Pau Golanó

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique.

Background: Recently, arthroscopic-assisted techniques have been described to treat lateral ankle instability with excellent results. However, complications including neuritis of the superficial peroneal or sural nerve, and pain or discomfort due to a prominent anchor or suture knot have been reported. The aim of this study was to describe a novel technique, the “all-inside arthroscopic lateral collateral ankle ligament repair,” and its results for treating patients with ankle instability. Methods: Sixteen patients (10 men and 6 women, mean age 29.3 years, 17-46) with lateral ankle instability were treated with an arthroscopic procedure. Using a suture passer and a knotless anchor, the ligaments were repaired with an all-inside technique. The right ankle was affected in 10 cases. Mean follow-up was 22.3 (12-35) months. Results: On arthroscopic examination, 13 patients had an isolated anterior talofibular ligament (ATFL) injury, and in 3 patients, both the ATFL and calcaneofibular ligament (CFL) were affected. All-inside arthroscopic anatomic repair of the lateral collateral ligament complex was performed in all cases. All patients reported subjective improvement of their ankle instability. The mean AOFAS score increased from 67 preoperatively to 97 at final follow-up. No major complications were reported. Conclusion: The all-inside arthroscopic ligament repair was a safe, reliable, and reproducible technique that both provided an anatomic repair of the lateral collateral ligament complex and restored ankle stability while preserving all the advantages of an arthroscopic technique. Level of Evidence: Level IV, retrospective case series.

An arthroscopic bone graft procedure for treating anterior–inferior glenohumeral instability

The purpose of this study is twofold: to present an arthroscopic method for treating anterior–inferior glenohumeral instability, and to evaluate its feasibility in a cadaveric model. This arthroscopic technique was performed in ten fresh frozen cadaver shoulder specimens. Quality of the results following the procedure were evaluated subjectively by assessing how the bone block graft was placed respect glenoid rim. We also evaluated adjacent axillary nerve and the neuro-vascular structures medial to the coracoid. We had six ‘good’ results, two ‘fair’ results, and two ‘poor’ results. The present study indicates that an anterior bone graft procedure for treating anterior bone defects of the glenoid in anterior inferior shoulder instability can be successfully performed. The worst results occurred during our first five procedures, suggesting a learning curve. However, the learning curve doesn’t appear to be steep, as the good results gained in the last five procedures confirm.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study.

Background: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. Methods: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. Results: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. Conclusion: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Endoscopic treatment for chronic Achilles tendinopathy

UNLABELLED This study presents our experience and results in patients with Achilles tendinopathy treated with an endoscopic technique. MATERIAL AND METHODS Eight patients with chronic tendinopathy of the Achilles underwent endoscopic treatment. A distal portal is created 2 cm proximal of the lateral margin of the tendon insertion. A slotted cannula is inserted in a proximal direction and toward the midline. A 4.5 mm diameter arthroscope is advanced through the cannula. An additional portal, equidistant to the lateral portal, can be created at the medial distal level if we need to access the most medial and distal part of the tendon. Pathological tissue is eliminated while performing multiple longitudinal tenotomies with a retrograde knife blade. Clinical outcome was assessed according to the Nelen scale. RESULTS Clinical results were scored as excellent, with all patients able to return to pre-procedure sports activity without limitations. There were no complications in any case. CONCLUSION Endoscopic treatment yielded satisfactory results with lower morbidity than other reported techniques.

The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies

PurposeA literature review of the deltoid ligament was conducted, examining the current literature on anatomy, function, and treatment strategies. In particular, anatomical inconsistencies within the literature were evaluated, and detailed anatomical dissections are presented.MethodsA literature search was conducted on PubMed using keywords relevant to the deltoid ligament in the ankle and medial ankle instability. Primary research articles, as well as appropriate summary articles, were selected for review.ResultsWhile it is well defined that the deltoid is contiguous and divided into one superficial and one deep portion, the creation of the individual fibres may be artificial. Furthermore, while improvements in imaging techniques and arthroscopy have not led to a consensus on the anatomy of the ligament, they may help improve recognition of deltoid injuries. Once identified, the majority of deltoid injuries can be treated via conservative treatment. However, reparative and reconstructive treatment strategies can also be used for complex acute injuries or chronic medial ankle instability.ConclusionGiven the continuing evolution of the anatomical understanding of the ligament, the current treatment protocol for deltoid injuries requires further standardization, with an emphasis on proper diagnosis.

The validity and reliability of the Klaue device.

Background: Excessive first ray mobility has been implicated as the cause of many forefoot abnormalities. The association between hypermobility and forefoot pathology is controversial, and this is largely related to the difficulty in quantifying first ray motion. Manual examinations have been shown to be unreliable. Klaue et al. developed a device consisting of a modified ankle-foot orthosis with an attached micrometer to objectively measure first ray mobility. The purpose of this study was to evaluate the validity and reliability of this device. Methods: Sixteen fresh-frozen, below-knee amputation specimens with hallux valgus were used for the study. The study was divided into two parts. Part I was an analysis of the validity of the Klaue device; first ray dorsal displacement was measured on lateral radiographs following manual manipulation, and values were statistically compared to the Klaue device measurements. Part II of the study was an evaluation of intraobserver and interobserver agreement. Two clinicians used the Klaue device on each of the cadaver limbs, and values of first ray sagittal mobility were recorded and compared. Results: The mean value of first ray mobility measured with the Klaue device was 7.5 mm and the average displacement measured from the lateral radiographs was 7.4 mm. Paired t-testing showed no significant difference between the Klaue and radiographic measurements (p = 0.83). The mean first ray mobility by examiners 1 and 2 with the Klaue device were identical (10.5 mm), and statistical analysis showed no significant interobserver or intraobserver differences. Conclusions: The results confirm the validity of the Klaue device and limited variability of measurements between experienced users.

