Prognostic Values of Clinical and Anthropometric Characteristics in Lateral Ankle Sprain Following Physiotherapy.

Lateral ankle sprain (LAS) is a common injury in sports and daily activities. The present study aimed to determine the prognostic value of clinical and anthropometric parameters in predicting LAS recovery after physiotherapy. Twenty-seven patients with acute LAS were included in this cohort study. First, prognostic factors and anthropometric variables were assessed, along with the time elapsed since the injury, pain score on a visual analogue scale (VAS), navicular drop, ankle range of motion (ROM), and ambulation status. Second, patients received physiotherapy, and their recovery status was assessed using the foot and ankle outcome score (FAOS) questionnaire immediately (first evaluation) and one month after physiotherapy (second evaluation). Univariate regression analysis and stepwise regression were used to evaluate the association between prognostic factors and outcome predictability. The results of this paper have shown that ambulation status was significantly correlated with all FAOS subscales in both the first and second evaluations, except for the FAOS-symptoms (FAOS-Sx) and FAOS-quality of life (FAOS-QOL) subscales in the first evaluation. The eversion ROM was significantly correlated with the FAOS-Sx and FAOS-Sports and Recreational activities (FAOS-Sport/Rec) subscales in the first evaluation. Additionally, age, height, and VAS were significantly correlated with FAOS-activity of daily living (FAOS-ADL) in the first evaluation, so this means that ambulation status is a valuable predictor of treatment success immediately and one month after physiotherapy intervention and compared to other FAOS subscales, the FAOS-QOL subscale is a more reliable predictor of the effectiveness of physiotherapy.

Repurposing of Angiotensin-converting-enzyme Inhibitor on Prevention of Post-surgical Tendon Adhesion.

BACKGROUND: Formation of adhesion bands is a frequent clinical complication after tendon injury or surgery with limited treatment options. This study investigates the repurposing of Angiotensin-Converting-Enzyme Inhibitor (ACEI) in attenuating post-operative tendon-sheath adhesion bands in an Achilles tendon rat model. METHODS: Structural, mechanical, histological, and biochemical characteristics of the Achilles tendons were compared in the presence and absence of oral ACEI (enalapril) using the Achilles tendon adhesion (TA) model in rats. Inflammation and total fibrosis of tendon tissues were compared between groups using molecular investigations along with macroscopic and histological scoring methods. RESULTS: ACEI significantly alleviated the severity, length, and density of Achilles TAs. Moreover, histopathological changes, recruitment of inflammatory cells, and inflammation were significantly decreased in post-operative tissue samples as quantified with the Moran scoring model. We showed that ACEI treatment elicits a potent anti-fibrotic effect on tendon tissue samples, as illustrated by decreasing the severity and extent of the formed fibrotic tissue and collagen accumulation at the site of surgery when scored either by Tang or Ishiyama grading systems. The H&E staining showed no histopathological changes or damage to the principal organs. CONCLUSION: Our results showed that ACEI is a safe and effective therapeutic candidate with potent immunomodulatory and anti-fibrotic features to alleviate surgery-induced development of fibrotic adhesive tissue. However, its efficacy needs to be further validated in clinical studies.

Use of Bio-integrative Screws for Fixation of Lisfranc Instability; Pros and Cons from Surgeons' Point of View in a Cadaver Study.

