C. N. van Dijk

MEDIAL ANKLE PAIN AFTER LATERAL LIGAMENT RUPTURE

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with low-velocity injury (a stumble).

Terminology for Achilles tendon related disorders

The terminology of Achilles tendon pathology has become inconsistent and confusing throughout the years. For proper research, assessment and treatment, a uniform and clear terminology is necessary. A new terminology is proposed; the definitions hereof encompass the anatomic location, symptoms, clinical findings and histopathology. It comprises the following definitions: Mid-portion Achilles tendinopathy: a clinical syndrome characterized by a combination of pain, swelling and impaired performance. It includes, but is not limited to, the histopathological diagnosis of tendinosis. Achilles paratendinopathy: an acute or chronic inflammation and/or degeneration of the thin membrane around the Achilles tendon. There are clear distinctions between acute paratendinopathy and chronic paratendinopathy, both in symptoms as in histopathology. Insertional Achilles tendinopathy: located at the insertion of the Achilles tendon onto the calcaneus, bone spurs and calcifications in the tendon proper at the insertion site may exist. Retrocalcaneal bursitis: an inflammation of the bursa in the recess between the anterior inferior side of the Achilles tendon and the posterosuperior aspect of the calcaneus (retrocalcaneal recess). Superficial calcaneal bursitis: inflammation of the bursa located between a calcaneal prominence or the Achilles tendon and the skin. Finally, it is suggested that previous terms as Haglund’s disease; Haglund’s syndrome; Haglund’s deformity; pump bump (calcaneus altus; high prow heels; knobbly heels; cucumber heel), are no longer used.

Arthroscopic treatment for osteochondral defects of the talus: RESULTS AT FOLLOW-UP AT 2 TO 11 YEARS

We reviewed 38 patients who had been treated for an osteochondral defect of the talus by arthroscopic curettage and drilling. The indication for surgical treatment was persistent symptoms after conservative treatment for at least six months. A total of 22 patients had received primary surgical treatment (primary group) and 16 had had failed previous surgery (revision group). The mean follow-up was 4.8 years (2 to 11). Good or excellent results, as assessed by the Ogilvie-Harris score, were found in 86% in the primary group and in 75% in the revision group. Two further procedures were required, one in each group. Radiological degenerative changes were seen in one ankle in the revision group after ten years. Arthroscopic curettage and drilling are recommended for both primary and revision treatment of an osteochondral defect of the talus.

Arthroscopic treatment of anterior impingement in the ankle

We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space.

PHYSICAL EXAMINATION IS SUFFICIENT FOR THE DIAGNOSIS OF SPRAINED ANKLES

We studied the merits of physical examination after inversion injury of the ankle in 160 consecutive patients. They had an explanatory operation if they had a positive arthrogram and/or positive signs on a delayed physical examination. To determine the interobserver variation in delayed physical examination, five different examiners were asked to give independent assessment of the injury. Those with limited clinical experience produced more accurate results when physical examination was performed at five days after the injury, rather than within 48 hours. The specificity and sensitivity of delayed physical examination for the presence or absence of a lesion of an ankle ligament were found to be 84% and 96%, respectively. The interobserver agreement for the delayed physical examination of the ankle was good (kappa values 0.5, 0.6, 0.6 and 1.0). Delayed physical examination gives information of diagnostic quality which is equal to that of arthrography, and causes little discomfort to the patient.

Tendoscopy of the peroneal tendons

An anatomic cadaver study was performed. Subsequently, in a prospective study, diagnostic and therapeutic tendoscopy (tendon sheath endoscopy) was performed in nine consecutive patients with a history of persistent posterolateral ankle pain for at least 6 months. All patients had pain on palpation over the peroneal tendons, a positive peroneal tendon resistance test, and most often local swelling. In two patients, a peroneal click was found without symptoms of dislocation of the tendons over the fibula. The indications for arthroscopy were diagnostic procedure postsurgery (3), diagnostic procedure postfracture (2), snapping sensation (2), removal of exostosis (1), and partial tendon rupture (1). Inspection and surgery of both tendons and tendon sheath could be performed well by a standard two-portal technique. A new finding is the vincula that was consistently present in all our autopsy specimens, as well as in all our patients. The vincula attaches both tendons to each other and to the tendon sheath. At a mean follow-up of 19 months, three of the four patients in which adhesions were found and resected were symptom free. In one patient, a symptomatic prominent peroneal tubercle was successfully removed. One patient had a longitudinal rupture of the peroneus brevis tendon that was successfully sutured. There were no complications.

A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over.

The aim of this study was to analyse the functional outcome after a displaced intracapsular fracture of the femoral neck in active patients aged over 70 years without osteoarthritis or rheumatoid arthritis of the hip, randomised to receive either a hemiarthroplasty or a total hip replacement (THR). We studied 252 patients of whom 47 (19%) were men, with a mean age of 81.1 years (70.2 to 95.6). They were randomly allocated to be treated with either a cemented hemiarthroplasty (137 patients) or cemented THR (115 patients). At one- and five-year follow-up no differences were observed in the modified Harris hip score, revision rate of the prosthesis, local and general complications, or mortality. The intra-operative blood loss was lower in the hemiarthroplasty group (7% > 500 ml), THR group (26% > 500 ml) and the duration of surgery was longer in the THR group (28% > 1.5 hours versus 12% > 1.5 hours). There were no dislocations of any bipolar hemiarthroplasty than in the eight dislocations of a THR during follow-up. Because of a higher intra-operative blood loss (p < 0.001), an increased duration of the operation (p < 0.001) and a higher number of early and late dislocations (p = 0.002), we do not recommend THR as the treatment of choice in patients aged ≥ 70 years with a fracture of the femoral neck in the absence of advanced radiological osteoarthritis or rheumatoid arthritis of the hip.

