01). Moreover, correlations were found between thickness and elasticity of the IOM (p < 0.001). ConclusionManual evaluation of FD seems to be correlated to physical properties of the IOM. Our results suggest that the forearm IOM is thicker at FD locations. This study needs replications on several anatomical areas and on the IOM of symptomatic subjects to confirm these findings. Moreover, research could focus on tissue changes after osteopathic treatment.

Generalized Arterial Calcification of Infancy (GACI): Optimizing Care with a Multidisciplinary Approach.

It is very unusual to see evidence of arterial calcification in infants and children, and when detected, genetic disorders of calcium metabolism should be suspected. Generalized arterial calcification of infancy (GACI) is a hereditary disease, which is characterized by severe arterial calcification of medium sized arteries, mostly involving the media with marked intimal proliferation and ectopic mineralization of the extravascular tissues. It is caused by inactivating variants in genes encoding either ENPP1, in a majority of cases (70–75%), or ABCC6, in a minority (9–10%). Despite similar histologic appearances between ENPP1 and ABCC6 deficiencies, including arterial calcification, organ calcification, and cardiovascular calcification, mortality is higher in subjects carrying the ENPP1 versus ABCC6 variants (40% vs 10%, respectively). Overall mortality in individuals with GACI is high (55%) before the age of 6 months, with 24.4% dying in utero or being stillborn. Rare cases show spontaneous regression with age, while others who survive into adulthood often manifest musculoskeletal complications (osteoarthritis and interosseous membrane ossification), enthesis mineralization, and cervical spine fusion. Despite recent advances in the understanding of the genetic mechanisms underlying this disease, there is still no ideal therapy for the resolution of vascular calcification in GACI. Although bisphosphonates with anti-calcification properties have been commonly used for the treatment of CAGI, their benefit is controversial, with favorable results reported at one year and questionable benefit with delayed initiation of treatment. Enzyme replacement therapy with administration of recombinant form of ENPP1 prevents calcification and mortality, improves hypertension and cardiac function, and prevents intimal proliferation and osteomalacia in mouse models of ENPP1 deficiency. Therefore, newer treatments targeting genes are on the horizon. In this article, we review up to date knowledge of the understanding of GACI, its clinical, pathologic, and etiologic understanding and treatment in support of more comprehensive care of GACI patients.

Ankle syndesmosis biomechanical evaluation by shear-waves elastography in healthy young adults: Assessment of the reliability and accuracy of the measurements and definition of a corridor of normality

BackgroundAims of this study were: 1/ to evaluate the shear wave speed (SWS) properties of the anteroinferior tibiofibular ligament (AITFL) and the distal interosseous membrane (DIOM) in neutral, dorsal flexion and plantar flexion positions in a cohort of healthy adult volunteers; 2/ to assess the reliability and reproducibility of these measurements. MethodsBoth ankles were analyzed by shear wave elastography (SWE) in 20 healthy patients (10 females/10 males) standing on a hinge support with their ankles in neutral, 20° dorsal flexion and 30° plantar flexion positions. Stiffness of AITFL and DIOM was evaluated by SWS measurement. ResultsThe SWS of AITFL and DIOM were minimal in the plantar flexion position (4.28 m/s [2.65–5.11] and 3.35 m/s [1.69–4.55], respectively). It increased significantly for both ligaments in neutral position (4.69 m/s [3.53–5.71] and 3.81 m/s [1.91–4.74], respectively; p < 0.0001), and reached their maximum values in dorsal flexion (6.58 m/s [5.23–8.34] and 4.79 m/s [3.07–6.19], respectively; p < 0.0001). There was no correlation between each ligament regardless the positions. SWS of AITFL was independent of demographic characteristics analyzed. SWS of DIOM was negatively correlated with height in dorsal flexion (ρ = −0.35; p = 0.03) and in plantar flexion (ρ = −0.37; p = 0.02). Female gender was associated with increased DIOM SWS in neutral (p = 0.005), dorsal flexion (p = 0.003), and plantar flexion (p = 0.001) positions. Moreover, foot morphology (foot arch, hind foot frontal deviation) did not impact AITFL nor DIOM SWS. Inter- and intra-observer measurements were all good or excellent. ConclusionThe AITFL and DIOM, stabilizers of the distal tibiofibular syndesmosis, increase in stiffness while dorsal flexion increases. This study describes a reliable and reproducible protocol to assess their stiffness by SWE, and defines a corridor of normality.

