Publications by authors named "Amir Reza Vosoughi"

50 Publications

On-Top Plasty in Post-Axial Polydactyly: A Case Report and Recommendation to Modify the Classifications.

J Hand Surg Asian Pac Vol 2022 Jun;27(3):548-552

Department of Science, University of British Columbia, Vancouver, BC, Canada.

Post-axial polydactyly (PAP) is almost always treated by ablation of the sixth ray since the ulnar duplicate is universally inadequate and the radial one is normal. We report a patient with bilateral PAP with skeletal abnormalities in both radial and ulnar duplicates. This unusual presentation cannot be classified according to previous classifications of PAP and precludes simple ablation as the treatment of choice. Both hands of this patient were treated by on-top plasty with excellent functional and cosmetic results. A modification of the previous classifications is recommended at the end of this article. Level V (Therapeutic).
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http://dx.doi.org/10.1142/S2424835522720213DOI Listing
June 2022

Closed isolated anterolateral calcaneal dislocation: a case report.

BMC Musculoskelet Disord 2022 Jun 7;23(1):546. Epub 2022 Jun 7.

Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Complete isolated calcaneal dislocation, defined as dislocation of talocalcaneal and calcaneocuboid joints with intact talonavicular joint without significant fracture, is an exceedingly rare injury.

Case Presentation: A 49-year-old man, after a motor vehicle collision, presented with a closed isolated anterolateral dislocation of the calcaneus associated with fracture of the sustentaculum tali, cuboid, lateral process of the talus, and avulsion fracture of superior peroneal retinaculum. Urgent successful closed reduction was immediately performed in the emergency room under sedation. Two days later, through sinus tarsi approach extended proximally to posterior of the lateral malleolus and distally to the calcaneocuboid joint, peroneal tendons were reduced in the retromalleolar groove and avulsion fracture of the superior peroneal retinaculum was reduced and fixed by a suture anchor. A chondral lesion (6 × 8 mm) was seen in the posterior facet of the calcaneus for that chondroplasty and microfracture were performed. Also, small bony fragments from the cuboid were excised. The reduced calcaneocuboid joint was fixed by two Kirschner wires. In the second stage, 10 days later, through medial approach to the talocalcaneal joint, multiple free bony fragments were excised. Then sustentaculum tali was reduced and fixed using a lag screw. Postoperatively, a non-weight bearing short leg cast was applied for six weeks. The patient had permission to start partial weight bearing 6 weeks after removal of K-wires. Finally, at the 10th postoperative week, he had full weight-bearing without any aid instrument. He was able to return to his regular activities about 6 months after the injury. At 34 months, the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale was 92 from 100. The foot function index percentile was 7% and the visual analogue score for pain was 1.9. The last radiographs revealed normal configuration of talocalcaneal, calcaneocuboid, and talonavicular joints with a little joint space narrowing in posterior part of the subtalar joint.

Conclusion: Patients with isolated anterolateral calcaneal dislocations, even with multiple associated fractures, can have acceptable outcomes, if it is urgently diagnosed and properly managed.
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http://dx.doi.org/10.1186/s12891-022-05506-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9172192PMC
June 2022

Author's Reply for Letter to the Editor on "American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language".

J Foot Ankle Surg 2022 Mar-Apr;61(2):439

Associate Professor of Orthopedic Surgery, Orthopedic Foot & Ankle Surgeon, Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

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http://dx.doi.org/10.1053/j.jfas.2021.10.032DOI Listing
March 2022

Evaluating the Validity and Reliability of the Persian Version of American Orthopedic Foot and Ankle Society Midfoot Scale.

Foot Ankle Spec 2022 Jan 7:19386400211068242. Epub 2022 Jan 7.

Family Medicine Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: The use of a valid and reliable outcome scoring system is crucial for evaluating the result of different treatment interventions. The aims of this study were to translate and culturally adapt the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scoring system into the Persian language and assess its validity and reliability.

Method: In total, 57 patients with midfoot injuries were enrolled. Forward-backward translation and cultural adaptation methods were used to develop the Persian version of AOFAS midfoot scoring system. Reliability and internal consistency were assessed using intraclass correlation coefficient (ICC) and Cronbach's alpha. The discriminant and convergent validities of the scoring system were assessed using the total score of the mental and physical component of SF-36.

Results: The mean age of the participants was 46.2 ± 16.3 years. The intra-observer reliability of the totals core of the Persian version of AOFAS midfoot scoring system was 0.96 (confidence interval [CI]: 0.92-0.97) and the inter-observer reliability of the scoring system was 0.90 (CI: 0.86-0.95). The Persian version of AOFAS midfoot scoring system had acceptable convergence with physical component scoring system of SF-36 and its subscales (0.57); moreover, it had acceptable discriminant validity with the mental component of SF-36 and its subscales (0.36).

Conclusion: The Persian version of AOFAS midfoot is a reliable and valid instrument and could be used by Persian language clinicians and researchers.

Level Of Clinical Evidence: 3.
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http://dx.doi.org/10.1177/19386400211068242DOI Listing
January 2022

The effect of posterior tibial and sural nerve blocks on postoperative pain of patients following open reduction and internal fixation of calcaneal fractures.

Foot Ankle Surg 2021 Nov 24. Epub 2021 Nov 24.

