Abstract
Paavola, M., Orava, S., Leppilahti, J., Kannus, P., and Järvinen, M.
Chronic Achilles tendon overuse injury: complications after surgical treatment.
Am. J. Sports Med.,
In 432 consecutive patients (336 [78%] men and 96 [22%] women; average age, 31 years; age range, 13 to 67 years), surgical treatment was done for chronic Achilles tendon overuse injury (anesthesia: spinal or local intravenous, 356 [82%] patients; local, 76 [18%] patients). Duration of symptoms was from 3 months to several years, and non-operative treatment (treatment duration: mean, 7 months; range, 3 to 18 months) did not relieve symptoms. Surgical approaches consisted of a lateral longitudinal incision, a more distal exposure for insertional problems, or an L-shaped incision. Procedures included debridement of scar tissue and tendinosis, tendon repair, excision of anomalous soleus muscle, partial dorsal calcanectomy, and retroachilles bursectomy. The postoperative regimen consisted of gradual mobilization, either immediate or delayed after a 2 week period of splinting. There were 46 (11%) complications: skin necrosis, 14 (30%) cases; superficial wound infection, 11 (24%) cases; seroma, 5 (11%) cases; hematoma, 5 (11%) cases; fibrotic reaction, 5 (11%) cases; sural nerve irritation, 4 (9%) cases; new partial rupture, 1 (2%) case; and deep vein thrombosis, 1 (2%) case. The complications occurred when surgery was done for treatment of peritendinitis in 27 (59%) cases, partial tendon rupture in 13 (28%) cases, retrocalcaneal bursitis or insertional tendinopathy in 5 (11%) cases, and tendinosis in 1 (2%) case. Reoperation was required for management of 14 (30%) complications, and the other 32 (70%) complications were treated non-operatively.
Petersen, W., Stein, V., and Tillmann, B.
Blood supply of the tibialis anterior tendon.
Arch. Orthop. Trauma Surg.,
The vascular supply of the tibialis anterior tendon was evaluated in 10 cadaver specimens (age: average, 67 years; range, 45 to 80 years) with India ink injection into the femoral artery (Spalteholz technique; pressure, 120 mm Hg; temperature, 40°C). The injection studies showed that the tendon specimens were supplied proximally by the anterior tibial artery and distally by branches of the medial tarsal arteries. Branches of both arteries were noted to reach the tendon via vincula from the posterior side. The major part of the tendon was covered by a peritenon in which blood vessels formed a web-like network. The blood vessels penetrated the tendon transversely from the peritenon. Within the tendon, there were fewer blood vessels than in the peritenon, and the majority of blood vessels were oriented longitudinally along the course of the tendon fibers. The distribution of blood vessels within the tendon was not homogeneous. The posterior half of the tendon had a complete vascular network from the musculotendinous junction to the medial cuneiform insertion. However, the anterior half of the tendon had an avascular zone (length of avascular zone: average, 57 mm; range, 45 to 67 mm) that was located an average of 10 mm (range, 5 to 16 mm) from the tendon insertion, corresponding anatomically to the location of the inferior and superior extensor retinacula. In 20 tendon specimens, immunohistochemistry showed that laminin was present in the blood vessel walls along the posterior half of all tendon specimens, but was absent from the middle part of the anterior half of the tendon corresponding to the avascular region noted with the injection studies.
Jernberg, E.T., Simkin, P., Kravette, M., Lowe, P., and Gardner, G.
The posterior tibial tendon and the tarsal sinus in rheumatoid flat foot: magnetic resonance imaging of 40 feet.
