A comparison of abductor hallucis muscle activation and medial longitudinal arch angle during nine different foot exercises.

BACKGROUND: Intrinsic foot muscles are known to support the medial longitudinal arch (MLA) and stabilize the foot, and they are activated with weight bearing and increased postural demand. Various types of intrinsic foot muscle training have been reported, but one of the most useful of these, the short foot exercise, is challenging to perform effectively and requires practice, making it difficult to implement in ordinary clinical settings. RESEARCH QUESTION: What are the differences in abductor hallucis longus (ABH) muscle activity and MLA angle during intrinsic foot muscle exercises that employ weight bearing and balancing conditions when they are performed with minimal practice? METHODS: Sixteen healthy volunteers performed nine different intrinsic foot muscle exercises, practiced once or twice. The exercises consisted of toe curl, short foot without pushing, short foot with pushing and toe spread exercises in sitting and standing positions, and single leg swing in a standing position. Each exercise was performed three times for five seconds. The activities of the ABH muscles were measured using surface electromyographic (EMG) sensors and the MLA angles during the exercises were captured using an optical motion tracking system. The integrals of the ABH EMG signals were calculated. RESULTS: Differences in the integral and maximum of the ABH EMG signal were found between the exercises (p < 0.001). Post-hoc pair-wise analysis revealed that the EMG activity was larger during the swing exercise than in exercises other than toe spread, both in sitting and standing positions, and short foot exercise with pushing while standing. The minimum MLA angle during each exercise was smaller for the toe spread exercise in a sitting position than other exercises (p < 0.023). SIGNIFICANCE: A single leg swing exercise may be effective for self-exercise of intrinsic foot muscles, particularly when intensive supervised physiotherapy is not possible.

The deltoid ligament is constantly formed by four fascicles reaching the navicular, spring ligament complex, calcaneus and talus.

PURPOSE: The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament. METHODS: Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken. RESULTS: The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures. CONCLUSION: The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries. LEVEL OF EVIDENCE: Not applicable (cadaveric study).

Deltoid ligament injuries: A review of the anatomy, diagnosis and treatments.

PURPOSE: Ankle sprains remain the most common soft tissue injury presenting to Emergency Departments. Recently, there has been increased awareness and reporting of deltoid ligament injuries in association with injuries to the lateral ligament complex as well as with fibula fractures. This article reviews the currently available literature on the anatomy of the deltoid ligament, clinical and radiological diagnosis of injuries to the deltoid ligament and treatment recommendations. METHODS: A literature review was conducted for keywords associated with deltoid ligament injuries. MEDLINE, PubMed and Embase databases were utilised for this search. Articles were included if involving an adult population, were English-language, were related to deltoid ligament injuries (with or without associated injuries) and reported on patho-anatomy, clinical or radiological diagnosis or treatment methods. RESULTS: A total of 93 articles were assessed for relevance from the database search, and 47 were included after the removal of irrelevant articles and duplicates. Several studies reported on the clinical findings of deltoid ligament injury, as well as the radiographic analysis. Arthroscopy was considered the gold standard of diagnosis, with authors reporting on the potential benefit of performing arthroscopic repair or reconstruction at the same time. There were no studies that provided a system for the classification of deltoid ligament injury or larger studies of treatment pathways. Long-term studies of the incidence of instability in deltoid ligament injuries were not available. CONCLUSION: There is limited evidence available regarding deltoid ligament injuries, particularly in terms of treatment options, either in isolation or with concomitant injuries. Long-term follow-up studies are needed to obtain more accurate data on the number of complications. LEVEL OF EVIDENCE: Level IV.

Chronic lateral ankle ligament instability - Current evidence and recent management advances.

Lateral ankle sprain is a common injury with a substantial negative impact on physical function, quality of life and health economic burden. Chronic lateral ankle instability (CLAI) as a sequela of lateral ankle sprain can lead to the development of posttraumatic ankle osteoarthritis in the long term. In this article, we explore the epidemiology, burden and definition of CLAI for the appropriate clinical assessment and imaging evaluation of patients with lateral ankle sprain and CLAI. Following that, recent advances and evidence on management of CLAI is critically distilled and summarized.