Objectives: Majority of Lisfranc fracture-dislocations require anatomic reduction and rigid internal fixation to prevent debilitating sequelae. Current methods include solid screws and flexible fixations which have been in use for many years. Biointegrative screw is a newer option that has not yet been thoroughly investigated for its effectiveness for Lisfranc injuries. Methods: The ligaments of the Lisfranc complex were resected in eight lower-leg cadaveric specimens. This was done by eight foot and ankle surgeons individually. Distraction forces were applied from opposite sides at the joint to replicate weight bearing conditions. Three methods of fixation - flexible fixation, metal, and biointegrative screws- were evaluated. The diastasis and area at the level of the ligament were measured at four conditions (replicated injury and each type of fixation) in neutral and distraction conditions using fluoroscopy images. The Wilcoxon test and Kruskal Wallis test were used for comparison. P value <0.05 was considered statistically significant. Results: The diastasis value for the transected ligament scenario (2.47 ± 0.51 mm) was greater than those after all three fixation methods without distraction (2.02 ± 0.5 for flexible fixation, 1.72 ± 0.63 mm for metal screw fixation and 1.67 ± 0.77 mm for biointegrative screw fixation). The transected ligament diastasis was also greater than that for metal screw (1.61 ± 1.31mm) and biointegrative screws (1.69 ± 0.64 mm) with distraction (p<0.001). The area at the level of the ligament showed higher values for transected ligament (32.7 ± 13.08 mm2) than the three fixatives (30.75 ± 7.42 mm2 for flexible fixation, 30.75 ± 17.13 mm2 for metal screw fixation and 29.53 ± 9.15 mm2 for biointegrative screw fixation; p<0.05). Conclusion: Metal screws, flexible fixation and biointegrative screws showed comparable effectiveness intra-op, in the correction of diastasis created as a consequence of Lisfranc injury.

Does the postoperative quality of reduction, regardless of the surgical method used in treating a calcaneal fracture, influence patients' functional outcomes?

BACKGROUND: The extensile lateral approach (ELA) and sinus tarsi approach (STA) are commonly utilized for surgically treating calcaneal fractures. This study compared the outcomes of ELA and STA in the management of calcaneal fractures and assessed the influence of postoperative quality of reduction on functional and pain scores. METHODS: The study included 68 adults with Sanders type-II and type-III calcaneal fractures who underwent either ELA or STA surgery. Pre- and postoperative radiographs and computed tomography scans were analyzed, and functional and pain scores were evaluated using the Manchester Oxford Foot Questionnaire (MOXFQ), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and Visual Analogue Score (VAS) during follow-up visits. RESULTS: Out of the total patients, 50 underwent ELA surgery while 18 underwent STA surgery. The anatomic (excellent) reduction was achieved in 33 (48.5%) patients. There were no significant differences between the ELA and STA groups concerning functional scores, pain scores, the proportion of excellent reduction, and complications. Additionally, anatomic reduction, compared to near or non-anatomic (good, fair, or poor) reduction, demonstrated a decrease in MOXFQ (unstandardized ß coefficient: -13.83, 95% CI: -25.47 to -2.19, p = 0.021), an increase in AOFAS (unstandardized ß coefficient: 8.35, 95% CI: 0.31 to 16.38, p = 0.042), and a reduction in VAS pain (unstandardized ß coefficient: -0.89, 95% CI: -1.93 to -0.16, p = 0.095) scores. CONCLUSION: In conclusion, we found no significant differences regarding complications, excellent reduction, and functional scores between STA and ELA surgeries. Therefore, STA may be an effective alternative for the treatment of calcaneal fractures in Sanders type II and type III calcaneal fractures. Furthermore, the anatomic reduction of the posterior facet correlated with improved functional scores, emphasizing the importance of achieving it for restoring foot function regardless of surgery type or time between injury and surgery.

Exploring new therapeutic potentials of curcumin against post-surgical adhesion bands.

BACKGROUND: Adhesion band formation is a common cause of morbidity for patients undergoing surgeries. Anti-inflammatory and anti-fibrotic properties of curcumin, a pharmacologically active component of Curcuma longa, have been investigated in several studies. The aim of this study is to explore the therapeutic potential of curcumin in attenuating post-operative adhesion band (PSAB) formation in both peritoneal and peritendinous surgeries in animal models. METHODS: Bio-mechanical, histological and quantitative evaluation of inflammation, and total fibrosis scores were graded and measured in the presence and absence of phytosomal curcumin. RESULTS: Results showed that phytosomal curcumin significantly decreased severity, length, density and tolerance of mobility of peritendinous adhesions as well as incidence and severity of abdominal fibrotic bands post-surgery. Curcumin may decrease inflammation by attenuating recruitment of inflammatory cells and regulating oxidant/anti-oxidant balance in post-operative tissue samples. Moreover, markedly lower fibrosis scores were obtained in the adhesive tissues of phytosomal curcumin-treated groups which correlated with a significant decrease in quantity, quality and grading of fibers, and collagen deposition in animal models. CONCLUSION: These results suggest that protective effects of phytosomal curcumin against PSAB formation is partially mediated by decreasing inflammation and fibrosis at site of surgery. Further studies are needed to investigate the therapeutic potential of this molecule in preventing PSAB.

