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Weightbearing computed tomography of the foot and ankle : emerging technology topical review

In the last decade, cone-beam computed tomography technology with improved designs allowing flexible gantry movements has allowed both supine and standing weight-bearing imaging of the lower extremity. There is an increasing amount of literature describing the use of weightbearing computed tomography in patients with foot and ankle disorders. To date, there is no review article summarizing this imaging modality in the foot and ankle. Therefore, we performed a systematic literature review of relevant clinical studies targeting the use of weightbearing computed tomography in diagnosis of patients with foot and ankle disorders. Furthermore, this review aims to offer insight to those with interest in considering possible future research opportunities with use of this technology. Level of Evidence: Level V, expert opinion.

Efeitos do tempo de descompressão após trauma medular na recuperação neurológica em ratos Wistar

Objective: Traumatic spinal Cord injuries are common in patients with high-energy trauma, and have significant morbidity and mortality rates, as well as high psychological and social costs, causing a major impact on public health. To date, the treatment of such lesions remains controversial, with various studies in the literature comparing the results of non-surgical treatment with immediate, early or late surgical decompression. The objective of the present study is to compare the results of immediate and early (within 1 hour) spinal Cord decompression. Methods: In the belief that the surgical treatment obtains the best result, this experimental study has a case-control design, with histopathological and functional analysis of the results of surgical treatment of 25 Wistar mice submitted to posterior laminectomy immediately, or after one hour of spinal Cord compression. Results: in terms of functional and neurological deficit, the responses were better in the mice treated with immediate surgical decompression than in those treated one hour after the lesion (p=0.036). Conclusion: The earlier the decompression of spinal Cord injuries is performed, the better the end results in terms of the function and presence of neurological deficit.

Results of lateral ankle ligament repair surgery in one hundred and nineteen patients: do surgical method and arthroscopy timing matter?

PurposeAnkle sprains are the most common athletic injury. One of five chronic lateral ankle instability patients will require surgery, making operative outcomes crucial. The purpose of this study is to determine if operative method influences failure and complication rates in chronic lateral ankle ligament repair surgery.MethodsWe retrospectively reviewed 119 cases (118 patients) of lateral ankle ligament surgery between 2006 and 2016. Patient charts and operative reports were examined for demographics, use and timing of ankle arthroscopy, ligament fixation method, type of surgical incision, presence of calcaneofibular ligament repair, and operative technique. Impact of operative methods on failure (one-year minimum follow-up) and complication outcomes was explored using Chi-square test of independence (or Fisher’s exact test). Statistical significance was set at p less than .05.ResultsMean age at surgery was 40 (range, 18-73) years. Mean follow-up was 51 (range, 12-260) weeks. Failure rate was 8.4% (10/89 cases) while complication rate was 17.6% (21/119). Failure rate did not differ significantly between any data subgroups (pxa0>xa0.05). Single stage arthroscopy was associated with a significantly lower complication rate (11%, 4/37) than double-stage arthroscopy (47%, 9/19) (pxa0<xa0.01) as was suture anchor ligament fixation (9%, 6/67) compared to direct suture ligament fixation (29%, 15/52) (pxa0<xa0.01).ConclusionFailure rate was not impacted by any of the studied variables. Use of suture anchors and concurrent ankle arthroscopy may be favourable options to achieve fewer complications in chronic lateral ankle instability repair surgery.

☆Diagnostic and therapeutic injections of the foot and ankle—An overview

Foot and ankle injections are useful diagnostic and therapeutic tools, particularly when the pain etiology is uncertain. A variety of foot and ankle injuries and pathologies, including degenerative joint disease, plantar fasciitis and different tendinopathies are amenable to injections. Understanding the foot and ankle anatomical landmarks, a thorough physical exam and knowledge of the different injection techniques is key for a successful approach to different pathologies. The objective of this study is to review the use of foot and ankle injections in the orthopaedic literature, present the readers with the senior authors experience and provide a comprehensive clinical guideline to the most common foot and ankle diagnostic and therapeutic injections.

