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Borrelli G, Albiero M, Jastifer J. Anatomy of the Naviculocuneiform Joint Complex. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241245396. [PMID: 38601321 PMCID: PMC11005504 DOI: 10.1177/24730114241245396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
Background The purpose of this study was to quantify the articular surfaces of the naviculocuneiform (NC) joint to help clinicians better understand common pathologies observed such as navicular stress fractures and arthrodesis nonunions. Methods Twenty cadaver NC joints were dissected and the articular cartilage of the navicular, medial, middle, and lateral cuneiforms were quantified by calibrated digital imaging software. Statistical analysis included calculating the mean cartilage surface area dimensions of the distal navicular and proximal cuneiform bones. Length measurements on the navicular were obtained to estimate the geographic location of the interfacet ridges. Lastly, all facets of the articular surfaces were described in regard to the shape and location of cartilaginous or fibrous components. Results were compared using Student t tests. Results Navicular cartilage was present over 75.4% of the surface area of the proximal NC joint, compared with 72.6% of combined cuneiform cartilage distally. The mean height of the deepest (dorsal-plantar) measurement of navicular articular cartilage was 18 ± 3 mm. The mean heights of the distal medial, middle, and lateral cuneiform articular facets were 15 ± 1 mm, 17 ± 2 mm, and 15 ± 2 mm, respectively. Conclusion There is significant variation among the articular surfaces of the NC joint. Additionally, the central third of the navicular was calculated to lie in the inter-facet ridge between the medial and middle articular facets of the navicular. Clinical Relevance Surgeons may consider this study data when performing joint preparation for NC arthrodesis as cartilage was present to a mean depth of 18 mm at the NC joint. Additionally, this study demonstrates that the central third of the navicular, where most navicular stress fractures occur, lies in the interfacet ridge between the medial and middle articular facets of the navicular.
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Affiliation(s)
- George Borrelli
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI, USA
| | - Maxwell Albiero
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI, USA
| | - James Jastifer
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI, USA
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2
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Flores DV, Goes PK, Damer A, Huang BK. The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment. Radiographics 2024; 44:e230163. [PMID: 38512730 DOI: 10.1148/rg.230163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Paola Kuenzer Goes
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Alameen Damer
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Brady K Huang
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
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Gremillion MJ, Martinez A, Ghanta RB, Borici N, Kushare I. An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations. PHYSICIAN SPORTSMED 2023; 51:572-581. [PMID: 36328959 DOI: 10.1080/00913847.2022.2143247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.
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Affiliation(s)
| | | | - Ramesh B Ghanta
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Neritan Borici
- Baylor College of Medicine, Houston, TX, USA
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Indranil Kushare
- Baylor College of Medicine, Houston, TX, USA
- Department of Orthopedic Surgery, Texas Children's Hospital, Houston, TX, USA
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4
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Ring M, Friemert B, Hackenbroch C, Achatz G. [Stress fractures in the military context]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:856-862. [PMID: 37910187 DOI: 10.1007/s00113-023-01375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist. OBJECTIVE Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities. MATERIAL AND METHODS A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options. RESULTS There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated. CONCLUSION Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.
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Affiliation(s)
- Matthias Ring
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - Benedikt Friemert
- Zentrales Klinisches Management, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Carsten Hackenbroch
- Klinik für Radiologie und Neuroradiologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Gerhard Achatz
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
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5
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Morimoto S, Iseki T, Shimmyo A, Tachibana T. Stress fracture of the lateral talar process in a male basketball player treated by percutaneous screw fixation: A case report. J Orthop Sci 2023; 28:1555-1560. [PMID: 34801344 DOI: 10.1016/j.jos.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 09/19/2021] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Shota Morimoto
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan.
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
| | - Airi Shimmyo
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
| | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, 663-8501, Hyogo, Japan
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6
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Lohrer H. [High-risk stress fractures in competitive athletes]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:848-855. [PMID: 37341736 DOI: 10.1007/s00113-023-01339-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/22/2023]
Abstract
Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.
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Affiliation(s)
- Heinz Lohrer
- ESN - European SportsCare Network, Zentrum für Sportorthopädie, Borsigstr. 2, 65205, Wiesbaden-Nordenstadt, Deutschland.
- Institut für Sport und Sportwissenschaft, Albert-Ludwigs-Universität, Freiburg, Deutschland.
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7
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Arévalo Hernández A, Mittlmeier T, Weber MA. [Contemporary imaging examinations for (suspected) stress fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:831-838. [PMID: 37650915 DOI: 10.1007/s00113-023-01358-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 09/01/2023]
Abstract
Stress fractures belong to the group of atraumatic fractures. A low-impact and repetitive load is the underlying cause and no fracture would occur under physiological circumstances. The conventional X‑ray examination remains the initial imaging modality when a stress fracture is suspected. In contrast, magnetic resonance imaging (MRI) is the gold standard and is also used to rule out other pathological changes. Computed tomography (CT) should be included if the MRI findings are unclear. New techniques, such as dual energy computed tomography (DECT) and magnetic resonance bone imaging (MR bone) should be used more frequently in practice in the future and become increasingly more important for the correct diagnosis.