Comparing the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability: Randomized controlled trial.

OBJECTIVE: To compare the effects of ankle integral and conventional physiotherapy on pain, range of motion, balance, disability, and treatment effectiveness in patients with chronic ankle instability (CAI). DESIGN: Two-arm, parallel-group, randomized, double-blind, controlled trial. PARTICIPANTS: 60 patients with unilateral CAI. INTERVENTION: integral physiotherapy (n = 30) or conventional physiotherapy (n = 30). OUTCOMES: Visual Analog Scale (VAS), dorsiflexion and plantarflexion range of motion, Star Excursion Balance Test (SEBT), Single Leg Hop (SLH) test, Foot and Ankle Outcome Score (FAOS), Lower Extremity Functional Score (LEFS), global rating of change, were gathered pre and post-intervention. RESULTS: The ANOVA results revealed statistically significant interaction for FAOS, and LEFS outcome measures (P < 0.05) and the mean change results showed there were a favorable clinical difference incline toward the integral group (meanintegral = 20.14 (14.95-25.37), meanConventional = 29.46 (24.09-34.83)). There were no interactions between group and time among other outcome measures (P > 0.05). The group main effect did not show any statistical significance (P > 0.05). CONCLUSION: Hip strengthening and balance exercises added to ankle rehabilitation could be more favorable on improving the patients' functional ability.

Effect of angiotensin II pathway inhibitors on post-surgical adhesion band formation: a potential repurposing of old drugs.

BACKGROUND: In this study we investigated the therapeutic potential of angiotensin II pathway inhibitors in attenuating post-surgical adhesion band formation in tendon injury. METHOD: We assigned 30 Wistar albino rats to 5 groups, including negative control, positive control, sham, Telmisartan- and Enalapril-treated groups (n=6). Telmisartan and Enalapril at a dose of 10 mg/kg were administered intraperitoneally for 21 days. Hematoxylin-Eosin, and Masson's trichrome staining were used to measure the inflammatory cell accumulation and collagen deposition in the Achilles tendon tissue sections. Oxidative stress markers were analyzed in tissue samples by spectrophotometric methods. Properties of Achilles tendon adhesions were compared based on Tang and Ishiyama scoring systems in the presence and absence of angiotensin II pathway inhibitors. RESULTS: Telmisartan and Enalapril reduced severity, length, and density of surgical-induced tendon adhesion at site of injury (***p < 0.001). Our results showed that administration of angiotensin II pathway inhibitors decreased infiltration of inflammatory cells to the injured area (*p < 0.05) and suppressed inflammation by regulating oxidative stress markers including MDA (***p < 0.001), total thiol (***p < 0.001), CAT (***p < 0.001), and SOD (***p < 0.001), in post-operative Achilles tendon tissues. Significant lower collagen deposition and formation of fibrotic tissues was seen in Telmisartan- and Enalapril-treated groups as detected by Masson's trichrome staining which correlated with a decrease in quantity (**p < 0.01) and grading of fibrosis score (***p < 0.001), in adhesive tissues. Moreover, inhibition of angiotensin II pathway could also ameliorate mechanical properties including ultimate load (***p < 0.001), and ultimate stress (*p < 0.05) in injured Tendons. CONCLUSION: Our results showed that ssuppression of inflammation and fibrosis are two mechanisms by which Telmisartan and Enalapril elicit potent protective responses post Achilles tendon injuries.

Visuomotor reaction time difference between patellofemoral pain syndrome and healthy individuals: Cross-sectional study.

