Ankle Osteoarthritis / Osteoartrite do tornozelo

Abstract Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing posttraumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents.

Resumo A osteoartrite (OA) é caracterizada por uma degradação crônica, progressiva e irreversível da superfície articular, associada a inflamação articular. A principal etiologia da OA do tornozelo é pós-traumática e sua prevalência é maior entre os jovens e obesos. Apesar dos avanços no tratamento das fraturas ao redor do tornozelo, o risco geral de desenvolver OA pós-traumática do tornozelo após 20 anos do trauma é de quase 40%; especialmente nas fraturas bimaleolares de Weber tipo B e C e fraturas envolvendo a borda tibial posterior. Nas fraturas do tálus, essa prevalência se aproxima de 100%, dependendo da gravidade da lesão e do tempo de seguimento. Nesse cenário, é fundamental a compreensão atual das vias de sinalização moleculares envolvidas na senescência e apoptose dos condrócitos. O tratamento da OA do tornozelo é estagiado e guiado pelos sistemas de classificação, condições locais e do paciente. Os principais problemas são a limitada capacidade de regeneração da cartilagem articular, o baixo suprimento de sangue e a escassez de células-tronco progenitoras. A presente atualização resume evidências científicas básicas recentes da OA póstraumática do tornozelo, com foco principal nas alterações metabólicas da sinóvia, da cartilagem e do líquido sinovial. Epidemiologia, fisiopatologia, implicações clínicas, e opções de tratamento são também discutidas.

Subtar arthroscopic debridment for the treatment of sinus tarsi syndrome: case series

SUMMARY OBJECTIVE: The objective of this study is to report the results of arthroscopic debridement of the subtalar joint in eight patients with Sinus Tarsi Syndrome (STS) refractory to conservative treatment. METHODS: This is a retrospective study of eight patients with STS who underwent subtalar arthroscopy for debridement of the sinus tarsi between January 2015 and January 2017 after six months of conservative treatment. All patients answered an epidemiological questionnaire and underwent functional evaluation with the Visual Analogue Pain Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in the preoperative and in the last evaluation (average of 12 months - 6-24 months). RESULTS: All patients showed severe synovitis in the region. Seven patients had remnants of the talocalcaneal ligaments and six of the cervical ligament. AOFAS increased by 30 points on average (51.75 in the preoperative period to 82.62 in the last follow-up) and the VAS decreased on average by 5 points (7.37 preoperatively to 2.12 in the last follow-up). These results were statistically significant with p = 0.043 and p = 0.032 respectively. Six patients described the result as excellent and two as good. No complications were reported. All patients returned to sports after six months of follow-up. CONCLUSION: The arthroscopic debridement of the subtalar joint is an effective and safe alternative in the treatment of STS refractory to conservative treatment. More studies, with a prospective methodology, are necessary to prove the results of this technique.

RESUMO OBJETIVO: O objetivo desse estudo é relatar os resultados do desbridamento artroscópico da subtalar em oito pacientes portadores da Síndrome do Seio do Tarso (SST) refratária ao tratamento conservador. MÉTODOS: Este é um estudo retrospectivo com oito pacientes com diagnóstico de STT que foram submetidos à artroscopia subtalar para desbridamento do seio do tarso entre janeiro de 2015 e janeiro de 2017, após seis meses de tratamento conservador. Todos os pacientes responderam questionário epidemiológico e foram submetidos à avaliação funcional com a Escala Visual Analógica de dor (EVA) e o American Orthopaedic Foot and Ankle Society Score (Aofas) no pré-operatório e na última avaliação, em uma média de 12 meses (6-24 meses). RESULTADOS: Todos os pacientes exibiram intensa sinovite na região. Sete pacientes tinham resquícios de ligamentos talocalcaneanos e seis do ligamento cervical. O Aofas aumentou 30 pontos em média (51,75 no pré-operatório para 82,62 no último seguimento) e a EVA diminuiu em média 5 pontos (7,37 no pré-operatório para 2,12 no último seguimento). Esses resultados foram estatisticamente significativos com p = 0,043 e p = 0,032, respectivamente. Seis pacientes descreveram o resultado como excelente e dois como bom. Nenhuma complicação foi relatada. Todos os pacientes retornaram ao esporte após seis meses de acompanhamento. CONCLUSÃO: O desbridamento artroscópico da subtalar é uma alternativa eficaz e segura no tratamento da SST refratária ao tratamento conservador. Mais estudos, com metodologia prospectiva, são necessários para comprovar os resultados da técnica.