Traumatic rupture of the midportion of the interosseous membrane: a rare cause of acute lower leg pain in two soccer players kicked in the anterior shin.

The interosseous membrane (IOM) of the leg is a component of the tibiofibular syndesmosis that serves an important role in stabilization, as well as transferring forces to the fibula during weight-bearing. We present two separate cases of acute traumatic rupture of the midportion of the interosseous membrane in high school soccer players with blunt trauma to the anterior shin with MRI and ultrasound confirmation.

Response of enthesopathy in ENPP1 deficiency to enzyme replacement therapy in murine models and enthesopathy comorbidities and quality of life in ENPP1‐deficient adults

Biallelic ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency leads to cardiovascular calcification in infancy, FGF23‐mediated hypophosphatemic rickets in childhood, and osteomalacia in adulthood. Excessive enthesis mineralization and cervical spine fusion have been previously reported in patients with biallelic ENPP1 deficiency, but their effect on quality of life is unknown. We describe additional musculoskeletal complications in patients with ENPP1 deficiency, namely osteoarthritis and interosseous membrane ossification, and for the first time evaluate health‐related quality of life (HRQoL) in patients with this disease, both subjectively via narrative report, and objectively via the Brief Pain Inventory – Short Form, and a Patient Reported Outcome Measurement Information System Physical Function (PROMIS PF) short form. Residual pain, similar in magnitude to that identified in adult patients with X‐linked hypophosphatemia, was experienced by the majority of patients despite use of analgesic medications. Impairment in physical function varied from mild to severe. To assess murine ENPP1 deficiency for the presence of enthesopathy, and for the potential response to enzyme replacement therapy, we maintained Enpp1asj/asj mice on regular chow for 23 weeks and treated cohorts with either vehicle or a long‐acting form of recombinant ENPP1. Enpp1asj/asj mice treated with vehicle exhibited robust calcification throughout their Achilles tendons, whereas two‐thirds of those treated with ENPP1 enzyme replacement exhibited complete or partial suppression of the Achilles tendon calcification. Our combined results document that musculoskeletal complications are a significant source of morbidity in homozygous ENPP1 Deficiency, a phenotype which is closely recapitulated in Enpp1asj/asjmice. Finally, we show that a long‐acting form of recombinant ENPP1 prevents the development of enthesis calcification at the relatively modest dose of 0.3 mg/kg per week, suggesting that suppression of enthesopathy may be attainable upon dose escalation.

Rare Forearm Muscle Variations Seen in Two Cadaveric Dissections

IntroductionAnatomical variations of the forearm muscles have been widely reported within the scientific literature, including variations or absence of the extensor pollicis brevis (EPB) and extensor pollicis longus (EPL) muscles. Rare instances have been found of an additional extensor forearm muscle, the extensor carpi radialis accessorius (ECRA). The authors describe a unique extra muscle originating from the muscle belly of the extensor carpi radialis longus (ECRL) and the distal humerus in two cadavers. One of these cadavers also had a complete absence of the EPB and an EPL with two sites of insertion.Case PresentationsDuring a cadaveric dissection course, two cadavers were found to have an extra extensor muscle of the left forearm. In both cases this muscle originated from the lateral surface of the ECRL muscle belly and the distal humerus; both muscles had a single tendon that traveled through the first extensor tunnel with the tendons of the abductor pollicis longus (APL) to insert onto the base of the first metacarpal. In addition, in one cadaver the EPB muscle was absent and the tendon of the EPL divided distally to insert into both the proximal and distal phalanx of the thumb.DiscussionThe ECRA is a rare additional extensor forearm muscle described to originate from the humerus below the ECRL and inserts into the first metacarpal bone of the thumb. The ECRA found in each of our two cadavers had an unusual origin from the muscle belly of the ECRL and from the distal humerus superior to the ECRL. This finding adds to the handful of known variations in the ECRA. The EPL and EPB are deep posterior forearm muscles. The EPL usually originates from the middle third of the ulna and inserts onto the base of the distal phalanx of the thumb. The EPB usually originates from the dorsal surface of the interosseous membrane and inserts onto the proximal phalanx of the thumb. In addition to the ECRA found in the left forearm, one of the cadavers also had anatomical variations in the extensor pollicis muscles on the same side. The EPB was absent and the EPL tendon divided distally to insert into the proximal and distal phalanx of the thumb. Variations in the EPB are common, and instances of an absent EPB have been cited in the literature. The EPL variation is most consistent with Turker Classification 1g. It’s possible this represents an anatomical adaptation to compensate for the absent EPB.ConclusionWhile an ECRA muscle is already rare, even more unusual is an ECRA originating from the ECRL and from the distal humerus superior to the ECRL and has not been reported. In addition, the concurrent existence of the three anatomic abnormalities within the same forearm has not been described previously. Knowledge of possible variants in forearm anatomy is crucial for surgeons to have a full understanding of possible causes of pathology. Alternatively, lack of awareness may cause diagnostic confusion or treatment failures.