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Affiliation(s)
- Andrés Arévalo Hernández
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Thomas Mittlmeier
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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8
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Reijnierse M, Griffith JF. High-resolution ultrasound and MRI in the evaluation of the forefoot and midfoot. J Ultrason 2023; 23:e251-e271. [PMID: 38020514 PMCID: PMC10668940 DOI: 10.15557/jou.2023.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Radiography is the appropriate initial imaging modality to assess for midfoot and forefoot pathology before turning to advanced imaging techniques. While most lesions of the mid- and forefoot can be diagnosed clinically, the exact nature and severity of the pathology is often unclear. This review addresses the use of the ultrasound, as well as the added value of magnetic resonance imaging, in diagnosing conditions of the midfoot and forefoot. Ultrasound allows a dynamic assessment as well as enabling imaging-guided interventions for diagnostic and therapeutic purposes. Practical tips for optimal examination of this area with ultrasound and magnetic resonance imaging are provided. Metatarsal stress fracture, Chopart's injury, Lisfranc injury, as well as the 1st metatarsophalangeal joint injury and lesser metatarsophalangeal plantar plate injury are injuries unique to the mid- and forefoot. The imaging anatomy of the 1st and lesser metatarsophalangeal joints is reviewed, as such knowledge is key to correctly assessing injury of these joints. Characteristic imaging features of masses commonly encountered in the mid- and forefoot, such as ganglion cyst, Morton neuroma, gouty tophus, plantar fibroma, foreign body granuloma, and leiomyoma are reviewed. The use of ultrasound and magnetic resonance imaging in assessing degenerative and inflammatory joint disorders, and in particular rheumatoid arthritis, of the mid- and forefoot region is also reviewed. In summary, when necessary, most lesions of the mid-and forefoot can be adequately assessed with ultrasound, supplemented on occasion with radiographs, computed tomography, or magnetic resonance imaging.
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Affiliation(s)
- Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - James F. Griffith
- Department of Imaging & Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
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Brown PJ, Wyse A, Patel K, Long J. Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00006. [PMID: 37831806 DOI: 10.2106/jbjs.cc.23.00356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
CASE A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training. CONCLUSION Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.
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Affiliation(s)
- Parker J Brown
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Aaron Wyse
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Karan Patel
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jeremiah Long
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Arizona
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10
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Carneiro BC, Ormond Filho AG, Guimarães JB. MRI of Pediatric Foot and Ankle Conditions. Foot Ankle Clin 2023; 28:681-695. [PMID: 37536825 DOI: 10.1016/j.fcl.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The increase in competitive sports practice among children and lack of ionizing radiation have resulted in a higher demand for MRI examinations. MRI of the children skeleton has some particularities that can lead orthopedists, pediatricians, and radiologists to diagnostic errors. The foot and ankle have several bones with abundant radiolucent and high signal intensity cartilage in several ossification centers, apophysis and physis, that can make this interpretation even harder. The present revision aims to show, how to differentiate between normal developmental findings and anatomic variants from pathologic conditions, whether mechanical, inflammatory, infectious, or neoplastic.
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Affiliation(s)
- Bruno Cerretti Carneiro
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde, São Paulo, SP, Brazil; Department of Diagnostic Imaging, United Health Group Brazil, São Paulo, SP, Brazil
| | - Alípio G Ormond Filho
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde, São Paulo, SP, Brazil
| | - Júlio Brandão Guimarães
- Department of Musculoskeletal Radiology, Fleury Medicina e Saúde, São Paulo, SP, Brazil; Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, SP, Brazil.
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11
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Kaiser PB, Guss D, DiGiovanni CW. Republication of "Stress Fractures of the Foot and Ankle in Athletes". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231195045. [PMID: 37590306 PMCID: PMC10426306 DOI: 10.1177/24730114231195045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff's law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete's training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered "high risk" due to poor intrinsic healing and may warrant more proactive operative management.
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Affiliation(s)
- Philip B Kaiser
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Daniel Guss
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
| | - Christopher W DiGiovanni
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
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12
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Jungmann PM, Schaeffeler C. Bone Stress Injuries at the Ankle and Foot. Semin Musculoskelet Radiol 2023; 27:283-292. [PMID: 37230128 DOI: 10.1055/s-0043-1766098] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Bone stress injuries (BSIs) are a frequent finding in athletes, particularly of the foot and ankle. A BSI is caused by recurring microtrauma to the cortical or trabecular bone exceeding the repair capacity of normal bone. The most frequent fractures at the ankle are low risk, characterized by a low risk for nonunion. These include the posteromedial tibia, the calcaneus, and the metatarsal diaphysis. High-risk stress fractures have a higher risk for nonunion and need more aggressive treatment. Examples are the medial malleolus, navicular bone, and the base of the second and fifth metatarsal bone.Imaging features depend on the primary involvement of cortical versus trabecular bone. Conventional radiographs may remain normal up to 2 to 3 weeks. For cortical bone, early signs of BSIs are a periosteal reaction or the "gray cortex sign," followed by cortical thickening and fracture line depiction. In trabecular bone, a sclerotic dense line may be seen. Magnetic resonance imaging enables early detection of BSIs and can differentiate between a stress reaction and a fracture. We review typical anamnestic/clinical findings, epidemiology and risk factors, imaging characteristics, and findings at typical locations of BSIs at the foot and ankle that may help guide treatment strategy and patient recovery.
