Isolated Medial Subtalar Joint Dislocation during Soccer (Football) Game: A Case Report and Review of the Literature

Ankles injuries are common in sports such as football and soccer and one of the most serious and most rare is the subtalar dislocation. This injury is rare, touches young male patients and usually associated to fractures of the talus, the malleoli or the fifth metatarsal. Usually, this injury occurs in high-energy trauma, but it is very rare in sports injuries. Here we present the case of a 36-year-old male with an isolated Medial Subtalar Joint Dislocation after a severe tackle in a football (soccer) game. We performed a closed reduction under general anesthesia, and then a short-leg cast was applied for 4 weeks, followed by active and passive range of motion. At one-year follow up from trauma, the patient had a pain-free ankle with active full range of motion. For isolated medial subtalar dislocation occurring during sports activities, the first choice is the conservative treatment: Immediate closed reduction needs to be achieved followed by a short immobilization. Active/passive range of motion need to be started early to avoid joint stiffness.

COVID-19: Epidemiology and Preventive Measures in Jiangsu Province, China

Objective: To analyze the epidemiological features of coronavirus disease 2019 (COVID-19) in Jiangsu Province after starting level 1 response to major public health emergencies and assess the effectiveness of epidemic prevention and control measures took by the government. Methods: Individual information on all novel coronavirus pneumonia confirmed cases from January 10, 2020 to March 18th in Jiangsu was collected from the official website of Health Commission of Jiangsu province and its cities, Hubei Health Commission and the Chinese Health Commission. The trends in demographic and epidemiological characteristics of confirmed cases were estimated and the real time reproduction number (Rt) were calculated. Results: 631 COVID-19 cases were diagnosed in Jiangsu Province, covering 13 districts in Jiangsu. The confirmed cases consisted of imported cases (30.27%) and local transmitted cases (69.73%). 64.15% (238/371) local transmitted cases had reported a history of exposure to COVID-19 cases or patients with acute respiratory infection. Close contact with COVID-19 infectors in families, parties or some public places is the main transmission route for local transmission cases. The epidemic peak occurred from January 30 to February 4, then began to decline. The ratio of male to female cases was 1.22 to 1, and most patients were in the group of 30-70 years old, 49 patients (7.8%) with mild symptom and 572 patients (90.6%) with common type accounted for the majority. As of March 18, the cities with higher cumulative confirmed cases were Nanjing (93 cases, 15%), Suzhou (87 cases, 14%) and Xuzhou (79 cases, 12%). The Rt reached a peak of 4.05 (95%CI 2.27-6.34) on January 20, then began to decline. Rt was below the epidemic threshold (Rt<1) after January 31 and maintained a continuing downward trend. Conclusion: The epidemic preventive and control measures have contributed to interrupt local transmission of COVID-19 in Jiangsu Province, and the epidemic in Jiangsu Province was well under control in less than a month.

Fibroblast Growth Factor-23 Secreting Tumour Induced Osteomalacia

Tumour Induced Osteomalacia (TIO) caused by a Fibroblast-Growth- Factor-23 (FGF-23) secreting tumour is a rare paraneoplastic disorder. Patients often present with non-specific complaints of pain and stiffness however findings of hypophosphataemia and inappropriately suppressed 1,25 dihidroxyvitamin D are almost pathognemonic of this condition. We present a previously healthy 51-year-old man who presented with an 18 month history of body aches, hypophosphataemia, and an incidental finding of atraumatic foot fractures on x-ray. Technetium bone scan identified diffuse skeletal pathologic fractures. He was further found to have persistent hypophosphataemia, suppressed 1-25-dihidroxyvitamin-D, renal phosphate wasting with reduced Tubular Reabsorption of Phosphate (TRP), and an FGF-23 level more than twice the upper limit of normal. Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET), Gallium-68 Dotatate PET and magnetic resonance imaging further identified and characterised a 40 mm FDG and Dotatate-avid lesion in the right third rib. Histopathological examination of a biopsy specimen revealed phosphaturic mesenchymal tumour with positive FGF-23 immunohistochemical staining arising in a background consistent with osteomalacia. After tumour resection, the patient’s hypophosphataemia, reduced TRP and elevated FGF- 23 normalised and he made an excellent recovery with rehabilitation. This case report illustrates the importance of a diagnosis of hypophosphataemia in a patient with musculo-skeletal aches and alerts clinicians of the differential diagnosis of TIO.

Traumatic Dislocation of the Knee Unsuitable for the Reconstruction of Ligamentous Injuries Because of Vascular Injury: A Case Report

Traumatic dislocation of the knee is rare, but often requires surgical intervention because complications frequently occur, including various ligamentous injuries. In this study, we report a case of knee dislocation with ligamentous injuries and injury to the popliteal artery. The patient was a 32-year-old man. He fell while bouldering and was diagnosed with dislocation of the right knee and multiple ligamentous injuries. Upon examination, we found that his right dorsal foot was numb, and the dorsal artery of the right foot was not palpable. His right leg felt cold compared to the other leg. Magnetic resonance imaging revealed injuries to the anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament. Computed tomography revealed that the patient’s right popliteal artery was partially obstructed. We planned to reconstruct the injured ligaments. Prior to the surgery, the radiologist performed angiography, and the patient’s popliteal artery became completely obstructed during angiography; therefore, revascularization was performed immediately. Although the blood flow in the right leg recovered, it remained cold, and we did not reconstruct the ligamentous injuries. Knee dislocation requiring revascularization is quite rare. However, it causes severe dysfunction of the knee. Thus, meticulous and frequent evaluation of vascular injuries is necessary for the treatment of knee dislocation.