Orthopedic Foot and Ankle Surgeon, Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Introduction: Postoperative pain control and achieving opioid-free anesthesia are major issues for surgically treated patients with calcaneal fractures. We evaluated the potential role of posterior tibial and sural nerve blocks as a part of multimodal pain control techniques in patients underwent open reduction and internal fixation (ORIF) of calcaneal fractures via extensile lateral approach.

Methods: Forty-eight patients randomly allocated to receive either posterior tibial and sural nerve blocks with bupivacaine (peripheral nerve block (PNB) group) or normal saline, after induction of general anesthesia. Patients were assessed for pain intensity, Interval from entrance to the recovery room to the first request for analgesic, recovery room and ward morphine consumption, global satisfaction and morphine side effects.

Results: PNB group had less pain score compared to sham block (SB) group at each time point measurement during recovery room stay. There was also significant difference between the 2 groups regarding the pain scores after 2, 4 and 6 h of the operation in the ward. Time to the first request for analgesic was significantly prolonged in the PNB group (P < 0.001). The recovery room and ward morphine consumption was significantly lower in the PNB group (P < 0.001). Global satisfaction in PNB group was significantly more than that of SB group. No complication related to the nerve block was detected at the first postoperative visit in the outpatient clinic.

Conclusion: Peripheral nerve block could result in less postoperative pain especially in the early hours after ORIF of calcaneal fractures and reduce opioid administration within the first 24 h following the surgery.
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http://dx.doi.org/10.1016/j.fas.2021.11.009DOI Listing
November 2021

Morphological Variations and Normal Parameters of the Cross-Sectional Anatomy of the Tibiofibular Syndesmotic.

Foot Ankle Spec 2021 Nov 2:19386400211055274. Epub 2021 Nov 2.

Associate Professor of Orthopedic Surgery, Orthopedic Foot and Ankle Surgeon, Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: The aim of this study was to determine morphological variations and normal parameters of the cross-sectional tibiofibular syndesmotic anatomy.

Methods: Configurations of syndesmosis, anterior syndesmotic width (ASW), posterior syndesmotic width (PSW), and overlap distance, defined as the overlap of medial fibula with a drawn line from tip of anterior tubercle of incisura fibularis to the posterior tip, were measured on normal computed tomography (CT) scans of 110 cases. Results: Seventy seven male (70%) and 33 female (30%) (left: 50 and right: 60) were assessed. Mean age of the cases was 33 ± 13 (range: 15-80) years. Three different syndesmotic configurations were crescent (55.5%), rectangular (39.1 %), and semicircle (5.4 %). Overall, mean ASW, PSW, and overlap distance were 2.72, 3.98, and 1.02 mm, respectively. Upper limit of normal ASW in crescent, rectangular, and semicircle was 4.80, 4.85, and 3.89 mm, respectively. The maximum of PSW in crescent, rectangular, and semicircle was 6.25, 6.50, and 4.97 mm, respectively. There was not significant difference between syndesmotic configurations based on age (P = .69) and sex (P = .16).

Conclusions: During interpreting axial CT scan to diagnose syndesmotic injuries, the normal range of parameters according to the different configurations of the tibiofibular syndesmosis should be carefully considered.

Level Of Evidence: Level 4.
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http://dx.doi.org/10.1177/19386400211055274DOI Listing
November 2021

Osteoporosis guideline awareness among Iranian nurses: results of a knowledge and attitudes survey.

J Prev Med Hyg 2021 Jun 30;62(2):E415-E420. Epub 2021 Jul 30.

Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.

Introduction: Osteoporosis is a chronic and progressive disease associated with gradual bone loss and elevated risk of fracture. Role of health care professional especially nurses in lowering burden of osteoporosis via patients and public education is critical. Current study conducted to evaluate knowledge and attitude regarding osteoporosis among the nurses in orthopedic wards and their experience with national clinical osteoporosis guideline.

Methods: A cross-sectional study was conducted from August to December 2016 among all nurses in orthopedic ward of hospitals affiliated to Shiraz University of Medical Sciences. The 23- item self-administered scale consisted of knowledge and attitude questions were used. Moreover, data regarding participation in osteoporosis training courses and awareness of the national osteoporosis clinical guideline were collected as a measure of nurses' experience with guideline. The gathered data were analyzed using SPSS (V. 16), student t-test was used to compare total knowledge and attitude scores between categorical demographic and professional data. Pearson test was used to calculate the correlation between total knowledge and attitude scores and years of practice. A p-value < 0.05 was considered statistically significant.

Results: From total of 160 nurses, 143 of them completed the questionnaire (response rate: 89.3%). The total mean ± SD knowledge and attitude scores were 11.60 ± 3.10 and 3.47 ± 0.92 respectively. Six nurses (4.2%) had participated in osteoporosis training courses after graduation, and 39 (27.3%) had been aware of the national osteoporosis clinical guideline. Knowledge and attitude scores among nurses who practice in private hospitals was higher than those practices in the teaching hospitals. These differences were statistically significant based on student t-test. According to Pearson correlation coefficient, there was positive and significant correlation between nurses' knowledge and attitude score (Correlation coefficient: 0.199, p-value = 0.037).