The interosseus crural nerve: An anatomical study of a rarely described structure.

The interosseous crural nerve (IOCn) is said to arise distally from muscular branches of the tibial nerve innervating the deep muscles of the posterior compartment of the leg. Here, we present the results of a cadaveric study of the IOCn to clarify this nerve's morphology and to discuss its potential clinical relevance. On 26 sides from 13 cadaveric specimens, the IOCn was dissected. The IOCn was identified on 14 out of 26 sides (53.8%). The mean diameter and length of the IOCn were 0.46 mm (range 0.3-0.72 mm) and 20.9 mm (range 13.5-33.0 mm), respectively. The origin of the IOCn was from a branch to the popliteus muscle on all sides. The nerve was found to have vascular, muscular, and ligamentous branches. In 53.8%, the nerve reached the inferior tibiofibular joint, and in 46.2%, the nerve terminated in the interosseous membrane of the leg. At its distal part, the IOCn gave off multiple vascular branches to the fibular artery. On one side (7.1%), the nerve pierced the interosseous membrane and innervated muscles of the anterior compartment of the leg. We believe this to be the first anatomical study of the IOCn. The nerve was found to have vascular, muscular, and ligamentous branches. Surgeons operating in the deep posterior compartment of the leg and ankle and clinicians treating patients with unusual presentations or pathology of the leg and ankle should be aware of this structure.

Comparative evaluation of methods for osteosynthesis of diaphyseal radial fractures by the method of mathematical modeling

RELEVANCE. The surgical treatment of patients with diaphyseal forearm fractures has a variety of methods and requires a precision technique. The need for postoperative immobilization after osteosynthesis of diaphyseal fractures remains a controversial issue, since osteosynthesis failure and the formation of a pseudoarthrosis are sometimes observed.In addition, very little information about the role of the interosseous membrane in the rotational function of the forearm during osteosynthesis is available in the literature.The OBJECTIVE was to determine the forces occurring during rotational movements of the forearm that lead to the above complications.METHODS AND MATERIALS. The clinical part included the results of surgical treatment of 330 patients with diaphyseal fractures of the forearm; it consisted of the main group (170 - interlocking osteosynthesis) and the comparison group (138 - plate osteosynthesis). The third group consisted of 22 patients with complications of surgical treatment of diaphyseal fractures of the forearm. We performed a comparative assessment of plate and interlocking osteosynthesis of radial bone fractures by mathematical modelling to determine the forces occurring during forearm rotation that lead to nonunion, instability and plate fractures.RESULTS. In the main group, healing was achieved in all (170 patients), in the comparison group, healing was achieved in 128 (92.8 %), consolidation was achieved in all 22 patients with fracture complications who underwent reconstruction. A comparative assessment revealed that during plate osteosynthesis, zones of high stress concentration were located around the plate opening above the area of fracture and the nearest to it holes from both sides. In interlocking osteosynthesis of the radius, the stresses are evenly distributed around the nail. Pronation-supination movements with an amplitude of (±90)°, according to the experimental results, should lead to the destruction of the cortical plate fairly soon after implantation, while the nail made of ultra-fine Ti-6Al-7Nb alloy will maintain its integrity.CONCLUSION. Based on these findings, external immobilization is advisable to avoid complications such as osteosynthesis instability or plate fracture.

