Wataru Miyamoto

Arthroscopic diagnosis of tibiofibular syndesmosis disruption

PURPOSE We have been able to diagnose tibiofibular syndesmosis injury by ankle arthroscopy, and in the present study we compare these results with the results from plain radiographs. TYPE OF STUDY Case series. METHODS Thirty-eight type-B (Weber system) distal fibular fractures in 38 patients were diagnosed to determine whether tibiofibular syndesmosis disruption was present. According to the Lauge-Hansen system, 16 patients had supination-external rotation fractures and 22 had pronation-abduction fractures. Standard non-weight-bearing anteroposterior radiographs and mortise radiographs were evaluated. Furthermore, ankle arthroscopy was performed on all patients. RESULTS Tibiofibular syndesmosis disruptions were diagnosed in 16 of the 38 patients (42%) by anteroposterior radiography, 21 of 38 patients (55%) by mortise radiography, and 33 of 38 patients (87%) by ankle arthroscopy. All of the patients who were diagnosed with tibiofibular syndesmosis disruption by anteroposterior radiography and mortise radiography were also confirmed by ankle arthroscopy to have injured their tibiofibular syndesmosis. In 12 patients, ankle arthroscopy was the only method used to diagnose the tibiofibular syndesmosis disruption. CONCLUSIONS Ankle arthroscopy excels in term of the diagnosis ratio for tibiofibular syndesmosis disruption compared with both anteroposterior and mortise radiography. Therefore, we conclude that ankle arthroscopy is necessary for the correct diagnosis of tibiofibular syndesmosis disruption.

Functional Treatment After Surgical Repair for Acute Lateral Ligament Disruption of the Ankle in Athletes

Background: There have been several reports showing 20% to 40% failure after nonoperative functional treatment for acute lateral ligament disruption of the ankle. Hypothesis: Functional treatment after primary surgical repair has the advantage of decreasing the failure rate in comparison with functional treatment alone. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 132 feet of 132 patients were included in this study. Of these, 78 patients were treated with functional treatment alone (group F), and the remaining 54 patients were treated with functional treatment after primary surgical repair (group RF). The clinical results were evaluated using the Japanese Society for Surgery of the Foot Ankle-Hindfoot scale (JSSF) score, measuring the talar tilt angle and the anterior displacement of the talus in stress radiography, and noting the elapsed time between the injury and the return to the full athletic activity with no external supports. Results: The mean JSSF scores at 2 years after injury were 95.6 ± 5.0 points in group F and 97.5 ± 2.6 points in group RF (P = .0669). The differences of the talar tilt angles compared with the contralateral side and displacement of the talus on stress radiography at 2 years after injury were 1.1° ± 1.5° and 3.6 ± 1.6 mm in group F, and 0.8° ± 0.9° and 3.2 ± 0.8 mm in group RF, respectively (P = .4093, .1883). In group F, 8 cases showed fair to poor results, with JSSF scores below 80 points and instability at 2 years after injury. In group RF, 9 cases (9.4%) showed dorsum foot pain along the superficial peroneal nerve, which disappeared within a month. The time elapsed between the injury and the patient’s return to full athletic activity without any external supports was 16.0 ± 5.6 weeks in group F and 10.1 ± 1.8 weeks in group RF (P < .0001). Conclusion: Nonoperative functional treatment alone and functional treatment after primary surgical repair showed similar overall results after acute lateral ankle sprain, but functional treatment alone had an approximately 10% failure rate and a slower return to full athletic activity. The authors recommend that treatment be tailored to suit each individual athlete.

Novel Approach to Repair of Acute Achilles Tendon Rupture Early Recovery Without Postoperative Fixation or Orthosis

Background Immobilization or orthosis is required after conventional Achilles tendon surgery. Hypothesis This new Achilles tendon repair approach enables early rehabilitation without any postoperative immobilization or orthosis. Study Design Case series; Level of evidence, 4. Methods Twenty consecutive patients (14 men and 6 women; mean age, 43.4 years; range, 16-70 years) who had acute subcutaneous Achilles tendon rupture were treated by the new method, with an average follow-up of 2.9 years (range, 2-4.8 years). Among them, 15 injuries were sports-related and 5 were work-related. The authors applied a side-locking loop technique of their own design for the core suture, using braided polyblend suture thread, with peripheral cross-stitches added. The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery. Results The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous singlelegged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications. Conclusion This new Achilles tendon repair approach enables early mobilization exercise without costly specialized orthosis or immobilization and allows an early return to normal life and sports activities, reducing the physical and economic burden on patients.

