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Abstract We describe a rare case of angioleiomyoma in the foot of a middle‐aged man.

Abstract Background Inversion ankle sprains, or lateral ankle sprains, often result in symptomatic lateral ankle instability, and some patients need lateral ankle ligament reconstruction to reduce pain, improve function, and prevent subsequent injuries. Although anatomically reconstructed ligaments should behave in a biomechanically normal manner, previous studies have not measured the strain patterns of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) after anatomical reconstruction. This study aimed to measure the strain patterns of normal and reconstructed ATFL and CFLs using the miniaturization ligament performance probe (MLPP) system. Methods The MLPP was sutured into the ligamentous bands of the ATFLs and CTLs of three freshly frozen cadaveric lower-extremity specimens. Each ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N m force was applied to the ankle and subtalar joint complex. Results The normal and reconstructed ATFLs exhibited maximal strain (100) during supination in three-dimensional motion. Although the normal ATFLs were not strained during pronation, the reconstructed ATFLs demonstrated relative strain values of 16–36. During the axial motion, the normal ATFLs started to gradually tense at 0° plantar flexion, with the strain increasing as the plantar flexion angle increased, to a maximal value (100) at 30° plantar flexion; the reconstructed ATFLs showed similar strain patterns. Further, the normal CFLs exhibited maximal strain (100) during plantar flexion-abduction and relative strain values of 30–52 during dorsiflexion in three-dimensional motion. The reconstructed CFLs exhibited the most strain during dorsiflexion-adduction and demonstrated relative strain values of 29–62 during plantar flexion-abduction. During the axial motion, the normal CFLs started to gradually tense at 20° plantar flexion and 5° dorsiflexion. Conclusion Our results showed that the strain patterns of reconstructed ATFLs and CFLs are not similar to those of normal ATFLs and CFLs.

Abstract Background Measuring the strain patterns of ligaments at various joint positions informs our understanding of their function. However, few studies have examined the biomechanical properties of ankle ligaments; further, the tensile properties of each ligament, during motion, have not been described. This limitation exists because current biomechanical sensors are too big to insert within the ankle. The present study aimed to validate a novel miniaturized ligament performance probe (MLPP) system for measuring the strain patterns of the anterior talofibular ligament (ATFL) during ankle motion. Methods Six fresh-frozen, through-the-knee, lower extremity, cadaveric specimens were used to conduct this study. An MLPP system, comprising a commercially available strain gauge (force probe), amplifier unit, display unit, and logger, was sutured into the midsubstance of the ATFL fibers. To measure tensile forces, a round, metal disk (a “clock”, 150 mm in diameter) was affixed to the plantar aspect of each foot. With a 1.2-Nm load applied to the ankle and subtalar joint complex, the ankle was manually moved from 15° dorsiflexion to 30° plantar flexion. The clock was rotated in 30° increments to measure the ATFL strain detected at each endpoint by the miniature force probe. Individual strain data were aligned with the neutral (0) position value; the maximum value was 100. Results Throughout the motion required to shift from 15° dorsiflexion to 30° plantar flexion, the ATFL tensed near 20° (plantar flexion), and the strain increased as the plantar flexion angle increased. The ATFL was maximally tensioned at the 2 and 3 o’clock (inversion) positions (96.0 ± 5.8 and 96.3 ± 5.7) and declined sharply towards the 7 o’clock position (12.4 ± 16.8). Within the elastic range of the ATFL (the range within which it can return to its original shape and length), the tensile force was proportional to the strain, in all specimens. Conclusion The MLPP system is capable of measuring ATFL strain patterns; thus, this system may be used to effectively determine the relationship between limb position and ATFL ankle ligament strain patterns.