ROLE OF BONE GRAFTS AND BONE GRAFT SUBSTITUTES IN ISOLATED SUBTALAR JOINT ARTHRODESIS

ABSTRACT Objectives: The purpose of this study was to compare union rates for isolated subtalar arthrodesis with and without the use of bone grafts or bone graft substitutes. Methods: We retrospectively reviewed 135 subtalar fusions with a mean follow-up of 18 ± 14 months. The standard approach was used for all surgeries. Graft materials included b-tricalcium phosphate, demineralized bone matrix, iliac crest autograft and allograft, and allograft cancellous chips. Successful subtalar fusion was determined clinically and radiographically. Results: There was an 88% (37/42) union rate without graft use and an 83% (78/93) union rate with bone graft use. Odds ratio of union for graft versus no graft was 0.703 (95% CI, 0.237-2.08). The average time to union in the graft group was 3 ± 0.73 months and 3 ± 0.86 in the non-graft group, with no statistically significant difference detected (p = 0.56). Conclusion: Graft use did not improve union rates for subtalar arthrodesis. Level of Evidence IV, Case Series.

Extensive synovial chondromatosis involving all flexor tendons in the tarsal tunnel: a case report

Synovial chondromatosis is a rare condition characterized by benign chondrogenic meta- plasia of extra-articular synovial tissue. It usually affects a single tendon sheath of the hand or foot. This report describes a rare case with extensive synovial chondromatosis affecting all flexor tendons in the tarsal tunnel, its radiological features, surgical treatment, and clinical outcome. The authors present a unique case of extensive synovial chondromatosis in a 48-year-old male involving the tendon sheaths of the flexor hallucis longus, flexor digitorum longus, and posterior tibialis tendons, at the level of the tarsal tunnel, with extension into the plantar aspect of the foot. The patient initially presented with symptoms of tarsal tunnel compression and was found to have a 4-cm mass in the posteromedial aspect of the ankle. The presumptive diagnosis of synovial chondromatosis was made based on radiographic and magnetic resonance imaging evidence. The patient underwent surgical resection of the tumor, as well as tarsal tunnel release and gastrocnemius recession. The diagnosis was confirmed postoperatively by surgical histopathology. The postoperative course of the patient was uncomplicated and his tarsal tunnel symptoms resolved. This represents a case of extensive synovial chondromatosis involving all flexor tendons in the tarsal tunnel that was correctly diagnosed by clinical and imaging findings, which required early surgical resection to avoid long-term neurovascular complications.

Cadaveric study of the infrapatellar branch of the saphenous nerve: Can damage be prevented in total knee arthroplasty?

BackgroundnThe infrapatellar branch of the saphenous nerve (IPBSN) is a purely sensory nerve innervating the anteromedial aspect of the knee and anteroinferior knee joint capsule. Total knee arthroplasty (TKA) is commonly used to treat end-stage arthritis, but the IPBSN is often injured and results in numbness around the anteromedial knee. The aim of this cadaveric study was to describe the course and variability of the IPBSN and to assess whether it is possible to preserve during a standard midline surgical approach in TKA.nnnMethodsnTen fresh-frozen cadaver legs were dissected using a midline approach to the knee. Skin and subcutaneous flap were reflected to expose both the saphenous nerve and its branches. The branches of the IPBSN were identified, and their vertical distances above the tibial tuberosity (TB) were recorded: TB to inferior branch, to middle branch, and to superior branch.nnnResultsnThere were 10 left-sided specimens (6 female, 4 male) with a mean age of 79.9u202f±u202f9.8u202fyears. 8 (80%) specimens had 2 branches of IPBSN while 2 (20%) specimens had 3 branches. The average distance from TB to the inferior branch was 16.8u202f±u202f8.3u202fmm (3.0-28.0); middle branch, 24.0u202f±u202f1.4u202fmm (23.0-24.9); and superior, 45.9u202f±u202f7.7u202fmm (32.0-54.5).nnnConclusionnOur cadaveric study found no consistent way to preserve the IPBSN using a standard midline approach in TKA. It is important to provide proper patient education on this complication, and surgeons should be aware of approximate locations and variations of IPBSN while performing other knee procedures.

