Left Ankle Research Articles

An invasive squamous cell carcinoma of the ankle: a case report.

The authors present the case of a male patient, 60 years old, who presented with a progressive mass on his left ankle for 2 years with a history of healed burns in that area. The ISCC was diagnosed using histopathology after which he underwent a marginal excision biopsy and split-thickness skin grafting. Wide-marginal excision and split-thickness skin grafting were done. It was noted that the graft had taken well and that there were clear tumour margins postoperatively. The skin graft was almost completely incorporated. No tumour cells were reported on the margins during the postoperative histopathology. This case highlights a successful outcome of the patient improved at the 12-month follow-up, and he expressed a high degree of satisfaction with the treatment. ISCC of the lower extremities is a rare disease that almost never affects the ankle and is frequently treated inappropriately since it mimics chronic wounds. It is important to have an index of suspicion in patients with a history of chronic irritation to the area of interest. Surgery is the primary option if ICCS is detected. Clear tumour margins are important, and, if done well, excision should be curative.

VRK1 mutation associated with adult-onset spinal muscular atrophy and persistently elevated creatine kinase (P3-8.011)

<h3>Objective:</h3> NA <h3>Background:</h3> NA <h3>Design/Methods:</h3> We present a patient with persistently elevated creatinine kinase and a clinical syndrome consistent with adult-onset spinal muscular atrophy (dSMA) without pontocerebellar atrophy secondary to a vaccinia-related kinase 1 (VRK1) mutation. <h3>Results:</h3> A 46-year-old male presented for evaluation of persistently elevated creatinine kinase, leg weakness, and decreased balance for more than 5 years. He reported mild weakness mainly in the lower extremities and reduced calf size. The patient has had persistently elevated creatine kinase (CK) for the past 5 years, ranging from 580–7,000 units/L. On examination, he had bilateral high arches, calf fasciculations, and atrophy. Motor showed decreased strength in feet dorsiflexion and minimal bilateral hand interosseous weakness. Reflexes were normal except for the absent left ankle reflex. The rest of the neurologic examination was unremarkable. EMG/NCS showed reduced motor responses with diffuse neurogenic changes in the right arm and leg concerning for motor neuropathy. CK level remained elevated along with aldolase; otherwise negative myopathy labs. The neuropathy panel showed two pathogenic mutations of the VRK1 gene, variant c1072C&gt;T (p.Arg358) and c.356 A&gt;G (p.His119Arg), consistent with compound heterozygosity. <h3>Conclusions:</h3> VRK1 mutation is a rare cause of distal predominant spinal muscular atrophy. This disease is characterized by slowly progressive distal symmetric limb muscle weakness and atrophy, frequently leading to foot deformities such as pes cavus, with minimal or no sensory involvement. Mild elevations in CK can be seen in up to 50% of motor neuron disease cases. Our patient’s presentation was consistent with adult-onset spinal muscular atrophy. There was no pontocerebellar hypoplasia, which has also been described with this mutation. Creatine kinase level remained very elevated in our patient, beyond what has previously been described in the literature. Future investigation should be done to determine the significance of this, including whether there may be a myopathic component to this illness. <b>Disclosure:</b> Dr. Rodriguez-Hernandez has nothing to disclose. Dr. Carranza-Renteria has nothing to disclose. Dr. Faktorovich has a non-compensated relationship as a Board of Directors with Brother’s Brother Foundation that is relevant to AAN interests or activities.

Long Covid Infection and Peripheral Neuropathy – Initial Presentation of Eosinophilic Granulomatous Polyangiitis (EGPA) (P14-4.005)