Conclusion: Our findings reveal that nurses' knowledge and attitude regarding osteoporosis was not satisfactory. Most of them were not aware of national osteoporosis clinical guideline and had not participated in osteoporosis training courses after their graduation. We need more empowered nurses to lowering burden of osteoporosis and its consequences in the future.
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http://dx.doi.org/10.15167/2421-4248/jpmh2021.62.2.1738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451363PMC
June 2021

Consequences of extensile lateral approach to the calcaneal fractures on balance and isokinetic strength of muscle groups crossing the ankle joint.

Foot Ankle Surg 2022 Aug 9;28(6):732-737. Epub 2021 Sep 9.

Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: Inherent characteristics of extensile lateral approach (ELA) for fixation of displaced intraarticular calcaneal fractures together with delayed or probably insufficient physical therapy programs may lead to weakness of the muscle groups crossing the ankle joint. Peroneal tendons might be involved more than others because of possible postoperative adhesions. The aim of this study was to evaluate the isokinetic strength of the muscle groups crossing the ankle joint and also to assess balance and functional ability in this group of patients.

Methods: Based on a pilot study, 23 patients undergone open reduction and internal fixation (ORIF) via ELA and 22 healthy subjects as the control group participated in this observational cross-sectional study. Patients more than 20 years of age with at least 12 months passed their unilateral closed intraarticular calcaneal fracture fixation without any postoperative complications like infection or wound dehiscence were included. Patients with history of concomitant lower extremity injury, spine trauma or surgery, cases underwent removal of calcaneal plates, and cases with neuromuscular or vestibular dysfunction were excluded. The outcome was assessed by isokinetic parameters such as peak torque, peak torque normalized to body weight, mean power and total work modified star excursion balance test, triple hop for distance test, and evertor-to-invertor (E/I) strength ratio. Isokinetic tests were performed at 60 and 120°/s.

Results: Greater strength was observed in all muscles in the control group at 60°/s (p < 0.05). Evertors and invertors were weaker in the operated group at 120°/s in comparison to the dorsiflexors and plantarflexors. Modified star excursion (p: 0.003) and triple hop tests (p: 0.001) were lower in the operated group. E/I ratio was not statistically significant between the two groups at 60°/s (p: 0.44) and 120°/s (p: 0.62).

Conclusions: Strength deficit in all muscle groups crossing the ankle joint, and not evertors in isolation, in addition to balance and functional impairments would be seen one year following ORIF of calcaneal fracture via ELA. A long-term rehabilitation program emphasizing different kinds of contraction at low and high speeds and balance training in these patients is highly recommended.
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http://dx.doi.org/10.1016/j.fas.2021.09.001DOI Listing
August 2022

Different patterns and characteristics of Talar injuries at two main orthopedic trauma centers in Shiraz, south of Iran.

BMC Musculoskelet Disord 2021 Jul 6;22(1):609. Epub 2021 Jul 6.

Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Categorizing different injury patterns of the talus, describing demographic data, mechanisms of injury and associated fractures are important issues in orthopedic trauma surgeries. Injuries of the talus require careful attention with appropriate treatment approaches in order to reduce possible complications.

Methods: In a cross-sectional study, the demographic characteristics, mechanism of injury, fracture type, and associated fractures were compiled from all patients' files and operation notes with diagnosis of talar injuries from January 2014 to December 2019.

Results: Among 367 patients, 317 (86.4%) males and 50 (13.6%) females with mean age of 31.8 ± 11.6 years were identified. There were three (0.8%) patients with bilateral talar fractures. The most common mechanism of injury was motor vehicle accident (MVA) (46.1%), followed by falls (43.3%), direct trauma (6.2%) and sport injuries (4.4%). About half of the patients injured in MVAs were motorcyclists. Isolated talar body fractures (21.9%) were more common than isolated talar neck (19.2%) or combined body & neck fractures (14.6%). Isolated lateral process fracture is the most frequent fractured process of the talus (14.3%). Hawkin type IIA (39.2%) was the most common type of talar neck, followed by Hawkin type III (22.3%), type I (21.5%), type IIB (14.6%) and type IV (2.3%). Medial malleolus, fibula and calcaneus were the most common associated fractures, respectively.

Conclusions: The population that is most affected by talar injury are active young men who are involved in motor vehicle accidents, especially motorcycle crashes, with fracture of body and/or neck of talus being the most common type.
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http://dx.doi.org/10.1186/s12891-021-04486-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261937PMC
July 2021

EFAS Score -Validation of Persian Version by the Score Committee of the European Foot and Ankle Society (EFAS).

Foot Ankle Surg 2021 Jul 18;27(5):496-500. Epub 2021 May 18.

National affiliate member, Score Committee European Foot and Ankle Society, c/o European Foot and Ankle Society (EFAS), Marseille, France.

Background: The Score Committee of the European Foot and Ankle Society (EFAS) developed, validated, and published the EFAS Score in nine European languages (English, German, French, Italian, Polish, Dutch, Swedish, Finnish, Turkish). From other languages under validation, the Persian version finished data acquisition and underwent further validation.

Methods: The Persian version of the EFAS Score was developed and validated in three stages: 1) item (question) identification (completed during initial validation study), 2) item reduction and scale exploration (completed during initial validation study), 3) confirmatory analyses and responsiveness of Persian version (completed during initial validation study in nine other languages). The data were collected pre-operatively and post-operatively at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using classical test theory and item response theory.