Role of the Lateral Ankle Ligaments in the Vertical Stability of the Fibula

Category:Basic Sciences/Biologics; Ankle; TraumaIntroduction/Purpose:In unstable ankle fractures, syndesmosis and the deltoid ligament have been widely studied, and their importance in their pathophysiology and treatment is recognized. This is not the case of the ankle lateral ligaments, and in particular, their role in the vertical stability of the fibula is unknown. Given their anatomical position, they should avoid proximal translation of the distal fragment of the fibula fracture. Purpose: To quantify the superior translation of the fibula by applying a constant proximal traction force as the syndesmosis and lateral ankle ligaments are sectioned sequentially.Methods:Eleven human ankle cadaveric specimens were used (6 female, 5 male). Removal of the skin and muscles was performed down to the ankle level, preserving the interosseous membrane (IOM). A deep dissection was performed to identify the inferior tibiofibular ligaments and the lateral ligaments of the ankle. Each piece was mounted on a platform specially designed for this work (fig 1), fixing the foot with an axial load of 25 kg, and a proximal traction force of 50 N was applied to the fibula. The syndesmotic ligaments, IOM, anterior talofibular ligaments (ATFL), and calcaneofibular ligament (CFL) were sequentially sectioned. The proximal displacement of the fibula was measured after each sequential section. Normality analysis was performed with the Kolmogorov-Smirnov and Shapiro-Wilkins tests. Differences between groups were evaluated with the ANOVA test with Dunnett and Newman-Keuls post-test.Results:When applying 50 N of proximal traction, the proximal and vertical displacement of the fibula was as follows; no sectioning 1.96 +- 1.19 mm, syndesmosis/IOM sectioning 3.96 +- 1.33 mm, ATFL sectioning 5.9 +- 1.73 mm and 10.2 +- 2.76 mm after sectioning the CFL. Normal distribution was observed in all groups. All measurements had a statistically significant difference between each group (p <0.05).Conclusion:In this model, a complete syndesmosis/IOM lesion produces a mean fibular proximal displacement of 3.96 mm. By adding the ATFL and CFL complete injury, it reaches 10.2 mm. Clinical relevance: In an unstable ankle dislocation with a significant fibular proximal displacement, there is probably a severe compromise of the lateral ligament complex, which could have clinical relevance as it is part of the bone and ligamentary stability ring of the ankle. This is the first study that describes the role of the lateral ligament complex in fibular vertical stability.

Conservative management of a specific subtype of Maisonneuve fractures: a report of two cases

Maisonneuve fractures are most commonly characterised by a specific pattern with a medial malleolar fracture or deltoid ligament rupture, a disruption of the ankle syndesmosis ligaments and a fracture of the proximal fibula. We hereby describe for the first time two cases of conservative therapy of Maisonneuve fracture with intact medial structures and with associated posterior malleolus fracture. Patients were assessed with ankle radiographs and magnetic resonance imaging (MRI). The distal fibula was anatomically positioned in its notch and the deltoid ligament and interosseous membrane (IOM) were intact. In addition, the posterior malleolus fracture was not associated with talar subluxation or articular impaction, and the mortise remained anatomically positioned on the initial radiographs. Based on clinical and imaging evaluations, the decision was made to follow conservative treatment. Follow-up showed stability criteria on standing radiographs, and their evolution was clinically uneventful with a good AOFAS score after 1 year. The discussion emphasized the scarce description of conservative therapy of Maisonneuve fractures for which surgical treatment is considered to be the gold standard. The good results of these two cases are in favour with conservative therapy, avoiding adverse events and complications related to surgery, and showed that conservative therapy should be also considered as an effective therapeutic option in selected cases. We also emphasize that the results of our two cases are, moreover, in favor of an early weight-bearing protocol.