<h3>Objective:</h3> Describe a case of EGPA after long COVID presenting with peripheral neuropathy, and negative antineutrophil cytoplasmic antibody (ANCA). <h3>Background:</h3> EGPA, formerly known as Churg-Strauss syndrome, a rare and potentially fatal systemic disorder, is characterized by Asthma, vasculitis, skin changes, hyper eosinophilia, and positive ANCA testing. Peripheral neuropathy with sensory deficits and pain is one of the presenting symptoms. Occasionally, EGPA presents as cranial nerve mononeuropathy. Rare cases of ANCA associated vasculitis have been reported during or soon after SARS-COV-2 and influenza infections. There is insufficient evidence that COVID-19 triggers EGPA. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 46-year-old woman presented with 25-pound weight loss within six months, 3-day history of pain, swelling, paresthesia of the left foot, pain in her left calf followed 6 days later by severe pain and paresthesia of the right foot. She had 1-day of transient binocular, oblique diplopia, right dilated, non-reactive pupil, and temporal area pain. One year before, she had SARS-COV-2 infection followed by intermittent episodes of dry cough, and shortness of breath that required inhaled corticosteroids. Neurological examination revealed hypoesthesia of dorsum and sole of the left foot, brisk left patellar reflex, decreased left ankle jerk, and down going plantar reflex. There was mild erythema over dorsum of the left foot with minimal tenderness. Laboratory testing showed hyper eosinophilia, elevated white cell count, ESR, serum IgE level, and rheumatoid factor; C-reactive protein, cyclic citrullinated peptide and ANCA were negative. EMG/NCS showed prolonged right H-reflex. Right sural nerve and gastrocnemius biopsy demonstrated necrotizing arteriolitis, vascular and perivascular chronic infiltrates with numerous eosinophils and mononuclear cells. MRI revealed pansinusitis. She responded to oral steroids and Mepolizumab. <h3>Conclusions:</h3> This case highlights the importance of having vasculitis in the differential diagnosis in patients with painful neuropathy and prior SARS-COV-2 infection. Nerve and muscle biopsy is a useful tool in confirming the diagnosis. <b>Disclosure:</b> Dr. Donegal has nothing to disclose. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Jacoby has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Argenx. Dr. Jacoby has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for N/A. The institution of Dr. Jacoby has received research support from ABPN. Dr. Treidler has nothing to disclose.

E032 Deficiency of Adenosine Deaminase 2: a rare diagnosis in a case of suspected vasculitis

Abstract Background/Aims Deficiency of adenosine deaminase 2 (DADA2) is a rare autosomal recessive condition first described in 2014 which is characterised by vasculitis, systemic inflammation, immunodeficiency and cytopenias. The vasculitis is difficult to differentiate from polyarteritis nodosa and typically presents with recurrent strokes. It can also affect the skin and present with livedo racemosa. Clinical presentation varies widely; from vasculitic manifestations which tend to present later in life to severe haematological abnormalities such as bone marrow failure which tend to present earlier in life. Treatment with TNF inhibitors reduces the risk of additional strokes and controls inflammation in the presence of vasculitis but is not very effective against bone marrow failure. Methods We present the case of a 44-year-old gentleman who was being investigated for possible vasculitis by the rheumatology team in view of a history of Raynaud’s, 20-year history of recurrent leg ulcers and a previous pontine infarct. He presented acutely to the emergency department with numbness below the midthoracic level, weakness of his lower limbs and hands and urinary retention. His symptoms had progressed over a period of a few hours. On examination power was 4/5 on the MRC power scale for shoulder abduction and elbow flexion, 2/5 for elbow extension, 3/5 for wrist extension and 1/5 for finger extension. Power was 1/5 on his lower limbs. Sensation to pain was reduced with a T6 sensory level. Proprioception and vibration sense were intact. Upper limb reflexes were brisk. Knee jerks and left ankle jerk were difficult to elicit. Plantars were downgoing. Cranial nerves were normal. Results Bloods showed a white cell count of 6.7x109/l, haemoglobin of 96g/l (microcytic), platelets of 243x109/l, creatinine 119μmol/l (baseline 85μmol/l) and CRP of 42.9mg/l. Vitamin B12 was 200ng/l and folate levels were 2.2μg/L. ANA, ANCA, cryoglobulins and hepatitis serology were negative. MRI brain showed a 4mm area of hyper-density in the left pons. MRI whole spine was unremarkable. CSF showed normal protein, white cell count and glucose level. The patient was transferred to a tertiary neurology centre and a diagnosis of anterior spinal cord infarction was made. A nerve biopsy was performed which showed evidence of vasculitis and he was pulsed with methylprednisolone and commenced on high dose oral steroids. Genetic testing showed a pathogenic mutation in the adenosine deaminase 2 gene. He is currently awaiting to commence treatment with TNF inhibitors. Conclusion We conclude that DADA2 is an important differential in a young patient with suspected vasculitis especially in the presence of infarction. Identification of DADA2 allows initiation of treatment with TNF inhibitors which reduces the risk of additional strokes. Disclosure M. Xenophontos: None. J. Gan: None. A.C. Seneviratne: None.

