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1.  Medial swivel dislocation of the talonavicular joint 
Indian Journal of Orthopaedics  2009;43(1):87-89.
Medial swivel dislocation, a variant of subtalar dislocation is uncommon. A 35 years old male presented after 6 weeks old injury to left ankle following motor cycle accident. He had pain, swelling around ankle and was unable to bear weight on left foot. Clinical examination revealed diffuse swelling and tenderness in mid foot region. His plain X rays and CT scan showed talonavicular dislocation with compression defect of the head of the talus. He was treated by open reduction and K-wire fixation. At 32 months follow up foot was painless, stable with normal range of ankle and subtalar motion.
PMCID: PMC2739503  PMID: 19753187
Medial swivel dislocation; subtalar-subluxation; talonavicular dislocation
2.  Direction of the oblique medial malleolar osteotomy for exposure of the talus 
A medial malleolar osteotomy is often indicated for operative exposure of posteromedial osteochondral defects and fractures of the talus. To obtain a congruent joint surface after refixation, the oblique osteotomy should be directed perpendicularly to the articular surface of the tibia at the intersection between the tibial plafond and medial malleolus. The purpose of this study was to determine this perpendicular direction in relation to the longitudinal tibial axis for use during surgery.
Materials and methods
Using anteroposterior mortise radiographs and coronal computed tomography (CT) scans of 46 ankles (45 patients) with an osteochondral lesion of the talus, two observers independently measured the intersection angle between the tibial plafond and medial malleolus. The bisector of this angle indicated the osteotomy perpendicular to the tibial articular surface. This osteotomy was measured relative to the longitudinal tibial axis on radiographs. Intraclass correlation coefficients (ICC) were calculated to assess reliability.
The mean osteotomy was 57.2 ± 3.2° relative to the tibial plafond on radiographs and 56.5 ± 2.8 on CT scans. This osteotomy corresponded to 30.4 ± 3.7° relative to the longitudinal tibial axis. The intraobserver (ICC, 0.90–0.93) and interobserver (ICC, 0.65–0.91) reliability of these measurements were good to excellent.
A medial malleolar osteotomy directed at a mean 30° relative to the tibial axis enters the joint perpendicularly to the tibial cartilage, and will likely result in a congruent joint surface after reduction.
PMCID: PMC3117279  PMID: 21165631
Medial malleolus; Osteotomy; Ankle; Radiography; Preoperative planning; Surgical approach
3.  Ankle reconstruction in type II fibular hemimelia 
Ankle reconstruction prior to limb lengthening for was performed in 13 patients with fibular hemimelia with complete radiological absence of the fibula (type II). There were different degrees of absence of metatarsal rays. The hindfoot deformity was a heel valgus in 12 patients and equinovarus in 1 patient. The patients’ ages ranged from 9 to 26 months. Excision of the fibular anlage was performed with lateral subtalar and ankle soft tissue releases to restore the ankle and subtalar joint relationships. In all cases, the fibular anlage ended distally in a cartilaginous lateral malleolar remnant that was fused to the talus in two patients. This fibular remnant was advanced distally and fixed to the tibia with 2 Kirschner wires to recreate an ankle mortise. The period of follow-up ranged from 12 to 38 months. All patients had a stable ankle without tendency to valgus deformity or subluxation. The ankle range of movement was a mean of 27.3° plantarflexion (25–30) and 18° dorsiflexion (15–20). Reconstruction of the ankle in type II fibular hemimelia using advancement of the cartilaginous lateral malleolar remnant has produced encouraging results in the short-term but longer follow-up is needed.
PMCID: PMC3332325  PMID: 22434224
Fibular hemimelia; Ankle reconstruction
4.  Searching for Hidden, Painful Osteochondral Lesions of the Ankle in Patients with Chronic Lower Limb Pain - Two Case Reports - 
The Korean Journal of Pain  2013;26(2):164-168.
