Posterior ankle impingement disguised as peroneal tendon subluxation in young athletes – a case report

Posterior ankle impingement is a cause of posterior ankle pain common in those who perform frequent plantarflexion activities. Three young patients presented with posterior ankle pain which was initially attributed to peroneal tendon subluxation. However, detailed physical exam and imaging confirmed the diagnosis of posterior ankle impingement as the actual cause of pain. The peroneal tendon subluxation was not causal but an unrelated co-incidental finding. After failed prolonged conservative management (rest, immobilization and physical therapy), the patients underwent posterior ankle arthroscopic debridement for the impingement resulting in return to prior sporting activity without limitation and no recurrence of pain at 19 months follow-up. Posterior ankle impingement diagnosis could be masked by co-incidental asymptomatic peroneal tendon subluxation in pediatric patients.     

Treatment of calcaneal fractures: the available evidence

Abstract Calcaneal fracture is the most common of the tarsal fractures and represents 1%–2% of all fractures. The fractures may be divided into extra-articular (not affecting the joint) and intra-articular (involving the talo-calcaneal and calcaneal cuboid joints) types. The management of heel fractures includes nonoperative and operative treatments, but no clear consensus has been reached. The choice of operative treatment is still controversial with many factors influencing the final clinical outcome. Many studies have assessed the outcome of treatment of calcaneal fractures, but there is a general disagreement on their management. The objective of this study was to collect and evaluate the scientific evidence reported in the literature supporting the different treatments for calcaneal fractures.     

Benefits of arthroscopic tuberculoplasty in posterior ankle impingement syndrome

The purpose of this work was to describe the posterior ankle impingement syndrome related to the posterolateral tubercle of the talus bone and to present a retrospective analysis of our results after arthroscopic plasty of the tubercle in 15 ankles with a mean 3-year follow-up. Fifteen cases of posterior ankle impingement (PAI) underwent arthroscopic excision of an impinging bone spur. All the patients (13) were retrospectively evaluated at an average of 36 months after index surgery. There were seven women (bilateral in two of them) and six men. Ten were involved in different kinds of sport and three were professional ballet dancers. Preoperative symptoms included pain localized in the posterior ankle, limitation of motion, weakness and swelling. All patients had failed a course of conservative therapies. Surgery was performed through posterolateral and posteromedial portals as described by van Dijk. After soft tissue debridement, partial resection of the posterolateral process was performed until there was complete plantar flexion without bone impingement. Postoperatively, all patients followed the same rehabilitation protocol. Improvement in their impingement symptoms was recorded in all of them according to AOFAS score. One of them (7%) still had occasional discomfort. The results suggest that arthroscopic bone decompression of the posterolateral tubercle in cases of PAI resistant to non-surgical therapies is an effective treatment.     

Radiology of postnatal skeletal development

The development of the second cervical vertebra is complex. The dens (odontoid process) develops two primary ossification centers that usually coalesce within three months following birth. These centers are separated from the primary ossification center of the vertebral centrum by a cartilaginous region—the dentocentral synchondrosis. This synchondrosis is a slow growing, bipolar physis similar to the triradiate catilage of the acetabulum. It contributes to the overall heights of both the dens as well as the vertebral body. Anatomically the dentocentral synchondrosis is below the level of the C1–C2 articulations. This cartilaginous structure is continuous throughout the vertebral body with similar cartilage in both the facet regions as well as the neurocentral synchondroses. These various carulaginous continuities progressively close—first, the connections to the facet regions, next the neurocentral synchondroses, and finally the dentocentral synchondrosis. Remnants of the incompletely closed dentocentral synchondrosis must be distinguished from a fracture, which usually propagates along this structure as a physeal injury in infants and children. The cartilaginous epiphysis at the tip of the dens may be transverse or may form a cleft (V) shape. At eight to ten years, a secondary ossification center—the ossiculum terminale—develops in this proximal dens epiphysis. Fusion of the ossiculum terminale with the rest of the dens occurs between ten and thirteen years.     