Genu varum (Rt) genu valgum (Lt), post traumatic ankle varus deformity (Lt)

Ilizarov Technique is a fantastic tool for correcting femoral varus, genu valgum and ankle varus. The case demonstrates an approach to large complex deformity in both right &amp; left knee, and left ankle region. All of the aforementioned deformities were fully corrected by the help of Ilizarov Technique.1,2,3

Postrenal transplant tuberculosis of the ankle joint

Tuberculosis (TB) is one of the common infections after renal transplantation in developing countries. Patients who receive kidney grafts are at an increased risk for the development of mycobacterial disease than the general population, because of uremia and the immunosuppressants used in the posttransplant period, all of which interfere with T-cell function. Extrapulmonary TB is more common in renal allograft recipients and may present with dissemination or atypical features. Although extrapulmonary TB occurs frequently, isolated ankle joint TB is a rare form of extrapulmonary TB infection. We report here a renal allograft recipient with ankle joint TB presenting 6 months after transplantation with persistent pain in the left ankle joint associated with swelling and mild restriction of joint movement. He was diagnosed to be having an osteomyelitis of the talus bone extending to the navicular and anterior part of the calcaneus. He underwent open debridement and CB-NAAT of the tissue, which showed mycobacterium TB and rifampicin resistance was not detected. He was started on antituberculous treatment. This report highlights the need for a high index of suspicion for diagnosing TB early among renal transplant recipients and diagnostic difficulties of the TB disease due to insidious and nonspecific clinical presentation. Also, the treatment has to be monitored closely due to drug interaction between immunosuppressants and anti-TB drugs.

The partial talus replacement (PTR) – An alternative treatment for severe osteochondral lesions of the talus utilizing a custom 3D printed talar hemiarthroplasty implant: A case report and technique guide

Large osteochondral lesions of the talus can lead to severe pain and disability. Various surgical interventions have been described in published literature. Customized implants developed through additive manufacturing are increasing in popularity with favorable results within foot and ankle surgery. This case study reports a 52-year-old male who has a history of failed prior surgical interventions with severe left ankle pain associated with a large osteochondral lesion of the talus. The patient underwent resection of the diseased bone with the aid of patient specific instrumentation followed by implantation of a custom 3D printed partial talus implant to resurface the talar dome. At a final follow up of 24 months, the patient continued to experience significant improvement in functional outcomes without radiographic evidence of implant complications.

The effect of a gait and balance training program on an unstable mudflats surface in older adults: A randomized controlled pilot study.

Balance training on an unstable support surface has been known to improve postural control. The aim of this study was to investigate the effect of a gait and balance training program on an unstable mudflats surface in older adults. A total of 28 older people were assigned to participate in a gait and balance training program on an unstable mudflats surface (experimental group) or on firm ground (control group). All participants received the training program for 55 minutes per session, 2 sessions per day for 5 days. The primary outcomes were the Berg Balance Scale (BBS) and single-leg stance (SLS) test. Secondary outcomes were Timed Up and Go (TUG), 10-meter walk test (10MWT), Modified Falls Efficacy Scale (MFES), Motricity Index (MI) of the lower extremities, and medical research council (MRC) scale of lower extremities. SLS with eyes open and the MRC of the left and right ankles showed a large effect size whereas the MI of the left and right lower extremities and MRC of the left and right knees showed a medium effect size in the experimental group. Intergroup differences in changes from baseline to after the exercise program included a large effect size of the SLS with eye open and MI of the right lower extremity and a medium effect size of the MI of the left lower extremity and MRC of the right ankle and left hip. Muscle strength and balance of older people could be improved with gait and balance training on an unstable mudflat surface.

