Fernando Raduan

Arthroscopic-Assisted Broström-Gould for Chronic Ankle Instability A Long-Term Follow-up

Background: Lateral ankle sprains account for 85% of ankle lesions. Hypothesis: Combined open and arthroscopic procedures could improve the diagnosis and management of intra-articular lesions and allow surgeons to perform minimally invasive anatomic reconstruction of the lateral ligament complex. Study Design: Case series; Level of evidence, 4. Methods: Forty consecutive patients underwent ankle arthroscopy for recurrent (2 or more episodes) lateral ankle instability unresponsive to nonoperative measures. The clinical diagnosis of mechanical instability was confirmed at imaging (plain radiographs and magnetic resonance imaging [MRI]) and arthroscopic assessment. All patients underwent arthroscopic Broström-Gould repair for management of lateral ankle instability; secondary lesions were also managed. Postoperatively, the American Orthopaedic Foot & Ankle Society (AOFAS) score was administered to assess the functional status; clinical examination and conventional radiographs were performed in all patients. Results: Thirty-eight patients were reviewed at an average postoperative follow-up of 9.8 years. The mean AOFAS score was 90 (range, 44-100) at the last follow-up. No significantly different outcomes were found in patients who had undergone microfractures for management of grade III to IV cartilage lesions compared with patients with no cartilage lesions. Postoperative AOFAS scores were graded as excellent and good in almost all patients (94.7%). Concerning failure rate, 2 patients (5.3%) reported a low AOFAS score: one patient underwent soft tissue removal for anterior impingement, and one received simultaneous medial ankle instability repair. Conclusion: The arthroscopic Broström-Gould–assisted technique could be a viable alternative to the gold-standard Broström-Gould procedure for anatomic repair of chronic lateral ankle instability and management of intra-articular lesions. Prospective randomized controlled trials are needed.

Prospective Evaluation of Protocol for Surgical Treatment of Lesser MTP Joint Plantar Plate Tears

Background: Instability of the lesser metatarsophalangeal (MTP) joints is a common cause of deformity and pain. The purpose of this study was to prospectively evaluate the surgical outcomes for the different grades of plantar plate tears and propose a treatment protocol. Methods: Sixty-eight patients (100 MTP joints) were prospectively enrolled and graded according to the anatomical grade system for plantar plate tears. Based on this classification, the appropriate surgical procedure was chosen as follows: grades 0 and I, thermal shrinkage with radiofrequency; grades II and III, direct reinsertion of the plantar plate; and grade IV, flexor-to-extensor tendon transfer. All surgical procedures were associated with a Weil metatarsal osteotomy. Evaluations were performed before and after surgical treatment with a mean follow-up of 2 years (12-36 months), using clinical and radiological parameters: American Orthopaedic Foot and Ankle Society (AOFAS) Lesser MTP-IF Scale, visual analog scale (VAS), ground touch, joint stability, and toe purchase. Results: The analysis of the clinical parameters demonstrated a significant improvement of all groups (P < .0001) after surgical treatment, but grade IV had less VAS improvement and a fair AOFAS average score (72 points). All groups improved regarding physical examination parameters, but grade I, III, and IV tears had proportionally less stable MTP joints following surgery, as well as a lower proportion of normal postoperative toe purchase and ground touch. All groups showed a significant improvement regarding radiographic parameters. Conclusion: All groups of operatively treated patients had significant improvement with regard to subjective and objective parameters. Grades I, III, and IV presented inferior results compared with grades 0 and II. Level of Evidence: Level IV, case series

Plantar approach for excision of a Morton neuroma: a long-term follow-up study.