It is easy to overlook osteochondral lesions (OCLs) of the ankle in patients with chronic lower limb pain, such as complex regional pain syndrome (CRPS) or thromboangiitis obliterans (TAO, Buerger's disease). A 57-year-old woman diagnosed with type 1 CRPS, and a 58-year-old man, diagnosed with TAO, complained of tactile and cold allodynia in their lower legs. After neurolytic lumbar sympathethic ganglion block and titration of medications for neuropathic pain, each subject could walk without the aid of crutches. However, they both complained of constant pain on the left ankle during walking. Focal tenderness was noted; subsequent imaging studies revealed OCLs of her talus and his distal tibia, respectively. Immediately after percutaneous osteoplasties, the patients could walk without ankle pain. It is important to consider the presence of a hidden OCL in chronic pain patients that develop weight-bearing pain and complain of localized tenderness on the ankle.
PMCID: PMC3629344  PMID: 23614079
ankle; cementoplasty; complex regional pain syndrome; osteochondritis dissecans; thromboangiitis obliterans
5.  The Anatomy and Mechanisms of Syndesmotic Ankle Sprains 
Journal of Athletic Training  2001;36(1):68-73.
To present a comprehensive review of the anatomy, biomechanics, and mechanisms of tibiofibular syndesmosis ankle sprains.
Data Sources:
MEDLINE (1966–1998) and CINAHL (1982–1998) searches using the key words syndesmosis, tibiofibular, ankle injuries, and ankle injuries–etiology.
Data Synthesis:
Stability of the distal tibiofibular syndesmosis is necessary for proper functioning of the ankle and lower extremity. Much of the ankle's stability is provided by the mortise formed around the talus by the tibia and fibula. The anterior and posterior inferior tibiofibular ligaments, the interosseous ligament, and the interosseous membrane act to statically stabilize the joint. During dorsiflexion, the wider portion anteriorly more completely fills the mortise, and contact between the articular surfaces is maximal. The distal structures of the lower leg primarily prevent lateral displacement of the fibula and talus and maintain a stable mortise. A variety of mechanisms individually or combined can cause syndesmosis injury. The most common mechanisms, individually and particularly in combination, are external rotation and hyperdorsiflexion. Both cause a widening of the mortise, resulting in disruption of the syndesmosis and talar instability.
Conclusions and Recommendation:
Syndesmosis ankle injuries are less common than lateral ankle injuries, are difficult to evaluate, have a long recovery period, and may disrupt normal joint functioning. To effectively evaluate and treat this injury, clinicians should have a full understanding of the involved structures, functional anatomy, and etiologic factors.
PMCID: PMC155405  PMID: 16404437
high ankle sprain; inferior tibiofibular joint; etiology of ankle injury
6.  Total ankle replacement in rheumatoid arthritis 
International Orthopaedics  2003;28(2):123-126.
We reviewed 21 patients with rheumatoid arthritis who had a total ankle replacement between 1984 and 2000. The average follow-up was 72 (15–169) months. Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. At the latest review, three ankles had been revised. Two ankles were excellent, seven good, three fair, and 12 poor. Eleven patients with 13 ankles had residual pain, with radiographs showing a high incidence of radiolucent lines. Migration of the tibial component was seen in 13 ankles and collapse of talus in nine. Although clinical results were poor, patient satisfaction was not.
PMCID: PMC3474485  PMID: 15224171
7.  Medial Impingement of the Ankle in Athletes 
Sports Health  2010;2(6):495-502.
Medial impingement syndrome of the ankle is common in the athletic population. A marginal osteophyte on the leading edge of the medial talar facet and a corresponding “kissing” osteophyte on the tibia, in front of the medial malleolus, may abut and cause pain and limited dorsiflexion.
Palpation of the talar osteophyte and standard imaging—especially, the oblique view of the foot—are useful in making the diagnosis. Surgical removal of the osteophyte may be necessary.
Ankle impingement is commonly seen in running and jumping sports, especially if the athlete has a subtle cavus foot. It may be associated with ankle instability, osteochondritis dissecans of the talus, and stress fractures of the foot.
PMCID: PMC3438865  PMID: 23015980
ankle; impingement; sports injuries; talus; medial malleolus
8.  Influence of Walking with Talus Taping on the Ankle Dorsiflexion Passive Range of Motion 
Journal of Physical Therapy Science  2013;25(8):1011-1013.