Influence of the Hawthorne effect on spatiotemporal parameters, kinematics, ground reaction force, and the symmetry of the dominant and nondominant lower limbs during gait

The Hawthorne effect is a change in behavior resulting from awareness of being observed or evaluated. This study aimed to determine whether awareness of being evaluated or presence of an observer influence gait. Twenty-one young women were asked to walk in three conditions. In the first condition (unawareness of evaluation; UE), participants were aware that it was a practice trial, and there was no observer. In the second condition (awareness of evaluation; AE), participants were aware that their gait was being evaluated. The third condition (AE + researcher observation; RO) was similar to the second condition except that an additional researcher observed the participant' gait. The spatiotemporal, kinematic, ground reaction forces, and ratio index (symmetry of both lower limbs) were compared among the three conditions. A higher ratio index indicated a relative increase in the value on left versus right. Gait speed (P = 0.012) and stride length (right and left; P = 0.006 and 0.007, respectively) were significantly increased in the AE + RO than in UE. Range of motion of the right hip and left ankle was significantly greater in AE than in UE (P = 0.039 and 0.012, respectively). The ratio index of ground reaction force during push-off was significantly higher in AE and AE + RO conditions than in UE (P < 0.001 and P = 0.004, respectively). The Hawthorne effect (awareness of being evaluated or presence of an observer) potentially influences gait. Thus, factors that influence gait analysis should be considered when evaluating normal gait.

EMG-Based Estimation of Lower Limb Joint Angles and Moments Using Long Short-Term Memory Network.

One of the fundamental limitations in human biomechanics is that we cannot directly obtain joint moments during natural movements without affecting the motion. However, estimating these values is feasible with inverse dynamics computation by employing external force plates, which can cover only a small area of the plate. This work investigated the Long Short-Term Memory (LSTM) network for the kinetics and kinematics prediction of human lower limbs when performing different activities without using force plates after the learning. We measured surface electromyography (sEMG) signals from 14 lower extremities muscles to generate a 112-dimensional input vector from three sets of features: root mean square, mean absolute value, and sixth-order autoregressive model coefficient parameters for each muscle in the LSTM network. With the recorded experimental data from the motion capture system and the force plates, human motions were reconstructed in a biomechanical simulation created using OpenSim v4.1, from which the joint kinematics and kinetics from left and right knees and ankles were retrieved to serve as output for training the LSTM. The estimation results using the LSTM model deviated from labels with average R2 scores (knee angle: 97.25%, knee moment: 94.9%, ankle angle: 91.44%, and ankle moment: 85.44%). These results demonstrate the feasibility of the joint angle and moment estimation based solely on sEMG signals for multiple daily activities without requiring force plates and a motion capture system once the LSTM model is trained.

The Effects of a Novel Lateral Ankle Strengthening Program in NCAA Division III Football Players

