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BackgroundIntra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies.MethodsA retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p

Category: Hindfoot; Other Introduction/Purpose: Plantar fasciitis (PF), a leading cause of persistent heel pain, results in almost a million physician visits annually. Conservative treatment is often the first line of management with insoles being frequently prescribed. While multiple studies have compared insoles based on the degree of customization to foot contour, the literature is lacking in data comparing insoles based on their material. In this randomized clinical trial, we compared the early effects of foam, polyurethane, and carbon fiber insoles in the treatment of PF, using a robust set of PROMS. Methods: A randomized clinical trial was designed at the foot and ankle research center of a tertiary care hospital in Massachusetts. Adult patients diagnosed with PF who had not received injectable or surgical treatment for it were included. Participants who consented were randomly allocated one of the three prefabricated insoles – carbon fiber insole (Group 1, n=13), polyurethane insole (Group 2, n=13), or foam insole (Group 3, n=9) for regular use. Their response was recorded using PROMIS 3a (for pain intensity), PROMIS 4a (for pain interference), FAOS (Foot and Ankle Outcome Score), and VAS for pain at baseline (T0), two (T2), six (T6) and twelve weeks (T12). A per-proto analysis was undertaken using Kruskal Wallis and Friedman tests. P< 0.05 was set as the level of significance. Results: Among groups 1, 2 and 3, the mean age of participants was 51.9±13.2, 51±12.5, and 47.9±13.5 years respectively and baseline weight varied as 211.6±32.7 lbs, 193.6±59.3 lbs, and 180.7±33 lbs respectively (p>0.05 for both). The group-wise distribution of participants based on sex and laterality of the affected foot showed no difference. Participants in each group reported similar intensity of the pain (VAS) at baseline and at all follow-up time points (p>0.05). A comparison of outcomes between baseline and subsequent timepoints showed significant improvement in quality of life (FAOS) at T12 (p=0.047) for carbon fibre insole users (Figure 1), significant pain relief on PROMIS Pain intensity and Pain Interference questionnaires for foam insoles at T3 and T12 (p=0.0003, 0.036 respectively). Conclusion: Carbon fiber insoles offered slightly better pain relief as early as six weeks into treatment and improved quality of life after twelve weeks of use. A possible link between the material of insole used and effective treatment of PF may exist. Conducting further analyses on the position of the foot during gait while using insoles and designing the insoles based on patient-specific criteria should be considered for future research.

Category: Midfoot/Forefoot; Lesser Toes Introduction/Purpose: Arch-support insoles are frequently included in the treatment plans for common foot ailments including metatarsalgia. Literature has demonstrated that insoles with metatarsal and arch support could relieve walking pain and improve patient-reported measures of function in metatarsalgia. The purpose of this study was to examine alterations in foot alignment among metatarsalgia patients who used arch support insoles. Methods: A clinical trial was initiated after the approval by the institutional review board. Patients with metatarsalgia (age: 18-65 y/o) were included after they consented to participate. Individuals with open wounds, feet asymmetry, using assistive device or brace, and those with BMI more than 35 were excluded. Participants underwent weightbearing computed tomography (WBCT), and weight-bearing x-ray of their feet while standing barefoot or on the insoles (Good Feet™, Dr.’s Own, LLC). The radiological measurements on WBCT and X-rays conducted in these patients are shown in Table 1. The Wilcoxon-Signed Rank test was used for comparison of the continuous measurements, and the interobserver reliability was analyzed with Intraclass Correlation Coefficient (ICC). Results: Ten patients with a mean age of 46.9±13.06 years were included in the study. Observed changes on X-rays include decreased 4th-5th intermetatarsal angle (p=0.04), 2nd-4th/2nd-5th metatarsal tangent angles (p=0.003, p=0.001), and 1st metatarsal length on antroposterior (AP) view (p=0.02). Also, 1st metatarsal declination angle (p=0.002), and talo-first metatarsal angle on AP view (p=0.05) were increased. No significant changes on the WBCT were found, except for a decrease in the first metatarsal pronation angle (p=0.02). Conclusion: Arch support insoles can bring about anatomical changes especially in the forefoot area of patients with metatarsalgia. While the causal correlation between these changes and alleviation of the symptoms cannot be proven based on our data, these outcomes can guide future clinical trials comparing different treatment for metatarsalgia to determine contributing factors to the healing process of this condition.

Category: Ankle; Other Introduction/Purpose: Anatomical reduction of the distal syndesmosis can be challenging. There is ongoing debate and variability in the methods used for evaluating the accuracy of reduction, including radiography, intra-operative CT, arthroscopy, and direct visualization. Tornetta et al. have described a method called ‘the articular surface method’ that evaluates the relationship between the articular cartilage of the distal anteromedial fibula and the anterolateral tibia as being significantly more accurate for detecting malreduction. However, it entails an additional surgical incision over the distal aspect of the ankle. The aim of this study was to find a non-invasive method using ultrasound to assess the accuracy of reduction in syndesmotic injuries. Methods: A cadaveric syndesmotic instability model was created by dissecting the PITFL, IOL, and AITFL through a small posterior incision. The fibula was fixed in incremental degrees of rotational malreduction to achieve a malreduction of 3, 5, and 7 mm. A blinded observer assessed the syndesmosis using a portable ultrasound device. The probe was placed in its short axis at the level of the ankle joint then moved proximally until both the anteromedial fibular and anterolateral tibial articular surfaces were visualized simultaneously in one view. In a reduced syndesmosis, the distal articular surfaces of the tibia and fibula overlap. This relationship is altered in a malreduced syndesmosis, which allows ultrasonographic waves to ‘penetrate’ through the malreduced articular surfaces and be readily detected. This sign was graded positive if an acoustic signal penetrated between the distal articular surfaces of the tibia and fibula, and negative if no acoustic signal was detected. Results: The gap penetrance sign was positive in all 3 instances of malreduced syndesmoses, and negative in an anatomically reduced syndesmosis. Figure 1 illustrates the outcomes in a reduced syndesmosis and malreduced syndesmosis, respectively. Conclusion: We introduced a novel sign that can be used as a surrogate of the ‘articular surface method’ to detect syndesmotic malreduction. It is accurate, can obviate the need for a separate surgical incision for direct visualization, permits rapid point-of- care evaluation in the operating room, and minimizes radiation exposure

Background: Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions. Methods: Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed. Results: A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) −0.244; 95% CI, −1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, −0.413 to 1.921; I2, 90.2%) and 3 months (WMD−0.089; 95% CI, −0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups. Conclusion: NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis. [ABSTRACT FROM AUTHOR]