Results: The internal consistency was confirmed in the Persian version (Cronbach's Alpha 0.82). The Standard Error of Measurement (SEM) was 0.38 and is similar to other language versions. Between baseline and follow-up, 97% of patients showed an improvement on their EFAS score, with excellent responsiveness (effect size 1.93).

Conclusions: The Persian EFAS Score version was successfully validated in patients with a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.
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http://dx.doi.org/10.1016/j.fas.2021.05.006DOI Listing
July 2021

Different types and epidemiological patterns of calcaneal fractures based on reviewing CT images of 957 fractures.

Foot Ankle Surg 2022 Jan 5;28(1):88-92. Epub 2021 Feb 5.

Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran; Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Introduction: Calcaneal fractures may have lifelong debilitating sequences, if not treated properly. Identifying different types of calcaneal fractures based on the computed tomography (CT) scans can increase our conception about these fractures.

Methods: In a cross-sectional study, the available CT images of all consecutive patients with the diagnosis of calcaneal fracture, from January 2015 to December 2018, were reviewed to determine different patterns and types of these fractures.

Results: CT images of 886 patients (mean age, 41.29 ± 14.9; range, 3-89 years; male/female, 4.86; pediatric: 3.7%) with 957 calcaneal fractures were evaluated. The peak incidence of calcaneal fractures was seen in patients between 30 to 39 years of age (29%). The rate of open fractures and bilateral involvements were 2.4% and 8.0%, respectively. Among 680 (71.0%) intra-articular calcaneal fractures, subtalar calcaneal fractures were the most common type (94.3%). The majority of intra-articular subtalar calcaneal fractures were displaced (95.0%) with calcaneocuboid joint (CCJ) involvement (59.9%). Fracture lines were extended to the CCJ in about 86.9% of Sanders type IV, 66.3% of type III, and 60.2% of type II. Among 261 extra-articular fractures (27.3%), calcaneal body fracture (55.6%) was the most frequent type, followed by medial tubercle fracture (24.1%), calcaneal tuberosity fracture (10.4%), Degan type I anterior process fractures (5.4%), Degan type II anterior process fracture (3.4%), and isolated lateral tubercle fracture (1.1%). Most of bilateral calcaneal fractures were intra-articular subtalar fractures with involvement of CCJ. Although majority of intra-articular calcaneal fractures were displaced; less than half of the extra-articular fractures were displaced.

Conclusion: Displaced intra-articular subtalar calcaneal fractures with CCJ involvement are the most frequent type of unilateral and bilateral calcaneal fractures. It appears that there is a correlation between Sanders type and the probability of CCJ involvement. Unlike intra-articular subtalar calcaneal fractures, the CCJ in the majority of extra-articular calcaneal body fractures was intact.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.fas.2021.02.002DOI Listing
January 2022

Closed Pantalar Dislocations: Characteristics, Treatment Approaches, and Outcomes.

J Am Acad Orthop Surg 2021 04;29(7):278-287

From the Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran (Vosoughi), and the Department of Orthopaedic Surgery, Case Western Reserve University, The MetroHealth System, Cleveland, OH (Vallier).

Closed pantalar dislocation mainly occurs among male adults aged 20 to 45 years and is usually associated with high-energy trauma, mostly falls (50.0%). The talus dislocates anterolaterally in about 85% of cases. Pure pantalar dislocation is more common (54.7%) than cases with concomitant fractures (45.3%). Ankle fractures are the most common associated fractures, followed by fractures of the talar posterior process. Among 40 reported cases, 24 had successful closed reduction (60%), 11 had unsuccessful closed reduction (27.5%), and 5 underwent open reduction without attempting closed reduction (12.5%). The success rate for closed reduction of closed pantalar dislocation is 68.5% (24/35 cases). Post-traumatic arthrosis occurs in 32.3%. Osteonecrosis occurs less often than previously reported. Infection after closed reduction of pantalar dislocation is very rare except after open reduction and fixation for concomitant talar fractures. Conclusively, closed pantalar dislocations are very rare injuries and may portend a poor prognosis. Urgent talar relocation restores ankle and hindfoot anatomy and reduces pressure on surrounding soft tissues to optimize outcome. A closed reduction maneuver should be attempted initially, followed by urgent open reduction when the talus is not accurately reduced through closed means.
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http://dx.doi.org/10.5435/JAAOS-D-20-00836DOI Listing
April 2021

CRISPR/Cas9 Technology as a Modern Genetic Manipulation Tool for Recapitulating of Neurodegenerative Disorders in Large Animal Models.

Curr Gene Ther 2021 ;21(2):130-148

Medical Biotechnology Research Center, Paramedicine Faculty, Guilan University of Medical Sciences, Rasht, Iran.

Background: Neurodegenerative diseases are often the consequence of alterations in structures and functions of the Central Nervous System (CNS) in patients. Despite obtaining massive genomic information concerning the molecular basis of these diseases and since the neurological disorders are multifactorial, causal connections between pathological pathways at the molecular level and CNS disorders development have remained obscure and need to be elucidated to a great extent.

Objective: Animal models serve as accessible and valuable tools for understanding and discovering the roles of causative factors in the development of neurodegenerative disorders and finding appropriate treatments. Contrary to rodents and other small animals, large animals, especially non-human primates (NHPs), are remarkably similar to humans; hence, they establish suitable models for recapitulating the main human's neuropathological manifestations that may not be seen in rodent models. In addition, they serve as useful models to discover effective therapeutic targets for neurodegenerative disorders due to their similarity to humans in terms of physiology, evolutionary distance, anatomy, and behavior.