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Affiliation(s)
- Pia M Jungmann
- Musculoskeletal Imaging, Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Christoph Schaeffeler
- Musculoskeletal Imaging, Department of Radiology, Kantonsspital Graubünden, Chur, Switzerland
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Kimura S, Yamaguchi S, Mikami Y, Nakajima H, Watanabe S, Sasho T, Ohtori S. Stress Fracture of the Ankle Medial Malleolus in Patients With Severe Varus Ankle Osteoarthritis: A Report of 5 Cases. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231183440. [PMID: 37425341 PMCID: PMC10328028 DOI: 10.1177/24730114231183440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Affiliation(s)
- Seiji Kimura
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
| | - Satoshi Yamaguchi
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
- Graduate School of Global and Transdisciplinary Studies, Chiba University, Chiba-shi, Chiba, Japan
| | - Yukio Mikami
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
| | - Hirofumi Nakajima
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
| | - Shotaro Watanabe
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
| | - Takahisa Sasho
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
- Center for Preventive Medical Sciences, Chiba University, Chiba-shi, Chiba, Japan
| | - Seiji Ohtori
- Graduate School of Medical and Pharmaceutical Sciences, Chiba University, Chiba-shi, Chiba, Japan
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14
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Beekman KM, Kuijer PPFM, Maas M. Imaging of Overuse Injuries of the Ankle and Foot in Sport and Work. Radiol Clin North Am 2023; 61:307-318. [PMID: 36739147 DOI: 10.1016/j.rcl.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Overuse injuries of the ankle and foot are common injuries both in sport and in a work-related context. After clinical assessment, imaging is key for early diagnosis. In this overview article, we focus on imaging techniques, protocols, and imaging findings of overuse injuries of the ankle and foot; we emphasize the important role of structured reporting; and we discuss clinical symptoms, epidemiology, and risk factors in sports and in a work-related context.
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Affiliation(s)
- Kerensa M Beekman
- Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - P Paul F M Kuijer
- Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Academic Center for Evidence-based Sports Medicine (ACES), Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
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15
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Navas A, Kassarjian A. Bone Marrow Lesions in Athletic Stress Injuries: An Overview. Semin Musculoskelet Radiol 2023; 27:54-72. [PMID: 36868245 DOI: 10.1055/s-0043-1761613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
This article discusses the presumed pathophysiology of osseous sport-related stress changes, the optimal imaging strategy for detecting the lesions, and the progression of the lesions as seen on magnetic resonance imaging. It also describes some of the most common stress-related injuries in athletes by anatomical location and introduces some new concepts in the field.
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Affiliation(s)
- Ana Navas
- Department of Radiology, Division of Musculoskeletal Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ara Kassarjian
- Department of Radiology, Division of Musculoskeletal Radiology, Olympia Medical Center, Elite Sports Imaging, Madrid, Spain
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16
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Guedes S, Sousa-Pinto B, Torres J. Radiological outcomes of bimalleolar fractures: Are timing of surgery and type of reconstruction important? Orthop Traumatol Surg Res 2022; 108:103314. [PMID: 35568298 DOI: 10.1016/j.otsr.2022.103314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 09/06/2021] [Accepted: 01/31/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The goal of open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is to reconstitute ankle anatomy. The most commonly used radiological parameters to assess adequacy of reduction are talocrural angle (TCA), medial clear space (MCS), tibiofibular overlap (TFO) and tibiofibular clear space (TFCS). There is little research about the radiological outcomes of surgery in bimalleolar fractures. We aimed at assessing the adequacy of ORIF and the factors involved in anatomical restoration (specifically time to surgery), postoperatively and at follow-up. METHODS TCA, MCS, TFO and TFCS were measured in preoperative and postoperative radiographs of 107 bimalleolar ankle fractures and in 83 follow-up radiographs, accounting for a total of 297 radiographs and 1182 measurements. Preoperative radiographs were categorized according to Danis-Weber classification. For all included cases, basic demographic data, dates of radiographs and surgery, and type of fixation used were acquired. Variables associated with postoperative and follow-up total anatomical reconstitution (i.e., when the four assessed radiological parameters were normalized), normalization of each radiological parameter, and improvement in the number of normalized radiological parameters were identified through univariable Cox regression analysis. RESULTS In our sample, 23.8% of the ankle fractures in postoperative radiographs and 28% in follow-up radiographs achieved a complete anatomical restoration. Type C fractures (hazard ratio [HR]=0.1, 95% confidence interval [CI]=0.02-0.7, P=0.021) were associated with lower chances of total anatomical reconstitution. The use of reconstruction plates (HR=0.1, 95% CI=0.03-0.7, P=0.014) and one third tubular plates (HR=0.2, 95% CI=0.03-0.8, P=0.026) decreased the chances of improving the number of normalized radiological parameters. Waiting days until surgery impaired total anatomical reconstitution (HR=0.8, 95% CI=0.6-0.9, P=0.012) and also reduced the chances of improving the number of normalized radiological parameters (HR=0.9, 95% CI=0.9-1.0, P=0.045). CONCLUSION The radiological results for the treatment of bimalleolar fractures are time sensitive, and surgery should thus be performed as soon as possible, using adequate fixation materials, in order to achieve a better restoration of ankle anatomy. