Anand Pillai

Bilateral patellar tendon ruptures: a missed diagnosis

Knee extensor mechanism disruption is an unusual but serious emergency presentation. Rarely disruption can occur within the patellar tendon which is often associated with systemic diseases such as rheumatoid arthritis and systemic lupus erythematosus. Surgical management is required to repair the patellar tendon after clinical assessment and diagnosis. We describe the case of a 75-year-old man without any known predisposing systemic disease presenting on several occasions before accurate diagnosis and treatment. We include a literature review of similar cases and discuss the importance of missed diagnosis and underlying causes. A treatment algorithm to avoid missing similar injuries is also proposed.

The anterior approach for the fixation of displaced talar neck fractures—A cadaveric study

BACKGROUND Talar neck fractures are rare and are associated with high complication rates. Adequate surgical exposure is essential in the operative management of these challenging injuries. The anterior approach is an alternative to the more commonly described and utilized anterolateral and anteromedial approaches. OBJECTIVE The main objective was to compare the surface area of talus visible and quality of exposure via the anterior approach, with the anteromedial and anterolateral approaches. MATERIALS AND METHODS An anterior approach was performed on five fresh frozen cadaveric specimens. The surface area of talus visible was measured using an Immersion Digital Microscribe and analyzed with the Rhinoceros 3D graphics package. Standard anterolateral and anteromedial approaches were performed in the same specimens and areas visible measured using the same method. RESULTS The talar surface area visible using the anterior approach is significantly greater than that visible using the anterolateral approach or anteromedial, without and with medial malleolar osteotomy, as well as combination approaches. CONCLUSION The anterior approach offers excellent visualization in the fixation of displaced talar neck fractures. Greater talar surface area is visible using this approach compared to traditional approaches.

Limb salvage talectomy for 3C Gustilo–Anderson fracture

Foot fractures vary in severity with complex midfoot fractures having poor morbidity rates and high amputation rates. Complex midfoot fractures are rarely reported since they are uncommon and only treated in specialist centres. Given the important role of the midfoot in foot function, reconstruction is preferable. Soft tissue management on the dorsal aspect of the foot poses further challenges to reconstructive surgeons. We report a case of a 55-year-old woman who sustained an open 3C Gustilo–Anderson fracture that was initially treated with open reduction internal fixation and free flap. She subsequently developed flap and internal fixation failure with osteomyelitis of the talus. We report a good outcome using primary limb shortening with a talectomy, tibiocalcaneal arthrodesis using external fixation and a combination of vancomycin-loaded calcium sulphate and intravenous antibiotics in our patient.

The metatarsosesamoid joint: An in vitro 3D quantitative assessment

BACKGROUND The anatomy of the first metatarsophalangeal (MTP) joint, particularly the metatarsosesamoid articulation, remains poorly understood. Our goal was to quantitatively define the excursion of the sesamoids. METHODS Seven cadavers were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions using a MicroScribe. RESULT For first MTP joint, excursion averaged 14.7mm for the tibial sesamoid in the sagittal plane and 7.5mm for the fibular sesamoid. The sesamoids also moved medially to laterally when the joint was dorsiflexed. For the maximally dorsiflexed joint, excursion averaged 2.8mm for the tibial sesamoid and 3.5mm for the fibular sesamoid. CONCLUSION Hallucal sesamoids appear to have differential tracking: the tibial sesamoid has greater longitudinal excursion; the fibular sesamoid has greater lateral excursion. The anatomical data will interest those involved with the design of an effective hallux arthroplasty.

Surgical tip: Titanium foam blocks can simplify fusion of failed total ankle replacements

Ankle arthrodesis following failed ankle replacements is a technically challenging task because of the large defect left behind after the prosthesis is removed. The usual practice is to use bulk grafts which are either autografts or allografts to fill the defect. We report our experience with the use of a titanium foam block specifically designed for fusion of failed ankle replacements. This particular method was chosen to avoid the technical difficulties and morbidities associated with the use of bulk autografts and allografts. We describe the surgical technique and early results in the first two cases performed in our unit. The satisfactory clinical and radiologic results in the two cases demonstrate the ability of the titanium foam block to simplify an otherwise complex procedure without compromising the outcome.