Introduction: Lateral ankle sprains (LAS) are among the most reported injuries in college athletics, typically resulting from excessive closed-kinetic chain (CKC) supination. The purpose of this study was to compare the effects of a novel CKC supination-style ankle strengthening program to a traditional ankle strengthening program on common LAS indices. Methods: Thirty NCAA Division III collegiate football players (19.9±1.0yrs., 182.2±6.9cm, 98.8±18.0kg) were randomly assigned to a novel exercise (SUP, n = 16) or traditional exercise group (TRA, n = 14). The SUP group performed dynamic bodyweight exercises with controlled ankle supination while the TRA group performed traditional ankle strengthening exercise using elastic bands and stability exercises 3 times per week for 6 weeks. Right and left ankle inversion (InvR, InvL) and eversion (EvR, EvL) strength (kg), ankle inversion range of motion (romR, romL) (deg.), and figure-8 hop test (fig8R, fig8L) (s) performance were assessed pre- and post-intervention. Results: Both groups showed significant improvements in all outcome measures pre- to post-test (ΔInvR: TRA 4.5±4.3kg, SUP 5.0±4.4kg; ΔIvL: TRA 4.0±3.8kg, SUP 4.8±3.6kg; ΔEvR: TRA 5.7±4.3kg, SUP 4.7±3.3kg; ΔEvL: TRA 4.7±2.9kg, SUP 4.5±2.2kg; ΔromR: TRA 4.5±2.6°, SUP 4.9±3.0°; ΔromL: TRA 4.7±4.5°, SUP 4.6±5.1°; Δfig8R: TRA -0.43±0.20s, SUP -0.37±0.31s; Δfig8L: TRA -0.40±0.22s, SUP -0.34±0.30s; p’s&lt;0.001), with no difference between groups. Conclusions: A bodyweight, supination style ankle training program can improve physical qualities related to LAS to a similar extent as a traditional program, and therefore, could potentially be a viable alternative strategy for reducing LAS in Division III NCAA football players.

Mucormycosis in compound grade IIIa tibial plafond with medial malleolus fracture: A case report

Tibial plafond fracture is defined by intra articular involvement of the distal tibia with metaphyseal extension. The plafond fracture accounts for less than 1% of lower limb injuries and 3–10% of tibial fractures. The rate of deep infection in open ankle fractures is approximately 5%. Pilon fractures are frequently associated with severe soft- tissue injuries that alter the management plan. Here we describe the case of 35year old man brought to ER after sustaining machinery injury to right ankle. On local examination a Laceration of 7x2x2 cms present over left ankle anteriorly extending from Medial Malleolus to Lateral Malleolus and cut ends of tendons of extensor digitorum longus, extensor hallucis longus and Tibialis anterior were identified. X-ray left ankle Ap and Lateral views were taken. X-ray showed Left Distal Tibia fracture. Thorough Wound wash given. Under spinal anesthesia debridement of wound was done and K-wire fixation done for distal tibia fracture. Tendon repair for extensor digitorum longus, extensor hallucis longus and tibialis anterior done using Ethibond suture material using Modified Kessler Technique. On 2 Post operative day a swab from the wound site sent for culture and sensitivity which revealed fungal growth of zygomycetes species. In view of angioinvasive properties of Zygomycetes, after checking Renal parameters patient was started on Inj Amphotericin B 1mg/kg for 4 days and later converted to Tablet Posaconazole 600mg BD. Patient was kept on posaconazole tablet for 6weeks. Regular dressings were done. On regular follow ups and regular dressings wound healed well.

Locomotion Outcome Improvement in Mice with Glioblastoma Multiforme after Treatment with Anastrozole

Glioblastoma Multiforme (GBM) is a tumor that infiltrates several brain structures. GBM is associated with abnormal motor activities resulting in impaired mobility, producing a loss of functional motor independence. We used a GBM xenograft implanted in the striatum to analyze the changes in Y (vertical) and X (horizontal) axis displacement of the metatarsus, ankle, and knee. We analyzed the steps dissimilarity factor between control and GBM mice with and without anastrozole. The body weight of the untreated animals decreased compared to treated mice. Anastrozole reduced the malignant cells and decreased GPR30 and ERα receptor expression. In addition, we observed a partial recovery in metatarsus and knee joint displacement (dissimilarity factor). The vertical axis displacement of the GBM+anastrozole group showed a difference in the right metatarsus, right knee, and left ankle compared to the GBM group. In the horizontal axis displacement of the right metatarsus, ankle, and knee, the GBM+anastrozole group exhibited a difference at the last third of the step cycle compared to the GBM group. Thus, anastrozole partially modified joint displacement. The dissimilarity factor and the vertical and horizontal displacements study will be of interest in GBM patients with locomotion alterations. Hindlimb displacement and gait locomotion analysis could be a valuable methodological tool in experimental and clinical studies to help diagnose locomotive deficits related to GBM.