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Sara Guedes
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Bernardo Sousa-Pinto
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Torres
- Faculty of Medicine, University of Porto, Porto, Portugal; Orthopaedics and Traumatology Department, Centro Hospitalar de São João, E.P.E., Porto, Portugal
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17
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Wang Y, Li Y, Lin G, Zhang Q, Zhong J, Zhang Y, Ma K, Zheng Y, Lu G, Zhang Z. Lower-extremity fatigue fracture detection and grading based on deep learning models of radiographs. Eur Radiol 2022; 33:555-565. [PMID: 35748901 DOI: 10.1007/s00330-022-08950-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the feasibility of deep learning-based diagnostic models for detecting and assessing lower-extremity fatigue fracture severity on plain radiographs. METHODS This retrospective study enrolled 1151 X-ray images (tibiofibula/foot: 682/469) of fatigue fractures and 2842 X-ray images (tibiofibula/foot: 2000/842) without abnormal presentations from two clinical centers. After labeling the lesions, images in a center (tibiofibula/foot: 2539/1180) were allocated at 7:1:2 for model construction, and the remaining images from another center (tibiofibula/foot: 143/131) for external validation. A ResNet-50 and a triplet branch network were adopted to construct diagnostic models for detecting and grading. The performances of detection models were evaluated with sensitivity, specificity, and area under the receiver operating characteristic curve (AUC), while grading models were evaluated with accuracy by confusion matrix. Visual estimations by radiologists were performed for comparisons with models. RESULTS For the detection model on tibiofibula, a sensitivity of 95.4%/85.5%, a specificity of 80.1%/77.0%, and an AUC of 0.965/0.877 were achieved in the internal testing/external validation set. The detection model on foot reached a sensitivity of 96.4%/90.8%, a specificity of 76.0%/66.7%, and an AUC of 0.947/0.911. The detection models showed superior performance to the junior radiologist, comparable to the intermediate or senior radiologist. The overall accuracy of the diagnostic model was 78.5%/62.9% for tibiofibula and 74.7%/61.1% for foot in the internal testing/external validation set. CONCLUSIONS The deep learning-based models could be applied to the radiological diagnosis of plain radiographs for assisting in the detection and grading of fatigue fractures on tibiofibula and foot. KEY POINTS • Fatigue fractures on radiographs are relatively difficult to detect, and apt to be misdiagnosed. • Detection and grading models based on deep learning were constructed on a large cohort of radiographs with lower-extremity fatigue fractures. • The detection model with high sensitivity would help to reduce the misdiagnosis of lower-extremity fatigue fractures.
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Affiliation(s)
- Yanping Wang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China
| | | | - Guang Lin
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China
| | - Qirui Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China
| | - Jing Zhong
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China
| | - Yan Zhang
- Department of Radiology, Nanjing Qinhuai Medical Area, Jinling Hospital, 210002, Nanjing, China
| | - Kai Ma
- Tencent Jarvis Lab, Shenzhen, 518000, China
| | | | - Guangming Lu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China.,State Key Laboratory of Analytical Chemistry for Life Science, Nanjing University, Nanjing, 210093, China
| | - Zhiqiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Rd, Nanjing, 210002, China. .,State Key Laboratory of Analytical Chemistry for Life Science, Nanjing University, Nanjing, 210093, China.
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18
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Crim J. The painful lateral column of the foot: from back to front. Skeletal Radiol 2022; 51:1115-1125. [PMID: 34642777 DOI: 10.1007/s00256-021-03936-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to focus attention on the abnormalities which the radiologist may encounter in patients presenting with lateral ankle or foot pain outside of the context of acute trauma. These include anterolateral impingement, subfibular impingement, subtalar instability and tarsal sinus syndrome, tarsal coalition, sural neuromas, peroneal tendon abnormalities, calcaneocuboid instability and occult cuboid fractures, and painful accessory ossicles. The expected and unexpected findings on radiographs, CT, US, and MRI are discussed.
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Affiliation(s)
- Julia Crim
- University of Missouri, Hospital Drive, Columbia, MO, 65212, USA.