Methods: In this review, we recommend different strategies based on the CRISPR-Cas9 system for generating animal models of human neurodegenerative disorders and explaining in vivo CRISPR-Cas9 delivery procedures that are applied to disease models for therapeutic purposes.

Results: With the emergence of CRISPR/Cas9 as a modern specific gene-editing technology in the field of genetic engineering, genetic modification procedures such as gene knock-in and knock-out have become increasingly easier compared to traditional gene targeting techniques. Unlike the old techniques, this versatile technology can efficiently generate transgenic large animal models without the need to complicate lab instruments. Hence, these animals can accurately replicate the signs of neurodegenerative disorders.

Conclusion: Preclinical applications of CRISPR/Cas9 gene-editing technology supply a unique opportunity to establish animal models of neurodegenerative disorders with high accuracy and facilitate perspectives for breakthroughs in the research on the nervous system disease therapy and drug discovery. Furthermore, the useful outcomes of CRISPR applications in various clinical phases are hopeful for their translation to the clinic in a short time.
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http://dx.doi.org/10.2174/1566523220666201214115024DOI Listing
December 2021

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

J Foot Ankle Surg 2021 Jan-Feb;60(1):85-88. Epub 2020 Sep 20.

General Practitioner and Forensic Medicine Expert, Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran.

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.
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http://dx.doi.org/10.1053/j.jfas.2020.09.005DOI Listing
June 2021

Clinical and radiological outcomes after arthrodesis of the first metatarsophalangeal joint.

Int Orthop 2021 03 14;45(3):711-719. Epub 2020 Sep 14.

Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.

Purpose: The main aim of this study was to investigate the correlation between radiographic findings and clinical outcomes following the first metatarsophalangeal (MTP) joint arthrodesis.

Methods: In a comparative retrospective study, on 46 patients (48 ft), the correlation between post-operative radiographic findings including hallux valgus angle (HVA) and first MTP dorsiflexion angle (MTPDA) and clinical outcomes including VAS pain, modified AOFAS hallux score, and FFI questionnaire were evaluated. Moreover, clinical outcomes were compared between cases with pre-operative diagnosis of first MTP inflammatory arthritis, hallux valgus, hallux varus, and grade 3 and 4 of hallux rigidus. The effect of first MTP arthrodesis on Meary's angle and intermetatarsal angle (IMA) were found out.

Results: The mean age of the patients was 56.3 ± 9.1 (range, 29-69) years, including 42 (91.3%) females and 4 (8.7%) males. We had fusion rate of 97.9%, one asymptomatic nonunion case (2.1%). Totally, mean scores of modified AOFAS hallux score, FFI percentage, and VAS pain were 88.9 ± 12.6, 9.4 ± 16.5, and 1.23 ± 2.24, respectively. Hallux varus was associated with the most favourable outcomes; whereas, patients with first MTP arthritis got the worst outcome. Regression analysis test between clinical outcomes and HVA > 15° and first MTPDA >15° showed correlation coefficient of almost zero. No statistically significant differences were found between the clinical outcomes of grade 3 and 4 of hallux rigidus (p value of modified AOFAS hallux score, FFI percentage, and VAS pain: 0.879, 0.906, and 0.298, respectively). Mean of HVA and IMA reduction in 15 hallux valgus underwent first MTP fusion were 34.4° and 8.4°, respectively. Meary's angle increased about 4° with statistically significant difference (p value 0.001).

Conclusion: Patients with first MTP fusion > 15° in coronal and transverse plans could have acceptable clinical outcomes. The clinical outcome of first MTP arthrodesis for grade 3 hallux rigidus is comparable with grade 4. First MTP fusion would have positive effect on IMA and Meary's angle.
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http://dx.doi.org/10.1007/s00264-020-04807-3DOI Listing
March 2021

COVID-19 Effect on Foot & Ankle Surgery in Shiraz, South of Iran.

J Foot Ankle Surg 2020 Sep - Oct;59(5):887. Epub 2020 Jun 22.

Medical Student, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.

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http://dx.doi.org/10.1053/j.jfas.2020.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308016PMC
September 2020

Cross-cultural adaptation, reliability and validity of the Persian version of the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A).

Disabil Rehabil 2022 03 14;44(6):983-991. Epub 2020 Jul 14.

Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Purpose: Achilles tendinopathy is a prevalent overuse injury among athletes and in those with a sedentary lifestyle. Current evidence indicates that the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire is a valid, reliable and disease-specific outcome measure for assessing the clinical symptoms in patients with Achilles tendinopathy. The objective of this study was to translate and cross-culturally adapt the VISA-A questionnaire into Persian (VISA-A-P) and evaluating its psychometric properties.

Materials And Methods: Cultural adaptation of VISA-A-P was conducted according to Beaton's guideline. The final version of VISA-A-P was handed to 61 patients for analysis of psychometric properties. Test-retest reliability, internal consistency, concurrent validity, item-total correlation, and floor/ceiling effect were evaluated in patients with Achilles tendinopathy. To assess test-retest reliability, 35 patients refilled the VISA-A-P twice within 5-7 days. Known-group validity was evaluated using 50 healthy individuals.