Effects of eccentric exercise in pressure pain threshold in subjects with functional ankle equinus condition

SUMMARY Stretching exercises are widely used by the population before sporting activities. One of the most common technique is eccentric exercise. Here, we made a clinical examination of 98 subjects with equinus condition before activity and after 30 min of running (49 participants with previous eccentric exercise and 49 with no previously eccentric exercise). The clinical assessment of the Achilles tendon was based on the pressure pain threshold (PPT). We identified significant PPT changes between the previous eccentric stretching and the non-previous eccentric stretching group in the Achilles tendon evaluations. Based on our findings, we propose that subjects with equinus condition could use eccentric stretching in order to improve the Achilles tendon status.

RESUMO Exercícios de alongamento são amplamente utilizados pela população antes da atividade esportiva. Uma das técnicas mais comuns é o exercício excêntrico. Aqui, fizemos um exame clínico de 98 indivíduos com condição de pé equino antes da atividade e após 30 minutos de corrida (49 corredores com exercício excêntrico anterior e 49 sem exercício excêntrico anterior). A avaliação clínica do tendão de Aquiles foi baseada no limiar de dor à pressão (PPT). Identificamos modificações significativas no PPT entre alongamentos prévios excêntricos e nenhum exercício anterior excêntrico de alongamento para as avaliações do tendão de Aquiles. Com base em nossos achados, propomos que sujeitos com condição de pé equino poderiam fazer alongamentos com exercícios excêntricos para melhorar o status do tendão de Aquiles.

Avaliação isocinética do tornozelo de pacientes com artrite reumatoide / Isokinetic assessment of ankles in patients with rheumatoid arthritis

RESUMOIntroduçãoO pé e o tornozelo na artrite reumatoide passam por sinovite altamente destrutiva, com perda de força muscular.ObjetivoAvaliar a força muscular do tornozelo de pacientes com artrite reumatoide com base em parâmetros da dinamometria isocinética.Materiais e métodosForam estudados 30 pacientes com diagnóstico de artrite reumatoide. O estudo envolveu 30 indivíduos saudáveis (grupo controle) pareados por idade, sexo, etnia, índice de massa corporal e dominância de membro inferior. Todos os indivíduos foram submetidos a avaliação da flexão dorsal, flexão plantar, inversão e eversão com o dinamômetro isocinético Cybex Norm. As variáveis foram comparadas entre os grupos artrite reumatoide e controle e entre os tornozelos direito e esquerdo. Foi determinada a relação de força muscular flexores dorsais/flexores plantares e inversores/eversores.ResultadosOs pacientes com artrite reumatoide tiveram resultados estatisticamente piores no teste de dinamometria isocinética para todos os movimentos do tornozelo. A relação de força muscular entre flexores dorsais e flexores plantares foi diferente nos dois grupos. Não foram observadas diferenças significativas na relação entre inversores e eversores. Nos dois grupos, os músculos flexores plantares eram estatisticamente mais fortes do que os flexores dorsais.ConclusãoOs pacientes com artrite reumatoide têm pior desempenho na dinamometria isocinética em todos os movimentos do tornozelo do que os indivíduos do grupo controle. Foram observados resultados semelhantes no teste isocinético para o lado direito e esquerdo, em ambos os grupos, com poucas exceções. A avaliação isocinética não representou risco adicional, como dor importante ou atividade inflamatória, em pacientes com artrite reumatoide.