Abstract Background There are few reports on the detailed biomechanics of the deltoid ligament, and no studies have measured the biomechanics of each ligamentous band because of the difficulty in inserting sensors into the narrow ligaments. This study aimed to measure the strain pattern of the deltoid ligament bands directly using a Miniaturization Ligament Performance Probe (MLPP) system. Methods The MLPP was sutured into the ligamentous bands of the deltoid ligament in 6 fresh-frozen lower extremity cadaveric specimens. The strain was measured using a round metal disk (clock) fixed on the plantar aspect of the foot. The ankle was manually moved from 15° dorsiflexion to 30° plantar flexion, and a 1.2-N-m force was applied to the ankle and subtalar joint complex. Then the clock was rotated every 30° to measure the strain of each ligamentous band at each endpoint. Results The tibionavicular ligament (TNL) began to tense at 10° plantar flexion, and the tension becomes stronger as the angle increased; the TNL worked most effectively in plantar flex-abduction. The tibiospring ligament (TSL) began to tense gradually at 15° plantar flexion, and the tension became stronger as the angle increased. The TSL worked most effectively in abduction. The tibiocalcaneal ligament (TCL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased. The TCL worked most effectively in pronation (dorsiflexion-abduction). The superficial posterior tibiotalar ligament (SPTTL) began to tense gradually at 0° dorsiflexion, and the tension became stronger as the angle increased, with the SPTTL working most effectively in dorsiflexion. Conclusion Our results show the biomechanical function of the superficial deltoid ligament and may contribute to determining which ligament is damaged during assessment in the clinical setting.

Open anatomic reconstruction of the lateral ligament (AntiRoLL) of the ankle with a gracilis Y graft and the inside-out technique are commonly used and have evolved to minimally invasive surgery, including arthroscopic AntiRoLL (A-AntiRoLL) and percutaneous AntiRoLL procedures. A-AntiRoLL allows assessment and treatment of intra-articular pathologies of the ankle concurrently with stabilization. However, the A-AntiRoLL technique is technically demanding, especially in the process of calcaneofibular ligament reconstruction under subtalar arthroscopy. In contrast, the percutaneous AntiRoLL procedure is a simple concept that does not require the skill of an experienced arthroscopist but requires an extra skin incision to assess and treat intra-articular pathologies of the ankle. This study describes the application of a minimally invasive anatomic reconstruction technique—hybrid AntiRoLL—for chronic instability of the ankle that does not require advanced arthroscopic technique to assess and treat intra-articular pathology simultaneously.

Bilateral chronic Achilles tendon rupture is a rare condition which is commonly associated with a predisposing factor such as long-term steroid therapy. Treatment of such patients requires special consideration since tendon fibers are usually weak due to steroid therapy and tendon ends are retracted. However, no consensus is available regarding the optimal surgical procedure. Ambulation after surgery is another problem; according to the literature, patients usually wore casts bilaterally and were kept non-weight bearing for several weeks after surgery, which means patients were usually not able to walk for several weeks after surgery. We present the case of bilateral chronic Achilles tendon ruptures in a patient on steroid therapy, which provided achievement of a good functional outcome with 1-year follow up through Achilles tendon reconstruction and early functional rehabilitation. This rehabilitation included starting to walk the day after surgery using patellar tendon bearing braces with wedges.

Ankle instability is a condition that often requires surgery to stabilize the ankle joint that will improve pain and function if nonoperative treatments fail. Ankle stabilization surgery may be performed as a repair in which the native existing anterior talofibular ligament or calcaneofibular ligament (or both) is imbricated or reattached. Alternatively, when native ankle ligaments are insufficient for repair, a reconstruction of the ligaments may be performed in which an autologous or allograft tendon is used to reconstruct the anterior talofibular ligament or calcaneofibular ligament (or both). Currently, ankle stabilization surgery is most commonly performed through an open incision, but arthroscopic ankle stabilization using repair techniques has been described and is being used more often. We present our technique for anatomic ankle arthroscopic reconstruction of the lateral ligaments (anti-ROLL) performed in an all–inside-out manner that is likely safe for patients and minimally invasive.

Recently, surgical treatment of a symptomatic unicameral cyst of the proximal femur has been achieved with less invasive procedures than traditional open curettage with an autologous bone graft. In this article we introduce endoscopic surgery for a symptomatic unicameral cyst of the proximal femur. The presented technique, which includes minimally invasive endoscopic curettage of the cyst and injection of a bone substitute, not only minimizes muscle damage around the femur but also enables sufficient curettage of the fibrous membrane in the cyst wall and the bony septum through direct detailed visualization by an endoscope. Furthermore, sufficient initial strength after curettage can be obtained by injecting calcium phosphate cement as a bone substitute.

