Arthroscopic matrix-associated chondrocyte implantation for osteochondral ankle lesions is safe and offers good overall clinical and magnetic resonance imaging results, according to these results.

Matthias Aurich, MD, of University Hospital in Jena, Germany, and colleagues performed a clinical and MRI review of 18 patients who had a total of 19 osteochondral ankle lesions and were treated with arthroscopic matrix-associated chondrocyte implantation (MACI) between February 2006 and May 2008. To assess the patients, the investigators used the pain and disability module of the Foot Function Index (FFI), the AOFAS clinical rating system, the Core Scale of the Foot and Ankle Module of the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Outcomes Assessment instruments, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. They compared the clinical results for up to 3 years after MACI with preoperative data for 14 cases with MRI data for 19 cases.

All clinical scores improved significantly. The FFI pain scores improved from 5.5 + 2.0 (pre-MACI) to 2.8 + 2.2 (post-MACI). The FFI disability scores improved from 5.0 + 2.3 to 2.6 + 2.2. Other improvements were seen as follows:

• AOFAS: 58.6 + 16.1 to 80.4 + 14.1;
• AAOS standardized mean: 59.9 + 16.0 to 83.5 + 13.2; and
• AAOS normative score: 23.0 + 13.0 to MACI: 42.2 + 10.7.

The AOFAS Hindfoot score indicated that 64% were rated excellent and good; 36% were rated fair and poor. The results correlated with patient age and symptom duration, but not with lesion size. Sixteen patients reported regular sports participation before symptom onset. Thirteen returned to sports after MACI; nine returned to the same level. The mean MOCART score was 62.4 + 15.8 points. Although filling the defect somewhat correlated with AAOS score, there was no association between MOCART score and clinical outcome.

interesting results for a another potential weapon in our fight against ankle pain.

Bruce Werber DPM, FACFAS

10900 N. Scottsdale Rd

Suite 604

Scottsdale, AZ 85254

480-948-2111

www.inmotionfootandankle.com

ankle sprain study

A new study in West Point cadets sheds a bit more light on risk factors for two relatively rare, but severe, types of ankle sprain.

So-called "high" and "inner" ankle sprains account for 10 to 15 percent of all ankle sprains, Dr. Brett D. Owens of Keller Army Hospital in West Point, New York, and his colleagues note in the American Journal of Sports Medicine.

Both types of sprain result in longer time lost due to injury and greater disability than more common sprains.

Ankle sprains usually involve the ligaments linking the lower leg to the heel, and typically occur when the foot twists inward. But high ankle sprains, technically known as syndesmotic sprains, affect the ligament holding together the two long bones of the lower leg, Owens explained in an interview.

Inner, or medial, sprains are even rarer and occur when the foot is twisted outward.

To better understand how common these types of ankle sprains are and what puts people at risk for them, Owens and his team looked at data on all ankle injuries among U.S. Military Academy cadets between 2005 and 2009.

Over the five years, 1,206 cadets sprained an ankle, with seven percent of those injuries being high sprains and five percent inner sprains.

In the entire cadet population during that period, the overall risk of experiencing a high ankle sprain was about half a percent for both men and women. For inner ankle sprains, the annual risk for male and female cadets was also less than one in 100, at 0.39 percent and 0.12 percent, respectively.

Eighty percent of the high sprains that occurred happened during athletics, as did 64 percent of the inner sprains. High-contact, high-impact sports accounted for most injuries, with top offenders for high sprains in men being sprint football, men's team handball, soccer, and basketball; for women, the highest-risk sports for high sprains were intercollegiate volleyball, followed by basketball and soccer. Inner sprains occurred most frequently during men's rugby, gymnastics, and soccer.

Men playing at the intercollegiate level were 3.5 times as likely as women playing intercollegiate sports to have inner ankle sprains, but there was no gender difference in the risk of high sprains. Athletes playing intercollegiate sports had 2.4 times the risk of high sprains compared to athletes playing intramurally.

Bulk also played a role in who was most at risk. The average body mass index (BMI, a measure of weight in relation to height that is used to gauge obesity but can also indicate high muscle mass) was higher for people who sustained either inner or high sprains. The BMI of those who were injured averaged about 26, versus 24 for people who were not hurt. A BMI between 18.5 and 24.9 is considered normal for most of the population.