ABSTRACTIntroductionThe foot and ankle in rheumatoid arthritis undergo highly destructive synovitis with loss of muscle strength.ObjectiveTo evaluate the muscle strength of ankles in patients with rheumatoid arthritis based on isokinetic dynamometry parameters.Materials and methodsThirty patients with a diagnosis of rheumatoid arthritis involving the ankle(s) and 30 healthy subjects (control group) matched for age, gender, race, body mass index and lower limb dominance were studied. Dorsiflexion, plantar flexion, inversion and eversion were evaluated in all subjects on an isokinetic Cybex Norm dynamometer. The variables were compared between the rheumatoid arthritis and control groups and between the right and left ankles, and the dorsiflexor/plantar flexor and invertor/evertor muscle strength ratio was determined.ResultsPatients with rheumatoid arthritis performed statistically worse in the isokinetic dynamometry test for all ankle movements. The muscle strength ratio between dorsiflexors and plantar flexors was different in the two groups. No significant differences were observed in the invertor and evertor ratios. In the two groups the plantar flexor musculature was statistically stronger than dorsiflexors.ConclusionWe conclude that patients with rheumatoid arthritis perform worse in isokinetic dynamometry regarding all ankle movements than control subjects, with similar isokinetic test results being observed for the right and left side in both groups, with few exceptions. Isokinetic evaluation posed no additional risk such as important pain or inflammatory activity to patients with rheumatoid arthritis.

Using standing postures as a practical alternative to gait analysis for assessing normal neuromotor activity variation of the ankle muscle antagonists: a soleus H-reflex and EMG activity study comparing patients with hemiplegia to healthy subjects / Uso de posturas erguidas como alternativa práctica al análisis de marcha para evaluar la actividad neuromotora normal de los antagonistas del tobillo: una comparación entre pacientes hemiplégicos y sujetos normales

The purpose of this study was to evaluate and compare the soleus H-reflex amplitudes recorded in three standing postures between a group of patients with stroke and a group of healthy subjects. Nine ambulatory patients were compared with 10 healthy subjects. Measures were recorded during quiet standing (QS), heels raised (PO) and with the foot of the measured leg held just off the ground while standing on the opposite leg (SW). The results showed that patients, as opposed to the healthy group, did not inhibit soleus H-reflex in the SW posture. As opposed to evaluating ankle motor control during gait, the PO and SW standing postures appeared to offer a practical and objective method to assess soleus H-reflex when the purpose is to determine impairment (or recovery) of ankle neuromotor control in stroke survivors.

El propósito de este estudio fue evaluar y comparar la amplitud de el reflejo H en el músculo sóleo en tres posturas en la posición de pie entre un grupo de pacientes con hemiplejia y un grupo de individuos sanos. Nueve pacientes ambulatorios fueron comparados con diez individuos sanos. Registros fueron obtenidos en la posición de pie bipedal (QS), bipedal con talones elevados (PO), y unipedal manteniendo el pie afectado ligeramente elevado sin contacto con el piso (SW). Los resultados mostraron que los pacientes, en contraste con el el grupo sano, no presentaron inhibición del reflejo H en la postura SW. Comparado a registros del reflejo H obtenidos durante la marcha, aquellos obtenidos con las posturas PO y SW aparecen como un método más práctico y objetivo para evaluar el reflejo H del soleus si el propósito es determinar nivel de pérdida (o recuperación) de el control neuromotor del tobillo en pacientes con hemiplejia.

Avaliação da anatomia arterial no pé torto congênito através da ultrassonografia com doppler colorido / Evaluation of arterial anatomy in congenital clubfoot with color doppler ultrasound

