Gout arthritis of the ankle successfully treated with arthroscopic debridement: A case report.

INTRODUCTION: Gout is an inflammatory arthritis that causes acute pain due to the accumulation of uric acid crystals. Hyperuricemia primarily causes it, resulting in the deposition of monosodium urate crystals in and around joints. Gout can affect joints such as the metatarsophalangeal joint and the foot's talus bone. Treatment involves addressing hyperuricemia and managing symptoms with medications like febuxostat. Surgical treatment is crucial, especially in cases of chronic tophaceous gout or severe joint damage, including arthroscopic debridement, ankle arthrodesis, or total ankle arthroplasty. CASE PRESENTATION: A 32-year-old male with a history of hyperuricemia experienced pain in his left ankle for a year. The ankle was swollen and prone to pain when he walked. Magnetic resonance imaging (MRI) tests revealed the thickening and irregular shape of the anterior talofibular ligament (ATFL), suggesting a rupture. The arthroscopic operation revealed a crystal deposit, leading to the diagnosis of gout arthritis and subsequent debridement for the patient. Following the surgery, the patient experienced minimal pain, an improved range of motion, and a significant improvement in swelling within a week. The patient was able to walk with minimal assistance and without aid. DISCUSSION: Gout arthritis and ATFL injuries share common clinical features, including joint swelling, limited motion, and joint deformity. The presence of monosodium urate (MSU) crystals and inflammation in both conditions complicates diagnosis. Performing arthroscopic debridement surgery in gout arthritis presents challenges due to tophi and inflammation, as well as the risk of articular cartilage damage. Expertise is crucial for successful arthroscopic debridement, with patient selection, preoperative planning, and thorough removal of MSU crystals being key factors. CONCLUSION: Thorough evaluation, patient selection, preoperative planning, joint identification, removal of MSU crystals, and comprehensive postoperative care are crucial for successful arthroscopic debridement for gout arthritis of the ankle.

A Novel Diabetic Arthritic Model in Rats Induced by Streptozotocin, High-Fat Diet, and Complete Freund's Adjuvant.

Introduction: Ankle arthrodesis is one of the treatments of choice, particularly in late-stage and unstable diabetic Charcot arthropathy. Unfortunately, poor healing capacity might play a role in the high nonunion rate (10-40%). The advancement in regenerative medicine opens a new horizon for enhancing fusion after ankle arthrodesis in patients with poor healing capacity. However, a suitable small animal model is warranted to study the effectivity of these regenerative medicine approaches. Streptozotocin (STZ)-induced diabetes models and adjuvant-induced arthritis models with complete Freund's adjuvant are two established models. However, no study has combined those two models to make a diabetic arthritic model that more closely resembles the condition in Charcot arthropathy. Methods: Twenty male Sprague-Dawley rats were assigned into five groups, consisting of one control group, and four diabetic groups which were induced by STZ injection and a high-fat diet. Among these diabetic rats, two groups received complete Freund's adjuvant (CFA) injections to the left ankle of the hind limb. The control group, one of the diabetic-only groups, and one of the arthritic-diabetic-induced groups were euthanized at 4 weeks after STZ induction, and the remainder were euthanized 6 weeks after STZ induction. Clinical, radiological, and histological examinations were then compared in all five groups. Results: Diabetic status was successfully achieved in the model, which was maintained until the completion of the study. The CFA-induced ankles were significantly larger than the contralateral ankles in all groups (p<0.05). Histopathological evaluation confirmed arthritic changes in the CFA-induced group with less variability after 4 weeks of arthritis induction. Conclusion: This rat model of arthritic diabetic mimics the progressive and chronic nature of Charcot arthropathy in humans. This model can be further use to study treatments that might enhance the fusion rate in ankle arthrodesis in healing-defective patients such as those with diabetes. Level of Clinical Evidence: 5.

Intramuscular haemangioma of abductor hallucis muscle - A rare case report.