[Purpose] This study investigated the effects of walking with talus taping on the ankle dorsiflexion passive range of motion (DF PROM) in individuals with limited ankle DF PROM. [Subjects] Fifteen ankles with limited DF PROM were examined. [Methods] After rigid strapping tape was applied to the ankles from the talus to the calcaneus, progressing posteriorly and inferiorly, the subjects walked on a walkway for 10 min. Using a goniometer, the ankle DF PROM was measured with the knee extended before and after walking with talus taping. The difference in ankle DF PROM between before and after walking with talus taping was analyzed using the paired t-test. [Results] The ankle DF PROM was significantly increased after walking with talus taping. [Conclusion] Our findings indicate that walking with talus taping is effective for increasing the ankle DF PROM in individuals with limited ankle DF PROM.
PMCID: PMC3820234  PMID: 24259905
Ankle passive range of motion; Mobilization with movement; Talus taping
9.  Completely extruded talus without soft tissue attachments 
Clinics and Practice  2011;1(1):e12.
A completely extruded talus without any remaining soft tissue attachments is extremely rare. The present report describes treatment of a 45-year-old man who sustained a completely extruded talus injury following a rock-climbing fall. Upon admission, the extruded talus was deep-frozen in our bone bank. The open ankle joint underwent massive wound debridement and irrigation for 3 days. Four days later we performed a primary subtalar fusion between the extruded talus and the calcaneus, anticipating revascularization from the calcaneus. However, aseptic loosening and osteolysis developed around the screw and talus. At 12 months post-trauma we performed a tibiocalcaneal ankle fusion with a femoral head allograft to fill the talar defect. Follow-up at 24 months post-trauma showed the patient had midfoot motion, tibio-talar-calcaneal fusion, and was able partake in 4-hour physical activity twice per week.
PMCID: PMC3981216  PMID: 24765266
completely extruded talus; primary subtalar fusion; osteolysis.
10.  The effect of osseous ankle configuration on chronic ankle instability 
Chronic ankle instability (CAI) is a common orthopaedic entity in sport. Although other risk factors have been studied extensively, little is known about how it is influenced by the osseous joint configuration.
To study the effect of osseous ankle configuration on CAI.
Case–control study, level III.
Radiological examination with measurement of lateral x rays by an independent radiologist using a digital DICOM/PACS system.
A group of 52 patients who had had at least three recurrent sprains was compared with an age‐matched and sex‐matched control group of 52 healthy subjects.
Main outcome measures
The radius of the talar surface, the tibial coverage of the talus (tibiotalar sector) and the height of the talar body were measured.
The talar radius was found to be larger in patients with CAI (21.2 (2.4) mm) than in controls (17.7 (1.9) mm; p<0.001, power >95%). The tibiotalar sector, representing the tibial coverage of the talus, was smaller in patients with CAI (80° (5.1°)) than in controls (88.4° (7.2°); p<0.001, power >95%). No significant difference was observed in the height of the talar body between patients with CAI (28.8 (2.6) mm) and controls (27.5 (4.0) mm; p = 0.055).
CAI is associated with an unstable osseous joint configuration characterised by a larger radius of the talus and a smaller tibiotalar sector. There is evidence that a higher talus might also play some part, particularly in women.
PMCID: PMC2465368  PMID: 17261556
11.  The importance of early arthroscopy in athletes with painful cartilage lesions of the ankle: a prospective study of 61 consecutive cases 
Ankle sprains are common in sports and can sometimes result in a persistent pain condition.
Primarily to evaluate clinical symptoms, signs, diagnostics and outcomes of surgery for symptomatic chondral injuries of the talo crural joint in athletes. Secondly, in applicable cases, to evaluate the accuracy of MRI in detecting these injuries. Type of study: Prospective consecutive series.
Over around 4 years we studied 61 consecutive athletes with symptomatic chondral lesions to the talocrural joint causing persistent exertion ankle pain.