Syndesmotic instability can be assessed by measuring the distance between the tibia and the fibula using an ultrasound without stress: a cadaver study

BackgroundUltrasound examinations for syndesmosis injury might be useful for the quantitative evaluation of syndesmotic instability. The purpose of this study was to evaluate the efficacy of ultrasound assessment by measuring the tibiofibular distance of syndesmosis injuries in various ligament-injured models and stress load conditions.MethodsFive normal ankles from Thiel-embalmed cadavers were used. Ultrasound assessment was performed by placing a probe in parallel with the ligament running just above the anterior inferior tibiofibular ligament (AITFL). The distance between the anterior border of the tibia and the fibula was measured in the intact condition. Next, Bassett’s ligament was cut arthroscopically to reduce damage to soft tissues as much as possible and measurement was performed in the same way. After that, the AITFL, interosseous membrane (IOM), deltoid ligament, and posterior inferior tibiofibular ligament (PITFL) were macroscopically cut and measured in that order. Ankle positions were without stress (natural plantar flexion without applying stress to the ankle joint), dorsiflexion stress, inversion stress, and external rotation stress. All stress to the ankle joint was carried out manually to the maximum extent.ResultsAs with the without-stress condition, significant increases in tibiofibular distances after AITFL dissection were seen compared with the intact state under all stress conditions (intact: 4.9 ± 1.0 mm without stress, 5.6 ± 1.2 mm with dorsiflexion, 5.9 ± 1.0 mm with inversion, and 6.7 ± 1.3 mm with external rotation; AITFL dissection: 6.7 ± 1.5 mm without stress, 7.3 ± 1.2 mm with dorsiflexion, 7.5 ± 1.4 mm with inversion, and 8.7 ± 1.6 mm with external rotation). AITFL dissection with external rotation stress significantly increased the tibiofibular distance compared to without stress.ConclusionChanges in tibiofibular distance with the severity of syndesmosis injury were measured by ultrasound using cadavers. No significant change was seen with Bassett’s ligament injury, but tibiofibular distance increased significantly with injuries of equal to or greater severity than AITFL injury. Results were similar not only for external rotation stress, but also for dorsiflexion stress and inversion stress, and even in unloaded states, significant tibiofibular widening was confirmed with injuries of equal to or greater severity than AITFL injury.

Essex-Lopresti Lesions and Longitudinal Radioulnar Instability: A Narrative Review.

An Essex-Lopresti injury (ELI) is classically described as a radial head fracture with a concomitant interosseous ligament complex (IOC) injury. However, multiple injury patterns may be present, and an interosseous membrane (IOM) injury should be evaluated for in any axial load injury through the forearm. ELI may result in longitudinal radioulnar instability (LRUI). Diagnosis of an IOC injury can be difficult. Evaluation begins with standard wrist and elbow radiographs and is supplemented with radiographs and intraoperative maneuvers to assess for proximal radial migration. Magnetic resonance imaging and ultrasonography may be useful in the acute setting, although indications and the clinical importance of the findings remain unclear. Surgical management of an acute ELI is focused on restoration of radial length and temporary distal radioulnar joint (DRUJ) stabilization. Radial head excision in the acute setting should be approached with caution because proximal migration may not be present acutely but may develop over time. The indication for acute IOM repair and reconstruction remains unclear. Surgical management of a chronic ELI is focused on restoration of radial length, wrist leveling, and treatment of degenerative changes (either at the radiocapitellar joint or the DRUJ). Reconstruction of the central band can restore forearm load transfer and produce favorable functional outcomes, but its indications continue to be debated.

The Diagnosis and Prevention of Fluorosis in Humans

Chronic fluoride intoxication in the form of fluorosis is a worldwide health problem and endemic at least in 25 countries. The principal cause of fluorosis in humans is the prolonged exposure of fluoride through drinking of fluoridated water. However, industrial fluoride emission and fluoride containing foods are also potential sources of fluoride exposures for the genesis of fluorosis. As per guidelines of the World Health Organization (WHO) fluoride content in the drinking water should not be higher than 1.5 mg/L (ppm). Above this limit of fluoride in drinking water, it becomes toxic and injurious for human health and causes diverse deformities in teeth and bones. In humans, basically three forms of fluorosis namely dental, skeletal and non-skeletal fluorosis have been recognised. The diagnosis of fluoride intoxication (fluorosis) in humans is made on the basis of history, clinical or pathognomonic signs and testing of biological samples. The current status of endemic fluorosis could be assessed by estimation of fluoride in the blood serum and urine. The presence of dental mottling and calcification of interosseous membrane on a forearm radiograph may be helpful in the diagnosis of dental and skeletal fluorosis, respectively. For the prevention of fluorosis, fluoride free drinking water and food items, diet having ample amount of nutrients, general awakening in people and collective efforts are important and highly needed. This editorial will be useful for researchers and health workers in the diagnosis and prevention of fluorosis in humans, respectively.