Reconstruction for chronic Achilles tendinopathy: comparison of flexor hallucis longus (FHL) transfer versus V-Y advancement

BackgroundSeveral operative techniques exist for Achilles tendinopathy. The purpose of our study was to compare the clinical and functional outcomes of flexor hallucis longus (FHL) transfer and V-Y advancement for the treatment of chronic insertional Achilles tendinopathy.MethodsRetrospective chart review from 2010 to 2016 of patients that underwent FHL transfer or V-Y advancement for chronic insertional Achilles tendinopathy. Outcome measures were compared for these two procedures.ResultsIn total, 46 patients (49 ankles) with a mean age of 55.0 (range 33–73)xa0years. Mean follow-up time 44.7u2009+/−u200925.5xa0months. FHL group had 21 patients (21 ankles) with 89% satisfaction, 14% complication rate, final VAS of 0.4, final VISA-A of 89.1, subjective strength improvement following surgery of 78%, and 94% would recommend the procedure. V-Y group had 25 patients (28 ankles) with 74% subjective satisfaction, 21% complication rate, final VAS of 1.4, final VISA-A of 78.4, subjective strength improvement following surgery of 67%, and 84% would recommend the procedure. There was no significant difference in any of the results rates between the two groups (pu2009>u2009.05).ConclusionV-Y advancement is comparable to FHL transfer for the operative management of insertional Achilles tendinopathy. Though our results trend towards less satisfactory results following V-Y advancement, we found high satisfaction rates with similar functional outcomes and complication rates in both operative groups. We suggest considering V-Y advancement as a viable option for the primary treatment of chronic insertional Achilles tendinopathy in patients who may not be an ideal candidate for FHL transfer.

Intraoperative tap test for coronal syndesmotic instability: A cadaveric study

INTRODUCTIONnPrecise diagnosis of distal tibiofibular syndesmotic injury is challenging, and a gold standard diagnostic test has still not been established. Tibiofibular clear space identified on radiographic imaging is considered the most reliable indicator of the injury. The Cotton test is the most widely used intraoperative technique to evaluate the syndesmotic integrity although it has its limitations. We advocate for a novel intra operative test using a 3.5u2009mm blunt cortical tap.nnnMETHODSnTibiofibular clear space was assessed in nine cadaveric specimens using three sequential fluoroscopic images. The first image was taken prior to the application of the tap test (intact, non-stressed). Then, a 2.5u2009mm hole was drilled distally on the lateral fibula, and a 3.5u2009mm cortical tap was then threaded in the hole. The tap test involved gradually advancing the blunt tip against the lateral tibia, providing a tibiofibular separation force (intact, stressed). This same stress was then applied after all syndesmotic ligaments were released (injured, stressed). Measurements were compared by one-way ANOVA and paired Students t-test. Intra and inter-observer agreements were evaluated by intraclass correlation coefficient (ICC). P-values <.05 were considered significant.nnnRESULTSnWe found excellent intra-observer (0.97) and inter-observer (0.98) agreement following the imaging assessment. Significant differences were found in the paired comparison between the groups (pu2009<u2009.05). When using an absolute value for TFCS >6u2009mm as diagnostic for coronal syndesmotic instability, the tap test demonstrated a 96.3% sensitivity and specificity, a 96.3% PPV and NPV and a 96.3% accuracy in diagnosing coronal syndesmotic instability.nnnCONCLUSIONSnOur cadaveric study demonstrated that this novel coronal syndesmotic instability test using a 3.5u2009mm blunt cortical tap is a simple, accurate and reliable technique able to demonstrate significant differences in the tibiofibular clear space when injury was present. It could represent a more controlled and stable alternative to the most used Cotton test.

Internal Fixation of Displaced Intra-articular Fractures of the Hallux Through a Dorsomedial Approach: A Technical Tip

Phalangeal fractures of the toes represent common injuries of the forefoot. In the hallux, most fractures occur at the distal phalanx and frequently result from a direct crushing type of injury. Intra-articular fractures of the hallux are usually treated nonoperatively, except when the fragments are displaced and the joint is incongruent. Displaced fractures treated nonoperatively can result in degenerative arthritis of the interphalangeal joint, causing pain and range of motion limitation, hindering gait and weightbearing. The aim of this study was to present an option of operative approach in the treatment of displaced interphalangeal joint fractures of the hallux, along the medial border of the extensor hallucis longus tendon. It is our understanding that this approach minimizes injury to the soft tissue envelope, allowing a rigid fixation and early weightbearing and range of motion. Levels of Evidence: Level V: Expert opinion