Ultrasound Densitometry of the Os Calcis in Patients with Hemiparesis Following a Cerebrovascular Accident

Ultrasound densitometry has been measured in the os calcis of 31 stroke patients (14 women, 17 men), ages 46–87 years, to determine whether bone density is lower than expected for normal subjects at this site, and to investigate whether or not the stroke side has lower values than the nonstroke side. We have also measured a large control group of 268(39 men, 228 women) subjects who showed similar values to other published data. Immobility is a known precursor to bone loss and so we also compared ultrasound Stiffness Index with an index of mobility in 22 of the stroke patients. In healthy subjects, ultrasound densitometry (measured as Stiffness) fell by 25% in females from 48–52 to 68–72 years. Stiffness (expressed as z-score) in patients with stroke was low in females (P < 0.02) but not in males, but both stroke side and nonstroke side were equally low. Stiffness did not decline with time since stroke, but did correlate with mobility after stroke, on the stroke (r = 0.73) and nonstroke (r = 0.62) side. The data suggest that stroke patients, particularly females, have low bone density before the stroke event. The greater ultrasound Stiffness with increasing mobility after stroke may suggest that active rehabilitation after stroke may produce denser bone. Received: 30 July 1997 / Accepted: 10 June 1999     

药用浮石与浮海石品种探讨

就药用浮石与浮海石的品种通过对古代、现代有关本草的考证比较进行研究和整理，认定浮石为火成岩类岩石的块状物，浮海石为胞孔科动物脊突苔虫和瘤苔虫的干燥骨骼，为澄清混乱，确保临床合理用药提供了理论依据。     

海螵蛸对骨愈合相关基因表达的影响

为揭示中药海螵蛸在骨折愈合过程中的干预作用,了解海螵蛸的调节靶点,探索建构中药基因组学的途径.通过在大鼠胫骨打孔的方法建立单因素干扰模型,在不同时间点采用原位杂交方法对各类mRNA的变化进行动态观察骨愈合过程中Ⅰ、Ⅱ、Ⅲ型前胶原mRNA、转化生长因子(TGG)-β1 mRNA、骨形态发生蛋白(BMP)-2mRNA、血管内皮生长因子(VEGF) mRNA表达情况.结果显示,海螵蛸在骨折早期对Ⅰ、Ⅲ型前胶原mRNA、VEGFmRNA、BMP-2mRNA的表达升高,而对Ⅱ型前胶原mRNA、TGF-β1 mRNA的表达量无明显影响;但达到峰值后,Ⅱ、Ⅲ型前胶原mRNA表达水平下降,VEGFmRNA、TGF-β1mRNA表达量中后期维持于较高水平.表明海螵蛸与血管形成有关,对骨折软骨形成早期具有促进骨诱导的作用,并对成骨细胞的增殖及合成活性有较大影响.     

The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: A cadaveric study

BackgroundArthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient. This study aims at evaluation of the safety of portal establishment and instrumentation of this technique.MethodsSixteen fresh-frozen cadaver specimens were used. The relationships of the posteromedial and posterolateral portals to the adjacent tendons and nerves and the relationship of the coaxial portal tract with the posterior ankle capsule and the flexor hallucis longus tendon were studied.ResultAngle θ₁ between the intermalleolar line and the posterior ankle coaxial portal tract averaged 1° (−10° to 22°). Angle θ₂ between the intermalleolar line and the metal rod where the neurovascular bundle started to move averaged 19° (10° to 30°). Angle θ₃ between the intermalleolar line and the metal rod where it reached the lateral border of the Achilles tendon was larger than angle θ₂ in all specimens. The angle of safety (θ_s) averaged 18° (−1° to 26°).ConclusionsInjury to the tendon, nerves or vessels is possible during establishment of the portals and resection of the os trigonum.     

Endocrinology of bone mineralization: An update

Throughout the world, millions of people suffer from fragilizing osteopathies such as osteomalacia and osteoporosis. Osteomalacia is a rare disorder, corresponding to mineralization abnormalities in adult bone, as opposed to rickets in children. Renal phosphate loss and hypophosphatasia are the main causes of vitamin-resistant osteomalacia. Diagnosis is based on clinical history, phosphocalcic metabolism assessment and, if necessary, molecular characterization, and must be rapid in order to initiate the most appropriate treatment and consider new treatments such as burosumab if necessary. Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fracture. Fracture-related burden is expected to increase over the coming decades linked to the aging of population and a treatment gap. In order to reduce this treatment gap, it is important to develop two strategies: improvement of screening and of treatment. Systematic screening using the FRAX® fracture risk assessment tool could be useful to increase anti-osteoporosis medical treatment and reduce fracture rates. The question of treatment sequencing in osteoporosis is another challenge, notably after denosumab cessation, complicated by a decrease in bone mineral density and increased risk of fracture. New treatments are also available, including romosozumab, a humanized monoclonal antibody, which promotes bone formation and inhibits bone resorption by inhibiting sclerostin. Romosozumab is approved in several countries, including France, for treating severe osteoporosis in postmenopausal women at high risk of fracture and free of cardiovascular comorbidity. Endocrinologists need to be aware of these fragilizing osteopathies in order to improve both diagnosis and treatment.