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Background Posterior tibial tendon (PTT) insufficiency is considered as the main cause of adult acquired flat foot and is three times more frequent in females. High estrogen levels exert a positive effect on the overall collagen synthesis in tendons. We have previously demonstrated the association between some genetic single-nucleotide polymorphism (SNP) and tendinopathy. In the present study, we investigated the association of PvuII c454-397T>C (NCBI ID: rs2234693) and XbaI c454-351A>G (NCBI ID: rs9340799) SNPs in estrogen receptor alfa (ER-α) gene with PPT dysfunction. Methods A total of 92 female subjects with PTT dysfunction, with histopathological examination of the tendon and magnetic resonance image (MRI) evidence of tendinopathy, were compared to 92 asymptomatic females who presented an intact PPT at MRI for PvuII and XbaI SNPs in the ER-α gene. Genomic DNA was extracted from saliva and genotypes were obtained by polymerase chain reaction restriction fragment length polymorphism. Results The analysis of PvuII SNPs showed no significant differences in the frequency of alleles and genotypes between control and PTT dysfunction groups. The XbaI SNPs in the ER-α gene showed significant differences in the frequency of genotypes between control and test groups ( p  = 0.01; OR 95% 1.14 (0.55–2.33). Conclusions The XbaI SNP in the ERα gene may contribute to tendinopathy, and the A/A genotype could be a risk factor for PTT tendinopathy in this population. The PvuII SNP studied was not associated with PTT tendinopathy.

Posterior tibial tendon (PTT) insufficiency is considered as the main cause of adult acquired flat foot and is three times more frequent in females. High estrogen levels exert a positive effect on the overall collagen synthesis in tendons. We have previously demonstrated the association between some genetic single-nucleotide polymorphism (SNP) and tendinopathy. In the present study, we investigated the association of PvuII c454-397T>C (NCBI ID: rs2234693) and XbaI c454-351A>G (NCBI ID: rs9340799) SNPs in estrogen receptor alfa (ER-[alpha]) gene with PPT dysfunction. A total of 92 female subjects with PTT dysfunction, with histopathological examination of the tendon and magnetic resonance image (MRI) evidence of tendinopathy, were compared to 92 asymptomatic females who presented an intact PPT at MRI for PvuII and XbaI SNPs in the ER-[alpha] gene. Genomic DNA was extracted from saliva and genotypes were obtained by polymerase chain reaction restriction fragment length polymorphism. The analysis of PvuII SNPs showed no significant differences in the frequency of alleles and genotypes between control and PTT dysfunction groups. The XbaI SNPs in the ER-[alpha] gene showed significant differences in the frequency of genotypes between control and test groups (p = 0.01; OR 95% 1.14 (0.55-2.33). The XbaI SNP in the ER[alpha] gene may contribute to tendinopathy, and the A/A genotype could be a risk factor for PTT tendinopathy in this population. The PvuII SNP studied was not associated with PTT tendinopathy.

Posterior tibial tendon (PTT) dysfunction is three times more common in females, and some patients may have a predisposition without a clinically evident cause, suggesting that individual characteristics play an important role in tendinopathy. The present study investigated the association of rs4986938 (+ 1730G > A; AluI RFLP) and rs1256049 (− 1082G > A; RsaI RFLP) single nucleotide polymorphisms (SNPs) of estrogen receptor-beta (ER-β) gene with PTT dysfunction. A total of 400 participants were recruited. The PTT dysfunction group: these patients underwent surgery, with PTT tendinopathy confirmed by histopathology and magnetic resonance image (MRI). The control group was composed of participants with no clinical or MRI evidence of PTT dysfunction. Each group was composed of 100 postmenopausal women, 50 premenopausal women, and 50 men. Genomic DNA was extracted from saliva samples, and genotypes were obtained by polymerase chain reaction restriction fragment length polymorphism (PCR–RFLP). Concerning the ER-β SNP rs4986938, there were significant differences in the frequencies of alleles between test and control groups of all the cases, only postmenopausal women and only men (p < 0.0001, p = 0.0016 and p = 0.0001). Considering the PTT dysfunction group and comparing postmenopausal women versus premenopausal women adding men, the analysis showed significant differences in the allelic distribution (p = 0.0450): the allele A in postmenopausal women is a risk factor. The ER-β SNP rs1256049 did not show differences in the frequencies of alleles and genotypes between groups. The ER-β SNP rs4986938, but not ER -β SNPs rs1256049, may contribute to PTT insufficiency in the Brazilian population, with additional risk in postmenopausal women. Addition, in men the genetic factor could be more determinant.