J. Rheumatol.,
In 20 patients (14 [70%] women and 6 [30%] men) with rheumatoid arthritis, 11 (55%) patients had hyper-pronated or flat feet (19 feet: 8 bilateral and 3 unilateral) based on clinical examination (depression of the medial longitudinal arch, valgus heel deformity, and medial talonavicular bulge). The physical findings suggestive of posterior tibial tendon dysfunction included inability to invert the heel with a heel raise (15 [83%] of 18 flat feet, with 1 foot excluded because of forefoot disease; 2 [10%] of 21 non-flat feet) and presence of forefoot abduction on standing (14 [74%] of 19 flat feet; 2 [10%] of 21 non-flat feet). Magnetic resonance imaging (MRI) of the 40 feet showed that a tear of the posterior tibial tendon was present in 14 (74%) flat feet (type I, 2 feet; type II, 11 feet; type III, 1 foot) and in 9 (43%) nonflat feet (type I, 2 feet; type II, 6 feet; type III, 1 foot). MRI abnormalities of the sinus tarsi (replacement of fat with intermediate signal in soft tissues and bony erosions) were noted in 13 (68%) flat feet but in only 1 (5%) non-flat foot. Presence of both posterior tibial tendon tear and sinus tarsi abnormalities on MRI was noted in 12 (63%) flat feet. A follow-up telephone interview showed that lateral foot pain and symptoms of instability were present in patients with and without sinus tarsi abnormalities on MRI.
Brown, T.D., Varney, T.E., and Micheli, L.J.
Malleolar bursitis in figure skaters: indications for operative and nonoperative treatment.
Am. J. Sports Med.,
Two cases of medial malleolar bursitis in competitive figure skaters were treated. First, a 16 year old woman had aseptic medial malleolar bursitis (pain, fluctuance, tenderness, and no erythema) that persisted despite a 10 month treatment course (padding, skate stretching, bursal aspirations, and a corticosteroid injection); surgical excision of the inflamed and hypertrophied bursa resulted in resolution. In this patient, skating was resumed 30 days after surgery, and there was no recurrence 1 year after surgery. The second patient, a 19 year old woman who had an inflamed medial malleolar bursa for 2 months, developed a new onset of pain, and examination showed cellulitis of the medial malleolus area. Treatment consisted of antibiotics (intravenous cefazolin, 10 days; oral cephalexin, 14 days) and incision and debridement followed 4 days later by complete resection of the thickened bursa (no purulence evident). The cultures were positive for Staphylococcus aureus, sensitive to cefazolin. She returned to skating later the following month.
Kelbérine, F., and Frank, A.
Arthroscopic treatment of osteochondral lesions of the talar dome: a retrospective study of 48 cases.
Arthroscopy,
In 48 osteochondral lesions of the talus (48 patients; 30 [62%] men and 18 [38%] women; mean age, 26 years), the lesions were classified radiographically as fracture (recent or not healed) in 18 (38%) cases, osteonecrosis (with sequestrum) in 27 (56%) cases, and subchondral cyst in 3 (6%) cases. All 18 fractures were at the anterolateral talar dome; the 30 cases of osteonecrosis and cyst were posteromedial in 27 cases, lateral in 2 cases, and central in 1 case. Arthroscopic treatment (4.5 mm arthroscope), usually via anterolateral and anteromedial portals, with distraction in 11 (23%) cases, was done based on lesion type: fractures were treated with excision of loose fragment or screw fixation; osteonecrosis was treated with excision of necrotic tissue, curettage to bleeding bone, and removal of sequestrum; cysts were treated with tran-schondral drilling. Follow-up evaluation at a mean of 5 years (range, 7 months to 11 years) after surgery showed that functional results (McCullough score) were excellent or good in 16 (89%) fractures, 17 (63%) cases of osteonecrosis, and 3 (100%) cysts. Complications included tendinitis in 3 (6%) patients and reflex sympathetic dystrophy in 1 (2%) patient.
Folk, J.W., Starr, A.J., and Early, J.S.
Early wound complications of operative treatment of calcaneus fractures: analysis of 190 fractures.