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 "Subchondral Pathology" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Methods: Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 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 characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results: A total of 9 statements on subchondral pathology reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. No statements achieved unanimous support, but all statements reached strong consensus (greater than 75% agreement). All statements reached at least 81% agreement. Conclusions: This international consensus statements regarding subchondral pathology of the talus derived from leaders in the field will assist clinicians in the assessment and management of this difficult pathology. [ABSTRACT FROM AUTHOR]

Background: Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace. Methods: We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot. Results: Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks. Conclusion: The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

The torque of the bacterial flagellum is generated by the rotor-stator interaction coupled with the ion flow through the channel in the stator. Anchoring the stator unit to the peptidoglycan layer with proper orientation around the rotor is believed to be essential for smooth rotation of the flagellar motor. The stator unit of the sodium-driven flagellar motor of Vibrio is composed of PomA and PomB, and is thought to be fixed to the peptidoglycan layer and the T-ring by the C-terminal periplasmic region of PomB. Here, we report the crystal structure of a C-terminal fragment of PomB (PomBc) at 2.0-A resolution, and the structure suggests a conformational change in the N-terminal region of PomBc for anchoring the stator. On the basis of the structure, we designed double-Cys replaced mutants of PomB for in vivo disulfide cross-linking experiments and examined their motility. The motility can be controlled reproducibly by reducing reagent. The results of these experiments suggest that the N-terminal disordered region (121-153) and following the N-terminal two-thirds of α1 (154-164) in PomBc changes its conformation to form a functional stator around the rotor. The cross-linking did not affect the localization of the stator nor the ion conductivity, suggesting that the conformational change occurs in the final step of the stator assembly around the rotor. [ABSTRACT FROM AUTHOR]

Abstract Objective  The purpose of this study was to clarify the efficacy of stress radiography (stress X-P), ultrasonography (US), and magnetic resonance (MR) imaging in the detection of the anterior talofibular ligament (ATFL) injury. Methods  Thirty-four patients with ankle sprain were involved. In all patients, Stress X-P, US, MR imaging, and arthroscopy were performed. The arthroscopic results were considered to be the gold standard. The imaging results were compared with the arthroscopic results, and the accuracy calculated. Results  Arthroscopic findings showed ATFL injury in 30 out of 34 cases. The diagnosis of ATFL injury with stress X-P, US, MR imaging were made with an accuracy of 67, 91 and 97%. US and MR imaging demonstrated the same location of the injury as arthroscopy in 63 and 93%. Conclusion  We have clarified the diagnostic value of stress X-P, US, and MR imaging in diagnosis of ATFL injury. We obtained satisfactory results with US and MR imaging. [ABSTRACT FROM AUTHOR]

Background: Few anatomical and minor invasive procedures have been reported for surgical reconstruction of the lateral ligaments to treat lateral instability of the ankle. Furthermore, there are no standards according to which ligaments should be recon- structed. Hypothesis: A new technique for anatomically reconstructing the lateral ligaments of the ankle using an interference fit anchoring system and determining which ligaments need to be reconstructed according to the results of standard stress radiography of the talocrural and subtalar joints will be effective for treating lateral instability of the ankle. Study Design: Case series; level of evidence, 4. Methods: Twenty-one patients with lateral instability of the ankle underwent surgery using the proposed interference fit anchor- ing system. Standard stress radiographs of the subtalar joint were performed, and if the talocalcaneal angle was less than 100, only the anterior talofibular ligament was reconstructed; if there was a 10° or greater opening of the talocalcaneal angle, both the anterior talofibular ligament and the calcaneofibular ligament were reconstructed. Results: In the 17 patients who received only the anterior talofibular ligament reconstruction, the mean talar tilt angle on standard stress radiography of the talocrural joint was 14.5° ± 1.7° before surgery and 2.6° ± 0.8° 2 years after surgery (Pc .0001). For the 4 patients who had both the anterior talofibular ligament and calcaneofibular ligament reconstructed, the mean talar tilt angle was 16.5° ± 1.5° before surgery and 3.0° ± 0.5° 2 years after surgery (P = .0015). The overall mean talocalcaneal angle on standard stress radiography of the subtalar joint was 11.30± 1.40 before surgery and 3.5° ± 0.8° 2 years after surgery (P = .0060). Conclusion: The proposed system has several advantages, including anatomical reconstruction with normal stability and range of motion restored, the need for only a small incision during the reconstruction, and sufficient strength at the tendon graft-bone tunnel junction, in comparison with the tension strength of the lateral ligaments of the ankle. [ABSTRACT FROM AUTHOR]