Unstable Osteochondral Fracture of the Talus, Osteochondritis Dissecans, and Chronic Lateral Ankle Instability in an Adolescent Athlete: A Case Report

A 15-year-old multisport athlete with chronic left ankle pain and instability 2 years following initial injury was diagnosed with an unstable osteochondral fracture of the lateral talar dome, osteochondritis dissecans, and lateral ligament instability. The patient underwent open surgical repair consisting of loose body excision, lateral ligament reconstruction, and talar dome debridement and microfracture followed by postoperative therapeutic exercise for 7 months. The patient successfully returned to competitive sports within a calendar year. Although not considered particularly rare among adult populations, osteochondral fracture of the talus is relatively rare in adolescents. This case demonstrates that a diagnosis of unstable osteochondral fracture and/or gross lateral ligament instability should be considered in cases involving adolescent athletes with significant ankle injury and prolonged pain and/or loss of function.

Diagnostic Evaluation of Mechanical Ankle Instability by Comparing Injured and Uninjured Contralateral Ankles Using Arthrometry.

Individuals with mechanical ankle instability (MAI) have obvious lateral ligament laxity and excessive ankle joint motion beyond the physiological range. Arthrometry has been introduced to quantitatively measure the laxity of the ankle joint. However, the diagnostic accuracy of arthrometry in MAI is still debatable. To (1) evaluate the difference in laxity between bilateral ankles in patients with and those without MAI and (2) calculate the diagnostic accuracy of ankle arthrometry using bilateral comparisons. Cross-sectional study. Research laboratory. A total of 38 individuals with unilateral MAI (age = 31.24 ± 7.90 years, height = 168.93 ± 7.69 cm, mass = 65.72 ± 10.47 kg) and 38 individuals without MAI (control group; age = 32.10 ± 7.10 years, height = 166.59 ± 7.89 cm, mass = 62.93 ± 10.72 kg). Bilateral ankle laxity in each participant was quantitatively measured by performing the arthrometric anterior drawer test. Continuous data of loading force and joint displacement were recorded. Data from both ankles were compared for the ankle joint displacement at a loading force of 75 N (D75) and load-displacement ratio from 10 to 40 N (LDR 10-40). The D75 between injured and uninjured ankles in patients with MAI was different (t37 = 9.78, P < .001). The mean LDR 10-40 in injured ankles was higher than that in uninjured ankles (t37 = 9.80, P < .001). In the control group, no differences were found between the left and right ankles. The MAI group had larger bilateral differences than the control group (t37 range = 7.33-8.18; P < .001). When LDR 10-40 was used to diagnose MAI, the arthrometer showed sensitivity and specificity of 0.900 and 0.933, respectively, with a cutoff value of 0.0351 mm/N. An ankle arthrometer can be used to quantitatively measure the difference in bilateral ankle laxity in patients with MAI. Arthrometer-measured LDR 10-40 can be used to diagnose MAI with high diagnostic accuracy.

Cardiologist’s exposure to radiation in cath lab measured with InstadoseTM dosimeter

Introduction: complex fluoroscopy-guided interventional procedures in cardiology are known to result in higher radiation doses for patients and staff. Purpose: to estimate the equivalent dose received in different regions of the cardiologist’s body in catheterism (CATH) and percutaneous coronary intervention (PCI) procedures, as well as to evaluate the effectiveness of monitoring the doses in the catheritization laboratory (cath lab) using a direct ion storage dosimeter. Materials and methods: the InstadoseTM and the thermoluminescent dosimeters (TLD-100) were fixed simultaneously in the following regions of the cardiologist’s body: near the eyes (left and right), the trunk region (over the lead apron) and the left ankle. Occupational doses were recorded during 86 procedures (60% CATH). Results: catheterization procedures showed third quartile dose values near to the left eye region equal to 0.10 mSv (TLD-100) and 0.12 (InstadoseTM) and for intervention 0.15 mSv (TLD-100 and InstadoseTM). The doses measured in the trunk region, over the lead apron, were about 13% higher for catheterization procedures and 20% higher for intervention procedures compared to left eye region measurements. The Wilcoxon–Mann–Whitney test was applied for unpaired data for all body regions, comparing the data obtained between the TLD-100 and InstadoseTM dosimeters. For CATH and PCI, the responses of the TLD-100 and InstadoseTM dosimeters are considered equal for all analysed regions (p > 0.05) with the exception of the right eye region. Conclusion: the InstadoseTM passive dosimeter can be useful as a complementary assessment in the monitoring of a cardiologist’s personal occupational doses in the cath lab.