Results: VISA-A-P showed excellent test-retest reliability (ICC = 0.90), excellent internal consistency (Cronbach's alpha = 0.95), strong correlation with FAAM, and moderate to strong correlation with FAOS questionnaires. There was a significant difference between the average score of patients (34.55 ± 18.24) and the healthy group (73.1 ± 20.10). VISA-A-P showed neither ceiling nor floor effect.

Conclusions: The VISA-A-P is a reliable and valid instrument for measuring the symptoms in Persian speaking populations with Achilles tendinopathy.Implications for rehabilitationAchilles tendinopathy is a debilitating overuse injury that insidiously affects tendoAchilles.VISA-A-P revealed acceptable validity and reliability and it could be used by Persian speaking clinicians and researchers to assess pain and function in people with Achilles tendinopathy.
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http://dx.doi.org/10.1080/09638288.2020.1781268DOI Listing
March 2022

Lisfranc fleck sign: characteristics and clinical outcomes following fixation using a percutaneous position Lisfranc screw.

Eur J Trauma Emerg Surg 2022 Feb 19;48(1):471-479. Epub 2020 Jun 19.

Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.

Background: Avulsion of the Lisfranc ligament, fleck sign, results in unstable Lisfranc injuries. This cross-sectional study was conducted to investigate the characteristics of Lisfranc injuries with fleck sign and the clinical and radiological outcomes following closed reduction and percutaneous screw fixation.

Methods: All consecutive operatively managed Lisfranc injuries with fleck sign were reviewed from 2016 to 2018. The injury pattern and characteristics of Lisfranc fleck sign were reviewed based on the preoperative CT scan. Postoperative complications besides radiological and clinical outcomes were assessed using visual analog scale (VAS) pain, American orthopedic foot and ankle society (AOFAS) midfoot scale, and foot function index (FFI).

Results: Thirty patients (20 males; mean age, 36.9 ± 17.0; range, 12-69 years) with mean follow-up 16.9 ± 7.4 (range, 6-31) months were enrolled. Among 12 cases with avulsed Lisfranc ligament from the second metatarsal base, only two cases had isolated second metatarsal base fracture in plantar medial part while others had concomitant avulsion fracture of plantar aspect of the adjacent third and/or fourth metatarsal base. Mean of postoperative VAS pain, AOFAS midfoot scale, and FFI were 1.03 ± 0.29, 91.43 ± 1.43, 24.43 ± 6.66, respectively. We had seven (23.3%) removal of screws, two (6.6%) broken screws, four (13.3%) pulled-out screws, and six (20%) lost reductions in the final follow-up with good clinical functions.

Conclusion: Closed reduction and percutaneous fixation of the Lisfranc injuries with fleck sign by a single position screw could be a good surgical option with reliable and predictable outcomes without needing to remove the hardware, routinely.
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http://dx.doi.org/10.1007/s00068-020-01415-zDOI Listing
February 2022

Comparative Study of Spring Ligament Reconstructions Using Either Hamstring Allograft or Synthetic Ligament Augmentation.

Foot Ankle Int 2020 07 1;41(7):803-810. Epub 2020 May 1.

Trauma and Orthopaedic Department, University Hospital Aintree, Lower Lane, Liverpool, UK.

Background: Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament.

Methods: Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters.

Results: Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved ( < .05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary's line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group.

Conclusion: Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group.

Levels Of Evidence: Level III, retrospective cohort study.
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http://dx.doi.org/10.1177/1071100720917375DOI Listing
July 2020

Peroneal Tendons Rupture in a Closed Talar Body Fracture: A Rare Injury.

J Foot Ankle Surg 2020 May - Jun;59(3):625-628

Professor, Foot and Ankle Center Vienna, Vienna, Austria.

The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.
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http://dx.doi.org/10.1053/j.jfas.2019.05.010DOI Listing
April 2021

Bone Graft Harvesting From the Calcaneus Using Lateral Wall Corticotomy Technique by an Osteotome.

Foot Ankle Spec 2021 Aug 24;14(4):298-301. Epub 2020 Apr 24.

Student research committee, Shiraz University of Medical Sciences, Shiraz, Iran (FK, AE).

The aim of this study was to evaluate the complications following calcaneal autologous bone graft harvesting using an osteotome in patients who underwent foot and ankle surgery with follow-up of at least 1 year. In a cohort study, all consecutive patients underwent forefoot or midfoot surgeries in conjunction with harvesting bone graft from the calcaneus using lateral wall corticotomy technique by an osteotome from 2015 till 2018 were asked to follow. The outcome and morbidity were assessed by visual analogue scale (VAS) pain, numbness in territory of the sural nerve, surgical site numbness or tenderness, infection, hematoma formation, or pathologic fracture. Also any possible restrictions on wearing desired shoes were asked. Totally, 50 patients (11 males, 39 females; 29 right foot, 21 left foot) with the mean age of 48.2 ± 13.8 years (range 8-66 years) were assessed. There were no major complications on donor site such as infection, hematoma formation, or pathologic fracture. The following results were seen; 90% without any pain (VAS 0/10), 96% without numbness at the incision site, 96% without point tenderness on lateral of heel, 98% without paresthesia or numbness in the sural nerve territory, and 84% were able to wear their favorite shoes. Forty-one (82%) cases said if they need another foot surgery, they would permit to harvest bone graft from their heel. Autologous bone graft harvesting from the calcaneus using lateral wall corticotomy technique by an osteotome could be a useful method with very low complications. Therapeutic, level IV: cohort, case series.
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http://dx.doi.org/10.1177/1938640020916269DOI Listing
August 2021

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language.