Does the Skeletal Phenotype of Osteogenesis Imperfecta Differ for Patients With Non-COL1A1/2 Mutations? A Retrospective Study in 113 Patients.

Osteogenesis imperfecta (OI) is a heritable disease characterized by bone fragility and other extra skeletal manifestations. Most patients with OI have mutations in the COL1A1 or COL1A2 genes. However, a significant minority of patients with clinical OI have non-COL1A1/2 mutations, which have become easier to detect with the use of genetic panels. Traditional understanding of OI pathogenesis was expanded because of these new mutations, and their phenotypic-genotypic relationship is largely unknown. We hypothesized that patients with non-COL1A1/2 mutations have different skeletal clinical presentations from those with OI caused by COL1A1/2 mutations. Patients were categorized into 4 groups according to our modified functional classification, namely, quantitative COL1A1/2 haploinsufficiency (group 1), qualitative COL1A1/2 dominant negative mutations (group 2), mutations indirectly affecting type I collagen synthesis, processing and posttranslational modification (group 3) and mutations altering osteoblast differentiation and function (group 4). Both group 3 and 4 were classified as non-COL1A1/2 mutation group. Of 113 OI patients included, 51 had COL1A1/2 quantitative haploinsufficiency mutations (group 1), 39 had COL1A1/2 qualitative dominant negative mutations (group 2), and 23 patients had OI caused by mutations in 1 of 9 other noncollagen genes (groups 3/4). Patients with non-COL1A1/2 mutations (groups 3 and 4) have severe skeletal presentations. Specifically, OI patients with non-COL1A1/2 mutations experienced more perinatal fractures, vertebral compression fractures and had more long bone deformities. Although the occurrence of scoliosis was similar, the cobb angle was larger in the non-COL1A1/2 mutation group. Radial head dislocations, ossification of interosseous membrane, extraskeletal ossification, cervical kyphosis, and champagne glass deformity of the pelvis were more frequent in this group. The clinical phenotype of OI in patients with non-COL1A1/2 is severe and has unique features. This information is useful for clinical diagnosis and prognosis. Level III.

Posterior Tibial Tendon Transfer for Central Foot Drop: A Case Report

INTRODUCTION: Peripheral causes of foot drop are widely known. However, causes stemming from the central nervous system are rare. Posterior tibial tendon (PTT) transfer has been widely used for treating peripheral causes of foot drop but not central causes. We report a case of central foot drop (CFD) that was corrected with PTT transfer. CASE REPORT: A 68-year-old female presented with progressive weakness and numbness of both feet due to old compression fracture of the 12th thoracic spine. She also had Parkinson disease with gait rigidity. The patient was diagnosed with central foot drop. The left foot PTT transfer was done through the interosseous membrane and fixed to the navicular bone with an interference screw. Three months after the procedure, there is an improvement on the gait, and the foot drop is corrected. PTT transfer has a good outcome in peripheral foot drop. However, it is still questionable for the CFD case. In our case, PTT transfer was considered because it is less invasive, and tenodesis or ankle fusion still could be performed later if the PTT transfer outcome is not favorable. CONCLUSION: PTT transfer is a possible option to correct CFD. It is less invasive and has a good outcome.