Synovial sarcoma of the tibial nerve - case report of a rare tumor in a rare location requiring early diagnosis

BackgroundWe present the case of a patient with a rare synovial sarcoma (SS) of the tibial nerve. So far, only 4 cases of patients with SS originating from the tibial nerve have been described in the literature, and our patient is only the second patient whose limb was saved during treatment. Synovial sarcomas are malignant mesenchymal tumors, i.e., tumors arising from connective tissue. Synovial sarcomas account for 5–10% of all soft tissue sarcomas. However, the name synovial sarcoma is misleading, because the tumor does not originate from synovial cells, but rather from primitive mesenchymal cells. The name most likely originated from the localization around the large joints on the limbs, more often on the lower ones, in the area of the knee joints.We point out the aspects of correct and quick diagnosis and subsequent treatment, which has very important effect on the patient’s prognosis. Primary less radical excision without prior biopsy verification leads to a higher risk of local recurrence, even if a proper reexcision was performed immediately after biopsy verification of the sarcoma.Case presentationA woman born in 1949 began to suffer at the end of 2020 with escalating pain under the left inner ankle with a projection to the sole and fingers. Her personal, family work and social history were insignificant. After the initial neurological examination, the patient was sent for an ultrasound examination of the ankle, which showed a lobular mass measuring 50 × 22 × 16 mm and according magnetic resonance imaging, the finding appeared to be a suspicious neurinoma of the tibial nerve. The tumor was surgically excised, without prior biopsy verification: a 50 × 20 mm tumor was dissected in the distal part of the tarsal canal, which grew through the structure of the tibial nerve and in some places into the surrounding area and appeared intraoperatively as a neurofibroma. But histologically the tumor was classified as monophasic synovial sarcoma. The patient was indicated for a wide reexcision of the skin with the subcutaneous tissue of size 91 × 20 × 15 mm. Now the patient is being treated with external radiotherapy to the tumor bed and she is able to walk.ConclusionThis report draws attention to a rare type of malignant nerve tumor, which both clinically and radiologically can mimic benign peripheral nerve sheath tumors. Synovial sarcoma should be considered in very painful resistances, typically located around the joints of the lower limbs, the growth of which can be slow. Because the size of the tumor is a negative prognostic factor, it is necessary to make a timely diagnosis using MR imaging and a biopsy with histological examination and to start treatment quickly. Surgical treatment should take place only after a biopsy with histological examination of the tumor so that it is sufficiently radical and does not have to undergo an additional reoperation, as happened in the case of our patient.

Arterial Stiffness is Associated with False-Positive ST-Segment Depression in Supine Bicycle Exercise Stress Echocardiography.

Although exercise stress electrocardiography (ECG) is a popular tool for detecting coronary artery disease (CAD), the induced ST-depression without coronary artery stenosis (FST) remains a challenge for accurate diagnosis. Exercise-induced ST depression is related to poor prognosis even in non-obstructive disease; however, its determinants have not been fully defined. We sought to investigate whether ventriculo-vascular interactional indexes such as arterial stiffness index, exercise hemodynamic parameters and echocardiographic left ventricular (LV) functional parameters were related to FST. In the current study, 609 participants who underwent both supine bicycle exercise echocardiography and brachial-ankle pulse wave velocity (baPWV) measurement without exercise-induced regional wall motion abnormalities (RWMA) were analyzed. Referral reasons for stress test were CAD detection or evaluation of patency of previous revascularization. Stepwise graded supine bicycle exercise was performed with simultaneous ECG recording and echocardiography after full conventional resting echocardiography. The FST was defined as newly developed 1 mm ST depression without RWMA during exercise. The median age of the study participants was 65 (59.0-70.5) years, and 222 (37%) patients were women. Among them, 103 (17%) patients showed FST during the exercise or recovery phase. The prevalence of FST did not differ between sexes. Older age, higher pulmonary arterial systolic pressure (PASP), left atrial volume index, baPWV and ankle brachial index at rest and hypertensive response, higher heart rate and rate-pressure product at peak exercise were significantly associated with FST. In multivariate analysis, higher peak heart rate, PASP, and baPWV were independently related to FST. Stress-induced RWMA in addition to ECG should be evaluated to detect CAD in patients with higher baPWV and PASP. FST might be linked to subclinical myocardial ischemia through arterial stiffness and diastolic dysfunction.