Time lost to play averaged about two weeks for high sprains, and while data on inner sprains wasn't complete, time lost to sport was higher than seen in previous studies of these injuries. By comparison, a past study by Owens and his colleagues in the same group of cadets found they lost an average of eight days due to lateral sprains, the most common type of ankle sprain.

Inner sprains were probably more common for men because men were more likely to engage in high-impact play, Owens noted.

While efforts to prevent inner and high ankle sprains wouldn't differ much from efforts to prevent more common sprains, such as the use of special braces, Owens said, the findings do help to identify which individuals face the greatest risk, and where these interventions should be targeted. "It's the contact sports that are most problematic, football, rugby...gymnastics, which is not surprising, given the amount of energy that goes into a jump landing," he said.

Bruce Werber DPM, FACFAS

10900 N. Scottsdale,

Suite 604

Scottsdale, AZ 85254

480-948-2111

www.inmotionfootandankle.com

Neuropathy treatment, a new approach.......

Ghrelin, a peptide produced in the stomach, given as an intravenous (IV) injection may help combat diabetic neuropathy, according to Japanese investigators.

The investigators presented data at the Endocrine Society's 92^nd Annual Meeting showing that diabetes-related nerve damage of the feet and legs (polyneuropathy) improves after treatment with ghrelin.

Ghrelin increases food intake and increases growth hormone secretion. It also suppresses inflammation and oxidative stress and promotes cell survival and proliferation. Because of its diverse action, ghrelin may have many clinical applications; it also is being tested for the treatment of anorexia nervosa, diabetic gastroparesis, and cachexia.

Ghrelin's main function is to transiently increase secretion of growth hormone. Patients with diabetes have suppressed growth hormone secretion, which is one of the causes of their metabolic imbalance.

“Ghrelin is a potential novel therapeutic approach for the treatment of polyneuropathy, an otherwise intractable disorder,” said researcher Masamitsu Nakazato, MD, PhD, Professor of Medicine at the University of Miyazaki in Miyazaki, Japan.

Dr. Nakazato and his colleagues first studied the effects of intraperitoneal administration of synthetic ghrelin in mice with chemically induced diabetes. They evaluated nerve injury using the nerve conduction velocities test, which measures the speed of electrical signals through the nerve in response to a mild electrical stimulation. A decreased velocity indicates nerve damage. The investigators found that ghrelin improved reductions in motor and sensory nerve conduction velocities in the diabetic mice and normalized their temperature sensation.

They then tested IV ghrelin therapy in three men with type 2 diabetes who were not taking insulin. These men received gherlin therapy for two weeks after breakfast so that the ghrelin would not stimulate food intake. “After ghrelin treatment, all three patients had improved nerve conduction velocity of the lower limbs and improved symptoms of polyneuropathy,” said Dr. Nakazato, who presented the study findings.

The patients did not gain any weight or have any worsening of their blood sugar levels as a result of ghrelin therapy. Overall, it appeared that this treatment did not alter glucose metabolism or body weight. The agent was tested in healthy individuals as well as the three diabetic subjects. Ghrelin therapy increased plasma growth hormone levels by 60 ng/mL in healthy subjects and 16 ng/mL in the diabetics 15 minutes after IV injection.

“We didn't find any side effects with ghrelin,” Dr. Nakazato said. “This may offer a new therapeutic paradigm for diabetes and diabetes complications.”

Bruce Werber DPM, FACFAS

inMotion Foot and Ankle Specialists

If you read many sports headlines, you know that ankle sprains are all over the place. NBA star Dwayne Wade suffered a mild sprain several weeks ago, and there were over 620 foot and ankle injuries in the 2004 Athens Olympics-many of which were sprains. The best, most coordinated athletes in the world suffer from ankle sprains, but they plague the rest of us as well.

A “sprain” is a stretching or a tearing of ligaments around a joint, and the ankle is the most commonly sprained joint in the body. The majority of sprains are “inversion-type” in which the ankle rolls inward, thus stretching the ligaments on the outside of the ankle. In more serious cases, however, even the muscle tendons can be stretched or torn.

Several factors can predispose an ankle to sprains. Weak muscles, poor rehab from a prior sprain, and a diminished sense of position are all common causes. Sprains range in their severity from 1^st degree which includes mild stretching and swelling to 3^rd degree which involves the complete rupture of a ligament and excruciating pain. Regardless of their degree, ankle sprains should be treated as soon as possible to promote a better outcome and minimize long-term pain and instability. A good pneumonic to remember is R.I.C.E. which stands for Rest the ankle, Ice it for 15-20 minutes several times per day, Compress it with wraps or bandages, and Elevate the ankle above the level of the heart as much as possible for 48 hours. Be careful not to apply ice directly to elderly individuals or those with blood-flow problems.