43% were professional full time athletes and 67% were semi-professional, elite or amateur athletes, main sports being soccer (49%) and rugby (14%). The main subjective complaint was exertion ankle pain (93%). Effusion (75%) and joint line tenderness on palpation (92%) were the most common clinical findings. The duration from injury to arthroscopy for 58/61 cases was 7 months (5.7–7.9). 3/61 cases were referred within 3 weeks from injury. There were in total 75 cartilage lesions. Of these, 52 were located on the Talus dome, 17 on the medial malleolus and 6 on the Tibia plafond. Of the Talus dome injuries 18 were anteromedial, 14 anterolateral, 9 posteromedial, 3 posterolateral and 8 affecting mid talus. 50% were grade 4 lesions, 13.3% grade 3, 16.7% grade 2 and 20% grade 1. MRI had been performed pre operatively in 26/61 (39%) and 59% of these had been interpreted as normal. Detection rate of cartilage lesions was only 19%, but subchondral oedema was present in 55%. At clinical follow up average 24 months after surgery (10–48 months), 73% were playing at pre-injury level. The average return to that level of sports after surgery was 16 weeks (3–32 weeks). However 43% still suffered minor symptoms.
Arthroscopy should be considered early when an athlete presents with exertion ankle pain, effusion and joint line tenderness on palpation after a previous sprain. Conventional MRI is not reliable for detecting isolated cartilage lesions, but the presence of subchondral oedema should raise such suspicion.
PMCID: PMC1635006  PMID: 17150124
12.  The Impact of Chiropractic Manipulative Therapy on Chronic Recurrent Lateral Ankle Sprain Syndrome in Two Young Athletes 
Journal of Chiropractic Medicine  2004;3(4):153-159.
To describe two cases of abrupt resolution of chronic, recurrent, inversion sprain to ankles in young recreational athletes.
Clinical Features
A 13-year-old, female, avid recreational soccer player with ankles that would spontaneously invert during various inconsistent points in the weight bearing gait cycle, sometimes with acute pain or sprain to the ankle. No intervention was attempted prior to her entry to the chiropractic office. A 17-year-old male avid skate- boarder and snowboarder whose left ankle routinely “gave out” into inversion upon mundane weight bearing activity, usually with pain and with dependence on wearing an ankle support when skateboarding to lessen ankle pain. The patient had used an ankle support prior to seeking chiropractic care.
Intervention and Outcome
High velocity, low amplitude chiropractic manipulative therapy applied to the spine, pelvis and extremity joints was the primary intervention in both cases, with particular focus on the ankle. Other procedures used included taping and orthotics, but not before the manipulation effect was noted.
High velocity, low amplitude chiropractic manipulative therapy to the spine, pelvis, and extremities, particularly at the ankle, should be considered when managing young recreational athletes with functional chronic, recurrent, ankle inversion sprains.
PMCID: PMC2647025  PMID: 19674638
Ankle Injuries; Sprains and Strains; Joint Instability; Chiropractic Manipulation; Lower Extremity
13.  A new approach to the treatment of congenital vertical talus 
Congenital vertical talus is an uncommon foot deformity that is present at birth and results in a rigid flatfoot deformity. Left untreated the deformity can result in pain and disability. Though the exact etiology of vertical talus is unknown, an increasing number of cases have been shown to have a genetic cause. Approximately 50% of all cases of vertical talus are associated with other neuromuscular abnormalities or known genetic syndromes. The remaining 50% of cases were once thought to be idiopathic in nature. However, there is increasing evidence that many of these cases are related to single gene defects. Most patients with vertical talus have been treated with major reconstructive surgeries that are fraught with complications such as wound necrosis, talar necrosis, undercorrection of the deformity, stiffness of the ankle and subtalar joint, and the eventual need for multiple operative procedures. Recently, a new approach to vertical talus that consists of serial casting and minimal surgery has resulted in excellent correction in the short-term. Longer follow-up will be necessary to ensure maintenance of correction with this new technique. A less invasive approach to the correction of vertical talus may provide more favorable long-term outcomes than more extensive surgery as has been shown to be true for clubfoot outcomes.
