Normative contact mechanics of the ankle Joint: Quantitative assessment utilizing bilateral weightbearing CT.

Alterations in ankle's articular contact mechanics serve as one of the fundamental causes of significant pathology. Nevertheless, computationally intensive algorithms and lack of bilateral weightbearing imaging have rendered it difficult to investigate the normative articular contact stress and side-to-side differences. The aims of our study were two-fold: 1) to determine and quantify the presence of side-to-side contact differences in healthy ankles and 2) to establish normative ranges for articular ankle contact parameters. In this retrospective comparative study, 50 subjects with healthy ankles on bilateral weight-bearing CT were confirmed eligible. Segmentation into 3D bony models was performed semi-automatically, and individualized cartilage layers were modelled based on a previously validated methodology. Contact mechanics were evaluated by using the mean and maximum contact stress of the tibiotalar articulation. Absolute and percentage reference range values were determined for the side-to-side difference. Amongst a cohort of individuals devoid of ankle pathology, mean side-to-side variation in these measurements was < 12 %, while respective differences of > 17 % talar peak stress and > 31 % talar mean stress indicate abnormality. No significant differences were found between laterality in any of the evaluated contact parameters. Understanding these values may promote a more accurate assessment of ankle joint biomechanics when distinguishing acceptable versus pathological contact mechanics in clinical practice.

Automation improves the efficiency of weightbearing CT scan 3D volumetric assessments of the syndesmosis.

BACKGROUND: Weight-bearing CT (WBCT) 3D volumetric measurement has shown promising accuracy for the diagnosis of syndesmotic instability. However, these measurements are rather complex and time-consuming, rendering them a clinically unfavorable option. We hypothesized that automatized measurements would be more accurate and time-efficient than manual ones. METHODS: Thirty cases of intraoperatively confirmed syndesmotic instability along with thirty individuals with no injuries to the ankle joint were recruited as cases and controls, retrospectively. Two observers conducted the manual volumetric measurements two times, at a one-week interval. An automated algorithm for 3D WBCT measurements was developed to conduct the measurements on the axial images. The time spent on each method was recorded. Mann-Whitney U test was used to compare the values between human raters and computers. Inter- and intra-class reliability were calculated. RESULTS: The intra-class correlation coefficient was found to be "excellent" for the automated measurements (0.97) and "good" for the observers (0.75). Similarly, the Cronbach's alpha was shown to be higher for the computer (0.88) than the observers (0.60 and 0.62). The mean time spent on the measurements was different between human raters and the computer-assisted method (p < 0.001). CONCLUSION: Automated volumetric assessment of syndesmosis seems to be a faster and more reliable option than the manual one. We suggest future larger-scale prospective studies conducted under actual clinical circumstances for more definitive conclusions. LEVEL OF EVIDENCE: Retrospective case-control study - Level 3.

Role of insole material in treatment of plantar fasciitis: A randomized clinical trial.

BACKGROUND: In this randomized clinical trial, we compared the early effects of polyethylene (PE), polyurethane (PU), and Carbon Fiber insoles in the treatment of PF using a set of patient-reported outcomes. METHODS: Patients were randomly allocated one of the three prefabricated insoles - Carbon Fiber (n = 14), PU (n = 14), or PE (n = 17) for regular use. Their response was recorded using PROMIS 3a (for pain intensity), PROMIS 4a (for pain interference), FAOS (Foot and Ankle Outcome Score), and VAS for pain at baseline, two, six, and twelve weeks. RESULTS: The PROMIS pain intensity scores improved in both the Carbon Fiber and the PE groups starting at the 6th week (p = 0.04) and 2nd week (p = 0.002), respectively. PROMIS pain interference scores also showed positive trends in these two groups (p = 0.02, p = 0.004, respectively). CONCLUSION: Prefabricated Carbon Fiber and PE insoles showed significant pain-reducing effects in patients with PF. LEVELS OF EVIDENCE: Level I, Randomized controlled trial.

Unveiling Syndesmotic Malreduction: A Proof-of-Concept towards Portable Ultrasound Detection.

Objectives: To evaluate the utility and diagnostic performance of portable handheld ultrasound for evaluating fibular rotation at the distal tibiofibular articulation after syndesmotic disruption. Methods: Four above-the-knee cadaveric specimens were included. Syndesmotic disruption was precipitated by transecting the Anterior Inferior Tibiofibular Ligament, Interosseous Ligament, and Posterior Inferior Tibiofibular Ligament. Thereafter, a proximal fibular osteotomy was performed, and three conditions were modeled at the distal syndesmosis: 1) reduced, 2) 5 degree internal rotation malreduction, and 3) 5 degree external rotation malreduction. Two blinded observers performed separate ultrasonographic examinations for each condition at the level of both the anterior and posterior distal tibiofibular articular surfaces. Syndesmotic gap penetrance, defined as the ability of the P-US to generate signal between the distal fibula and tibia at the level of the incisura, was graded positive if the sonographic waves penetrated between the distal tibiofibular joint and negative if no penetrating waves were detected. The accuracy measures of the anterior and posterior gap penetrance were evaluated individually. Results: Our preliminary results showed that posterior gap penetrance showed good performance when detecting either internal or external rotational malreduction of the fibula with very good specificity (87.5%) and PPV (90.0%). On the other hand, the anterior gap penetrance showed limited performance when detecting either form of rotational malreduction. Conclusion: We introduced a novel sign, the "gap penetrance sign", best measured from the posterior ankle, which can accurately detect syndesmotic malreduction using P-US in a manner that does not require specific quantitative measurements and is readily accessible to early P-US users.

Case Report: Portable handheld ultrasound facilitates intra-articular injections in articular foot pathologies.

Background: Intra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies. Methods: A retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant. Results: We included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study. Conclusion: This pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis.

BACKGROUND: Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. METHODS: Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. RESULTS: A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. CONCLUSION: NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Stromal cell derived factor-1, CXCR4 and CXCR7 gene transcripts in pterygia.

PURPOSE: Pterygium is a pathologic process with angiogenic and tumor cell like characteristics. Chemokine and chemokine receptors may contribute to the formation and growth of pterygia. The aim of this study was to assess the expression of stromal cell derived factor (SDF)-1, as an angiogenic chemokine, and its receptors, CXCR4 and CXCR7, gene transcripts in pterygia. METHODS: RNA was extracted from tissue samples of 33 patients with primary pterygium and 35 volunteers with conjunctiva as the control group. Then the mRNA expression of SDF-1, CXCR4, and CXCR7 was assessed through quantitative Real Time PCR method using appropriate primers. RESULTS: SDF-1 and both receptors transcripts had significantly higher expression in pterygia samples compared to the control group (P < 0.05). The ratio of CXCR7 transcript expression to CXCR4 was 26.4 in patients while it was 11 in controls. CONCLUSION: As SDF-1 and its receptors, CXCR4 and CXCR7, were up-regulated in pterygia, SDF-1/CXCR4/CXCR7 axis may contribute to pterygium formation which can be possibly restrained by down-regulating this signaling pathway.