Clinical and PROMIS Outcomes of Maisonneuve Fractures

Category:Ankle; TraumaIntroduction/Purpose:Torsional injury to the foot and ankle may result in high fibular fracture with disruption of the syndesmotic ligaments, interosseous membrane, and other associated injuries to medial, posterior structures of the ankle. High Fibular Fracture at the fibular neck is referred as Maisonneuve Fracture of Fibula (MFF). These injuries are often missed or misdiagnosed as ankle sprains. Most of the current classification consider MFF a variant of ankle fracture with disruption of syndesmosis and high fibular fracture {Lauge Hansen PER, AO C3, Weber type C}. Only a few articles have described associated injuries and surgical treatment outcomes. The study's primary aim is to evaluate the associated injuries of MFF and the outcomes of our treatment approach.Methods:All patients undergoing syndesmotic fixation (CPT 27829) at a large tertiary academic center from 2012-2020 were identified. In these 748 patients, patient radiographs were reviewed to identify patients with Maisonneuve fractures (AO-44C3). Medical records were reviewed for patient characteristics, energy information of original injury, operative variables, and complications. Radiographic reduction was assessed on standard radiograph with assessment of the tibiofibular clear space and tibiofibular overlap on AP and mortise views, talocrural angle, the medial clear space, shenton line, and fibular station. An abnormality in one of these parameters was considered an abnormal reduction. Patients were contact to complete PROMIS Physical function and Pain Interference postoperatively. A total of 24 patients with Maisonneuve fractures were identified and included in analysis. Eleven patients completed PROMIS outcomes measures for a response rate of 55%, as four patients were deceased or incarcerated at the time of survey.Results:The average age was 45.3 (16 SD) with a mean BMI of 31.3 (10.4 SD). Nineteen patients were male (79.2%) with only 5 females (20.8). The mechanism of injury was low energy in 16/24 patients (66.7%) leaving 8 (33.3%) patients with high energy mechanisms. In addition to the high fibular fracture, a total of 13 patients (54.2%) had a posterior malleolar fracture, 11 (45.8%) had a medial malleolar fracture, and 8 (33.3%) had a deltoid ligament injury. Seven patients (29.2%) received screw fixation compared to 14 patients (58.3%) with tightrope fixation. Three patients (12.5%) received both tightropes and screws. No patient developed wound complications, and two patients underwent reoperation. Abnormal reduction occurred in 5/24 patients (20.8%) at final clinical follow up. At a median of 20 months (25 IQR) postoperatively, the median PROMIS physical function and pain interference scores were 41.2 (13.0 IQR) and 52.8 (4.8 IQR), respectively.Conclusion:Maisonneuve fractures are an extremely rare ankle fracture variant with a diverse subset of injury patterns. Our results show the clinical outcomes of Maisonneuve fractures are largely satisfactory in terms of wound complications and intermediate term outcomes. While 21% of patients were determined to have abnormal reduction postoperatively, we are limited by the inherent difficulties of assessing syndesmosis on plain radiographs rather than advanced imaging. PROMIS outcome scores demonstrate Maisonneuve fractures patients are more impacted by loss of function than pain, but both are within a standard deviation of the population mean.

Comparison of Suture-Button Fixation with Suture-Tape Augmentation and Trans-Syndesmotic Screw Fixation for Syndemosis Injury: A Biomechanical Study

Category:Ankle; Basic Sciences/BiologicsIntroduction/Purpose:The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of suture-button fixation with suture-tape augmentation with those of screw fixation.Methods:Ten matched pairs of human cadaver specimens were subjected to suture-button fixation with suture-tape augmentation or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of axial loading with peak of 750N, 10 cycles of external torsional loading with peak of 7.5Nm, and 10 cycles of combined axial and external torsional loading with peak of 750N and 7.5Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, posterior tibiofibular ligament and medial malleolar fracture were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combinedaxial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured.Results:Mean failure torques were 15.99 +- 8.88 Nm in the suture-button fixation with suture-tape augmentation and 17.10 +- 10.38 Nm in the screw group. There was no significant difference in average failure torque between two groups (p-value = 0.669)Average failure angle in screw-fixation group (39.37 +- 10.19 deg) was significantly lower than average failure angle suture- button fixation with suture-tape augmentation (56.64 +- 9.64 deg) (p-value = 0.001).Average rotational stiffness in screw-fixation group (0.53 +- 0.24 Nm/deg) was significantly higher than average rotational stiffness in suture-button fixation with suture-tape augmentation group (0.35 +- 0.19 Nm/deg) (p-value = 0.033).Conclusion:Suture-button fixation with suture-tape augmentation for ankle syndesmotic injury provides similar torsional strength to that of screw fixation and has lower stiffness than screw fixation. Therefore, Suture-button fixation with suture-tape augmentation can be considered as an alternative treatment option for syndesmosis injury.

