James Calder

Osteochondral lesions of the talus

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Topical Glyceryl Trinitrate and Noninsertional Achilles Tendinopathy A Clinical and Cellular Investigation

Background Topical glyceryl trinitrate (GTN) therapy has been advocated in the treatment of Achilles tendinopathy. The mechanism of action is unknown but may be related to modulation of local nitric oxide levels. Hypothesis Topical GTN therapy for noninsertional Achilles tendinopathy will significantly enhance clinical improvement and will be associated with increased collagen synthesis within the tendon. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Forty patients were recruited. Twenty underwent standard nonoperative physical therapy, and 20 underwent physical therapy and topical GTN daily. Clinical outcome was assessed using the Ankle Osteoarthritis Scale (AOS) visual analog score. Patients who failed to improve with conservative measures and who underwent surgical decompression had histological and immunohistochemical examination of samples from the Achilles tendon. Results Glyceryl trinitrate did not offer any additional clinical benefit over standard nonoperative treatment for noninsertional Achilles tendinopathy. After 6 months of treatment, there was no significant difference in scores between the groups for pain (3.0 vs 3.1, P = .42) or disability (2.15 vs 2.25, P = .38). Histological examination did not show any difference in neovascularization, collagen synthesis, or stimulated fibroblasts between the 2 groups. There was no evidence of modulation of nitric oxide synthase, a marker of nitric oxide production, in those tendons treated with GTN. Conclusion and Clinical Relevance This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperative therapy.

MR Morphometry of Posterior Tibialis Muscle in Adult Acquired Flat Foot

We conducted magnetic resonance imaging of the posterior tibial (PT) and flexor digitorum longus (FDL) muscle bellies in 12 patients undergoing surgical treatment for unilateral posterior tibial tendon (PTT) dysfunction. All patients had atrophy of the PT muscle compared to the normal leg (mean 10.7%, p=0.008). In those patients with a complete rupture of PTT there was replacement of the PT muscle by fatty infiltration. Conversely, the FDL muscle showed a compensatory hypertrophy (mean 17.2%, p<0.002). We support the use of FDL as an appropriate tendon for augmentation of PTT in stage II disease. This study also demonstrates that in the presence of a complete rupture, excision of the PTT is a reasonable surgical procedure and pure tenodesis will be more likely to fail because the PT muscle belly undergoes fatty infiltration. In patients with a diseased but intact PTT there was no fatty infiltration and the muscle volume was at least 83% of the normal side in all cases. We therefore suggest that in the presence of an intact PTT the PT muscle belly may provide some useful function if used to augment the FDL transfer when the diseased tendon is excised.

The Achillon achilles tendon repair: is it strong enough?

Background: Open repair of the Achilles tendon is associated with wound breakdown, infection and percutaneous methods risk sural nerve injury. The Achillon® mini-incision technique can reduce these risks and may provide the opportunity for early active rehabilitation. The aim of this study was to compare the strength of the Achillon® method with the commonly used Kessler method and to assess whether the strength of the repair was related to tendon diameter. Materials and Methods: Simulated ruptures in sheep Achilles tendons were repaired using either the Achillon® method or a two-strand Kessler technique with a No. 2 Ticron suture (Tyco Healthcare, UK). Each tendon diameter was measured, and matched for both groups. Specimens were loaded to failure using an Instron tensile testing machine (Instron Limited, UK). Results: Mean load to failure for the Achillon® repair was 153 N ± 60 (range, 65 to 270), and the mean load to failure for the Kessler Repair was 123 N ± 24 (range, 75 to 150). This difference was not statistically significant (p = 0.21). There was a statistically significant higher mean load to failure for wider tendons repaired by the Achillon® method (p = 0.05), however mean load to failure was not related to tendon width in Kessler repairs (p = 0.23). Conclusion: This is the first study to compare these two methods of repair. The Achillon® repair has comparable tensile strength to the Kessler Repair. Clinical Relevance: The Achillon® repair appears to be a biomechanically sound method of repair for the acutely ruptured Achilles tendon.

Achilles tendinoscopy and plantaris tendon release and division in the treatment of non-insertional Achilles tendinopathy.

BACKGROUND The mainstay of treatment for non-insertional Achilles tendinopathy is non-operative, however a proportion of patients will fail conservative measures. We describe the results of Achilles tendinoscopy with plantaris tendon release in patients who have failed first line conservative treatment for at least 6 months. METHODS A consecutive series of 11 patients with a minimum of 2 years follow up. RESULTS The mean AOFAS scores significantly improved from 68 pre-op to 92 post op (p=0.0002) as did the AOS scores for both pain (28% pre-op to 8% post op (p=0.0004)) and disability (38% pre-op to 10% post op (p=0.0005). The mean SF-36 scores also improved but were not statistically significant (pre-op 76, post op 87 (p=0.059). There were no complications. 8 of the 11 patients were satisfied, the other 3 somewhat satisfied. CONCLUSIONS The results of Achilles tendinoscopy and division of the plantaris tendon are encouraging but further studies are required to compare it to other treatments. It is minimally invasive and low risk so should not affect the ability to perform a formal open procedure if unsuccessful.

Lesion Size Is a Predictor of Clinical Outcomes after Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review

Background: The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm2 in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs. Purpose: To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs. Study Design: Systematic review. Methods: A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes. Results: Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm2 in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm2, while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm2. The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies. Conclusion: An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm2 in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle

AbstractAlthough several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive. Level of evidence Therapeutic study, Level V.

Treatment of Recurring Peroneal Tendon Subluxation in Athletes: Endoscopic Repair of the Retinaculum

Traumatic peroneal tendon subluxation is a rare lesion that occurs most frequently during sporting activities and generally after an ankle sprain. There is consensus regarding the need for surgical stabilization in symptomatic patients, but there is also a general agreement that acute subluxation or dislocations may require surgery in the athlete. Many surgical techniques have been described to treat this lesion. Overall, studies have reported excellent or good results in 90% of cases, although there have been reports of significant complications following open surgical procedures. Endoscopic anatomical retinacular repair offers an attractive alternative to open repair and may reduce complications and allow early return to sports.

Ultrasound-guided treatments for chronic Achilles tendinopathy: an update and current status

Minimally-invasive treatments for chronic Achilles tendinopathy may prevent the need for surgery when conservative methods have failed. Whilst injections have traditionally been used to manage symptoms, recently described therapies may also have disease-modifying potential. Ultrasound provides the ability to guide therapeutic interventions, ensuring that treatment is delivered to the exact site of pathology. Treatments can be broadly categorised according to their intended therapeutic targets, although some may act through several possible mechanisms. In this article, we review the ultrasound-guided techniques currently used to treat chronic Achilles tendinopathy, with reference to the available literature. There is strong pilot-level evidence supporting the use of many of these techniques, although large definitive trials are lacking. An approach towards the management of chronic Achilles tendinopathy is suggested.