OBJECTIVE: Although many studies indicated a decreased reaction time in post-traumatic complaints including ACL injury, no study has been devoted to measure reaction time in patients with patellofemoral pain syndrome (PFPS). The purpose of the present study was to compare the visuomotor reaction time between PFPS and healthy individuals. METHODS: Twenty five patients with PFPS (20 women and 5 men, mean age 29.28 years, SD 5.59) and 25 healthy controls (19 women, 6 men, mean age 29.32, years SD 5.30) were recruited in the present study. The dependent variables were upper extremity reaction time, upper extremity error rate, knee extension reaction time in both involved and non-involved legs, plantar flexion reaction time in both involved and non-involved legs. RESULTS: The results of one-way multiple analysis of variance showed that patients with PFPS had slower upper extremity reaction time (P=0.047, Effect size (ES)=0.39) and plantar flexion reaction time (symptomatic side) (P<0.001, ES=0.77) as compared with healthy control. The symptomatic knee extension reaction time was slower than the healthy matched leg, but this difference was not statistically significant (P=0.296, ES= 0.19). CONCLUSION: The present study suggests that the reaction time might be considered as a factor associated with PFPS.

Metformin inhibits polyphosphate-induced hyper-permeability and inflammation.

Circulating inflammatory factor inorganic polyphosphate (polyP) released from activated platelets could enhance factor XII and bradykinin resulted in increased capillary leakage and vascular permeability. PolyP induce inflammatory responses through mTOR pathway in endothelial cells, which is being reported in several diseases including atherosclerosis, thrombosis, sepsis, and cancer. Systems and molecular biology approaches were used to explore the regulatory role of the AMPK activator, metformin, on polyP-induced hyper-permeability in different organs in three different models of polyP-induced hyper-permeability including local, systemic short- and systemic long-term approaches in murine models. Our results showed that polyP disrupts endothelial barrier integrity in skin, liver, kidney, brain, heart, and lung in all three study models and metformin abrogates the disruptive effect of polyP. We also showed that activation of AMPK signaling pathway, regulation of oxidant/anti-oxidant balance, as well as decrease in inflammatory cell infiltration constitute a set of molecular mechanisms through which metformin elicits it's protective responses against polyP-induced hyper-permeability. These results support the clinical values of AMPK activators including the FDA-approved metformin in attenuating vascular damage in polyP-associated inflammatory diseases.

Comparison of Partially Threaded and Fully Threaded 4mm Cancellous Screws in Fixation of Medial Malleolar Fractures.

BACKGROUND: Several devices have been described for fixation of displaced medial malleolar fractures. Fully threaded cancellous screws engaging the bone may provide advantages compared to partially threaded screws. This study was designed to compare the clinical results of fully and partially threaded 4 millimeter cancellous screws in fixation of medial malleolar fractures. METHODS: In a randomized clinical trial study 44 patients with displaced closed medial malleolar fractures were randomly divided into two groups. Two fully threaded four millimeter cancellous screws were used for fracture stabilization (FT group) in the first group, while, the second group was operated by use of two partially threaded four millimeter cancellous screws (PT group). The clinical outcomes and complications were compared in two groups at one year follow up. RESULTS: Nineteen patients in FT group and 21 in PT group were present at final follow up. Nonunion was not developed in either group but two cases (9%) of delayed union occurred in PT group. The rate of postoperative infection and symptomatic hardware were not statistically different. Functional assessment using AOFAS, MOXFQ and VAS scores showed no significant difference between the two groups. CONCLUSION: Both fully and partially threaded 4 mm cancellous screws can be considered as acceptable devices for the fixation of medial malleolar fractures with good and comparable clinical results.

Novel oral transforming growth factor-ß signaling inhibitor potently inhibits postsurgical adhesion band formation.

Here, we have investigated the therapeutic potency of EW-7197, a transforming growth factor-ß type I receptor kinase inhibitor, against postsurgical adhesion band formation. Our results showed that this pharmacological inhibitor prevented the frequency and the stability of adhesion bands in mice model. We have also shown that downregulation of proinflammatory cytokines, reduce submucosal edema, attenuation of proinflammatory cell infiltration, inhibition of oxidative stress, decrease in excessive collagen deposition, and suppression of profibrotic genes at the site of surgery are some of the mechanisms by which EW-7197 elicits its protective responses against adhesion band formation. These results clearly suggest that EW-7197 has novel therapeutic properties against postsurgical adhesion band formation with clinically translational potential of inhibiting key pathological responses of inflammation and fibrosis in postsurgery patients.