2^nd and 3^rd degree ankle sprains should receive professional treatment immediately. Your podiatrist can perform X-rays to confirm the diagnosis and rule out an avulsion injury which is a fracture of the ligament’s attachment site to bone. He or she can also screen for potential causes of long-term future pain such as fractures, impingements, or bony fragments within the joint.

There are also several steps you can take to prevent your ankle from re-spraining. Continue to stretch your calf muscles-particularly on the affected leg-and wear an ankle brace or strapping device. Balancing exercises are good if tolerable. A wedge can also be placed in your shoe to prevent your ankle from tipping over. Finally, for individuals with chronic ankle sprains, surgery is available to tighten the ligaments and shift the tendons in order to stabilize your foot.

for more information

www.inmotionfootandankle.com

www.brucewerberdpm.com

ankle hurt? check this out

Ankle Pain/Sprains:

Chronic ankle pain can cause a severe limitation in daily activities as well as sport activities. Ankle pain can be caused by a wide variety of problems, however more commonly it is due to ankle instability. The ankle as with most joints is stabilized and held in place by a myriad of soft tissue structures including ligaments and tendons. When these ligaments or tendons become stretched or strained by repetitive motions or injury, they do not perform optimally and allow the ankle joint to become unstable. The loosened tendons and ligaments allow increased motion in all directions across the ankle joint and may even allow the ankle joint to become temporarily dislocated during activity. This temporary dislocation of the ankle joint is known as an ankle sprain. Multiple ankle sprains in an individual are an indication that the ankle joint is very unstable and no longer functions appropriately. This requires treatment to rebalance and stabilize the ankle.

Treatments vary and can range from conservative non-surgical techniques to surgical repair of ankle ligaments or tendons. A common non-surgical intervention involves ankle bracing or strapping. An ankle brace or strap may be applied to the ankle during periods of increased activity and functions as a bolster that supports the ankle and allows the joint to function correctly.

Another conservative treatment method may include the use of arch supports that are inserted into the patient‘s shoe, and offer stability to the ankle by providing a stable platform and support for the foot. Arch supports are available in generic type devices which are made to fit a variety of individuals or in a custom device that is tailored to fit the specific individual.

Ankle braces and arch supports may also be used in combination to produce a superior result than either treatment alone and when coupled with physical therapy can be quite effective.

Bruce Werber DPM, FACFAS
www.arizonafeet.com

Ankle Joint replacement - artificial ankle

Advancements in orthopedic technology continue to revolutionize surgical options. Todays surgical instruments and implants make orthopedic surgery more precise and more effective than ever before. One such advancement can now be seen in the Salto Talaris tm which has been modeled after the human anatomy and is positioned to redefine the classic approach to ankle arthroplasty.

The innovative Salto Talaris now provideds surgeons the ability to reproduce the natural flexion/extension axis of the ankle with an anatomic design. The Salto Talaris tm implant design and instrumentation is founded on the Salto mobile-bearing ankle prosthesis, which has been in clinical use since 1997 and at 6.4 year mean followup has a 93% survivorship. The Salto Talaris provides accuracy and reproducibility with the precision instrumentation that has evolved to allows a fixed-bearing implant design and represents the philosophy "Less is Sometimes More"

Anatomic design to restore normal anatomy for optimal range of motion.
Highly accurate and reproducible instrumentation.

A total ankle replacement may be needed for those patients with chronic ankle arthritis causing pain that conservative measures such as rest, physical therapy, or medications were unable to correct.

How can Ankle replacement surgery (Ankle arthroplasty) help?

If you are considering ankle joint replacement surgery or ankle arthroplasty [ARE-throw-plas-tee], this brochure may contain some helpful information.

Reduce or eliminate ankle pain and regain range of motion.

Return to normal daily activities that were previously limited by the ankle damage. Success will depend on your age, activity level, as well as other factors.

The ankle joint absorbs four times the body weight with each step, that’s more than double what the hip and knee absorb. As you age, your ankles may develop osteoarthritis, rheumatoid arthritis, or arthritis resulting from injury such as fractures or frequent sprains.