Anatomical reconstruction and Evans tenodesis of the lateral ligaments of the ankle: CLINICAL AND RADIOLOGICAL FINDINGS AFTER FOLLOW-UP FOR 15 TO 30 YEARS

In this retrospective study, we assessed the outcome in 99 patients who underwent reconstruction of the lateral ligaments of the ankle for chronic anterolateral instability with a minimum follow-up of 15 years. Two techniques were compared: 54 patients had an anatomical reconstruction (AR group) and 45 had an Evans tenodesis (ET group). They were followed up for 19.9+/-3.6 years and 21.8+/-4.6 years, respectively. During follow-up, seven patients in the AR group and 17 in the ET group required a further operation (p = 0.004). At follow-up, significantly more patients (n = 15) in the ET group had limited dorsiflexion than in the AR group (n = 6, p = 0.007) and 18 in the ET group had a positive anterior drawer test compared with seven in the AR group (p = 0002). In the ET group 27 had tenderness on palpation of the ankle compared with 15 in the AR group (p = 0.001). Stress radiographs showed ligamentous laxity significantly more often in the ET group (n = 30) than in the AR group (n = 13, p < 0.001). The mean values for talar tilt and anterior talar translation were significantly higher in the ET group than in the AR group (p < 0.001, p = 0.007, respectively). There were degenerative changes on standard radiographs in 32 patients in the AR group and 35 in the ET group (p = 0.05). Four patients in the ET group had developed severe osteoarthritis compared with none in the AR group (p = 0.025). Assessment of functional stability revealed a mean Karlsson score of 83.7+/-10.4 points in the AR group and 67.0+/-15.8 points in the ET group (p < 0.001). According to the Good rating system, 43 patients in the AR group had good or excellent results compared with 15 in the ET group (p < 0.001). Compared with anatomical reconstruction, the Evans tenodesis does not prevent laxity in a large number of patients. Long-standing ligamentous laxity leads to degenerative change in the ankle, resulting in chronic pain, limited dorsiflexion and further operations. The functional result deteriorates more rapidly after the Evans tenodesis than after anatomical reconstruction.

Hindfoot endoscopy for posterior ankle impingement. Surgical technique

BACKGROUND The surgical treatment of posterior ankle impingement is associated with a high rate of complications and a substantial time to recover. An endoscopic approach to the posterior ankle (hindfoot endoscopy) may lack these disadvantages. We hypothesized that hindfoot endoscopy causes less morbidity and facilitates a quick recovery compared with open surgery. METHODS Fifty-five consecutive patients with posterior ankle impingement were treated with an endoscopic removal of bone fragments and/or scar tissue. The symptoms were caused by trauma (65%) or overuse (35%). All patients were enrolled in a prospective protocol. At baseline, the age, sex, work and sports activities, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and preinjury Tegner scores were determined for all patients. At the time of follow-up, AOFAS hindfoot scores and Tegner scores were assessed and the time to return to work and sports activities was determined. Complications were recorded. Patients scored the overall result as poor, fair, good, or excellent by means of a 4-point Likert scale. RESULTS The median duration of follow-up was thirty-six months, and no patient was lost to follow-up. The median AOFAS hindfoot score increased from 75 points preoperatively to 90 points at the time of final follow-up. The median time to return to work and sports activities was two and eight weeks, respectively. At the time of follow-up, patients in the overuse group were more satisfied than those in the posttraumatic group, and the AOFAS hindfoot scores were higher in patients in the overuse group (median, 100 points) compared with patients in the posttraumatic group (median, 90 points). A complication occurred in one patient who had a temporary loss of sensation of the posteromedial aspect of the heel. CONCLUSIONS The outcome after endoscopic treatment of posterior ankle impingement compares favorably with the results of open surgery reported in the literature. Hindfoot endoscopy appears to cause less morbidity than open ankle surgery and facilitates a quick recovery. Patients treated for posterior ankle impingement caused by overuse have better results than those treated following trauma.

Anatomical reconstruction versus tenodesis for the treatment of chronic anterolateral instability of the ankle joint: a 2- to 10-year follow-up, multicenter study.

Abstract The clinical outcome of anatomical reconstruction or tenodesis in the treatment of chronic anterolateral ankle instability was assessed in a retrospective multicenter study. The anatomical reconstruction group (group A) consisted of 106 patients (mean age at operation 24 ± 8.4 years) and the tenodesis group (group B) of 110 patients (mean age at operation 26 ± 11.4 years). Patients were evaluated at a mean follow-up of 5.5 ± 2.8 years in group A and 5.2 ± 2.9 years in group B. The review protocol included patient characteristics, physical examination, two ankle scoring scales to evaluate the functional results, and standard anteroposterior and lateral radiographs to evaluate degenerative changes. Mechanical stability was evaluated using standardized stress radiographs. A larger number of reoperations was performed in group B (P = 0.008). At physical examination, more patients in group B had a smaller range of ankle motion than those in group A (P = 0.009). ¶A larger proportion of patients in group B had medially located osteophytes, as seen on standard radiographs (P = 0.04). On stress radiographic examination, the mean talar tilt (P = 0.001) and mean anterior talar translation (P < 0.001) were seen to be significantly greater in group B than in group A. There were no differences in mean Karlsson score between the groups, but more patients in group A had an excellent result on the Good score (P = 0.011). Unlike anatomical reconstructions, tenodeses do not restore the normal anatomy of the lateral ankle ligaments. This results in restricted range of ankle motion, reduced long-term stability, an increased risk of medially located degenerative changes, a larger number of reoperations, and less satisfactory overall results.