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19
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Morimoto S, Iseki T, Morooka T, Yoshiya S, Tachibana T, Tanaka J. The Effectiveness of Intramedullary Screw Fixation Using the Herbert Screw for Fifth Metatarsal Stress Fractures in High-Level Athletes. Am J Sports Med 2021; 49:4001-4007. [PMID: 34652232 DOI: 10.1177/03635465211045998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intramedullary screw fixation is the most common operative procedure used for treatment of fifth metatarsal stress fractures in athletes. However, the optimal implant in intramedullary screw fixation is still being investigated. PURPOSE To review experiences with intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures in high-level athletes. STUDY DESIGN Case series; Level of evidence, 4. METHODS The authors retrospectively analyzed 37 high-level athletes (Tegner activity score ≥7) who underwent intramedullary screw fixation using the Herbert screw for fifth metatarsal stress fractures between August 2005 and August 2017. The minimum follow-up period of the patients was 2 years. In assessing the surgical results, time to obtain bone union, time to return to original level of sport participation, and treatment failures/complications were reviewed. Additionally, the effect of intraoperative plantar gap widening caused by the screw insertion was analyzed. The surgical results of the 2 groups, the no-gap group (intraoperative plantar gap widening, <1 mm) and the gap group (intraoperative plantar gap widening, ≥1 mm), were compared, while correlations between intraoperative plantar gap widening and the surgical results were statistically analyzed. RESULTS Bone union and return to the original sport were attained in all patients without treatment failures/complications such as delayed union, nonunion, or refracture. The mean time to obtain bone union was 10.1 weeks, and the mean time to return to sport was 10.9 weeks. In comparing the no-gap group (n = 16) and the gap group (n = 21), no significant differences in the time to obtain bone union (P = .392) or to return to sport (P = .399) were noted. Additionally, there was no correlation between intraoperative plantar gap widening and the time to obtain bone union (r = 0.131; P = .428) or to return to sport (r = 0.160; P = .331). CONCLUSION The use of the Herbert screw for intramedullary screw fixation to treat fifth metatarsal stress fractures in high-level athletes provided satisfactory results enabling all the athletes to return to the original sport without treatment failures/complications. Additionally, intraoperative plantar gap widening does not affect the surgical results using this technique.
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Affiliation(s)
- Shota Morimoto
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tomoya Iseki
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | | | - Toshiya Tachibana
- Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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20
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Stress Imaging of Bone. Clin Sports Med 2021; 40:765-779. [PMID: 34509210 DOI: 10.1016/j.csm.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article defines stress injury, including insufficiency and fatigue fractures. The pathophysiology and risk factors for development of stress injuries are also discussed. The most common locations, including specific imaging examples, are reviewed with an emphasis on early detection and differentiation of high-risk and low-risk locations. Optimal imaging modalities with associated imaging findings are covered, as well as some potential pitfalls to avoid. The importance of correlating imaging findings with symptoms and the prognostic value of imaging grading are also discussed.
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21
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Stress Fractures of the Foot and Ankle. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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[Stress fractures of the lower limbs]. DER ORTHOPADE 2021; 50:763-774. [PMID: 34415371 DOI: 10.1007/s00132-021-04139-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
Stress reactions and fractures represent an important differential diagnostic entity, especially in patients active in sports. The lower extremities have predilection sites for stress fractures, which require special treatment in the context of the underlying risk factors. Clinically, patients usually complain of stress-dependent pain in the affected region and sport activities are mostly limited or even impossible. The detection of acute stress fractures is usually missed by conventional X‑ray within the first 4-6 weeks. The gold standard diagnostic tool is magnetic resonance imaging (MRI). Depending on the location, a distinction must be made between low-risk and high-risk stress fractures. Low-risk fractures show a high healing rate after conservative treatment including load and stress reduction as well as avoiding risk factors. High-risk fractures can take a complicated course under conservative treatment measures and in some cases, surgical intervention is required.
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23
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Abstract
Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.
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24
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Abstract
This article reviews the magnetic resonance imaging (MRI) findings of the normal anatomy and various pathologic conditions of the ankle and foot commonly encountered in clinical practice. The spectrum of entities discussed includes osseous and osteochondral injuries, ligamentous injuries, common traumatic and degenerative tendon pathology, abnormalities of transverse tarsal joint (Chopart) and tarsometatarsal joint (Lisfranc) complexes, pathological conditions affecting capsuloligamentous structures of the great toe and lesser toes, as well as pedal infection, with a focus on diabetic osteomyelitis and neuropathic osteoarthropathy.
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25
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Abstract
The assessment of bone mainly relies on standard radiographs, CT, MRI, and bone scintigraphy depending on the anatomic region complexity and clinical scenario. Ultrasound (US), due to different acoustic impedance between soft tissues and the bone cortex, only allows the evaluation of the bone surfaces. Nevertheless, US can be useful in the evaluation of several bone disorders affecting the limbs as a result of its tomographic capabilities and high definition. This pictorial review article summarises our clinical experience in adults and reviews the literature on US bone examination. We first present the US appearance of normal bone and the main congenital anatomic variations, after which we illustrate the US findings of a variety of bone disorders. Although US has limits in bone assessment, its analysis must be a part of every musculoskeletal US examination.
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Affiliation(s)
- Stefano Bianchi
- CIM SA Cabinet Imagerie Médicale, 40a route de Malagnou, 1208, Geneva, Switzerland.