While ankle fractures and ankle sprains may heal, they can lead to problems much later in life. These injuries can cause long-term damage to the cartilage that cushions the ankle joint. Sometimes the cartilage surface is damaged so severely, surgery may be the most effective option to relieve pain.

To learn more about ankle surgical options including ankle replacement.

If your ankle pain is debilitating, you should Dr. Werber (480-948-2111) regarding your treatment options.

10900 N. Scottsdale Road

Scottsdale, AZ 85254

480-948-2111

WWW. InMotionfootandankle.com

Ankle Sprain

For rapid healing of a severely sprained ankle, think below-knee cast, according to investigators here. Action Points Explain to patients that this study showed that a below-knee cast leads to more rapid improvement in recovery from ankle sprain compared with other commonly used mechanical supports. Severe ankle sprains healed significantly more quickly with a below-knee cast or air-cell brace compared with a Bledsoe boot or a tubular compression bandage, investigators here reported. The 10-day below-knee cast and the Aircast resulted in 8% to 9% improvement in the quality of 90-day recovery compared with a tubular compression bandage, Sarah Lamb, D.Phil., of the University of Warwick, and colleagues reported in the Feb. 14 issue of The Lancet. The degree of improvement with the Bledsoe boot did not differ significantly from that of the tubular compression bandage, which was the least effective device. The quality of recovery at nine months did not differ among the four devices. "Contrary to popular clinical opinion, a period of immobilization was the most effective strategy for promoting rapid recovery," the authors said. "This was achieved best by the application of a below-knee cast. The Aircast brace was a suitable alternative to below-knee casts." "Results for the Bledsoe boot were disappointing, especially in view of the substantial additional cost of this device," they added. "Tubular compression bandage, which is currently the most commonly used of all the supports investigated, was, consistently, the worst treatment." Severe ankle injuries (grade II-III) can cause significant incapacitation and require three to nine months for recovery in most affected individuals, the authors noted. Systematic reviews have revealed lack of high-quality evidence to aid clinical decision-making related to management of severe ankle injuries. In an attempt to fill some of the data void, Dr. Lamb and colleagues performed a multicenter, randomized clinical trial involving 584 patients treated in eight emergency departments for severe ankle sprain. Participants were randomized to tubular compression bandage (reference), Bledsoe boot, 10-day below-knee cast, or Aircast. All patients began wearing the supports within three days of their injury. Trained healthcare professionals provided advice about use of the supports and strategies to reduce swelling and pain. The primary outcome was the quality of ankle function at three months, as determined by the standardized Foot and Ankle Score (FAOS). Evaluation of functional outcomes continued for nine months. After three months, patients assigned to tubular compression bandage had an average FAOS score of 54. Patients given the below-knee had a 9% improvement in recovery compared with the reference group (95% CI 2.4 to15, effect size 0.36). Support with the Aircast resulted in an 8% difference compared with the reference (95% 1.8 to14.2, ES 0.33) but there were little differences for pain, symptoms, and, activity. The Bledsoe boot led to a 6% improvement in FAOS versus the compression bandage, but the difference did not achieve statistical significance (95% CI 0 to12.3, ES 0.25). The below-knee cast and Aircast also led to greater improvement compared with the compression bandage on the FAOS subscales related to symptoms, pain, activities of daily living, and sports. although the Aircast brace was not as wide-ranging in its benefits as the below-knee cast, Patients assigned to the Bledsoe boot had mixed results on the subscales, including some scores that were worse than those of patients assigned to the compression bandage. The superior results in evidence at three months with the below-knee cast and Aircast were not sustained at nine months, as the four groups had similar levels of recovery. Scores on the physical and mental components of the SF-12 scale differed little among the four treatment groups. The results demonstrate advantages for the 10-day below-knee cast for patients with acute ankle sprains, Jay Hertel, Ph.D., of the University of Virginia in Charlottesville, said in a commentary. However, the results also failed to support widely used approaches to management of ankle sprains. "Since the short-term benefits were identified at three months, but the intermediate-term benefits at nine months follow-up were not found, the results of this study call into question the current standard of aggressive functional treatment of patients recovering from acute ankle sprains," said Dr. Hertel. The study was funded by the Department of Health in England. The authors and Dr. Hertel reported no potential conflicts of interest.

Primary source: The Lancet Source reference: Lamb SE, et al "Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomized controlled trial" Lancet 2009; 373: 575-581. Additional source: The Lancet Source reference: Hertel J "Immobilization for acute severe ankle sprain" Lancet 2009; 373: 524-526.