OBJETIVO: Avaliação ultrassonográfica das artérias tibial anterior e posterior no pé torto congênito (PTC). MATERIAL E MÉTODO: Foram incluídos 20 pacientes portadores de PTC idiopático compreendendo 18 casos unilaterais e dois bilaterais, sendo que 17 pacientes foram submetidos a tratamento cirúrgico e três a tratamento conservador. Todos os pacientes apresentavam pés plantígrados e foram submetidos à avaliação clínica e radiográfica, seguido pelo exame de ultrassom Doppler colorido (UDC), visando a identificação das artérias tibiais anterior e posterior na altura do tornozelo. O nível funcional foi classificado pelos critérios de Lehman. RESULTADOS: Nesta série de 20 pacientes, somente em um não foi identificada a artéria tibial anterior. Nos 12 pacientes submetidos à mensuração de fluxo e calibre pelo UDC, foi encontrada uma correlação positiva entre o grau funcional do PTC e o calibre da artéria tibial anterior. Não houve redução estatisticamente significante entre o fluxo e calibre da artéria tibial anterior do lado normal em comparação com o lado alterado (nos casos de doença unilateral). CONCLUSÕES: Não houve alteração significativa da morfologia e fluxo arterial quando comparamos os lados afetado e normal. Além disso, quanto melhor o resultado clínico da correção do PTC, maior foi o calibre da artéria tibial anterior.

OBJECTIVE: This investigation intended to evaluate anterior and posterior tibial arteries at the ankle joint level in congenital clubfoot, by using color Doppler ultrasound (CDU). MATERIAL AND METHOD: Twenty patients with idiopathic clubfoot were selected, from which 18 had unilateral involvement and two had bilateral involvement. Of the 18 patients with unilateral clubfoot, 16 went through surgical treatment and the other two were submitted to conservative treatment with serial casting. Of the bilateral cases, one patient was treated surgically and the other was treated with serial casting. All patients were clinically and radiographically assessed. We used the functional rating as described by Lehman. Then, CDU was applied bilaterally at the ankle joint level, trying to identify both posterior and anterior tibial arteries. RESULTS: In our present series of 20 cases with idiopathic clubfoot, in just one patient we could not identify the anterior tibial artery at the ankle joint level. In 12 patients who have had their arterial flow speeds and diameters measured by UDC, a positive correlation was found between functional level and anterior tibial artery diameter. No statistically significant differences were found between both flow speed and diameter of anterior tibial artery of the normal side, when compared to the affected side (in patients with unilateral disease). CONCLUSION: In our sample, we could not find any significant differences in arterial morphology and flow speed between the normal and the affected side. Furthermore, we noticed that the better the clinical result of clubfoot correction, the larger the diameter of anterior tibial artery in affected feet.

Star excursion balance training: effects on ankle functional stability after ankle sprain.

OBJECTIVES: To study the effects of Star Excursion Balance training on functional stability of athletes with ankle sprain. MATERIAL AND METHOD: Thirty-two male athletes with grade 2 ankle sprain, aged 15-22 years old were enrolled. They were random sampling into training group (n=15) and control group (n=17). All received conventional physical therapy program for 4 weeks. The training group also underwent the Star Excursion Balance training 3 days per week for 4 weeks. Single leg stance time (SLST) was assessed at pre- and post-training. Re-injuries were recorded during 3 months follow-up. RESULTS: After the program, subjects from both groups demonstrated significant improvement in SLST The training group gained SLST of the injured sides 2 times more than the control group (p = 0.002 tested with eyes closed, p = 0. 007 tested with eyes open), and also improved the SLST during eyes closed of the normal sides (p = 0.015). Re-injuries were found in 1/15 of the training group and 2/17 of the control group. CONCLUSION: Star Excursion Balance training is more effective than the conventional therapy program in improving functional stability of the sprained ankle.