J. Orthop. Trauma,
During a 6 year period, 179 patients (age: average, 35 years; range, 17 to 77 years) were treated for 190 calcaneal fractures (11 bilateral) with open reduction and internal fixation using a full-thickness, L-shaped lateral approach, plate and screw fixation, at an average of 8 days (range, 0 to 38 days) after injury. Autogenous bone graft was used in 12 (6%) fractures, and hydrox- yapatite bone graft substitute was used in 23 (12%) fractures. Cefazolin was given before surgery and for 24 hours after surgery; the 18 open fractures were treated with intravenous antibiotics, initial and follow-up (every 48 hours until the wound could be closed) irrigation and debridement, and delayed open reduction after the wound was dry and swelling was decreased (wrinkled skin noted). Aftercare consisted of elevation, splinting, early (starting from the third to the tenth postoperative day) active range of motion exercises, and non-weightbearing (3 months). There were 48 (25%) fractures with wound complications, and 40 (21%) fractures had complications that required surgical treatment (average, 1.4 additional procedures). Surgery done to treat complications consisted of wound debridement in 36 (19%) fractures, hardware removal in 22 (12%) fractures, free myocutaneous flap in 11 (6%) fractures, and amputation in 4 (2%) fractures. Factors associated with an increased risk of wound complications included smoking (37 [31%] wound complications in 118 fractures in current smokers; relative risk, 1.2; P = 0.03), open fracture (13 [72%] wound complications in 18 open fractures; relative risk, 2.8; P < 0.001), and diabetes (7 [78%] wound complications in 9 fractures in diabetics; relative risk, 3.4; P = 0.02). The presence of more than one of these risk factors increased the relative risk of wound complication. Patient age, delay in surgical treatment, and use of bone graft (autogenous or substitute) were not significant predictors of wound complications.
Cunningham, B.W., DiStefano, A.F., Kirjanov, N.A., Levine, S.E., and Schon, L.C.
A comparative mechanical analysis of the pointe shoe toe box.
Am. J. Sports Med.,
Five different brands of ballet pointe shoes (Capezio, Freed, Gaynor Minden, Leo's, and Grishko; size 6 1/2 to 7) were evaluated. Similarities between shoes were noted in toe box area determined from vernier caliper measurements of the outer dimensions of toe box depth, height, and width. Toe box volume, determined by measuring the volume of polymethylmethacrylate beads required to fill the toe box to the vamp edge, was smallest for the Leo's (46 ± 4 ml) and largest for the Grishko (76 ± 3 ml) shoes. Static testing using a servohydraulic testing device with a cylindrical steel ram applied to the toe box (displacement rate, 0.5 mm/sec) until failure (decrease in registered load or 7 mm collapse of toe box) showed that the shoes were stiffer and stronger under axial loading (pointe direction) than vertical loading (dorsal-plantar direction) conditions. Axial compressive stiffness was significantly greatest for the Leo's shoe, and axial compressive strength was significantly lowest for the Freed shoe. Vertical compressive stiffness was significantly greatest for the Freed shoe, and vertical compressive strength was significantly greatest for the Gaynor Minden and Freed shoes. Cyclical fatigue testing (axial direction; load, 2 kN; rate, 10 Hz) showed that the mean number of cycles to failure was significantly greatest for the Gaynor Minden shoe. A questionnaire of 200 ballet dancers (average age, 19.3 ± 0.3 years; average ballet experience, 11.3 ± 0.7 years; average pointe experience, 6 ± 0.4 years) showed that the most preferred characteristics of pointe shoes were, in decreasing order of importance: fit, comfort, box and platform shape, vamp shape, and durability.
Khan, F.A., Khoshhal, K., and Saadeddin, M.
Tuberculosis of talus and cuboid — a report of 2 children.
Acta Orthop. Scand.,
Two cases of tuberculosis of the foot in children were treated. First, a 5 year old Saudi boy had mild ankle pain and limp for 6 weeks, and a tender, swollen area was noted at the anteromedial ankle. Radiographs and computed tomography showed a cystic lesion at the body and neck of the talus. Dorsal exposure showed seropurulent fluid in the talar neck, and the cyst was treated with curettage and irrigation. Reoperation, with curettage and bone grafting, was done after 6 weeks.