Sex differences in biomechanical properties of the Achilles tendon may predispose men to higher risk of injury: A systematic review.

IMPORTANCE: Men have a higher risk of Achilles tendon (AT) injury, and the impact of morphological and mechanical sex differences may play a role. AIM: The aim of this study is to systematically review the literature to determine whether there are sex-specific differences in AT morphological and mechanical properties and analyze how these differences may impact AT injury in both men and women. EVIDENCE REVIEW: A systematic literature search of articles published between 2001 and 2021, in the MEDLINE, EMBASE, and Cochrane databases was performed during May 2022 according to PRISMA. The primary outcome measures included sex-related differences in the mechanical and morphological properties of the Achilles tendon. Secondary outcomes included impact of sex on Achilles tendon properties and adaptation. FINDINGS: Nineteen studies with a total of 1,143 participants (613 men and 530 women) were included in this systematic review. Men had increased measurements when compared with women in the following: AT length, thickness, cross-sectional area (CSA), stiffness, peak force, loading rate, and voluntary muscle contraction. Women had an increase in CSA deformation, strain, and compliance. CONCLUSIONS AND RELEVANCE: Our study demonstrates that men have an increased AT length, thickness, and CSA, indicating that men may be subjected biomechanically to higher loads in their day-to-day activities. In addition, men have lower deformation and compliance properties, along with increased AT stiffness, reducing their capacity to adapt during loading, potentially increasing their risk of injury. LEVEL OF EVIDENCE: IV.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes.

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design: Case series; Level of evidence, 4. Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Differential elongation of the gastrocnemius after Achilles tendon rupture: a novel technique of selective shortening to treat push-off weakness with case series and literature review.

PURPOSE: Differential elongation of the gastrocnemius after Achilles tendon rupture (ATR) may compromise the ability of athletes to return to competition. Recognition of this differential elongation of the gastrocnemius relative to the soleus is vital to treat patients with weakness in push-off. This paper describes a novel technique performed for selective shortening of the gastrocnemius to treat push-off weakness. METHODS: Three patients with differential proximal retraction of the gastrocnemius greater than 20 mm after treatment for ATR with inability to run and jump underwent surgical correction with this novel technique and were followed-up for 2 years. A novel selective shortening of the gastrocnemius with autologous hamstring graft was performed in these patients. The Achilles Tendon Total Rupture Score (ATRS) and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were recorded preoperatively and at the final follow-up. RESULTS: All three patients were able to return to running and jumping at final follow-up. The ATRS improved significantly in the strength, fatigue, running and jumping domains but there appeared to be a less notable improvement in activities of daily living domain. The AOFAS score showed improvement with the greatest margin in the domain of activity limitation. CONCLUSION: This procedure is the first described selective shortening method of the gastrocnemius tendons after differential elongation following ATR. It is a safe and reliable technique providing improved ATRS and AOFAS scores in three patients who were all able to return to running and jumping sports at 2-year follow-up. LEVEL OF EVIDENCE: IV.

Republication of "High-Speed Video Analysis of Syndesmosis Injuries in Soccer-Can It Predict Injury Mechanism and Return to Play? A Pilot Study".

Background: Ankle syndesmosis injuries in professional soccer may lead to an unpredictable and prolonged recovery. This injury has been investigated in anatomical and radiologic studies but the precise mechanism leading to syndesmosis injury is not well understood and remains debated. The 2 goals of this study were to (1) evaluate the relationship between the mechanism of syndesmosis injury as determined by high-speed video analysis and the injured structures identified by clinical and radiologic examination and to (2) investigate the relationship between mechanism of injury and time of return to play. Methods: This pilot study prospectively reviewed high-speed video analysis of 12 professional soccer players who sustained syndesmosis injuries. The mechanism of injury was compared with the clinical and MRI evaluation and the time taken to return to play. Results: Higher-grade syndesmosis injuries occurred during ankle external rotation with dorsiflexion. Supination-inversion injuries with a standard lateral ankle sprain (rupture of the anterior talofibular ligament) may extend proximally, causing a lower-grade syndesmosis injury. These may present with signs of a high ankle sprain but have a quicker return to sport than those following a dorsiflexion-external rotation injury (mean 26 days vs 91 days). Conclusions: Video analysis confirmed that at least 2 mechanisms may result in injury to the ankle syndesmosis. Those "simple" ankle sprains with signs of syndesmosis injury had a quicker return to play. This new finding may be used by club medical teams during their initial assessment and help predict the expected time away from soccer in players with suspected high ankle sprains. Level of Evidence: Level IV, retrospective cohort study.