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26
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Spezielle Aspekte bei Stressfrakturen. Radiologe 2020; 60:506-513. [DOI: 10.1007/s00117-020-00657-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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27
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Geometric and "True" Densitometric Characteristics of Bones in Athletes with Stress Fracture and Menstrual Disturbances: A Systematic Review. Sports Med 2020; 49:1059-1078. [PMID: 31041601 DOI: 10.1007/s40279-019-01109-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Stress fractures can lead to short- and long-term consequences, impacting participation in sport and general health. Recognizing which skeletal characteristics render bones susceptible to stress fracture may aid stress-fracture prevention. Menstrual disturbances among exercising women are a known risk factor for stress fracture; therefore, assessing skeletal commonalities between women with stress fractures and women with menstrual disturbances may increase our understanding of why menstrual disturbances put athletes at greater risk for stress fracture. Three-dimensional (3D) bone imaging tools provide detailed information about volumetric bone mineral density (vBMD) and bone structure that cannot be obtained using traditional two-dimensional (2D) techniques. OBJECTIVES This systematic review serves to: (1) evaluate the current literature available on vBMD, bone geometry, and bone structure in exercising women with menstrual disturbances and exercising women with stress fractures, and (2) assess the common skeletal characteristics between both conditions. Our aim is to reveal bone properties beyond 2D areal BMD that may indicate increased susceptibility to stress fracture among exercising women with menstrual disturbances. SEARCH METHODS A search of the PubMed/Medline database was completed in May 2018. ELIGIBILITY CRITERIA Eligible articles included those that reported vBMD, bone geometry, or bone structure obtained from 3D imaging techniques or estimated from 2D imaging techniques. Only studies conducted in premenopausal exercising women and girls who had a stress fracture, a menstrual disturbance, or both were included. RESULTS Twenty-four articles met the inclusion criteria. Bone area and cortical thickness at the tibia were identified as altered both in women with menstrual disturbances and in women with stress fractures; however, there was inconsistency in the results observed for all bone parameters. The majority of skeletal parameters of the lower extremities were not significantly different between exercising women with and without stress fractures and between those with and without menstrual disturbances. DISCUSSION Most studies were moderate or low quality based on study design, and only one article combined both conditions to explore vBMD and bone geometry in athletes with menstrual disturbances and a history of stress fracture. These findings highlight the need for more skeletal research on the intersection of these health conditions in exercising women. The lack of observed differences in skeletal parameters suggests that risk factors other than bone geometry and structure may be the primary causes of stress fracture in these women.
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28
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Tibial bone stress injury: diagnostic performance and inter-reader agreement of an abbreviated 5-min magnetic resonance protocol. Skeletal Radiol 2020; 49:425-434. [PMID: 31420694 DOI: 10.1007/s00256-019-03297-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/08/2019] [Accepted: 08/05/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the diagnostic performance and inter-reader agreement of an abbreviated (5 min) MR protocol compared to a complete (25 min) protocol, for evaluation of suspected tibial bone stress injury. MATERIALS AND METHODS This IRB-approved retrospective study consisted of 95 consecutive MR examinations in 88 patients with suspected tibial bone stress injury. Three musculoskeletal radiologists independently classified all examinations utilizing both an abbreviated protocol consisting only of axial T2-weighted images with fat suppression, and after a washout period again classified the complete examinations. Accuracy was calculated as proportion of cases classified exactly, within 1 grade, within 2 grades, and also utilizing a simplified "clinically relevant" classification combining grades 2, 3, and 4A into a single group. Significance testing was performed with the chi-test, and a post-hoc power analysis was performed. Inter-reader agreement was calculated with Kendall's coefficient of concordance, with significance testing performed utilizing the z-test after bootstrapping to obtain the standard error. RESULTS AND CONCLUSIONS There was no significant difference in accuracy of grading tibial bone stress injuries between complete and abbreviated examinations. For complete exams, pooled exact accuracy was 47.8%; accuracy within 1 grade was 82.8%; and accuracy within 2 grades was 96.1%. For the abbreviated protocol, corresponding accuracies were 50.2, 82.0, and 93.9%. With the "clinically relevant" simplified classification, accuracy was 58.6% for complete exams and 64.2% for abbreviated exams. There was no significant difference in inter-reader agreement, with substantial agreement demonstrated for both complete (Kendall coefficient of concordance 0.805) and abbreviated examinations (coefficient of 0.767).
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29
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Calcaneal insufficiency fractures following total knee arthroplasty: Classification and clinical findings. Injury 2019; 50:2339-2345. [PMID: 31606135 DOI: 10.1016/j.injury.2019.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Calcaneal insufficiency fracture (IF) following total knee arthroplasty (TKA) is a rare disorder. This study aimed to examine the prevalence and clinical findings of calcaneal IF following TKA. METHODS We retrospectively reviewed 3,585 consecutive patients undergoing primary TKA between 2012 and 2017 in four hospitals. Calcaneal IF following TKA was diagnosed by plain radiography or magnetic resonance imaging. First, we investigated the prevalence and clinical findings of calcaneal IF following TKA. Second, we classified calcaneal IF into three types based on its location: type 1, fracture by traction force around the Achilles tendon insertion; type 2, compression fracture around the posterior subtalar joint; and type 3, fracture by ground reaction force at the bottom of the calcaneus. Finally, we compared the clinical findings between calcaneal IF with and without TKA. RESULTS Calcaneal IF following TKA was seen in 17 (0.5%) of the 3,585 patients undergoing primary TKA. All patients were female, with a mean age of 76.5 ± 5.9 years, relatively high body mass index (BMI), and osteoporosis. All fractures achieved bone union with conservative treatment. Type 1 fractures were the most common. Calcaneal IFs following TKA were significantly shorter in height and the patients had higher BMI than those without TKA. The locations of calcaneal IF following TKA varied, while only type 1 calcaneal IFs were seen in cases without TKA. However, there were no significant differences with regard to the bone union period or malunion between the two groups. CONCLUSIONS Calcaneal IF should be suspected in patients presenting with ipsilateral foot pain following TKA, particularly in female patients with a relatively high BMI and osteoporosis. Calcaneal IF can be classified into three types based on the fracture location. These variations in calcaneal IF may be due to differences in conditions and changes in mechanical loading of the lower extremity and bone quality following TKA.
