Sameh A. Labib

Heel pain triad (HPT): the combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome.

Between 1996 and 1999, we evaluated 286 patients with chronic heel pain. We identified 14 patients who were diagnosed and surgically treated for a unique combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome. We postulate that failure of the static (plantar fascia) and dynamic (posterior tibial tendon) support of the longitudinal arch of the foot has resulted in traction injury to the posterior tibial nerve, i.e., tarsal tunnel syndrome. The combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome was recognized and treated. We have called this combination the “Heel Pain Triad (HPT).” Using the AOFAS hindfoot rating system, retrospective chart review and patient examination revealed marked improvement in 85.7% of patients. Follow-up was done four to 33 months (mean follow-up was 17.1 months). Marked improvement was noted in the categories of pain, activity level, walking distance, walking surface and limp. Improvement was statistically significant for all categories.

Clinical Outcomes in High Flexion Total Knee Arthroplasty Were Not Superior to Standard Posterior Stabilized Total Knee Arthroplasty. A Multicenter, Prospective, Randomized Study

High flexion prostheses have been introduced to achieve high flexion and improve clinical outcomes. Controversy exists in the literature regarding outcomes of high flexion vs. standard implants. This multicenter study compares outcomes in patients receiving a high flexion prosthesis vs. standard prosthesis. 278 high flexion and standard knee prostheses were used. Patients were followed for two years and evaluated prospectively. The mean HSS was 87.3 for the standard group and 88.9 for the flexion group. At two-year follow up the standard prosthesis group had mean flexion of 121° and the high flexion group had mean flexion 120°. No knee had aseptic loosening, infection, or osteolysis. At two-year follow up, there were no significant differences in range of motion, clinical outcome, or radiographic evaluation. Pre-operative motion and functional status have greater impact on clinical outcome than implant alone.

The “Giftbox” Repair of the Achilles Tendon: A Modification of the Krackow Technique

BACKGROUND The Krackow locking loop technique has been used for Achilles tendon repair with documented success in allowing early range of motion with stable fixation. Previous studies documented failure at the rupture site by knot failure. We propose a modification of the traditional Krackow technique where the knots of the suture are tied away from the rupture site (aka the Giftbox technique). We compared the tensile strength of Achilles tendons repaired using the traditional Krackow technique with those repaired using the Giftbox technique. MATERIALS AND METHODS Thirteen pairs of fresh frozen cadaveric Achilles tendons were harvested. An Achilles tendon rupture was created 4 cm from the calcaneal insertion. Thirteen Achilles ruptures were repaired using the traditional Krackow technique and 13 pairs were repaired using the Giftbox technique. The Achilles tendons were then tested to failure as defined as a gap of 1 cm. RESULTS The mean force to failure for the tendons using the Giftbox technique was 168 N, whereas the mean for the traditional Krackow technique was 81 N (p < 0.0001). CONCLUSION Based on our biomechanical study, Achilles tendons repaired using the Giftbox technique are more than twice as strong as those repaired using the traditional Krackow technique. CLINICAL RELEVANCE We recommend the Giftbox modification to minimize gap formation and improve the strength of the repair of a ruptured Achilles tendon.

Joint preservation procedures for ankle arthritis.

This Current Concept Review is presented by the American Academy of Orthopaedic Surgeons (AAOS) Ankle Arthritis Clinical Guideline Work Group. Its purpose was to review the evidence on the surgical procedures available to treat ankle arthritis while preserving the joint. This included open and arthroscopic debridement, realignment osteotomies of the distal tibia and foot, distraction arthroplasty, interpositional arthroplasty, and allograft arthroplasty. This report was based on a recent systematic review of the published English language literature performed by members of the AAOS Ankle Arthritis Work Group. The work group was comprised of AAOS research staff and volunteer physicians.

Particulated Juvenile Articular Cartilage Implantation in the Knee A 3-Year EPIC-µCT and Histological Examination

Objective: The goal of this report is to describe the outcome of sequential particulated cartilage allograft and autologous osteochondral transfer treatments for an osteochondral lesion of the medial femoral condyle. Methods: A 44-year-old woman was treated with a particulated juvenile articular cartilage allograft (DeNovo NT) for a chondral lesion of the knee. As a result of continued pain, she had 2 further surgeries, including an autologous osteochondral transfer system procedure and finally a unicondylar knee arthroplasty. At the final procedure, the areas of the allograft and autograft tissue were biopsied for histological evaluation. The quality of the residual cartilage tissue was assessed first by equilibrium partitioning of an ionic contrast agent via micro–computed tomography (EPIC-µCT), and then by hematoxylin and eosin, Safranin O staining, and polarized light microscopy. Results: Despite showing good healing at 7 months postsurgery by MRI, at 28 months post DeNovo NT tissue implantation the excised cartilage tissue was heterogeneous, with some regions of hyaline-like cartilage and some regions of fibrocartilage. The later mosaicplasty may have helped maintain hyaline-like cartilage of the DeNovo NT tissue in its vicinity. Conclusion: This case report describes the cartilage repair tissue produced by DeNovo NT implantation and compares it with autologous osteochondral plug tissue.

The effect of ankle position on the static tension in the Achilles tendon before and after operative repair: a biomechanical cadaver study.