Effective and sustainable syndesmotic injury repair using endobuttons and fibre-wire, in bimalleolar fractures

Ankle fractures are the most frequent fractures accounting for 10% of all fractures, having an incidence of about 184/100,000 per year. Moreover, after external rotation or dorsiflexion injuries, syndesmotic disruption typically occurs at the ankle. The physiologic normality of the joint gets affected after a transverse syndesmotic screw fixation, which decreases the magnitude of motion at the lower extremes of the tibia and fibula, reducing contact forces between bones, and increasing stress on the crural interosseous membrane (which may lead to screw breakage). With this concern, we thus suggested to achieving a semi-rigid dynamic stabilization of the syndesmosis, using an endobutton and transosseous suture. We present a case of a 22-year-old active male who had a Lauge-Hansen pronation-abduction type injury. He was managed with an eight holes anatomical plate for lateral malleolus, two 65 mm CC screws with a washer for medial malleolus, and two endobuttons (one on the tibial and other on the fibular side) with transosseous sutures to provide stabilization of the syndesmosis. With this concern, we thus suggested achieving a semi-rigid dynamic stabilization of the syndesmosis, using an endobutton and transosseous suture; which can help in early mobilization, is cost effective, and prevent a second surgery for the removal of the syndesmotic screw.

Topographical measurement of the attachments of the central band of the interosseous membrane on interosseous crests of the radius and ulna.

BackgroundTo suggest a reasonable isometric point based on the anatomical consistency of interosseous membrane (IOM) attachment in association with topographic characteristics of the interosseous crests, the footprints of the central band (CB) of the IOM on the radial and ulnar interosseous crests (RIC and UIC) were measured.MethodsWe measured the distance from the CB footprints from each apex of both interosseous crests in 14 cadavers and the angles between the forearm axis of rotation (AOR) and the distal slopes of the RIC and UIC in 33 volunteers.ResultsThe CB footprints lay on the downslope of both interosseous crests with its upper margin on average 3-mm proximal from the RIC's apex consistently in the radial length, showing normality (p>0.05), and on average 16-mm distal from the UIC's apex on the ulna without satisfying normality (p<0.05). The average angle between the UIC's distal slope and the AOR was 1.3°, and the RIC's distal slope to the AOR was 14.0°, satisfying the normality tests (p>0.05), and there was no side-to-side difference in both forearms (p<0.05).ConclusionsThe CB attached to the downslope just distal to the RIC's apex constrains the radius to the UIC that coincides with the AOR of the forearm circumduction, maintaining itself both isometrically and isotonically.

Effect of acupuncture at Zusanli\xa0(ST36) point on antral contraction function under ultrasound guidance: study protocol of a randomized controlled trial

BackgroundAlthough the relationship between deqi sensations and curative effect has always been controversial, deqi sensations has been regarded as the key indicator of clinical efficacy of acupuncture therapy. There is little evidence for standardization or visualization of the mechanism of acupuncture’s therapeutic effect. This trial aims to evaluate the effect of needling at Zusanli (ST36) on antral contraction function as visualized by ultrasound.MethodsThis is a two-arm, single-blind, randomized, controlled trial. A total of 116 acupuncture-naïve healthy subjects will be randomly allocated to the acupuncture group or sham acupuncture group in a 1:1 ratio. Participants in the acupuncture group will receive manual acupuncture at Zusanli (ST36) with the needling depth at crural interosseous membrane. Those in the sham acupuncture group will be given penetrating needling depth at the superficial fascia layer. The primary outcome will be the changes in antral contraction frequency (ACF) before and after acupuncture. The secondary outcomes will be the changes in the thermal infrared spectrum of gastric area skin, the antral contraction amplitude (ACA), the antral movement index (AMI), and the scores on the Chinese version of Massachusetts General Hospital Acupuncture Sensation Scale (C-MASS). The adverse events will be evaluated and recorded in detail.DiscussionThis study may provide visual and objective evidence regarding the safety and efficacy of manual acupuncture at Zusanli (ST36). In addition, the results of this study will help to identify the role of Zusanli (ST36)in the inducing deqi.Trial registrationChinese Clinical Trial Registry ChiCTR2000040686. Registered on 8 December 2020