Biomechanical Assessment with Electromyography of Post-Stroke Ankle Plantar Flexor Spasticity

Spasticity has been defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone). Muscle tone consists of mechanical-elastic characteristics, reflex muscle contraction and other elements. The aims of this study were to determine whether to assess spasticity quantitatively, and to characterize biomechanical and electromyographic spasticity assessment parameters. These assessment parameters were described by investigating the correlation between clinical measures and the response to passive sinusoidal movement with consecutive velocity increments. Twenty post-stroke hemiplegic patients and twenty normal healthy volunteers were included in the study. Five consecutive sinusoidal passive movements of the ankle were performed at specific velocities (60, 120, 180, and 240 degrees/ sec). We recorded the peak torque, work, and threshold angle using a computerized isokinetic dynamometer, and simultaneously measured the rectified integrated electromyographic activity. We compared these parameters both between groups and between different velocities. The peak torque, threshold angle, work, and rectified integrated electromyographic activity were significantly higher in the post-stroke spastic group at all angular velocities than in the normal control group. The threshold angle and integrated electromyographic activity increased significantly and linearly as angular velocity increased, but the peak torque and work were not increased in the post-stroke spastic group. Peak torque, work, and threshold angle were significantly correlated to the Modified Ashworth scale, but the integrated electromyographic activity was not. The biomechanical and electromyographic approach may be useful to quantitatively assess spasticity. However, it may also be very important to consider the different characteristics of each biomechanical parameter.

Importância da podobarometria computadorizada na precricao de órteses para redução das hemartroses de repetição dos tonrnozelos, em pacientes hemofílicos / Significance of the computadorised pedobarography to prescription of orthosis for repetitive anckle haemarthrosis reduction, on hemophilic patients

Nos países em desenvolvimento, por falta de recursos para se fazer profilaxia para todos os hemofílicos, ainda vemos muitos pacientes incapacitados pelas hemartroses de repetição. Sabe-se que a instabilidade articular contribuiria para aumentar a frequência dessas complicações e prescrevem-se órteses que limitam muito os pacientes. Diante desse quadro buscamos um instrumento para qualificar os desvios nos tornozelos instáveis durante a marcha, dinamicamente e em tempo real. Essa avaliação permitiria a prescrição de palmilhas de fácil confecção, de calçados com contrafortes posteriores e, nos casos / Developing countries, due to the lack of resources available to perform prophylaxis to all haemophilic, there can still be seen many patients disabled by the repetitive haemarthrosis. It is known that the joint instability can contribute to increase the frequency of those complications and are prescribed orthosis which severely limit the patients...

Osteocondrosis del hueso trígono (os trigonum) causa poco frecuente de dolor en tobillo. Informe de un caso / Os trigonum osteochondrosis as an unusual cause of pain. Case report

Se presenta un caso de dolor en tobillo, en un adolescente, producido por un osteocondrosis de crecimiento del hueso trígono

Mechanism and classification of ankle fracture

The ankle joint being an important instrument of walking makes the proper understanding of the mechanism of its fracture and the method for restoring its integrity and function, an important factor in regaining a normal ankle action. In this paper a description of the ankle injuries were made following a cadaveric study and a modification of Ashhurst and Bromer classification will be described. The paper will also review the result of the treatment undertaken in 117 ankle fractures, and review the importance of the restoration of the inferior tibio-fibular syndesmosis. The paper will furthermore re-explore the question of the tibio-talar contact area and the need for the proper placement of the talus in the mortise in order to maintain the contact area to as normal a position as possible

El tratamiento de las partes blandas en la correccion de las deformidades del pie / Soft-tissue surgery in foot deformities

En las malformaciones y deformaciones del pie, durante mucho tiempo realizamos de preferencia en el niño su correccion con procedimientos conservadores. En los fracasos, la cirugia. En los adolescentes y adultos haciamos las tarsectomias y artrodesis modelantes. Estos procedimientos convertian a los pies en rigidos y dolorosos. Nos indujo a un cambio sustancial de esa orientacion: 1) la insatisfaccion por los resultados ; 2) la comprobacion de la efectividad de la operacion de Storen para la correccion del pie bot del adulto ; 3) una interpretacion personal mas ajustada de la fisiopatologia de estas deformaciones, y 4) nuestra tendencia actual a realizar cirugia precoz en las malformaciones. Como premisas generales de la correccion afirmamos que la mayoria de las deformidades del pie pueden ser corregidas por la cirugia de sus partes blandas que logran restablecer sus relaciones anatomicas normales con nula o escasa actuacion a nivel oseo