Leg Anterior Compartment Syndrome Following Ankle Arthroscopy After Maisonneuve Fracture

We report a case of leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. A 21-year-old football player sprained his left ankle. Plain radiography of his left ankle showed a lateral dislocation of the talus without obvious fractures. Plain radiography of his left lower extremity showed a spiral fracture of the proximal fibula approximately one third distal to the fibular head. According to these findings, we diagnosed this fracture as a Maisonneuve fracture and treated it by ankle arthroscopy and drilling of the talar osteochondral injury followed by arthroscopic ankle visualization during syndesmosis screw fixation. Six hours after surgery, the patient complained of pain in the lower extremity. We diagnosed acute compartment syndrome and performed emergent fasciotomy. One year after surgery, he was able to fully participate in athletic activities. We consider ankle arthroscopy to be available for the treatment of ankle fracture with the suspected complication of an intra-articular disorder such as a Maisonneuve fracture. However, with this type of ankle fracture, there is a higher potential risk of acute compartment syndrome developing than with other types of ankle fractures. Therefore we suggest that surgeons guard against this complication.

Management of chronic disruption of the distal tibiofibular syndesmosis.

Disruption of the distal tibiofibular syndesmosis is frequently accompanied by rotational ankle fracture such as pronation-external rotation and rarely occurs without ankle fracture. In such injury, not only inadequately treated or misdiagnosed cases, but also correctly diagnosed cases can possibly result in a chronic pattern which is more troublesome to treat than an acute pattern. This paper reviews anatomical and biomechanical characteristics of the distal tibiofibular joint, the mechanism of chronic disruption of the distal tibiofibular syndesmosis, radiological and arthroscopic diagnosis, and surgical treatment.

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.

Accelerated Versus Traditional Rehabilitation After Anterior Talofibular Ligament Reconstruction for Chronic Lateral Instability of the Ankle in Athletes

Background: Although several reconstruction procedures for chronic lateral ankle instability using autografts have been reported, all have recommended postoperative immobilization and a nonweightbearing period. Hypothesis: Reconstructive surgery with a gracilis autograft using an interference fit anchoring system for chronic lateral ankle instability enables early accelerated rehabilitation and recovery with a return to activity without requiring immobilization. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 33 patients (33 feet) who underwent reconstruction of the anterior talofibular ligament with a gracilis autograft using interference screws were included; 15 were followed for 4 weeks with postoperative cast immobilization (group I), while 18 were followed with accelerated rehabilitation without immobilization (group A). Clinical and radiological results were evaluated based on the Karlsson and Peterson score, talar tilt angle, anterior displacement of the talus on stress radiography, and time between surgery and return to full athletic activity. Results: The mean Karlsson and Peterson scores before and 2 years after surgery were the following: for group I: 62.3 ± 4.7 (range, 54-72) and 94.4 ± 7.1 (range, 76-100), respectively (P < .001), and for group A: 64.1 ± 4.8 (range, 57-70) and 91.7 ± 7.7 (range, 74-100), respectively (P < .001). The mean difference in the talar tilt angle compared with the contralateral side and mean displacement of the talus on stress radiography before and 2 years after surgery were the following: for group I: 8.7° ± 2.6° and 7.7 ± 1.8 mm and 3.8° ± 1.5° and 4.0 ± 1.6 mm, respectively, and for group A: 10.5° ± 3.4° and 8.7 ± 2.1 mm and 4.3° ± 1.8° and 4.3 ± 1.2 mm, respectively. Radiography revealed significantly improved postoperative outcomes in both groups (P < .0001). No significant differences in the score and any parameters on stress radiography were evident at 2 years after surgery between the groups. The mean time between surgery and return to full athletic activity was significantly higher in group I (18.5 ± 3.5 weeks) than in group A (13.4 ± 2.2 weeks) (P < .0001). No cases of reinjury were reported, and no differences in athletic performance ability were observed between the groups. Conclusion: Patients in group A returned to full athletic activity 5 weeks earlier than those in group I, demonstrating the advantage of accelerated rehabilitation after surgery.

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.

Vascular Leiomyoma Resulting in Ulnar Neuropathy: Case Report

We report a case of vascular leiomyoma arising from the distal ulnar artery in the palm that revealed symptoms similar to those of Guyons canal syndrome.