Tratamiento quirúrgico percutáneo del hallux valgus mediante osteotomías múltiples

Objetivo Se presenta la experiencia del tratamiento del hallux valgus mediante la realizacion de osteotomia distal del primer metatarsiano y osteotomia de la falange con liberacion del abductor por tecnicas percutaneas. Material y metodo Desde junio de 1996 hasta junio de l997 han sido intervenidos 64 pacientes, la mayor parte mujeres con hallux valgus de grado moderado con un angulo intermetatarsiano medio de 14,5° y un angulo del complejo articular proximal (PASA) de 17,7° de media. Resultados Los resultados obtenidos desde el punto de vista radiologico pusieron de manifiesto una correccion media de 5° del angulo intermetatarsal y se obtiene un valor medio del PASA de 8,2°. La consolidacion de las osteotomias se consiguio en el 100% de los pies sin retardos de consolidacion significativos, salvo en un caso que preciso mas de tres meses. Por lo que se refiere a las complicaciones, al no utilizar ningun medio de fijacion, el desplazamiento de las osteotomias fue muy frecuente, pero solo en un 8% de la serie tuvieron repercusion clinica. El acortamiento del primer metarsiano fue la norma alcanzando como media 0,7 cm, lo que se intento compensar con un descenso de la cabeza del primer metatarsiano; la metatarsalgia por trasferencia en esta serie ocurrio en el 25% de los casos. No se presentaron alteraciones neurologicas, infeccion ni sindromes flebiticos postquirurgicos. Conclusion Parece que la tecnica de Reverdin-Isham, por via percutanea, es un buen metodo para el tratamiento del hallux valgus, ya que proporciona unos resultados clinicos muy aceptables, sin presentar complicaciones importantes; en el momento actual hay que asociar con mucha mas frecuencia la realineacion metatarsal a la cirugia del hallux valgus para evitar las metatarsalgias por trasferencia.

First Metatarsophalangeal Joint Motion After Hallux Valgus Correction: A Cadaver Study

Background: Surgical correction of hallux valgus deformities often results in decreased first metatarsophalangeal joint (MTPJ) range of motion. Loss of motion has been shown to affect patient satisfaction. The purpose of this study was to evaluate the immediate change in MTPJ range of motion that occurs after a distal soft-tissue reconstruction (DSTR) and proximal metatarsal osteotomy (PMO). Methods: DSTR and PMO were done on 16 below-knee cadaver specimens with clinically apparent hallux valgus deformities. Two examiners assessed preoperative and postoperative dorsiflexion (DF), plantarflexion (PF), and the total range of motion of the first MTPJ. The hallux valgus angle (HVA) and 1–2 intermetatarsal angle (1–2 IMA) were measured on simulated weightbearing radiographs before and after operative correction. Changes in motion were analyzed and correlated with the angular measurements. Results: The mean total range of motion preoperatively was 85.4 degrees (DF 70.5 degrees, PF 14.9 degrees) and significantly decreased (p < 0.005) 23.2 degrees to a postoperative value of 62.2 degrees (DF 47.9 degrees, PF 14.3 degrees). There was a significant (p < 0.005) decrease in DF (22.6 degrees) with the operative correction, but the loss of PF (0.6 degrees) was not significant (p = 0.7). There was no correlation between the magnitude of correction (HVA, 1–2 IMA) and the change in PF, DF, or total motion. Conclusions: Correction of a hallux valgus deformity with a DSTR and PMO is associated with an immediate loss of range of motion that primarily affects the DF arc of the first MTPJ. The selective loss of DF may be related to a nonisometric capsular repair or tight intrinsic musculature, although there was no correlation with the magnitude of angular correction. The immediate decrease in motion observed in this cadaver study underscores the importance of early postoperative joint mobilization to prevent long-term stiffness after bunion surgery.

Endoscopic resection of a calcaneonavicular coalition

Calcaneonavicular coalition is a congenital anomaly characterized by a connection between the calcaneus and the navicular. Surgery is required in case of chronic pain and after failure of conservative treatment. The authors present here the surgical technique and results of a 2-portals endoscopic resection of a calcaneonavicular synostosis. Both visualization and working portals must be identified with accuracy around the tarsal coalition with fluoroscopic control and according to the localization of the superficial peroneus nerve, to avoid neurologic damages during the resection. The endoscopic procedure provides a better visualization of the whole resection area and allows to achieve a complete resection and avoid plantar residual bone bar. The other important advantage of the endoscopic technique is the possibility to assess and treat in the same procedure-associated pathologies such as degenerative changes in the lateral side of the talar head with debridement and resection.