Validation of the Persian Version of the American Orthopedic Foot and Ankle Society Score (AOFAS) Questionnaire.

BACKGROUND: American Orthopedic Foot and Ankle Society Score (AOFAS) is a reliable and reproducible measurement tool which is commonly used for the assessment of foot and ankle conditions. In this study we aimed to translate and assess the psychometric properties of the Persian version of AOFAS questionnaire. METHODS: In this study, we enrolled 53 patients with ankle and hindfoot conditions. Our study was conducted according to five staged cross-cultural adaption steps including translation, synthesis, back translation, expert committee review, and pretesting. After that reliability of the subjective parts calculated by Cronbach's alpha and the intraclass correlation coefficient (ICC) and the reliability of the objective items estimated using Cohen's kappa test. Also, construct validity was assessed by testing the Persian AOFAS against the SF-36 questionnaire. RESULTS: Chronbach's alpha coefficient was 0.696, which was considered acceptable. Furthermore, the test-retest reliability measured by using the ICC for the subjective subscales was 0.853 (P<0.001). The reliability of testing the objective subscales was calculated by using Kappa, which indicated acceptable values. Pearson correlation coefficient between AOFAS and SF-36 was 0.415 (P=0.008). In addition, floor and ceiling effects were calculated 1.9% and 7.5% respectively. CONCLUSION: In our study, Persian translation of AOFAS demonstrated acceptable validity and reliability with no need to be culturally adapted.

Combination of High Tibial Osteotomy and Autologous Bone Marrow Derived Cell Implantation in Early Osteoarthritis of Knee: A Preliminary Study.

BACKGROUND: High tibial osteotomy (HTO) is a recommended treatment for medial compartment knee osteoarthritis. Newer cartilage regenerative procedures may add benefits to the results of HTO. In this prospective study we have investigated the safety and also results of HTO associated with autologous bone marrow derived cells (BMDC) implantation in relatively young and middle aged active individuals with early osteoarthritis of the knee. METHODS: A total of 24 patients (mean age of 47.9 years) with varus knee and symptomatic medial compartment osteoarthritis were treated with medial opening-wedge high tibial osteotomy in conjunction with implantation of bone marrow derived cells into the chondral lesions. The clinical outcomes were assessed by IKDC, KOOS, VAS, and Tegner scores. The radiographic studies were performed preoperatively and at follow-ups. RESULTS: No major complications were seen during the operations and postoperative follow-ups. All clinical scores were significantly improved for the IKDC score (from 32.7±15 to 64±21) (P<0.005), KOOS score (from30±11 to 68±19) (P<0.005), VAS (from 7.5 to 3) and Tegner score (from 1.2 to 2.1) (P<0.004). CONCLUSION: HTO in conjunction with BMDC implantation is a safe and feasible treatment and is associated with good results in short term follow up for early medial compartment osteoarthritis in varus knees.Level of evidence: IV.

Prognostic Factors Affecting the Results of Modified Thompson Quadricepsplasty for the Treatment of Extension Contracture of the Knee.

BACKGROUND: Knee extension contracture is a disabling complication after fractures around the knee. In this study we aimed to study factors influencing the outcomes of quadricepsplasty for the treatment of traumatic knee extension contracture. We hypothesized that there is no factor influencing the final range of knee motion. METHODS: In this retrospective study, we included 64 patients who underwent modified Thompson quadricepsplasty between 2008 to 2011 with a mean follow-up time of 36 months. RESULTS: The mean change in flexion was 66 degrees. Using Judet criteria, results were excellent in 41 patients (64%), good in 15 (23%), fair in 4 (6%) and poor in 4 (6%). Preoperative arc of flexion, duration of extension contracture, number of previous surgeries on the limb, and BMI of the patients were independently influencing the final flexion. CONCLUSION: Modified Thompson quadricepsplasty is associated with high number of excellent and good results especially when it is performed earlier in more severe contractures. Preoperative arc of flexion, interval between trauma surgery and quadricepsplasty, the number of prior surgeries, and BMI influence the outcomes of quadricepsplasty.