Comparison of Intra-Articular versus Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Study

Background: Total Knee Arthroplasty (TKA) is widely used in clinical applications. Considerable postoperative blood loss, however, is an unavoidable occurrence due to the extensive soft-tissue release, and the large area of cancellous bone osteotomy associated with the procedure. Besides, knee flexion and extension activities those begin the day after the operation adds to the problem. Aim of the Work: To compare between the intra-articular and the intravenous application of Tranexamic Acid (TXA) in total knee arthroplasty. Patients and Methods: It is a prospective Double-blinded Randomized controlled trial. This prospective study was conducted at El-Hussein University Hospital & El Agouza Hospital on 30 patients who undergo total knee arthroplasty and fulfill all inclusion and exclusion criteria. Results: The results were the average total blood loss in the drain after 48hrs. In the 1st group was 365±74.722 while average blood loss in the 2nd group was 575±88.976. This indicates a significant decrease in blood loss in the 1st group (intraarticular TXA group) than the 2nd group (intravenous TXA group) the P value <0.001 which is highly significant. It was found that The decrease in Hb level is less in the 1st group than in the 2nd group which indicates less postoperative anemia in the blood count, the P-value <0.05 considered significant.

Sarcoidosis: Review of Diagnosis and Treatment

Background: Sarcoidosis is a systemic heterogenous granulomatous disease of unknown etiology that results in inflammation of pulmonary and extrapulmonary sites. In a minority of patients it can result in fibrosis and permanent organ damage. Most commonly mentioned causes of sarcoidosis include atypical mycobacterium, proprionobacterium and inorganic dusts. Once exposed to an organic or inorganic, an Antigen Presenting Cell (APC) prepares and presents the antigen to a T cell and its respective HLA locus. In a susceptible person, this provides cytokine production, differentiation into T helper cells and provokes an immune response that in its early stages is allayed by corticosteroids or other immunomodulatory agents. In the majority of patients appropriate immunomodulatory therapy will control the disease and prevent progression. However, in 20-25 % the disease can progress and lead to organ damage or compromise and fibrosis. Sarcoidosis is a relatively common disease with an incidence of 2.3-17.8 per 100,000. It is 2-4 times more common in African Americans than Caucasian Americans with the mean age of onset of 45-50 years of age. Unlike autoimmune rheumatic disease the disease occurs almost as commonly in men than women. Sources: A Medline, Pub Med review from 1999-2021. Spectrum of Disease: Sarcoidosis occurs in 90-98 % of patients during the course of their disease. Eleven to twenty two percent of patients have involvement of either the liver, Skin, ocular (uveitis), Lymph nodes and spleen. The upper airway, liver, CNS and heart comprise <10% of cases each and the bone, joints/ muscle, and hypercalcemia < 5%. Diagnosis: With the exception of Lofgren’s and Heerfordt’syndromes the presence of non-caseating/necrotizing granuloma must be present on biopsy of at least one site and mycobacterial or fungal infections or malignancy must be ruled out. If clinically suspicious, Skin and peripheral lymph nodes are the least invasive areas for biopsy and if hilar or mediastinal nodes are suggestive, an EBUS approach is recommended. In organs such as the heart and CNS where biopsy is either insensitive or invasive, a Cardiologist and Neurologist in concert with a Rheumatologist can make a probable diagnosis based on clinical presentation, PET or MRI and exclusion of alternative diseases.

Rheumatoid Arthritis Induced by Botulinum Toxin Type A: A Case Report and Review of the Literature

Introduction: Botulinum Toxin Type A (BoNT/A) is a bacterial toxin commonly used in cosmetic therapy. Although there has been a great deal of clinical and basic research on the potential therapeutic applications of botulinum toxin there are few reports on its clinical toxicity and side effects. Patient Concerns: A previously healthy 26-year-old woman developed joint pain and redness in her right toe, swelling in the posterior left foot and the interphalangeal joint of the right index finger, occasional shoulder pain, and morning stiffness for 30 minutes daily, 6 months after BoNT/A injection. Diagnosis: Laboratory testing showed elevated Rheumatoid Factor (RF), anti-cyclic citrullinated peptide (anti-CCP), C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR). Doppler ultrasound examination of the right hand and both feet showed synovial hyperplasia of the right wrist, right second proximal interphalangeal joint, both ankles, and right first metatarsophalangeal joint, as well as bony erosion in a left intertarsal joint. Magnetic Resonance (MR) examination for right hand showed multiple joint changes of right hand and wrist, which included synovium thickening and enhancement. She was diagnosed as rheumatoid arthritis. Interventions: BoNT/A injection was stopped. Methotrexate 10mg was given once weekly and hydroxychloroquine 0.2g was given twice daily with subsequent remission of arthritis. Outcomes: At 12 months from diagnosis, patient reported complete joints remission. Conclusions: This is the first report of rheumatoid arthritis caused by botulinum toxin injection, and we speculate on the mechanism of its occurrence in this paper. In addition, we systematically introduce the latest research results on the development mechanism of BoNT/A causing RA. This review suggests that it is necessary to further explore the specific mechanism of RA or osteochondral injury caused by BoNT/A, which will not only help to improve the current understanding of the potential toxic and side effects of BoNT/A in clinical application, but also promote the standardization of clinical application of BoNT/A.

Surgical Treatment of Tarsal Tunnel Syndrome - Case Report

The first description of tarsal tunnel syndrome is recent. Koppel in 1960 evoked the after-effects of lesions of the posterior tibial nerve. Keck in 1969 was the first to describe compression of the posterior tibial nerve by the internal annular ligament. It was a young soldier who, after intensive training, had bilateral plantar anesthesia. The opening of the internal annular ligament had allowed a total recovery in 48 hours. Our objective here is to discuss the circumstances of the diagnosis of this syndrome, to analyze its anatomical and pathological causes, to present the types of treatments followed, in the light of the literature.