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30
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Stein CJ, Sugimoto D, Slick NR, Lanois CJ, Dahlberg BW, Zwicker RL, Micheli LJ. Hallux sesamoid fractures in young athletes. PHYSICIAN SPORTSMED 2019; 47:441-447. [PMID: 31109214 DOI: 10.1080/00913847.2019.1622246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: To describe the evaluation, management and recovery time of hallux sesamoid fractures in young athletes.Methods: A retrospective chart review was performed in a large academic teaching institution over a 5-year period (1/1/2010-12/31/2014). All patients with a sesamoid injury were initially included. Excluded were those patients who: 1) did not receive the diagnosis of hallux sesamoid fracture, had a history of prior foot surgery, or had medical records inadequate for analysis, 2) had missing or unclear diagnostic imaging, 3) were age >21 years, or 4) did not report sports participation. Descriptive statistics were employed to analyze the data.Results: Fifty-eight patients (51 females and 7 males) with a mean age of 15.4 years (range: 9-21) were identified with a total of 59 sesamoid fractures. Dancing (37.9%), running (13.8%), and gymnastics (13.8%) were the most common sports reported among these patients. A greater number of fractures were classified as repetitive stress injuries (83.1%), rather than acute traumatic injuries (16.9%). Fractures were treated conservatively in the majority of cases (89.8%), and only six fractures (10.2%) were treated surgically. Most patients (84.7%) were able to return to sports and activities. The average time from diagnosis/start of treatment to pain-free state/cleared to return to sport was 161.4 days.Conclusion: Diagnosis of sesamoid fractures can be challenging, but overall most patients do well with conservative treatment and are able to return to sports and activities. Providers should keep sesamoid fracture in the differential when evaluating patients with pain in the area around the base of the first toe, especially in dancers, gymnasts, and runners. Understanding that the recovery from a sesamoid fracture can be a prolonged process may help patients develop realistic expectations.
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Affiliation(s)
- Cynthia J Stein
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Dai Sugimoto
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
| | - Nathalie R Slick
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Corey J Lanois
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Bridget W Dahlberg
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Rebecca L Zwicker
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.,The Micheli Center for Sports Injury Prevention, Waltham, MA, USA
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31
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[Stress fracture of athletes as a cause of groin pain]. Radiologe 2019; 59:204-211. [PMID: 30701303 DOI: 10.1007/s00117-019-0493-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CLINICAL/METHODICAL ISSUE In this article, suitable imaging of stress reactions and stress fractures in athletes will be examined. STANDARD RADIOLOGICAL METHODS Diagnostic procedures include X‑ray, computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy. METHODICAL INNOVATIONS MRI represents the gold standard for these types of injuries. PERFORMANCE Of all imaging techniques, MRI shows the highest sensitivity in terms of diagnostic and prognostic aspects in stress reactions and stress fractures. PRACTICAL RECOMMENDATIONS Early performance of MRI to evaluate the staging, therapy and prognosis of the healing process is recommended.
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32
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Abstract
Metatarsal and toe fractures are the most frequent injuries of the foot skeleton. Nondislocated fractures can be conservatively treated with good success. Long-term relief and immobilization including the ankle joint are unnecessary. Metatarsal fractures close to the base are nearly always associated with Lisfranc luxation and treatment must also take the instability of the tarsometatarsal joints into consideratíon. Basal fractures of the 5th metatarsal bone require a differentiated consideration. The correct classification is necessary in order to initiate an adequate treatment. In general, intra-articular layer formation, inclination >10° and shortening between 3 mm and 5 mm, taking the position of the head of the metatarsal bone into consideration, are recommended as indications for surgery. Operative treatment of toe fractures is only rarely necessary.
