Ken Innami

Arthroscopic and Magnetic Resonance Image Appearance and Reconstruction of the Anterior Talofibular Ligament in Cases of Apparent Functional Ankle Instability

Background Many patients report feeling functional ankle instability, despite having no clinically demonstrable lateral instability. Hypothesis Some patients who experience functional instability of the ankle have substantial abnormalities of the anterior talofibular ligament despite having apparently normal lateral laxity in clinical examination. Study Design Case series; Level of evidence, 4. Methods Fourteen patients who had functional ankle instability after sprain, despite having no clinically demonstrable lateral instability, were included in this study. All subjects underwent standard stress radiography, magnetic resonance imaging, and ankle arthroscopy. These patients were treated with anatomical reconstruction of the anterior talofibular ligament. Results Arthroscopic assessment revealed 3 cases with no ligamentous structure with scar tissue, 9 cases with partial ligament tears and scar tissue on the disrupted anterior talofibular ligament fiber, and 2 cases of abnormal course of the ligament at the fibular or talar attachment. Magnetic resonance imaging revealed the following: 5 cases of discontinuity of the anterior talofibular ligament, 2 cases of narrowing of the anterior talofibular ligament, 4 cases of high-intensity lesion in the anterior talofibular ligament, and 3 normal cases. The mean American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale score was 66.2 ± 3.2 points at preoperation and 92.3 ± 4.4 points 2 years after surgery. Conclusion All patients in this study with functional ankle instability, despite their having no demonstrable abnormal lateral laxity, had morphologic ligamentous abnormality on arthroscopic assessment.

Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle.

Although several arthroscopic surgical techniques for the treatment of lateral instability of the ankle have been introduced recently, some concern remains over their procedural complexity, complications, and unclear clinical outcomes. We have simplified the arthroscopic technique of Broström repair with Gould augmentation. This technique requires only two small skin incisions for two ports (medial midline and accessory anterolateral ports), without needing a percutaneous procedure or extension of the skin incisions. The anterior talofibular ligament is reattached to its anatomical footprint on the fibula with suture anchor, under arthroscopic view. The inferior extensor retinaculum is directly visualized through the accessory anterolateral port and is attached to the fibula with another suture anchor under arthroscopic view via the anterolateral port. The use of two small ports offers a procedure that is simple to perform and less morbid for patients.

Endoscopic Surgery for Plantar Fasciitis: Application of a Deep-Fascial Approach

PURPOSE The purpose of this study was to determine the clinical results of deep-fascial medial and lateral portals in performing endoscopic surgery for plantar fasciitis. METHODS In 10 feet in 8 patients who were treated conservatively for more than 6 months with failure to relieve their symptoms, endoscopic surgery was performed. After the patient was placed in the supine position, a medial portal was made 5 mm deep to the plantar fascia and 10 mm anterior to its origin on the calcaneus under fluoroscopy. The lateral portal was established by placing a blunt trocar deep and perpendicular to the plantar fascia. A 2.7-mm-diameter arthroscope was passed through the deep-lateral portal, and the operative devices were inserted through the deep-medial portal. A motorized shaver was used for making a working space to excise the fat tissue along with a portion of the flexor digitorum brevis muscle. If a heel spur existed, it was resected to establish a clear view of the plantar fascia by use of an arthroscopic burr. After exposure of the plantar fascia, its medial half was removed with electric devices such as an Arthro-Knife (ConMed Linvatec, Largo, FL). RESULTS The mean score on the American Orthopedics Foot and Ankle Society Ankle Hindfoot Scale was 64.2 ± 6.3 points before surgery and 92.6 ± 7.1 points at 2 years after surgery (P < .0001). The mean duration to full weight bearing after surgery was 13.9 ± 8.4 days. All patients returned to full athletic activities by a mean of 10.7 ± 2.6 weeks. CONCLUSIONS Endoscopic surgery for plantar fasciitis through a deep-fascial approach allows a wide field of vision and working space, permitting reliable resection of the plantar fascia and heel spur. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Retrograde Cancellous Bone Plug Transplantation for the Treatment of Advanced Osteochondral Lesions With Large Subchondral Lesions of the Ankle

Background: The surgical results have been reported as poor for advanced osteochondral lesions of the ankle with large subchondral lesions including subchondral cyst. Hypothesis: Transplanting an autologous cancellous bone plug from the pelvis to the lesions retrogradely may bring good clinical results for the treatment of advanced osteochondral lesions with large subchondral lesions including subchondral cyst of the ankle. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-five osteochondral lesion patients who had large subchondral lesions of the ankle (diameter ≥10 mm on magnetic resonance imaging) met the criteria of this study. Fourteen of those patients were treated with arthroscopic antegrade drilling (group AD), and the other 11 patients were treated with arthroscopic retrograde cancellous bone plug transplantation from the iliac crest (group RC). The clinical results in conjunction with the American Orthopaedic Foot and Ankle Society (AOFAS) scores, diameters of the subchondral lesions on magnetic resonance imaging, and the regenerative cartilage in second-look arthroscopy using International Cartilage Repair Society (ICRS) visual repair assessment score were evaluated. Results: The mean AOFAS score at 2 years after surgery was 82.2 ± 7.2 in group AD and 95.8 ± 4.6 in group RC (P < .0001). Diameter of the subchondral lesion was almost unchanged in 11 cases (78.5%) in group AD, compared with disappearance in 7 cases (73.8%) and decreased lesion size in 4 cases (36.4%) in group RC. The mean ICRS score at second-look arthroscopy was 5.1 ± 1.9 in group AD and 10.5 ± 0.8 in group RC (P = .0001). Conclusion: The authors recommend arthroscopic retrograde autologous cancellous bone plug transplantation from the iliac crest as a surgical procedure for the treatment of advanced osteochondral lesions with large subchondral lesions of the ankle.