J Foot Ankle Surg 2020 Jul - Aug;59(4):729-732. Epub 2020 Mar 20.

Associate Professor of Orthopedic Surgery and Orthopedic Foot & Ankle Surgeon, Department of Orthopedic Surgery, Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between -0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.
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http://dx.doi.org/10.1053/j.jfas.2020.01.006DOI Listing
June 2021

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle.

Foot Ankle Surg 2021 Jan 5;27(1):40-45. Epub 2020 Feb 5.

Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Purpose: The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan.

Methods: Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans.

Results: Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively.

Conclusions: In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.fas.2020.02.002DOI Listing
January 2021

Three-Stage Treatment of Transcalcaneal Talonavicular Fracture Dislocation; A Case Report and Literature Review.

Bull Emerg Trauma 2019 Oct;7(4):411-415

Bone and Joint Diseases Research Center, Department of Orthopedics Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.

Transcalcaneal talonavicular fracture dislocation is an extremely rare debilitating injury with high complication rates. The present case report demonstrates highly comminuted joint-depressed fracture of left calcaneus treated with primary subtalar arthrodesis following reduction and fixation of the calcaneus. The right ankle sustained a highly comminuted fracture of calcaneal body with completely-destroyed posterior facet, fracture dislocation of the calcaneocuboid joint, dorsally dislocated talonavicular joint, fracture of anterior of tibial plafond, and subluxation of the tibiotalar joint. At first, talonavicular joint was reduced and fixed using a plate followed by reduction of calcaneus and arthrodesis of subtalar and calcaneocuboid joints. The plate of talonavicular joint was removed after 70 days. Logical approach to this injury can lead to an acceptable function.
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http://dx.doi.org/10.29252/beat-070411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911717PMC
October 2019

Simvastatin increases temozolomide-induced cell death by targeting the fusion of autophagosomes and lysosomes.

FEBS J 2020 03 14;287(5):1005-1034. Epub 2019 Oct 14.

Department of Human Anatomy and Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.

Temozolomide (TMZ) is a chemotherapy agent used to treat Grade IV astrocytoma, also known as glioblastoma (GBM). TMZ treatment causes DNA damage that results in tumor cell apoptosis and increases the survival rate of GBM patients. However, chemoresistance as a result of TMZ-induced autophagy significantly reduces this anticancer effects over time. Statins are competitive inhibitors of HMG-CoA reductase, the rate-limiting enzyme of the mevalonate (MEV) cascade. Statins are best known for their cholesterol (CH)-lowering effect. Long-term consumption of statins, prior to and in parallel with other cancer therapeutic approaches, has been reported to increase the survival rate of patients with various forms of cancers. In this study, we investigated the potentiation of TMZ-induced apoptosis by simvastatin (Simva) in human GBM cell lines and patient GBM cells, using cell monolayers and three-dimensional cell culture systems. The incubation of cells with a combination of Simva and TMZ resulted in a significant increase in apoptotic cells compared to cells treated with TMZ alone. Incubation of cells with CH or MEV cascade intermediates failed to compensate the decrease in cell viability induced by the combined Simva and TMZ treatment. Simva treatment inhibited the autophagy flux induced by TMZ by blocking autophago-lysosome formation. Our results suggest that Simva sensitizes GBM cells to TMZ-induced cell death in a MEV cascade-independent manner and identifies the inhibition of autophagosome-lysosome fusion as a promising therapeutic strategy in the treatment of GBM.
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http://dx.doi.org/10.1111/febs.15069DOI Listing
March 2020

Management of tibialis anterior tendon rupture: Recommendations based on the literature review.

Foot Ankle Surg 2020 Jul 21;26(5):487-493. Epub 2019 Jun 21.

Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Tibialis anterior tendon (TAT) rupture is a rare injury that commonly diagnosed late due to mild clinical signs and symptoms. Management of TAT rupture is a topic without a clear consensus in the literature. This current concept review tries to shed some light on the data and treatment. Our extensive literature review identified 81 case reports and case series from 1905 to 2018. Several reported management techniques with their advantages and disadvantages were analyzed and our treatment recommendations are given based on current available evidences. LEVELS OF EVIDENCE: IV.
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http://dx.doi.org/10.1016/j.fas.2019.06.003DOI Listing
July 2020

Mechanisms of simvastatin myotoxicity: The role of autophagy flux inhibition.

Eur J Pharmacol 2019 Nov 23;862:172616. Epub 2019 Aug 23.