In vivo evaluation of ankle kinematics and tibiotalar joint contact strains using digital volume correlation and 3 T clinical MRI.

BACKGROUND: In vivo evaluation of ankle joint biomechanics is key to investigating the effect of injuries on the mechanics of the joint and evaluating the effectiveness of treatments. The objectives of this study were to 1) investigate the kinematics and contact strains of the ankle joint and 2) to investigate the correlation between the tibiotalar joint contact strains and the prevalence of osteochondral lesions of the talus distribution. METHODS: Eight healthy human ankle joints were subjected to compressive load and 3 T MRIs were obtained before and after applying load. The MR images in combination with digital volume correlation enabled non-invasive measurement of ankle joint kinematics and tibiotalar joint contact strains in three dimensions. FINDINGS: The total translation of the calcaneus was smaller (0.48 ± 0.15 mm, p < 0.05) than the distal tibia (0.93 ± 0.16 mm) and the talus (1.03 ± 0.26 mm). These movements can produce compressive and shear joint contact strains (approaching 9%), which can cause development of lesions on joints. 87.5% of peak tensile, compressive, and shear strains in the tibiotalar joint took place in the medial and lateral zones. INTERPRETATION: The findings suggested that ankle bones translate independently from each other, and in some cases in opposite directions. These findings help explain the distribution of osteochondral lesions of the talus which have previously been observed to be in medial and lateral regions of the talar dome in 90% of cases. They also provide a reason for the central region of talar dome being less susceptible to developing osteochondral lesions.

Clinical Relevance and Function of Anterior Talofibular Ligament Superior and Inferior Fascicles: A Robotic Study.

BACKGROUND: Ankle lateral ligament sprains are common injuries in sports, and some may result in persistent ankle pain and a feeling of instability without clinical evidence of instability. The anterior talofibular ligament (ATFL) has 2 distinct fascicles, and recent publications have suggested that injury isolated to the superior fascicle might be the cause of these chronic symptoms. This study aimed to identify the biomechanical properties conferred by the fascicles in stabilizing the ankle in order to understand potential clinical problems that may follow when the fascicles are injured. PURPOSE/HYPOTHESIS: The aim of this study was to determine the contribution of superior and inferior fascicles of the ATFL in restraining anteroposterior tibiotalar resistance, internal external tibial rotation resistance, and inversion eversion talar rotation resistance. It was hypothesized that an isolated injury of the ATFL superior fascicle would have a measurable effect on ankle stability and that the superior and inferior fascicles would restrain different motions of the ankle. STUDY DESIGN: Descriptive laboratory study. METHODS: A robotic system with 6 degrees of freedom was used to test ankle instability in 10 cadavers. Serial sectioning following the most common injury pattern (from superior to inferior fascicles) was performed on the ATFL while the robot ensured reproducible movement through a physiological range of dorsiflexion and plantarflexion. RESULTS: Sectioning of only the ATFL superior fascicle had a significant and measurable effect on ankle stability, resulting in increased internal rotation and anterior translation of the talus, especially in plantarflexion. Sectioning of the entire ATFL resulted in significantly decreased resistance in anterior translation, internal rotation, and inversion of the talus. CONCLUSION: Rupture of only the superior fascicle of the ATFL may lead to minor instability or microinstability of the ankle joint, without objective clinical findings of gross clinical laxity. CLINICAL RELEVANCE: Some patients develop chronic symptoms after an ankle sprain without overt signs of instability. This may be explained by an isolated injury to the ATFL superior fascicle, and diagnosis may require careful clinical evaluation and magnetic resonance imaging examination looking at the individual fascicles. It is possible that such patients may benefit from lateral ligament repair despite having no gross clinical instability.