Endoscopic Surgery for Young Athletes With Symptomatic Unicameral Bone Cyst of the Calcaneus

Background: Open curettage with bone graft has been the traditional surgical treatment for symptomatic unicameral calcaneal bone cyst. Endoscopic procedures have recently provided less invasive techniques with shorter postoperative morbidity. Hypothesis: The authors’ endoscopic procedure is effective for young athletes with symptomatic calcaneal bone cyst. Study Design: Case series; Level of evidence, 4. Methods: Of 16 young athletes with symptomatic calcaneal bone cyst, 13 underwent endoscopic curettage and percutaneous injection of bone substitute under the new method. Three patients were excluded because of short-term follow-up, less than 24 months. For the remaining 10 patients, with a mean preoperative 3-dimensional size of 23 × 31 × 35 mm as calculated by computed tomography, clinical evaluation was made with the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale just before surgery and at the most recent follow-up (mean, 36.2 months; range, 24-51 months), and radiologic assessment was performed at the most recent follow-up, to discover any recurrence or pathologic fracture. Furthermore, the 10 patients—all of whom returned to sports activities—were asked how long it took to return to initial sports activity level after surgery. Results: Mean ankle-hindfoot scale score improved from preoperative 78.7 ± 4.7 points (range, 74-87) to postoperative 98.0 ± 4.2 points (range, 90-100) (P < .001). Pain and functional scores significantly improved after surgery (P < .01 and P < .05, respectively). Radiologic assessment at most recent follow-up revealed no recurrence or pathologic fracture, with retention of injected calcium phosphate cement in all cases. All patients could return to their initial levels of sports activities within 8 weeks after surgery (mean period, 7.1 weeks; range, 4-8 weeks), which was quite early as compared with past reports. Conclusion: Endoscopic curettage and injection of bone substitute appears to be an excellent option for young athletes with symptomatic calcaneal bone cyst for early return to sports activities, because it has the possibility to minimize the risk of postoperative pathologic fracture and local recurrence after early return to initial level of sports activities.

Minimally invasive subtalar arthrodesis with iliac crest autograft through posterior arthroscopic portals: a technical note.

Level of Evidence: V, Expert Opinion

Technique Tip: Open Ankle Athrodesis Using Locking Compression Plate Combined With Anterior Sliding Bone Graft

Level of Evidence: V, Expert Opinion

Acute Achilles Tendon Rupture Treated by Double Side-Locking Loop Suture Technique With Early Rehabilitation

Background: Although early accelerated rehabilitation is recommended for the treatment of acute Achilles tendon rupture, most traditional rehabilitation techniques require some type of brace. Methods: We retrospectively analyzed 44 feet of 44 patients (25 male and 19 female) with a mean age of 31.8 years who had an acute Achilles tendon rupture related to athletic activity. Patients had been treated by a double side-locking loop suture (SLLS) technique using double antislip knots between stumps and had undergone early accelerated rehabilitation, including active and passive range of motion exercises on the day following the operation and full weight-bearing at 4 weeks. No brace was applied postoperatively. The evaluation criteria included the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale (AOFAS) score; active plantar flexion and dorsiflexion angles; and the intervals between surgery and the time when patients could walk normally without any support, perform double-leg heel raises, and perform 20 continuous single-leg heel raises of the operated foot. Results: Despite postoperative early accelerated rehabilitation, the AOFAS score and active dorsiflexion angles improved over time (6, 12, and 24 weeks and 2 years). A mean of 4.3 ± 0.6 weeks was required for patients to be able to walk normally without any support. The mean period to perform double-leg heel raises and 20 continuous single-leg heel raises of the injured foot was 8.0 ± 1.3 weeks and 10.9 ± 2.1 weeks, respectively. All patients, except one who was engaged in classical ballet, could return to their preinjury level of athletic activities, and the interval between operation and return to athletic activities was 17.1 ± 3.7 weeks. Conclusion: The double SLLS technique with double antislip knots between stumps adjusted the tension of the sutured Achilles tendon at the ideal ankle position and provided good clinical outcomes following accelerated rehabilitation after surgery without the use of a brace. Level of Evidence: Level IV, retrospective case series.

Valgus Deformity of the Great Toe Interphalangeal Joint Treated by Reversed Sliding Osteotomy of the Proximal Phalanx: A Case Report

Level of Evidence: V, Expert Opinion

Technique Tip: Interposition of Extensor Digitorum Longus after Resection Arthroplasty of Lesser Metatarsophalangeal Joints for Rheumatoid Forefoot Deformity

Level of Evidence: V, Expert Opinion