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Affiliation(s)
- M Beck
- Klinik für Orthopädie und Unfallchirurgie, St. Bernward Krankenhaus, Treibestr. 9, 31134, Hildesheim, Deutschland.
| | - A Wichelhaus
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - R Rotter
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - P Gierer
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - T Mittlmeier
- Abteilung für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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McKissack HM, He JK, Montgomery TP, Wilson JT, Jha AJ, Moraes LV, Shah A. Is Use of Bone Cement for Treatment of Second Metatarsal Stress Fractures Safe? A Case Report. Cureus 2018; 10:e3436. [PMID: 30546983 PMCID: PMC6289564 DOI: 10.7759/cureus.3436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Metatarsal stress fractures are common injuries of the foot and can be a source of chronic pain without appropriate management. Conservative management is first line, but surgery may be indicated in athletes, cases of nonunion, and fractures of the fifth metatarsal. We report a case of a 34-year-old female who presented to clinic for intractable pain of the left foot secondary to a stress fracture of the left second metatarsal, which had been previously treated with injectable acrylic bone cement. Calcium sulfate hydroxyapatite cement has a multitude of applications in orthopedic surgery, but to our knowledge no studies have documented its use in the treatment of metatarsal stress fractures. Our findings suggest that injectable calcium sulfate hydroxyapatite cement is not a suitable stand-alone treatment in fractures of the second metatarsal.
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Affiliation(s)
| | - Jun Kit He
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Tyler P Montgomery
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - John T Wilson
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Aaradhana J Jha
- Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Leonardo V Moraes
- Orthopedics, Instituto De Assistência Médica Ao Servidor Público Estadual (IAMPSE), São Paulo, BRA
| | - Ashish Shah
- Orthopaedics, University of Alabama at Birmingham, Birmingham, USA
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34
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Bilateral Stress Fractures of the Talus Associated with Adult-Acquired Flatfoot Deformities. Case Rep Orthop 2018; 2018:5376384. [PMID: 30271647 PMCID: PMC6151209 DOI: 10.1155/2018/5376384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/04/2018] [Indexed: 11/18/2022] Open
Abstract
Adult-acquired flatfoot deformity is a progressive flattening of the arch of the foot that results from posterior tibial tendon insufficiency with a predilection for middle-aged women. A lateralized force vector associated with hindfoot valgus in adult-acquired flatfoot produces lateral ankle pain due to impingement at the lateral hindfoot, which can even lead to stress fractures of the distal fibula. Here, we present the rare case of a 73-year-old woman who presented with stress fractures of the bilateral taluses and unilateral distal fibula accompanied by severe adult-acquired flatfoot deformities.
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Sun D, Liu J, Shi Q, Mu H, Zhou D. Regulatory role of microRNA-185 in the recovery process after ankle fracture. Exp Ther Med 2018; 16:3261-3267. [PMID: 30233673 DOI: 10.3892/etm.2018.6534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 07/10/2018] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to investigate the expression of microRNA (miR)-185 in the bone and blood tissues following ankle fracture, and its regulatory mechanism in the ankle fracture recovery process. In total, 28 patients with ankle fractures were included, including 15 cases receiving surgical treatment within 1-7 days after fracture, and 13 cases receiving surgery within 8-14 days after fracture. Reverse transcription-quantitative polymerase chain reaction was performed to detect the mRNA expression levels. Western blot analysis and ELISA were used to determine the protein expression levels. Bioinformatics analysis and dual-luciferase reporter assay were applied to predict and confirm the upstream regulator of tumor growth factor (TGF)-β1. An MTT assay was performed to assess the cell proliferation. Compared with the 1-7-day surgery group, the mRNA and protein expression levels of TGF-β1 were significantly elevated, while the expression levels of miR-185 were significantly declined in the bone and blood tissues in the 8-14-day surgery group. Bioinformatics analysis and dual-luciferase reporter assay predicted and confirmed that TGF-β1 was the direct target gene of miR-185. Moreover, upregulated expression of miR-185 significantly decreased the protein expression levels of TGF-β1 and reduced the proliferating activity of hFOB1.19 cells. Within two weeks after ankle fracture, the expression levels of TGF-β1 are significantly upregulated in the bone and blood tissues, which may have been associated with the downregulated expression of miR-185. miR-185 may modulate TGF-β1 to regulate the recovery of ankle fracture. These findings may contribute to the understanding of the biological functions and effects of miRNA-185 and TGF-β1 in ankle fractures.
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Affiliation(s)
- Deping Sun
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China.,Department of Orthopedic Trauma, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong 264000, P.R. China
| | - Juntao Liu
- Department of Orthopedic Trauma, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong 264000, P.R. China
| | - Qingpeng Shi
- Department of Orthopedic Trauma, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong 264000, P.R. China
| | - Haibo Mu
- Department of Orthopedic Trauma, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong 264000, P.R. China
| | - Dongsheng Zhou
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
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36
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Kaiser PB, Guss D, DiGiovanni CW. Stress Fractures of the Foot and Ankle in Athletes. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418790078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff’s law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete’s training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered “high risk” due to poor intrinsic healing and may warrant more proactive operative management.
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Affiliation(s)
- Philip B. Kaiser
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
| | - Daniel Guss
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
| | - Christopher W. DiGiovanni
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Newton-Wellesley Hospital, Newton, MA, USA
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37
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Galluzzo M, Greco F, Pietragalla M, De Renzis A, Carbone M, Zappia M, Maggialetti N, D'andrea A, Caracchini G, Miele V. Calcaneal fractures: radiological and CT evaluation and classification systems. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:138-150. [PMID: 29350643 PMCID: PMC6179077 DOI: 10.23750/abm.v89i1-s.7017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/31/2022]
Abstract
Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)
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