Mitigation of Respirable Aerosol Particles from Speech and Language Therapy Exercises.

INTRODUCTION: Phonation and speech are known sources of respirable aerosol in humans. Voice assessment and treatment manipulate all the subsystems of voice production, and previous work (Saccente-Kennedy et al., 2022) has demonstrated such activities can generate >10 times more aerosol than conversational speech and 30 times more aerosol than breathing. Aspects of voice therapy may therefore be considered aerosol generating procedures and pose a greater risk of potential airborne pathogen (eg, SARS-CoV-2) transmission than typical speech. Effective mitigation measures may be required to ensure safe service delivery for therapist and patient. OBJECTIVE: To assess the effectiveness of mitigation measures in reducing detectable respirable aerosol produced by voice assessment/therapy. METHODS: We recruited 15 healthy participants (8 cis-males, 7 cis-females), 9 of whom were voice-specialist speech-language pathologists. Optical Particle Sizers (OPS) (Model 3330, TSI) were used to measure the number concentration of respirable aerosol particles (0.3 µm-10 µm) generated during a selection of voice assessment/therapy tasks, both with and without mitigation measures in place. Measurements were performed in a laminar flow operating theatre, with near-zero background aerosol concentration, allowing us to quantify the number concentration of respiratory aerosol particles produced. Mitigation measures included the wearing of Type IIR fluid resistant surgical masks, wrapping the same masks around the end of straws, and the use of heat and moisture exchange microbiological filters (HMEFs) for a water resistance therapy (WRT) task. RESULTS: All unmitigated therapy tasks produced more aerosol than unmasked breathing or speaking. Mitigation strategies reduced detectable aerosol from all tasks to a level significantly below, or no different to, that of unmasked breathing. Pooled filtration efficiencies determined that Type IIR surgical masks reduced detectable aerosol by 90%. Surgical masks wrapped around straws reduced detectable aerosol by 96%. HMEF filters were 100% effective in mitigating the aerosol from WRT, the exercise that generated more aerosol than any other task in the unmitigated condition. CONCLUSIONS: Voice therapy and assessment causes the release of significant quantities of respirable aerosol. However, simple mitigation strategies can reduce emitted aerosol concentrations to levels comparable to unmasked breathing.

The Burden of the "Simple Ankle Sprains": A Review of the Epidemiology and Long-Term Impact.

Lateral ankle sprain (LAS) is not as simple as it was believed to be as it has substantial negative impacts on the active sporting population. The negative impact on physical function, quality of life (QoL) and economic burden is significant with increased risk of reinjury, development of chronic lateral ankle instability and posttraumatic ankle osteoarthritis resulting in functional deficits, decreased QoL and chronic disabilities. Economic burden from a societal perspective demonstrated notably higher indirect costs from productivity loss. Preventative interventions with early surgery for a selective cohort of active sporting population may be considered to mitigate morbidities associated with LAS.

Epidemiological Characteristics of Foot and Ankle Injuries in 2 Professional Ballet Companies: A 3-Season Cohort Study of 588 Medical Attention Injuries and 255 Time-Loss Injuries.