BACKGROUND When nonsurgical treatment of a Morton neuroma is unsuccessful, neurectomy is indicated. The purpose of the present retrospective study was to evaluate the long-term outcomes, complications, and adverse events following a distal plantar transverse incision for the excision of an intermetatarsal neuroma. METHODS We conducted a retrospective review of 168 consecutive patients who underwent surgical excision of a Morton neuroma that had been unresponsive to nonsurgical treatment. The clinical diagnosis was confirmed by means of magnetic resonance imaging and histological analysis. All patients underwent excision of the neuroma through a distal transverse plantar approach; concomitant foot and ankle disorders were also treated. Postoperatively, a three-grade patient satisfaction scale was administered to assess the results of the procedure and a clinical examination was performed for all patients. RESULTS One hundred and sixty patients (204 feet, 227 neuromas) were assessed at a median of 7.1 ± 3.9 years (range, one to twenty-one years) postoperatively. A good result was reported for 143 patients (89.4%); a fair result, for eleven (6.9%); and a poor result, for six (3.8%). The eleven patients with a fair result reported scar-related symptoms such as skin hardening, loss of sensation at the incision site, discomfort wearing shoes with high heels, and local paresthesias with no recurrence of the neuroma. The six patients with a poor result reported pain and paresthesias, and the recurrence of a neuroma was confirmed at the time of reoperation. CONCLUSIONS Producing a marked reduction in pain and high overall patient satisfaction, a distal transverse plantar incision is comparable with other surgical approaches for the surgical treatment of a Morton neuroma.

Percutaneous Ankle Reconstruction of Lateral Ligaments (Perc-Anti RoLL).

Summary Chronic ankle instability following ankle sprains causes pain and functional problems such as recurrent giving way. If non-operative treatments fail, then operative ankle stabilization may be required to improve pain and function. Operative options include both anatomic repair and reconstruction techniques. Anatomic repair techniques utilize pre-existing ligament remnants that are either reattached or tightened to improve stability of the ankle. If pre-existing ligament structures have been damaged beyond repair or are insufficient to allow repair, then it is appropriate to choose an anatomic reconstructive technique. These procedures have traditionally been performed using open techniques and have been successful in restoring function and decreasing pain. In 2005, an open anatomic reconstruction technique using a gracilis Y-graft and Inside-out technique was reported with good results. In the current paper we describe a Percutaneous Reconstruction of the Lateral Ligaments (Perc-Anti RoLL), which is a new minimally invasive surgical technique for anatomic reconstruction of the lateral ligaments of the ankle that utilizes the anatomic Y-graft and Inside-out technique. The Perc-Anti RoLL technique can be performed percutaneously using fluoroscopic guidance.

Lesser Metatarsal Phalangeal Joint Arthroscopy: Anatomic Description and Comparative Dissection

PURPOSE The aim of this article is to describe the normal arthroscopic anatomy of the lesser metatarsophalangeal (MTP) joints and compare it with that seen in open dissection in cadaveric models. METHODS We performed arthroscopic examination of 18 MTP joints of 6 normal fresh frozen feet. The second, third, and fourth MTP joints were studied because of the higher incidence of pathologic conditions found in these joints. During arthroscopy, each anatomic structure identified was named and marked with different colored sutures using straight suture needles. After the arthroscopic procedure of identification and marking, each MTP joint was dissected, and all the anatomic structures were grossly identified. With these data, the correlation between the arthroscopic and the direct visualization of a normal MTP joint was established. RESULTS Considering the joint regions, we found that the examination accuracy of the medial gutter was 91%, whereas the central joint accuracy reached 100% and the accuracy of the lateral gutter was 98%. The overall arthroscopic accuracy for the lesser MTP joints was 96%. CONCLUSIONS There is a high level of anatomic accuracy at the lesser MTP joint with arthroscopy. CLINICAL RELEVANCE The high overall level of anatomic accuracy of lesser MTP joint arthroscopy (96%) allows us to consider this resource as a valuable tool in the diagnosis and treatment of these joints, expanding the spectrum of indications using this method.