Background: Achilles tendinopathy (AT) rehabilitation traditionally includes progressive tendon loading exercises. Recent evidence suggests a biopsychosocial approach that incorporates patient education on psychosocial factors and mechanisms of pain can reduce pain and disability in individuals with chronic pain. This is yet to be examined in individuals with AT. Objective: This study aims to compare the effects on movement-evoked pain and self-reported function of pain education as part of a biopsychosocial approach with pathoanatomical education for people with AT when combined with a progressive tendon loading exercise program. Methods: A single-site, randomized, double-blind, placebo-controlled clinical trial will be conducted in a university-based hospital in a laboratory setting and/or by telehealth. A total of 66 participants with chronic (>3 months) midportion or insertional AT will be randomized for the Tendinopathy Education of the Achilles (TEAch) study. All participants will complete progressive Achilles tendon loading exercises over 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. All participants will complete 6-7 one-to-one sessions with a physical therapist to progress exercises in a standardized manner over 8 weeks. During the last 4 weeks of the intervention, participants will be encouraged to maintain their home exercise program. Participants will be randomized to 1 of 2 types of education (pain education or pathoanatomic), in addition to exercise. Pain education will focus on the biological and psychological mechanisms of pain within a biopsychosocial framing of AT. Pathoanatomic education will focus on biological processes within a more traditional biomedical framework of AT. Evaluation sessions will be completed at baseline and 8-week follow-up, and self-reported outcome measures will be completed at the 12-week follow-up. Both groups will complete progressive Achilles loading exercises in 4 phases throughout the 12 weeks and will be encouraged to continue with self-selected exercises as tolerated. Primary outcomes are movement-evoked pain during heel raises and self-reported function (patient-reported outcome measure information system—Physical Function). Secondary outcomes assess central nervous system nociceptive processing, psychological factors, motor function, and feasibility. Results: Institutional review board approval was obtained on April 15, 2019, and study funding began in July 2019. As of March 2020, we randomized 23 out of 66 participants. In September 2020, we screened 267 individuals, consented 68 participants, and randomized 51 participants. We anticipate completing the primary data analysis by March 2022. Conclusions: The TEAch study will evaluate the utility of pain education for those with AT and the effects of improved patient knowledge on pain, physical function, and clinical outcomes. International Registered Report Identifier (IRRID): DERR1-10.2196/19111

Category: Other; Hindfoot Introduction/Purpose: WBCT (Weightbearing CT) has been increasingly employed to evaluate and treat patients with varied pathologies such as progressive collapsing foot deformity (PCFD), post-traumatic deformity, hallux valgus, ankle arthritis, Charcot arthropathy, lisfranc and syndesmosis injuries. However, little is known regarding its overall availability to foot and ankle providers and how it is being used in clinical practice. The goal of this study is to assess the utilization of WBCT among AOFAS members, identify the indications for use in clinical practice and potential barriers for implementation. Methods: A survey was emailed to AOFAS members inquiring about the use WBCT in clinical practice. Practice and demographic information were also collected. A total of 220 responses were collected over a 2-month period. Respondents were queried with respect to the availability of WBCT in practice, indications for use, frequency of use, ownership of the scanner and barriers to implementation. Results: 58% of respondents did not have access to WBCT. Most respondents were in practice 10 yrs or more (69%). Single-specialty private practice was the most common practice type. Of those with access to WBCT, 5 or fewer scans were ordered per week (57% of respondents). Evaluation of hindfoot/ankle deformity was the most common indication (69% of respondents) with it being used as a preoperative evaluation tool approximately 25% of the time (57% of respondents). Radiology dept owned WBCT in most institutions (34%). 75% of respondents with WBCT use it postoperatively less than 25% of the time. Of those without WBCT, 94% stated they would like to have it with cost being the most significant barrier to implementation. Conclusion: Most respondents surveyed did not have access to WBCT, with cost being the greatest barrier. However, 94% of those without it would like to have it. For those with access, it is used 5 or fewer times per week with evaluation of hindfoot/ankle deformity being the most common indication.