PMCID: PMC2656724  PMID: 19308490
Congenital vertical talus; Flatfoot; Treatment; Genetics; Etiology
14.  Effects of Prefabricated Ankle Orthoses on Postural Stability in Basketball Players with Chronic Ankle Instability 
Asian Journal of Sports Medicine  2012;3(4):274-278.
Ankle sprain is one of the most common injuries among athletes and instability and injury to this joint is responsible for long time loss of physical and recreational activity. Also, it can impose high costs to sport teams. Prevention of this injury is an important concern of practice and rehabilitation. One way of reducing the possibility of ankle joint injury is using an ankle orthosis. The present study aimed at inspecting the effects of two ankle orthoses on dynamic and semi-dynamic postural stability in athletes with chronic ankle instability (CAI).
Twenty basketball players with CAI and fifteen non-injured athletes volunteered to participate in this study. Biodex Balance System was used to assess the participants’ postural stability in bilateral position at level 8 and level 2. Repeated measures analysis of variance (ANOVA) was performed in order to examine the effects of ankle orthoses. Statistical significance level was determined at P< 0.05.
Statistical analyses revealed the significant effect of ankle supports on dynamic and semi-dynamic postural stability in the two groups and results indicated there wasn't significant difference between groups.
According to our results the orthoses improved both dynamic and semi-dynamic postural stability. Therefore, orthoses can prevent injury and its reoccurrence.
PMCID: PMC3525824  PMID: 23342226
Postural Balance; Ankle; Joint Instability; Basketball; Orthoses
15.  Lengthening osteotomy of the fibula for post-traumatic malunion  
International Orthopaedics  1998;22(3):149-152.
Relative shortening of the fibula may occur after any type of ankle fracture when the lateral malleolus is involved. Patients complain of pain and restriction of their daily and sporting activities. Clinically, there is valgus of the hind foot due to abduction and lateral rotation of the talus. The goal of treatment is to restore the initial length of the fibula by a horizontal or Z-osteotomy, which will also correct the malposition of the talus. This study shows that the operative reconstruction of a widened mortise is a relatively safe procedure, independent of the type of osteotomy used. Lengthening of the fibula is an important step in the treatment of the painful ankle when the fibula is short after trauma, even when degenerative changes of the joint are already present.
PMCID: PMC3619596  PMID: 9728305
16.  Hip Kinematics During a Stop-Jump Task in Patients With Chronic Ankle Instability 
Journal of Athletic Training  2011;46(5):461-467.
Chronic ankle instability (CAI) commonly develops after lateral ankle sprain. Movement pattern differences at proximal joints may play a role in instability.
To determine whether people with mechanical ankle instability (MAI) or functional ankle instability (FAI) exhibited different hip kinematics and kinetics during a stop-jump task compared with “copers.”
Cross-sectional study.
Sports medicine research laboratory.
Patients or Other Participants:
Sixty-three recreational athletes, 21 (11 men, 10 women) per group, matched for sex, age, height, mass, and limb dominance. All participants reported a history of a moderate to severe ankle sprain. The participants with MAI and FAI reported 2 or more episodes of giving way at the ankle in the last year and decreased functional ability; copers did not. The MAI group demonstrated clinically positive anterior drawer and talar tilt tests, whereas the FAI group and copers did not.
Participants performed a maximum-speed approach run and a 2-legged stop jump followed by a maximum vertical jump.
Main Outcome Measure(s):
An electromagnetic tracking device synchronized with a force plate collected data during the stance phase of a 2-legged stop jump. Hip motion was measured from initial contact to takeoff into the vertical jump. Group differences in hip kinematics and kinetics were assessed.
The MAI group demonstrated greater hip flexion at initial contact and at maximum (P = .029 and P = .017, respectively) and greater hip external rotation at maximum (P = .035) than the coper group. The MAI group also demonstrated greater hip flexion displacement than both the FAI (P = .050) and coper groups (P = .006). No differences were noted between the FAI and coper groups in hip kinematic variables or among any of the groups in ground reaction force variables.
The MAI group demonstrated different hip kinematics than the FAI and coper groups. Proximal joint motion may be affected by ankle joint function and laxity, and clinicians may need to assess proximal joints after repeated ankle sprains.