Reliability of Baropodometry on the Evaluation of Plantar Load Distribution: A Transversal Study

Introduction. Baropodometry is used to measure the load distribution on feet during rest and walking. The aim of this study was to evaluate changes in plantar foot pressures distribution due to period of working and due to stretching exercises of the posterior muscular chain. Methods. In this transversal study, all participants were submitted to baropodometric evaluation at two different times: before and after the working period and before and after stretching the muscles of the posterior chain. Results. We analyzed a total of 54 feet of 27 participants. After the working period, there was an average increase in the forefoot pressure of 0.16 Kgf/cm2 and an average decrease in the hindfoot pressure of 0.17 Kgf/cm2. After stretching the posterior muscular chain, the average increase in the forefoot pressure was 0.56 Kgf/cm2 and the hindfoot average pressure decrease was 0.56 Kgf/cm2. These changes were not statistically significant. Discussion. It was reported that the strength of the Achilles tendon generates greater forefoot load transferred from the hindfoot. In our study, no significant variation in the distribution of plantar pressure was observed. It can be inferred that baropodometry was a reliable instrument to determine the plantar pressure, regardless of the tension of the posterior chain muscles.

How to classify plantar plate injuries: parameters from history and physical examination

Objective To find the best clinical parameters for defining and classifying the degree of plantar plate injuries. Method Sixty-eight patients (100 metatarsophalangeal joints) were classified in accordance with the Arthroscopic Anatomical Classification for plantar plate injuries and were divided into five groups (0 to IV). Their medical files were reviewed and the incidence of each parameter for the respective group was correlated. These parameters were: use of high heels, sports, acute pain, local edema, Mulders sign, widening of the interdigital space, pain in the head of the corresponding metatarsal, touching the ground, “drawer test”, toe grip and toe deformities (in the sagittal, coronal and transversal planes). Results There were no statistically significant associations between the degree of injury and use of high-heel shoes, sports trauma, pain at the head of the metatarsal, Mulders sign, deformity in pronation or displacement in the transversal and sagittal planes (although their combination, i.e. “cross toe”, showed a statistically significant correlation). Positive correlations with the severity of the injuries were found in relation to initial acute pain, progressive widening of the interdigital space, loss of “touching the ground”, positive results from the “drawer test” on the metatarsophalangeal joint, diminished grip strength and toe deformity in supination. Conclusions The “drawer test” was seen to be the more reliable and precise tool for classifying the degree of plantar plate injury, followed by “touching the ground” and rotational deformities. It is possible to improve the precision of the diagnosis and the predictions of the anatomical classification for plantar plate injuries through combining the clinical history and data from the physical examination.

Combined Spring and Deltoid Ligament Repair in Adult-Acquired Flatfoot

Background: Adult-acquired flatfoot deformity (AAFD) is usually due to a combination of mechanical failure of the osteoligamentous complex that maintains the medial longitudinal arch of the foot and attenuation or complete tear of the posterior tibial tendon. Magnetic resonance imaging studies in patients with flatfoot deformities have reported the posterior tibial tendon to be pathologic in up to 100% of patients, the spring ligament in up to 87%, and the deltoid ligament in 33%. Many studies in the literature describe reconstruction of the spring ligament or the deltoid ligament associated with AAFD, but there is no study in which both (spring and deltoid) ligaments are reconstructed at the same time. We describe a novel technique to reconstruct the deltoid ligament and the spring ligament at the same time. Methods: We described the technique and evaluated 10 consecutive patients with AAFD and insufficient ankle and midfoot ligaments. Results: We found no postoperative complications, stiffness, or loss of correction. Conclusion: We present a novel technique to reconstruct the failed deltoid and spring ligament during flatfoot correction. It is unique in that it uses internal brace augmentation with FiberTape® to help and protect the soft tissue healing. Level of Evidence: Level IV, retrospective case series.

Diagnosis and treatment of osteochondral lesions of the ankle: current concepts

We conducted a wide-ranging review of the literature regarding osteochondral lesions of the ankle, with the aim of presenting the current concepts, treatment options, trends and future perspectives relating to this topic.

Foot and ankle injuries in professional soccer players: diagnosis, treatment, and expectations

Soccer is one of the most popular sports in the world. It has undergone many changes in recent years, mainly because of increased physical demands, and this has led to an increased injury risk. Direct contact accounts for half of all injuries in both indoor and outdoor soccer and ankle sprains are the most common foot and ankle injury. There is a spectrum of foot and ankle injuries and their treatment should be individualized in these high-demand patients. An injury prevention program is also important and should the players, the trainer, responsible physician, and physical therapists.