INTRODUCTION: Haemangioma is a slow growing benign soft tissue tumor and its presentation in the foot is rare. Intramuscular haemangioma (IH) are usually found before 30 years of age, with gender predominance is still inconclusive. PRESENTATION OF CASE: An 18-year-old woman came with pain and mass in the left foot for the past 3 years. Magnetic Resonance Imaging (MRI) of the left foot shown a heterogenous multilobulated mass, with previously thought originated from flexor digitorum brevis (FDB) muscle. Wide excision was performed and intraoperative findings showed that the mass actually originated from abductor hallucis muscle. Post-operative histopathological findings confirmed the diagnosis of cavernous-type of intramuscular haemangioma. DISCUSSION: The rare occurrence of intramuscular haemangioma of the foot can cause a delayed diagnosis and treatment to the patient. The differential diagnosis include lipoma, fibroma, enlargement of the lymph nodes, compartment syndrome, hematoma, hernia, and soft-tissue sarcoma. Anytime a soft tissue mass is identified in the skeletal muscle of a young adult, haemangioma should be considered. CONCLUSION: Literature research identified very few cases of intramuscular haemangioma of the foot. Wide excision of the muscle is a feasible surgical treatment option.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy.

BACKGROUND: Traditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy. METHODS: A total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated. RESULTS: Of 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet. CONCLUSIONS: Conservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

Hypersensitivity to orthopaedic implant manifested as erythroderma: Timing of implant removal.

INTRODUCTION: Incidence of hypersensitivity to orthopaedic implant, once estimated in less than 1% of population, recently has increased to 10%. Controversies about the timing of implant removal remain, especially due to the fact that implant hypersensitivity may be a contributing factor to implant failure. We present a case report and literature reviews to establish the decision making for the timing of implant removal in the presence of implant hypersensitivity. PRESENTATION OF CASE: Female, 42 years old with nonunion of mid-shaft tibia and fibula which was treated with ORIF with conventional SAE16 stainless steel plate and bone graft. A week after, she developed a generalized rash, which is later diagnosed as erythroderma, that relapsed despite adequate systemic corticosteroid. Poor healing of surgical site wound were marked. After the implant removal, the cutaneous condition improved and no relapse were found. DISCUSSION: Management of hypersensitivity to implants involved corticosteroid administration, removal or replacement of implants, or implants coating with polytetrafluoroethylene. Currently there are no specific guidelines regulating the management of implant allergy based on the timing of the onset, especially in fracture cases. The decision-making would be straightforward if union was already achieved. Otherwise, controversies would still occur. In this paper, we proposed an algorithm regarding the steps in managing metal allergy due to implant in fracture cases. CONCLUSION: Despite the concerns regarding implant survival in hypersensitivity cases, the decision whether the implant should be removed or replaced should be based on the time and condition of the fracture healing process.

Point-Connecting Measurements of the Hallux Valgus Deformity: A New Measurement and Its Clinical Application.

PURPOSE: The aim of this study was to investigate new point-connecting measurements for the hallux valgus angle (HVA) and the first intermetatarsal angle (IMA), which can reflect the degree of subluxation of the first metatarsophalangeal joint (MTPJ). Also, this study attempted to compare the validity of midline measurements and the new point-connecting measurements for the determination of HVA and IMA values. MATERIALS AND METHODS: Sixty feet of hallux valgus patients who underwent surgery between 2007 and 2011 were classified in terms of the severity of HVA, congruency of the first MTPJ, and type of chevron metatarsal osteotomy. On weight-bearing dorsal-plantar radiographs, HVA and IMA values were measured and compared preoperatively and postoperatively using both the conventional and new methods. RESULTS: Compared with midline measurements, point-connecting measurements showed higher inter- and intra-observer reliability for preoperative HVA/IMA and similar or higher inter- and intra-observer reliability for postoperative HVA/IMA. Patients who underwent distal chevron metatarsal osteotomy (DCMO) had higher intraclass correlation coefficient for inter- and intra-observer reliability for pre- and post-operative HVA and IMA measured by the point-connecting method compared with the midline method. All differences in the preoperative HVAs and IMAs determined by both the midline method and point-connecting methods were significant between the deviated group and subluxated groups (p=0.001). CONCLUSION: The point-connecting method for measuring HVA and IMA in the subluxated first MTPJ may better reflect the severity of a HV deformity with higher reliability than the midline method, and is more useful in patients with DCMO than in patients with proximal chevron metatarsal osteotomy.