Background: The foot and ankle are often reported as the most common sites of injury in professional ballet dancers; however, epidemiological research focusing on foot and ankle injuries in isolation and investigating specific diagnoses is limited. Purpose: To investigate the incidence rate, severity, burden, and mechanisms of foot and ankle injuries that (1) required visiting a medical team (medical attention foot and ankle injuries; MA-FAIs) and (2) prevented a dancer from fully participating in all dance-related activities for at least 24 hours after the injury (time-loss foot and ankle injuries; TL-FAIs) in 2 professional ballet companies. Study Design: Descriptive epidemiological study. Methods: Foot and ankle injury data across 3 seasons (2016-2017 to 2018-2019) were extracted from the medical databases of 2 professional ballet companies. Injury-incidence rate (per dancer-season), severity, and burden were calculated and reported with reference to the mechanism of injury. Results: A total of 588 MA-FAIs and 255 TL-FAIs were observed across 455 dancer-seasons. The incidence rates of MA-FAIs and TL-FAIs were significantly higher in women (1.20 MA-FAIs and 0.55 TL-FAIs per dancer-season) than in men (0.83 MA-FAIs and 0.35 TL-FAIs per dancer-season) (MA-FAIs, P = .002; TL-FAIs, P = .008). The highest incidence rates for any specific injury pathology were ankle impingement syndrome and synovitis for MA-FAIs (women 0.27 and men 0.25 MA-FAIs per dancer-season) and ankle sprain for TL-FAIs (women 0.15 and men 0.08 TL-FAIs per dancer-season). Pointe work and jumping actions in women and jumping actions in men were the most common mechanisms of injury. The primary mechanism of injury of ankle sprains was jumping activities, but the primary mechanisms of ankle synovitis and impingement in women were related to dancing en pointe. Conclusion: The results of this study highlight the importance of further investigation of injury prevention strategies targeting pointe work and jumping actions in ballet dancers. Further research for injury prevention and rehabilitation strategies targeting posterior ankle impingement syndromes and ankle sprains are warranted.

Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI.

PURPOSE: Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI. METHODS: Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed. RESULTS: Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery). CONCLUSION: Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex. LEVEL OF EVIDENCE: Level III.

Ability to return to sports after early lateral ligament repair of the ankle in 147 elite athletes.

PURPOSE: The literature on elite athletes' ability to return to sports (RTS) after early lateral ligament repair of the ankle remains inadequate. The time needed to RTS after modified Broström repair for acute grade III lateral ligament injuries in a large cohort of elite athletes was evaluated while assessing the impact of other associated injuries. METHODS: Prospective data from 147 elite athletes who underwent a primary lateral ligament repair for acute grade III injuries with clinical ankle instability from 2015 to 2019 with a minimum of 2-year follow-up were reviewed. Pertinent details such as characteristics of injury, time taken to RTS, impact of associated injuries on RTS and complications were recorded and analysed. RESULTS: The average age was 24.4 years (S.D = 4.9) with 89.1% males. Approximately two-thirds of the elite athletes were football players (66.0%) and 21.1% were rugby players. Isolated lateral ligament complex injuries were sustained by 122 (83%) patients, while 25 (17%) had associated injuries (osteochondral lesions of the talus/deltoid injury/syndesmosis injury). All 147 athletes returned to their preinjury level of sports with a median time of 69 days (range 58-132 days). There was no significant difference found in time to RTS between gender, age, and types of sports. However, there was a statistically significant difference noted in the time taken to RTS earlier in patients with isolated lateral ligament injuries when compared to those with associated injuries (68.6 vs. 82.8 days; p = 0.004). Multiple conditional linear regression yielded three independent predictors of longer time taken to RTS which were associated deltoid injury (7.5 days longer; 95% CI 2.9-12.3; p = 0.002), associated syndesmosis injury (6.7 days longer; 95% CI 0.5-12.8; p = 0.034) and associated OLT (30.3 days longer; 95% CI 25.1-35.5; p = 0.000). CONCLUSION: Early surgical repair for acute grade III lateral ligament injuries in elite athletes yielded excellent rate of RTS at 9-10 weeks and a re-injury rate of 2%. Concomitant injuries will delay RTS after surgical intervention. These findings serve as important guide to managing elite athletes following acute rupture of the lateral ligament complex. LEVEL OF EVIDENCE: Level III.

Quantification of Respirable Aerosol Particles from Speech and Language Therapy Exercises.

