April 2013

   According to the study, in addition to lateral ligamentous ankle pathology, peroneal tendon pathology and ankle joint pathology are commonly associated with unstable ankles. Study authors conclude that successful treatment for these three pathologies, which they have termed the “lateral ankle triad,” includes ankle arthroscopy, lateral ankle stabilization and peroneal tendon repair.

   In this retrospective review, researchers evaluated the results of 302 patients who had ankle arthroscopy, lateral ankle stabilization and peroneal tendon repair. Study authors note that radiological imaging may not always allow the surgeon to identify the source of pathology effectively in an unstable ankle. Therefore, they recommend peroneal tendon inspection during lateral ankle stabilization and ankle arthroscopy to find intra-articular lesions that one may have missed preoperatively. As the study notes, the researchers observed that most peroneus brevis tendon tears were large, longitudinal tears against the posterior fibula, which is indicative of a tendon compensating for an unstable ankle.

   Babak Baravarian, DPM, FACFAS, the study’s co-author, emphasizes the importance of inspecting the peroneal tendons during a lateral ankle stabilization procedure to evaluate their integrity as they are often pathological in cases of ankle instability.

   “If you are planning a repair of the ligaments, I suggest a magnetic resonance image (MRI) to check the peroneals for tear … If there is no tear on the MRI but the surgeon still suspects a possible tear, a longer incision will allow ligament repair and tendon exploration,” explains Dr. Baravarian, an Assistant Clinical Professor at the UCLA School of Medicine.

   Dr. Baravarian notes that MRI is necessary prior to surgery to check tendon, ligament and articular issues. In a case of a peroneal tendon pathology, he recommends repairing the peroneal tendon with a non-absorbable nylon suture and wrapping the tendon with an amniotic membrane to prevent scar formation. Dr. Baravarian notes that he uses a human amniotic membrane (Amniox Medical), which absorbs at three to four months.

   When it comes to lateral ankle instability, Dr. Baravarian still advocates initial conservative therapy and only considering surgery when conservative modalities fail to achieve results.

   “We always perform conservative care with bracing, physical therapy and possibly platelet rich plasma (PRP) injections. If that fails and the patient has pain and/or instability, we proceed with surgical options,” adds Dr. Baravarian.

Can A Medical Food Help Alleviate Diabetic Neuropathy Symptoms?

By Brian McCurdy, Senior Editor

A recent randomized trial in the American Journal of Medicine notes that a combination of L-methylfolate, methylcobalamin and pyridoxal-5’-phosphate (Metanx, Pamlab) can improve the symptoms in patients with diabetic neuropathy.

   The study focused on 214 patients with diabetic neuropathy, who were randomly assigned to treatment with Metanx or a placebo. The authors found that those taking Metanx reported consistent relief of symptoms, showing improved Neuropathy Total Symptom Scores at week 16 as well as improvement in their quality of life.

   Mackie J. Walker Jr., DPM, FACFAS, FASPS, says for the vast majority of patients, Metanx has minimal side effects with significant benefits and improvement in sensory perception and quality of life after three to six months of therapy. He also notes the prescription medical food is less expensive than medications that only provide relief of symptoms of painful diabetic neuropathy.

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