ObjectiveTo evaluate the influence of weight-bearing (WB) load in standard axial ankle syndesmotic measurements using cone beam CT (CBCT) examination of asymptomatic uninjured ankles.Materials and methodsIn this IRB approved, prospective study, patients with previous unilateral ankle fractures were recruited. We simultaneously scanned the injured ankles and asymptomatic contralateral ankles of 27 patients in both WB and NWB modes. For this study, only asymptomatic contralateral ankles with normal plain radiographs were included. Twelve standardized syndesmosis measurements at two axial planes (10 mm above the tibial plafond and 5 mm below the talar dome) were obtained by two expert readers using a custom CBCT viewer with the capability for geometric measurements between user-identified anatomical landmarks. Inter-reader reliability between two readers was obtained using the intra-class correlation coefficient (ICC). We compared the WB and NWB measurements using paired t test.ResultsSignificant agreement was observed between two readers for both WB and NWB measurements (p <0.05). ICC values for WB and NWB measurements had a range of 50–95 and 31–71 respectively. Mean values of the medial clear space on WB images (1.75, 95% confidence interval [95% CI]: 1.6, 1.9) were significantly lower than on NWB images (2.05, 95% CI: 1.8, 2.2) measurements (p <0.001). There was no significant difference between the remaining WB and NWB measurements.ConclusionMeasurements obtained from WB images are reliable. Except for the medial clear space, no significant difference in syndesmotic measurements were observed during the WB mode of CBCT acquisition, implying that the tibio-fibular relationship remains unchanged when the physiological axial weight-bearing load is applied.

Category: Midfoot/Forefoot; Ankle Introduction/Purpose: Lisfranc(LF) injuries are challenging to diagnose due to the subtlety of instability and low diagnostic sensitivity of traditional imaging methods like MRI and CT. These modalities fall short in accurately identifying subtle LF injuries because they do not simulate physiological load or provide sufficient bone detail under non-weightbearing conditions. Weightbearing computed tomography (WBCT) has emerged as a superior diagnostic technique, leveraging load-bearing conditions and superior bony visualization to detect subtle joint instabilities that other methods miss. This systematic review advances previous findings by comparing WBCT to conventional CT in diagnosing LF injury, as well as the ability to detect LF injuries of differing severity. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this study. The PubMed, CINAHL, MEDLINE, SPORTDiscus, and Web of Science databases were searched from database inception until July 5th, 2023. The search algorithm utilized keywords that pertained to computed tomography and tarsometatarsal to find relevant articles. Eligibility criteria included articles using CT or WBCT. Articles were then retrieved, duplicates removed, and screening conducted based on article title, abstract, and full text using inclusion and exclusion criteria. Data extraction included author, publication year, patient demographic, injury description, imaging modality used, measurements, and p values. Articles were graded using the Methodological Index for Non-Randomized Studies (MINORS) scale, and statistical analysis of the extracted data conducted. Results: Out of the 498 articles retrieved, 9 met inclusion criteria. Several studies reported that WBCT was able to provide a higher level of accuracy than conventional CT when measuring the Lisfranc area, with enhanced sensitivity to subtle alterations in joint structure. WBCT also demonstrated superior sensitivity when it came to distinguishing between healthy and injured Lisfranc joint, especially when it came to identifying dorsal ligament damage. WBCT was able to detect significant variation in important measurements such as the first-second (M1-M2) distance, the first cuneiform (C1)-M2 distance, and joint volumes. WBCT also demonstrated good intra- and inter-observer reliability. This enables a more comprehensive assessment of the Lisfranc joint health, especially when it came to cases of subtle joint instability. Conclusion: This systematic review demonstrates the value of WBCT over conventional CT when it comes to diagnosing LF injury. Not only was WBCT able to detect deviations in asymmetry and LF area that conventional CT was unable to identify, but it detected instability in cases of subtle injury, and was able to differentiate between injury groups at various lower levels of injury. This review is the first to include comparisons of objective image modalities, as well as Lisfranc injuries of various severities.