Background: We hypothesized that there no need to position the foot in plantarflexion after operative repair of an Achilles tendon rupture. Methods: In five fresh cadaver lower extremity specimens, the static tension in the Achilles tendon was measured as the ankle was sequentially dorsiflexed from 30, to 20, to 10, to 0 degrees of plantarflexion. The tendon was then transected and repaired using a modified Krakow locking loop suture technique. The tension in the tendon was again measured as the foot was sequentially dorsiflexed through the same range of motion: 30, to 20, to 10, to 0 degrees. The repair was then tensile tested to failure. Results: The intact Achilles tendons generated on average 10 N, 10 N, 15.8 N and 31.9.0 N of tension at 30, 20, 10, and 0 degrees of plantarflexion, respectively. After a modified Krakow locking loop repair, the tension across the repair site was 10 N, 11.46 N, 18.4 N, and 30.3 N at 30, 20, 10, and 0 degrees of plantarflexion. Thus, moving the ankle from 30 degrees to neutral placed an additional force of 21.9 N on the intact tendon and 20.3 N on the repaired tendon. The mean tensile strength of the modified Krakow repair was 598.6 N (range 167 1129 N). Conclusions: The tension in the repaired tendon at neutral position is only a small percentage (6.4%) of the strength of the tendon when operatively repaired by a modified Krakow locking loop suture technique. Clinical Relevance: Our results suggest that the ankle joint does not have to be positioned in plantarflexion after operative repair using the described technique.

Intramedullary Screw Fixation of the Fifth Metatarsal: An Anatomic Study and Improved Technique

Intramedullary screw fixation has been found to be a reliable treatment for certain fractures of the fifth metatarsal. Techniques for this treatment have been described relying largely on intraoperative fluoroscopy. Ten human cadaver specimens had their fifth metatarsals osteotomized and underwent retrograde intramedullary pin placement. Anatomic landmarks and the location of the sural nerve in relation to this starting point were measured. The trajectory of a pin reducing the osteotomy was analyzed. Using the resultant starting point and guide pin trajectory, intramedullary screw placement was performed reliably without the aid of fluoroscopy. This study demonstrates that intramedullary screw fixation of proximal fifth metatarsal fractures may be performed with the use of anatomic landmarks, which decreases the amount of intraoperative fluoroscopy needed.

Lateral Femoral Cortical Breach During Anterior Cruciate Ligament Reconstruction: A Biomechanical Analysis

PURPOSE The purpose of our study was to determine whether secondary fixation is needed when lateral femoral wall breach occurs and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of 3 different suspensory fixation devices. METHODS Sixty fresh-frozen porcine femora were dissected to isolate the anterior cruciate ligament (ACL) footprint. Femoral ACL tunnels were then drilled at diameters of 7, 8, 9, and 10 mm. We conducted 5 separate cyclical and ultimate load testing trials, at each tunnel diameter, for 3 different cortical suspension devices. RESULTS The mean load to failure decreased as the tunnel size enlarged for all 3 devices. In 7-mm tunnels, mean failure load ranged from 1,163.7 to 1,455.0 N across the 3 devices; in 8-mm tunnels, 1,154.7 to 1,643.2 N; in 9-mm tunnels, 820.8 to 1,125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N. Modes of failure also varied as the tunnel sizes enlarged. The ultimate load was not different among the 3 manufacturers (P = .08), but there was a difference in the ultimate load across the 4 tunnel diameters (P < .05), except when we compared the 7-mm tunnel with the 8-mm tunnel (P = .91). CONCLUSIONS With 7- and 8-mm-diameter tunnels, failure loads with each of the suspensory devices tested exceeded the documented interference screw load to failure. CLINICAL RELEVANCE Our findings suggest that, for soft-tissue ACL grafts, femoral tunnels of 8 mm or less can be drilled through the lateral femoral cortex while still using a suspensory device for graft fixation. With pediatric, double-bundle, and anatomic ACL reconstructions, smaller and shorter tunnels are routinely used. Thus, breaching the lateral cortex when using suspensory fixation may increase tunnel length while still achieving stable fixation.

A simple technique for transpatellar fixation of quadriceps tendon rupture.

Transpatellar repair of quadriceps tendon rupture can be simplified using a Beath pin to drill and pass three sutures to be tied over the inferior pole of the patella.

The Gift Box Open Achilles Tendon Repair Method: A Retrospective Clinical Series

Previous biomechanical studies have shown that the gift box technique for open Achilles tendon repair is twice as strong as a Krackow repair. The technique incorporates a paramedian skin incision with a midline paratenon incision, and a modification of the Krackow stitch is used to reinforce the repair. The wound is closed in layers such that the paratenon repair is offset from paramedian skin incision, further protecting the repair. The present study retrospectively reviews the clinical results for a series of patients who underwent the gift box technique for treatment of acute Achilles tendon ruptures from March 2002 to April 2007. The patients completed the Foot Function Index and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale. The tendon width and calf circumference were measured bilaterally and compared using paired t tests with a 5% α level. A total of 44 subjects, mean age 37.5 ± 8.6 years, underwent surgery approximately 10.8 ± 6.5 days after injury. The response rate was 35 (79.54%) patients for the questionnaire and 20 (45.45%) for the examination. The mean follow-up period was 35.7 ± 20.1 months. The complications included one stitch abscess, persistent pain, and keloid formation. One (2.86%) respondent reported significant weakness. Five (14.29%) respondents indicated persistent peri-incisional numbness. The range of motion was full or adequate. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score was 93.2 ± 6.8) and the mean Foot Function Index score was 7.0 ± 10.5. The calf girth and tendon width differences were statistically significantly between the limbs. The patients reported no repeat ruptures, sural nerve injuries, dehiscence, or infections. We present the outcomes data from patients who had undergone this alternative technique for Achilles tendon repair. The technique is reproducible, with good patient satisfaction and return to activity. The results compared well with the historical repeat rupture rates and incidence of nerve injury and dehiscence for open and percutaneous Achilles tendon repairs.