PMCID: PMC3418949  PMID: 22488131
motion analysis; landings; ankle sprains
17.  Closed subtalar dislocation with non-displaced fractures of talus and navicular: a case report and review of the literature 
Cases Journal  2009;2:8793.
Closed subtalar dislocations associated with talus and navicular fractures are rare injuries. We report on a case of a 43-year-old builder man with medial subtalar dislocation that was further complicated by minimally displaced talar and navicular fractures. Successful closed reduction under general anesthesia was followed by non-weight bearing and ankle immobilization with a below-knee cast for 6 ;weeks. At 3 years post-injury, the subtalar joint was stable, the foot and ankle mobility was in normal limits and the patient could still work as a builder. However, he complained for occasionally mild pain due to the development of post-traumatic arthritis in subtalar and ankle joints. Our search in literature revealed that conservative treatment of all the successfully reduced and minimally displaced subtalar fracture-dislocations has given superior results compared to surgical management. However, even in cases with no or slight fracture displacement, avascular necrosis of the talus or arthritis of the surrounding joints can compromise the final functional outcome.
PMCID: PMC2769472  PMID: 19918402
18.  Ankle Arthritis in a 6-Year-Old Boy After a Tick Bite – A Case Report 
Monoarthritis of the ankle is a rare condition in children, and is most often caused by a bacterial infection. Lyme disease is endemic in southern Scandinavia, and diagnosis remains a challenge. The clinical presentation of Lyme disease varies greatly, and often with considerable delay between exposure and presentation.
Case Presentation:
We report a case of ankle arthritis in a boy who presented one year earlier with a tick bite on the dorsum of the foot. He was suboptimally treated with oral antibiotics for one week, and developed in the following months a painless limp. Radiographs revealed a severe arthritis of the right ankle joint with necrosis of the talus and deformation of the talocrural and subtalar joints. There was no history of malaise, fever or other systemic symptoms. He remains seronegative for antibodies against B. burgdorferi.
The suboptimal oral antibiotic treatment may have hindered the antibody production against B burgdorferi, while not being therapeutic, resulting in severe ankle arthritis due to seronegative Lyme disease.
PMCID: PMC3096051  PMID: 21594002
Arthritis; children; seronegative Lyme disease; borreliosis.
19.  Three-Dimensional Matrix-Induced Autologous Chondrocytes Implantation for Osteochondral Lesions of the Talus: Midterm Results 
Advances in Orthopedics  2012;2012:942174.
Introduction. We evaluate the midterm results of thirty patients who underwent autologous chondrocytes implantation for talus osteochondral lesions treatment. Materials and Methods. From 2002 to 2009, 30 ankles with a mean lesion size of 2,36 cm2 were treated. We evaluated patients using American Orthopaedic Foot and Ankle Surgery and Coughlin score, Van Dijk scale, recovering time, and Musculoskeletal Outcomes Data Evaluation and Management System. Results. The mean AOFAS score varied from 36.9 to 83.9 at follow-up. Average of Van Dijk scale was 141.1. Coughlin score was excellent/good in 24 patients. MOCART score varied from 6.3 to 3.8. Discussion. This matrix is easy to handle conformable to the lesion and apply by arthroscopy. No correlation between MRI imaging and clinical results is found. Conclusions. Our results, compared with those reported in literature with other surgical procedures, show no superiority evidence for our technique compared to the others regarding the size of the lesions.
PMCID: PMC3337586  PMID: 22570793
20.  CAM-Type Impingement in the Ankle 
Anterior ankle impingement with and without ankle osteoarthritis (OA) is a common condition. Bony impingement between the distal tibia and talus aggravated by dorsiflexion has been well described. The etiology of these impingement lesions remains controversial. This study describes a cam-type impingement of the ankle, in which the sagittal contour of the talar dome is a non-circular arc, causing pathologic contact with the anterior aspect of the tibial plafond during dorsiflexion, leading to abnormal ankle joint mechanics by limiting dorsiflexion.