Background: After ankle sprain, there can be many causes of disability, the origins of which cannot be determined using standard diagnostic tools. Hypothesis: Ankle arthroscopy is a useful tool in identifying intra-articular disorders of the talocrural joint in cases of residual ankle disability after sprain. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The authors gathered the independent diagnostic results of physical examination, standard mortise and lateral radiography, stress radiography of the talocrural joint, and magnetic resonance imaging for 72 patients with residual ankle disability lasting more than 2 months after injury (mean, 7 months after injury). They performed arthroscopic procedures and compared the double-blind results. Results: In all cases, the arthroscopic results matched those of other means of diagnosis. In 14 cases, the arthroscopic approach exceeded the capabilities of the other methods. including duplications, 39 patients (54.2%) had anterior talofibular ligament injuries, 17 patients (23.6%) had distal tibiofibular ligament injuries, 29 patients (40.3%) had osteochondral lesions, 13 patients (18%) had symptomatic os subfibulare, 3 patients (4.2%) had anterior impingement exostosis, and 3 patients (4.2%) had impingement due to abnormally fibrous bands. There were only 2 cases in which the cause of symptoms could not be detected by ankle arthroscopy, compared with 16 cases in which the cause of disability could not be detected using standard methods. In 3 cases (17.6%) of distal tibiofibular ligament injuries, 8 cases (27.6%) of osteochondral lesions, and all 3 cases (100%) of impingement of an abnormal fibrous band, ankle arthroscopy was the only method capable of diagnosing the cause of residual ankle pain after a sprain. Conclusion: The present results suggest that arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic examination has shown that the regenerative cartilage that appears after arthroscopic drilling for the treatment of osteochondral lesions of the talar dome does not always cover the cartilage defect sufficiently. Hypothesis: The remaining degenerative cartilage at the lesions may obstruct the healing of the articular cartilage. Study Design: Prospective cohort study. Methods: Thirty-nine patients underwent arthroscopic drilling that kept the remaining cartilage at the lesion (group A), and 30 patients underwent arthroscopic drilling that removed the remaining cartilage at the lesion (group B). At 1 year after the operation, we performed ankle arthroscopy to evaluate the cartilage condition. Results: The arthroscopic findings revealed that in group A, 11 cases (28.2%) were improved, 12 cases (30.8%) were unchanged, and 16 cases (41.0%) had deteriorated; in group B, 27 cases (93.1%) were improved and 2 cases were unchanged. There were significant differences between group A and group B in the rate of cases whose cartilage condition was seen to improve under arthroscopic examination (P < 0.0001). Conclusions: The study shows that in the treatment of osteochondral lesions of the talar dome, the removing of the remaining degenerative cartilage may be of some benefit in the treatment of these lesions. [ABSTRACT FROM AUTHOR]

Ankle sprains are common musculoskeletal injuries, with approximately 27,000 occurring every day in the U.S. alone. The anterior talofibular ligament (ATFL) is the most commonly injured ligament. Although most acute lateral ankle sprains can be treated conservatively, up to 20% of these injuries result in chronic lateral ankle instability and may require surgical stabilization. Recently, an arthroscopic lateral ankle ligament repair technique has become increasingly popular. This minimally invasive procedure is expected to reduce postoperative pain and promote faster recovery. The current article presents an ATFL repair using a 2-portal, non-distraction arthroscopic technique. Chronic lateral ankle instability refractory to physical therapy for 3 to 6 months is the main indication for surgical treatment, and sufficient quality of ligament tissue remnant is required for arthroscopic repair. Compared with an open procedure, equivalent clinical results and earlier recovery following arthroscopic ATFL repair have been reported. The major steps of the procedure, demonstrated in this video article, are (1) placement of portals for the arthroscopic procedure, (2) suture anchor insertion into the distal aspect of the fibula, (3) needle insertion into the ATFL remnant, (4) a lasso-loop stitch using a suture relay technique, (5) reattachment of the ATFL remnant, and (6) postoperative protocol. Complications are rare, and earlier return to daily activities compared with a standard open technique can be achieved. [ABSTRACT FROM AUTHOR]