Retrofibular osteochondroma with peroneal tendon subluxation

Osteochondroma of the bone can cause a range of complications involving tendons, joints and neurovascular structures. Distal fibular osteochondroma and non-traumatic peroneal tendon subluxation are both rare. In this case report, we describe an unusual case of distal retrofibular osteochondroma in a 36-year old male causing peroneal tendon subluxation. He presented with pain and instability around his ankle, but with no history of trauma. He successfully underwent osteochondroma excision, peroneal groove deepening and a Brostrom-Gould type reconstruction for the lateral ankle ligament insufficiency. Complete resolution of the symptoms of instability and subluxation was noted upon 6-month follow up.

Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique

BACKGROUND Chronic osteomyelitis necessities appropriate infected bone and soft tissue excision. The authors describe the Silo surgical technique for the treatment of calcaneal osteomyelitis using a new antibiotic-loaded absorbable calcium sulphate/hydroxyapatite biocomposite. METHODS The Silo method involves debridement of the dead bone and local delivery of antibiotic in drilled tunnels using the biocomposite. It is combined with multiple sampling and culture-specific systemic antibiotic treatment guided by a multidisciplinary team. Twelve consecutive diabetic patients with heel ulcers and calcaneal osteomyelitis were treated with the above method. All had comorbidities (Cierny-Mader (C-M) Class B hosts). The mean age was 68 years (range 50-85). A retrospective review of radiographs and electronic medical records was conducted. RESULTS Patients were followed up until clinical cure of the ulcer for a mean of 16 weeks (range 12-18). Infection was eradicated in all 12 patients with a single stage procedure following a bone preserving technique. One patient required a subsequent flap operation and six vacuum-assisted closure (V.A.C.). There was also one case of prolonged wound leakage and no calcaneal fractures. CONCLUSIONS The Silo technique is an effective method of local delivery of antibiotics and can be effectively implemented into the single-stage treatment of calcaneal osteomyelitis offering increased bone preservation and local delivery of antibiotic, decreasing the need for a major amputation. LEVEL OF EVIDENCE Level IV- case series.

Foreign body reaction with granuloma following Achilles tendon reconstruction with the LARS ligament

Abstract Ligament reconstruction with the LARS ligament has been a popular choice owing to its low-complication rates compared with previously commercially available grafts. The non-active nature of the implant also meant that there were no foreign body reactions that had been described with other synthetic grafts. We describe the first reported case of a granulomatous foreign body reaction in a LARS ligament Achilles tendon graft and a technique to reconstruct the tendon following its excision.

Distraction osteogenesis for brachymetatarsia using initial circular fixator and early trans-fixation metatarsal K—wires—a series of three cases

Abstract Brachymetatarsia is a rare forefoot deformity predominantly affecting the fourth metatarsal. Current treatment include gradual lengthening by distraction osteogenesis using an external fixator or single-stage lengthening with bone grafting or a combination of the above two procedures. Our aim was to assess outcomes and complications of a novel technique for gradual metatarsal lengthening using a circular fixator. The procedure was performed on three female patients with unilateral congenital shortening of the fourth ray. All participants reported aesthetic dissatisfaction as well as pressure related complications of the deformity and opted for lengthening and distraction osteogenesis using a frame. Mean duration of the treatment was 122 days and average length gained was 12 mm. The desired metatarsal length was achieved in all three patients with no significant complications. This method of treatment of brachymetatarsia is effective and reproducible. This a promising technique, owing to its low complication rates and efficacy in lengthening.

Complex ankle arthrodesis with step-cut osteotomy in Charcot arthropathy with bone loss

We report a case of a complex limb salvage ankle arthrodesis in a patient with Charcot arthropathy. A step-cut osteotomy was performed in order to tackle the issues of anterior tibial bone loss; worsening leg length discrepancy; soft tissue contraction; joint instability and high risk of non-union. The construct formed by the step-cut allowed for the preservation of good bone stock; avoidance of further limb shortening; increased torsional stability and increased surface area for bony union. This resulted in a patient with a stable, plantigrade foot appropriate for footwear. We use this case to highlight this technique as an option in the operative management of complex ankle fusions with sagittal or coronal plane deformity with bone loss and subluxation of the ankle joint.