ObjectivesTo assess high-bandwidth and compressed sensing-(CS)-SEMAC turbo spin echo (TSE) techniques for metal artifact reduction MRI of total ankle arthroplasty (TAA) implants.MethodsFollowing institutional approval and consent, 40 subjects with TAA implants underwent 1.5-T MRI prospectively. Evaluations included bone-implant interfaces, anatomical structures, abnormal findings and differential diagnoses before and after MRI. AUCs of P-P plots were used to determine superiority. Statistical differences were evaluated with McNemar and chi-square tests. P-values ≤ 0.05 were considered significant.ResultsCS-SEMAC TSE was superior to high-bandwidth TSE in showing the bone-implant interfaces (AUC=0.917), periprosthetic bone, tendons and joint capsule (AUC=0.337–0.766), bone marrow oedema (43 % difference, p=0.041), interface osteolysis (63 %, p=0.015), tendinopathy (62 %, p=0.062), periprosthetic fractures (60 %, p=0.250), synovitis (43 %, p=0.250), as well as reader confidence for bone marrow oedema (p=<0.001), fracture (p=0.001), interface osteolysis (p=0.003), synovitis (p=0.027) and tendinopathy (p=0.034). The number of differential diagnoses in symptomatic subjects after the MRI with CS-SEMAC decreased from 3 (1–4) to 1 (1–2) (p<0.001).ConclusionsMRI of TAA implants with CS-SEMAC improves the diagnosis of interface osteolysis, periprosthetic bone marrow oedema, fractures and tendinopathy when compared to high-BW TSE, and has a positive effect on patient management.Key Points• High-bandwidth TSE and compressed sensing SEMAC improve MRI of ankle arthroplasty implants.• Compressed sensing SEMAC improves bone-implant interfaces, periprosthetic bone, tendons and joint capsule visibility.• Compressed sensing SEMAC improves the diagnosis of osteolysis, tendinopathy, fractures and synovitis.• MRI decreases the number of clinical differential diagnoses of painful ankle arthroplasty implants.

Background: Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high–impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details. Results: Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA. Conclusion: This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

The decade from 2010–2020 has seen the development of cone beam weight-bearing CT (WBCT) as a major innovation in the foot and ankle realm, becoming an important modality for bone and joint imaging. The ability to provide three-dimensional images of the naturally loaded skeleton has enabled several subsequent innovations to arise with aims to hasten image processing and to extend the clinical applications of WBCT. The objective of this work was to identify, categorize and explain those emerging techniques. We performed a structured review of the literature according to PRISMA standards, finally including 50 studies. We subsequently proposed a classification of these techniques. Segmentation and distance mapping were identified as key features. We conclude that although WBCT has already been adopted in a number of clinical communities with an immediate improvement in patient workflows, adoption of advanced techniques is yet to come. However, that relies mostly not on the technology itself, but on improvements in AI software allowing practitioners to quickly process images in daily practice and enabling the clinicians to obtain an accurate three-dimensional evaluation of the segment considered. Standardization will be paramount to amass large amounts of comparable data, which will fuel further innovations in a potentially virtuous circle.