A 75-year-old with left ankle pain.

A 75-year-old female with a history of smoking presented with left foot pain after a fall. She was cleaning her pool when she lost her footing while walking down a step. On extremity examination of her left ankle, there was plantar flexion weakness, a palpable dell at the insertion of the Achilles tendon, and a bony mass proximal to the gap (Figure 1). Left ankle radiographs were remarkable for an acute fracture of the posterior proximal aspect of the left calcaneus (Figure 2). Before surgery, the skin had become ecchymotic and edematous. The patient underwent open reduction with internal fixation with podiatric surgery. As there was enough bone remaining, 2 cannulated screws were placed to fix the fracture along with the attached Achilles tendon. The patient was discharged with a recommendation of non-weight-bearing status for the left lower extremity, a cast, and orthopedic follow-up in 2 weeks. Calcaneal fractures account for 1%–2% of all fractures. Calcaneal avulsion fractures account for less than 3% of calcaneal fractures.1 The calcaneus is the largest tarsal bone; it supports axial load from the body. This report demonstrates a type 2 calcaneal avulsion fracture; a “beak fracture” where the tendon pulls on the tuberosity causing a horizontal fracture.2 It also demonstrates a rare tongue-type fracture where the tuberosity splits into a superior and an inferior fragment.3 Patients often present with pain, swelling, and ecchymosis near the posterior aspect of the calcaneus. Patients can have skin tenting that can lead to skin necrosis if not treated.3 This woman had ecchymosis before surgery but did not have skin necrosis. It is important to assess these patients for neurovascular compromise and signs of other injuries. A plain radiograph is usually sufficient for diagnosis. Treatment depends on the severity. Fractures with skin tenting, neurovascular injury, or significant displacement will likely require open reduction and internal fixation in the operating room.4 This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

A Minimal Sensor Inertial Measurement Unit System Is Replicable and Capable of Estimating Bilateral Lower-Limb Kinematics in a Stationary Bodyweight Squat and a Countermovement Jump.

This study aimed to validate a 7-sensor inertial measurement unit system against optical motion capture to estimate bilateral lower-limb kinematics. Hip, knee, and ankle sagittal plane peak angles and range of motion (ROM) were compared during bodyweight squats and countermovement jumps in 18 participants. In the bodyweight squats, left peak hip flexion (intraclass correlation coefficient [ICC] = .51), knee extension (ICC = .68) and ankle plantar flexion (ICC = .55), and hip (ICC = .63) and knee (ICC = .52) ROM had moderate agreement, and right knee ROM had good agreement (ICC = .77). Relatively higher agreement was observed in the countermovement jumps compared to the bodyweight squats, moderate to good agreement in right peak knee flexion (ICC = .73), and right (ICC = .75) and left (ICC = .83) knee ROM. Moderate agreement was observed for right ankle plantar flexion (ICC = .63) and ROM (ICC = .51). Moderate agreement (ICC > .50) was observed in all variables in the left limb except hip extension, knee flexion, and dorsiflexion. In general, there was poor agreement for peak flexion angles, and at least moderate agreement for joint ROM. Future work will aim to optimize methodologies to increase usability and confidence in data interpretation by minimizing variance in system-based differences and may also benefit from expanding planes of movement.