A group of 269 consecutive adult patients from the University of Iowa Hospitals and Clinics who were treated for anterior bony impingement syndrome were evaluated as the study population. As a control group, 41 patients without any evidence of impingement or arthrosis were evaluated. Standardized standing lateral ankle radiographs were evaluated to determine the contour of the head/neck relationship in the talus. Two investigators made all the radiographic measurements and intra- and inter-observer reliability were measured.
34% of patients were found to have some anterior extension of the talar dome creating a loss of the normal concavity at the dorsal medial talar neck. A group of 36 patients (13%) were identified as having the most severe cam deformity in order to assess any correlation with coexisting radiographic abnormalities. In these patients, a cavo-varus foot type was more commonly observed. Comparison with a control group showed much lower rates of anterior-medial cam-type deformity of the talus.
Cam type impingement of the ankle is likely a distinct form of bony impingement of the ankle secondary to a morphological talar bony abnormality. Based on the findings of this study, this form of impingement may be related to a cavovarus foot type. In addition, there may be long term implications in the development of ankle OA.
Level of Evidence
Level III
PMCID: PMC3565388  PMID: 23576914
21.  Effect of a 6-week dynamic neuromuscular training programme on ankle joint function: A Case report 
Ankle joint sprain and the subsequent development of chronic ankle instability (CAI) are commonly encountered by clinicians involved in the treatment and rehabilitation of musculoskeletal injuries. It has recently been advocated that ankle joint post-sprain rehabilitation protocols should incorporate dynamic neuromuscular training to enhance ankle joint sensorimotor capabilities. To date no studies have reported on the effects of dynamic neuromuscular training on ankle joint positioning during landing from a jump, which has been reported as one of the primary injury mechanisms for ankle joint sprain. This case report details the effects of a 6-week dynamic neuromuscular training programme on ankle joint function in an athlete with CAI.
The athlete took part in a progressive 6-week dynamic neuromuscular training programme which incorporated postural stability, strengthening, plyometric, and speed/agility drills. The outcome measures chosen to assess for interventional efficacy were: [1] Cumberland Ankle Instability Tool (CAIT) scores, [2] Star Excursion Balance Test (SEBT) reach distances, [3] ankle joint plantar flexion during drop landing and drop vertical jumping, and [4] ground reaction forces (GRFs) during walking.
CAIT and SEBT scores improved following participation in the programme. The angle of ankle joint plantar flexion decreased at the point of initial contact during the drop landing and drop vertical jumping tasks, indicating that the ankle joint was in a less vulnerable position upon landing following participation in the programme. Furthermore, GRFs were reduced whilst walking post-intervention.
The 6-week dynamic neuromuscular training programme improved parameters of ankle joint sensorimotor control in an athlete with CAI. Further research is now required in a larger cohort of subjects to determine the effects of neuromuscular training on ankle joint injury risk factors.
PMCID: PMC3141569  PMID: 21658224
ankle sprain; ankle instability; ankle injury; rehabilitation; injury prevention
22.  The Effect of Modified Brostrom-Gould Repair for Lateral Ankle Instability on In Vivo Tibiotalar Kinematics 
Lateral ankle instability leads to an increased risk of tibiotalar joint osteoarthritis. Previous studies have found abnormal tibiotalar joint motions with lateral ankle instability that may contribute to this increased incidence of osteoarthritis, including increased anterior translation and internal rotation of the talus under weight-bearing loading. Surgical repairs for lateral ankle instability have shown good clinical results, but the effects of repair on in vivo ankle motion are not well understood.
The modified Broström-Gould lateral ligament reconstruction decreases anterior translation and internal rotation of the talus under in vivo weight-bearing loading conditions.
Study Design
Controlled laboratory study.
Seven patients underwent modified Brostöm-Gould repair for unilateral lateral ankle instability. Ankle joint kinematics as a function of increasing body weight were studied with magnetic resonance imaging and biplanar fluoroscopy. Tibiotalar kinematics were measured in unstable ankles preoperatively and postoperatively at a mean follow-up of 12 months, as well as in the uninjured contralateral ankles of the same individuals.