Department of Human Anatomy & Cell Science, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Center for Comparative Respiratory Biology and Medicine, Davis, CA, USA; Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada; Research Institute of Oncology and Hematology, Cancer Care Manitoba, University of Manitoba, Winnipeg, Canada; Autophagy Research Center, Health Policy Research Centre, Shiraz University of Medical Science, Shiraz, Iran. Electronic address:

Statins are some of the most widely used drugs worldwide, but one of their major side effects is myotoxicity. Using mouse myoblast (C2C12) and human alveolar rhabdomyosarcoma cell lines (RH30) in both 2-dimensional (2D) and 3-dimensional (3D) cell culture, we investigated the mechanisms of simvastatin's myotoxicity. We found that simvastatin significantly reduced cell viability in C2C12 cells compared to RH30 cells. However, simvastatin induced greater apoptosis in RH30 compared to C2C12 cells. Simvastatin-induced cell death is dependent on geranylgeranyl pyrophosphate (GGPP) in C2C12 cells, while in RH30 cells it is dependent on both farnesyl pyrophosphate (FPP) and GGPP. Simvastatin inhibited autophagy flux in both C2C12 and RH30 cells and inhibited lysosomal acidification in C2C12 cells, while autophagy inhibition with Bafilomycin-A1 increased simvastatin myotoxicity in both cell lines. Simvastatin induced greater cell death in RH30 cells compared to C2C12 in a 3D culture model with similar effects on autophagy flux as in 2D culture. Overall, our results suggest that simvastatin-induced myotoxicity involves both apoptosis and autophagy, where autophagy serves a pro-survival role in both cell lines. The sensitivity to simvastatin-induced myotoxicity differs between 2D and 3D culture, demonstrating that the cellular microenvironment is a critical factor in regulating simvastatin-induced cell death in myoblasts.
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http://dx.doi.org/10.1016/j.ejphar.2019.172616DOI Listing
November 2019

CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture.

Foot Ankle Int 2019 Jun 17;40(6):648-655. Epub 2019 Feb 17.

2 Aintree University Hospital, Lower Lane, Liverpool, United Kingdom.

Background: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of posteromedial fracture fragments to enable better surgical planning.

Methods: All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female).

Results: Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries.

Conclusion: The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer.

Level Of Evidence: Level III, retrospective comparative series.
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http://dx.doi.org/10.1177/1071100719830999DOI Listing
June 2019

Agreement between Sanders classification of intraarticular calcaneal fractures and assessment during the surgery.

Foot Ankle Surg 2020 Jan 19;26(1):94-97. Epub 2018 Dec 19.

Bone and Joint Diseases Research Center, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: Sanders classification, based on the number of displaced fractured fragments of posterior facet, can predict the prognosis of calcaneal intraarticular fractures. The aim of the study was assessing not only intraobserver reproducibility and interobserver reliability of Sanders classification but also the agreement between preoperative reported types based on computed tomography (CT) scan and direct observation during the surgery.

Methods: In this cross-sectional study, preoperative CT scans of 100 patients with intra-articular calcaneal fracture operated by a single surgeon were studied by two orthopedic and trauma surgeons (A & B), twice with an interval of three weeks. Their result were compared with each other and with the number of displaced fractured fragments recorded in the operation notes. Quadratic weighted kappa test was used to check the agreement between two observers and between the observers and the surgeon.

Results: Intraobserver reproducibility for Sanders classification of intraarticular calcaneal fractures was found to be good to excellent (A1-A2: 0.91 and B1-B2: 0.75). There was a moderate agreement between the two observers (A1-B1: 0.56, A1-B2:0.58, A2-B1:0.48, and A2-B2:0.51). The agreement between reported types of Sanders classification and the number of displaced fractured fragments seen during the surgery was fair (A1-surgeon: 0.27, A2-surgeon: 0.29, B1-surgeon: 0.38, and B2-surgeon: 0.50).

Conclusions: Agreement between Sanders classification and what is real during surgery is fair. Hence, Sanders classification as determined in the widest cut of coronal CT scan extended posteriorly should be cautiously interpreted for surgery.
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http://dx.doi.org/10.1016/j.fas.2018.12.001DOI Listing
January 2020

American Orthopaedic Foot and Ankle Society ankle-hindfoot scale: A cross-cultural adaptation and validation study from Iran.

Foot Ankle Surg 2018 Jun 17;24(3):219-223. Epub 2017 Feb 17.

Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: The use of valid and reliable outcome rating scales is essential for evaluating the result of different treatments and interventions. The purposes of this study were to translate and culturally adapt the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale (AOFAS-AHFS) into Persian languages and evaluate its psychometric properties.

Methods: Forward-backward translation and cultural adaptation method were used to develop Persian version of AOFAS-AHFS. From March to July 2016, one hundred consecutive patients with ankle and hindfoot injuries were included. Internal consistency and reproducibility were evaluated using Cronbach's alpha, Spearman's rank correlation coefficient and Intraclass correlation coefficient (ICC) respectively. Construct validity reported which compare the outcome rating scale measurements with Short Form-36 (SF-36), also convergent and discriminant validity evaluated using Spearman's rank correlation coefficient.

Results: Mean age (SD) of the patients was 41.95±13.45years. Cronbach's α coefficient, Spearman's rho and ICC values were 0.71, 0.89 and 0.90 respectively. Total score of AOFAS-AHFS and SF-36 domains has a correlation ranged between 0.17-0.55. Spearman's rank correlation coefficient of 0.4 was exceeded by all items with the exception of stability. The Spearman's rank correlation between each item in functional subscales with its own subscales was higher than the correlation between these items and other subscales.

Conclusions: Persian version of AOFAS-AHFS provides additional reliable and valid instrument which can be used to assess broad range of patients with foot and ankle disorders that speaking in Persian. However, it seems that the original version of AOFAS-AHFS needs some revisions.
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http://dx.doi.org/10.1016/j.fas.2017.02.007DOI Listing
June 2018
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