INTRODUCTION: Voice assessment and treatment involve the manipulation of all the subsystems of voice production, and may lead to production of respirable aerosol particles that pose a greater risk of potential viral transmission via inhalation of respirable pathogens (eg, SARS-CoV-2) than quiet breathing or conversational speech. OBJECTIVE: To characterise the production of respirable aerosol particles during a selection of voice assessment therapy tasks. METHODS: We recruited 23 healthy adult participants (12 males, 11 females), 11 of whom were speech-language pathologists specialising in voice disorders. We used an aerodynamic and an optical particle sizer to measure the number concentration and particle size distributions of respirable aerosols generated during a variety of voice assessment and therapy tasks. The measurements were carried out in a laminar flow operating theatre, with a near-zero background aerosol concentration, allowing us to quantify the number concentration and size distributions of respirable aerosol particles produced from assessment/therapy tasks studied. RESULTS: Aerosol number concentrations generated while performing assessment/therapy tasks were log-normally distributed among individuals with no significant differences between professionals (speech-language pathologists) and non-professionals or between males and females. Activities produced up to 32 times the aerosol number concentration of breathing and 24 times that of speech at 70-80 dBA. In terms of aerosol mass, activities produced up to 163 times the mass concentration of breathing and up to 36 times the mass concentration of speech. Voicing was a significant factor in aerosol production; aerosol number/mass concentrations generated during the voiced activities were 1.1-5 times higher than their unvoiced counterpart activities. Additionally, voiced activities produced bigger respirable aerosol particles than their unvoiced variants except the trills. Humming generated higher aerosol concentrations than sustained /a/, fricatives, speaking (70-80 dBA), and breathing. Oscillatory semi-occluded vocal tract exercises (SOVTEs) generated higher aerosol number/mass concentrations than the activities without oscillation. Water resistance therapy (WRT) generated the most aerosol of all activities, ∼10 times higher than speaking at 70-80 dBA and >30 times higher than breathing. CONCLUSIONS: All activities generated more aerosol than breathing, although a sizeable minority were no different to speaking. Larger number concentrations and larger particle sizes appear to be generated by activities with higher suspected airflows, with the greatest involving intraoral pressure oscillation and/or an oscillating oral articulation (WRT or trilling).

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle.

BACKGROUND: The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. METHODS: Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%. RESULTS: A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement. CONCLUSIONS: This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries. DESIGN: A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions. RESULTS: Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies. CONCLUSIONS: This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome. PROSPERO REGISTRATION NUMBER: CRD42020176641.

A comparison of respiratory particle emission rates at rest and while speaking or exercising.

Background: The coronavirus disease-19 (COVID-19) pandemic led to the prohibition of group-based exercise and the cancellation of sporting events. Evaluation of respiratory aerosol emissions is necessary to quantify exercise-related transmission risk and inform mitigation strategies. Methods: Aerosol mass emission rates are calculated from concurrent aerosol and ventilation data, enabling absolute comparison. An aerodynamic particle sizer (0.54-20 µm diameter) samples exhalate from within a cardiopulmonary exercise testing mask, at rest, while speaking and during cycle ergometer-based exercise. Exercise challenge testing is performed to replicate typical gym-based exercise and very vigorous exercise, as determined by a preceding maximally exhaustive exercise test. Results: We present data from 25 healthy participants (13 males, 12 females; 36.4 years). The size of aerosol particles generated at rest and during exercise is similar (unimodal ~0.57-0.71 µm), whereas vocalization also generated aerosol particles of larger size (i.e. was bimodal ~0.69 and ~1.74 µm). The aerosol mass emission rate during speaking (0.092 ng s-1; minute ventilation (VE) 15.1 L min-1) and vigorous exercise (0.207 ng s-1, p = 0.726; VE 62.6 L min-1) is similar, but lower than during very vigorous exercise (0.682 ng s-1, p < 0.001; VE 113.6 L min-1). Conclusions: Vocalisation drives greater aerosol mass emission rates, compared to breathing at rest. Aerosol mass emission rates in exercise rise with intensity. Aerosol mass emission rates during vigorous exercise are no different from speaking at a conversational level. Mitigation strategies for airborne pathogens for non-exercise-based social interactions incorporating vocalisation, may be suitable for the majority of exercise settings. However, the use of facemasks when exercising may be less effective, given the smaller size of particles produced.