Surgical repair resulted in statistically significant decreases in anterior translation of the talus (0.9±0.3mm, p=0.018) at 100% bodyweight and internal rotation of the talus at 75% (2.6±0.8°, p=0.019) and 100% (2.7±0.8°, p=0.013) bodyweight compared to ankle kinematics measured before repair. No statistically significant differences were detected between repaired ankles and contralateral normal ankles.
The modified Broström-Gould repair improved the abnormal joint motion observed in patients with lateral ankle instability, decreasing anterior translation and internal rotation of the talus.
Clinical Relevance
Altered kinematics may contribute to the tibiotalar joint degeneration that occurs with chronic lateral ankle instability. The findings of the current study support the efficacy of this repair in improving the abnormal ankle motion observed in these patients.
PMCID: PMC3535340  PMID: 22886690
Lateral Ankle Instability; Brostöm-Gould repair; Anterior Talofibular Ligament; Ankle Biomechanics; Osteoarthritis
23.  Therapeutic management of complicated talar extrusion: literature review and case report 
Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.
PMCID: PMC3052426  PMID: 21350893
Total talar dislocation; Talar extrusion; Missing talus; Distally-based sural fasciocutaneous flap
24.  Therapeutic management of complicated talar extrusion: literature review and case report 
Total extrusion of the talus with interruption of all ligaments (missing talus) is a rare injury. We describe the case of a 27-year-old man who reported total extrusion of the talus after a motorbike accident with interruption of all talar ligaments. In the first repair effort, the articular void left by the talus was filled with antibiotic cement and the wound was closed primarily. Nevertheless, the skin overlying the talar joint displayed necrosis. In order to cover the cutaneous defect, improve local vascularization, and allow reimplantation of the talus, a sural fasciocutaneous island flap was harvested. Subsequently, the original talus was placed and arthrodesis of the subtalar joint was performed. The patient was able to walk bearing full weight without support equipment after 6 months. Several therapeutic options have been suggested in such cases, including replacing the talus, tibiocalcaneal arthrodesis, and pseudoarthrodesis. The rarity and peculiarity of such cases make the establishment of generalized guidelines an arduous task, leaving the choice of treatment to the surgeon, in conformity with each case’s peculiarity. In this case use of the flap may have promoted the vascularization of the reimplanted talus, thus avoiding avascular necrosis and allowing successful reimplantation of the original talus.
PMCID: PMC3052426  PMID: 21350893
Total talar dislocation; Talar extrusion; Missing talus; Distally-based sural fasciocutaneous flap
25.  The 2BFit study: is an unsupervised proprioceptive balance board training programme, given in addition to usual care, effective in preventing ankle sprain recurrences? Design of a Randomized Controlled Trial 
There is strong evidence that athletes have a twofold risk for re-injury after a previous ankle sprain, especially during the first year post-injury. These ankle sprain recurrences could result in disability and lead to chronic pain or instability in 20 to 50% of these cases. When looking at the high rate of ankle sprain recurrences and the associated chronic results, ankle sprain recurrence prevention is important.
To evaluate the effect of a proprioceptive balance board training programme on ankle sprain recurrences, that was applied to individual athletes after rehabilitation and treatment by usual care.
This study was designed as a randomized controlled trial with a follow-up of one year. Healthy individuals between 12 and 70 years of age, who were actively participating in sports and who had sustained a lateral ankle sprain up to two months prior to inclusion, were eligible for inclusion in the study. The intervention programme was compared to usual care. The intervention programme consisted of an eight-week proprioceptive training, which started after finishing usual care and from the moment that sports participation was again possible. Outcomes were assessed at baseline and every month for 12 months. The primary outcome of this study was the incidence of recurrent ankle injuries in both groups within one year after the initial sprain. Secondary outcomes were severity and etiology of re-injury and medical care. Cost-effectiveness was evaluated from a societal perspective. A process evaluation was conducted for the intervention programme.
The 2BFit trial is the first randomized controlled trial to study the effect of a non-supervised home-based proprioceptive balance board training programme in addition to usual care, on the recurrence of ankle sprains in sports. Results of this study could possibly lead to changes in practical guidelines on the treatment of ankle sprains. Results will become available in 2009.
Trial registration
PMCID: PMC2412867  PMID: 18492235

Results 1-25 (541985)