The second patient was a 22 month old Pakistani girl who had a 4 week history of pain and swelling of the anterolateral right foot, with firmness and tenderness overlying the cuboid. The temperature was 38°C. Radiography showed an osteolytic lesion in the cuboid, corresponding to an area of increased uptake on bone scan. Exploration showed seropurulent fluid from the cuboid, and treatment included curettage and irrigation.
In both cases, bacterial culture from the initial curettage was negative and histology showed granulomatous inflammation with multinucleated giant cells. The patients received isoniazid (12 months), pyrazinamide (12 months), and rifampin (6 months). The cysts were healed at 3 months after surgery. At follow-up 1 year after surgery, the patients were asymptomatic and no recurrence was evident.
Choong, P.F.M., Qureshi, A.A., Sim, F.H., and Unni, K.K.
Osteosarcoma of the foot: a review of 52 patients at the Mayo Clinic.
Acta Orthop. Scand.,
During a 50 year period, 52 histologically confirmed cases of osteosarcoma of the foot were evaluated in consultation or received treatment (14 [27%] cases treated). There were 29 (56%) women and 23 (44%) men (male to female ratio = 0.8:1), and the mean age was 35 years (range, 6 to 89 years). The tumors were located in the calcaneus in 28 (54%) cases, metatarsals in 10 (19%) cases, talus in 6 (11%) cases, phalanges in 4 (8%) cases, navicular in 2 (4%) cases, cuboid in 1 (2%) case, and medial cuneiform in 1 (2%) case. Histologic appearance was osteoblastic in 24 (46%) cases, fibroblastic in 15 (29%) cases, and chondroblastic in 13 (25%) cases. Histologic grade was grade II in 8 (15%) cases, grade III in 25 (48%) cases, and grade IV in 19 (37%) cases. Radiography showed that all tumors had cortical penetration and were associated with a soft tissue mass, and most had a mixture of lysis, sclerosis, and rarefaction. Pain was a presenting comlaint in all patients, and symptoms were present for 1 to 24 months. There was a history of previous trauma in half of the patients. Tenderness was present at the affected bone in all patients. One patient had pulmonary metastasis at presentation. All of the 14 cases treated at this institution had below knee amputation, and one-third of the cases received chemotherapy. Follow-up evaluation at a mean of 6.5 years (range, 1 to 20 years) showed that 9 (64%) of the treated patients had died of metastasis after a mean of 2.5 years (range, 1 to 6 years).
Carro, L.P., Llata, J.I.E., and Agueros, J.A.M.
Arthroscopic medial bipartite sesamoidectomy of the great toe.
Arthroscopy,
A 20 year old woman was evaluated for a 6 month history of severe pain and tenderness under the left first metatarsal head that persisted despite low heeled shoes, a molded insole, and local steroids. Examination showed tenderness at the medial sesamoid. Radiography showed a medial bipartite sesamoid, and magnetic resonance imaging showed no signal changes in either sesamoid. Arthroscopic sesamoidectomy was done with epidural anesthesia, toe-finger trap traction (4 kg), tourniquet control, and a 2.7 mm, 30° arthroscope. A dorsolateral portal was used for the arthroscope. Debridement of hyaline cartilage and removal of the sesamoid was done through a dorsomedial portal using a 2 mm burr, with attention to avoid disruption of the flexor hallucis brevis and sesamoid ligament complex. The patient was discharged on the day of surgery, and encouraged to begin early MP joint motion. The hallux was strapped into slight varus for 3 weeks to prevent hallux valgus deformity. Radiographs confirmed successful sesamoidectomy. At 1 year after surgery, no deformity was present at the hallux, and the patient was asymptomatic.