Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain.

BACKGROUND: After ankle sprain, there can be many causes of disability, the origins of which cannot be determined using standard diagnostic tools. HYPOTHESIS: Ankle arthroscopy is a useful tool in identifying intra-articular disorders of the talocrural joint in cases of residual ankle disability after sprain. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The authors gathered the independent diagnostic results of physical examination, standard mortise and lateral radiography, stress radiography of the talocrural joint, and magnetic resonance imaging for 72 patients with residual ankle disability lasting more than 2 months after injury (mean, 7 months after injury). They performed arthroscopic procedures and compared the double-blind results. RESULTS: In all cases, the arthroscopic results matched those of other means of diagnosis. In 14 cases, the arthroscopic approach exceeded the capabilities of the other methods. Including duplications, 39 patients (54.2%) had anterior talofibular ligament injuries, 17 patients (23.6%) had distal tibiofibular ligament injuries, 29 patients (40.3%) had osteochondral lesions, 13 patients (18%) had symptomatic os subfibulare, 3 patients (4.2%) had anterior impingement exostosis, and 3 patients (4.2%) had impingement due to abnormally fibrous bands. There were only 2 cases in which the cause of symptoms could not be detected by ankle arthroscopy, compared with 16 cases in which the cause of disability could not be detected using standard methods. In 3 cases (17.6%) of distal tibiofibular ligament injuries, 8 cases (27.6%) of osteochondral lesions, and all 3 cases (100%) of impingement of an abnormal fibrous band, ankle arthroscopy was the only method capable of diagnosing the cause of residual ankle pain after a sprain. CONCLUSION: The present results suggest that arthroscopy can be used to diagnose the cause of residual pain after an ankle sprain in most cases that are otherwise undiagnosable by clinical examination and imaging study.

Surgical Management of Freiberg's Infraction: A Systematic Review.

UNLABELLED: Avascular necrosis of the second metatarsal head was first described by Freiberg in 1913. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. Should conservative treatment fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. This systematic review was undertaken to determine which surgical procedure allows for the best resolution of symptoms and return to activity. Included studies were restricted to articles published in English language peer-reviewed journals that consecutively enrolled patients of all ages, with Freiberg's infraction of any stage, who underwent operative treatment, and had a mean follow-up of greater than or equal to 12 months duration. Eighty-five publications were identified, of which 38 (44.7%) met all the inclusion criteria. Surgical techniques and outcomes were grouped into joint sparing and joint destructive procedures. A total of 70 joint destructive procedures were performed with a combined mean follow-up time of 15.0 months. A greater than 70% resolution of pain and full return to activity was reported. A total of 257 joint sparing procedures were performed with a combined mean follow-up of 30.4 months. A greater than 90% resolution of pain and full return to activity was reported. Results of this systematic review reveal that the results of joint sparing procedures are reported more often and appear to have a better prognosis for symptom resolution and return to activity. Smillie stage was not consistently reported, making it difficult to determine its effect on procedure selection. LEVEL OF EVIDENCE: Therapeutic, Level IV: Systematic review of Level IV studies.

Thompson and Hamilton type IV Freiberg's disease with involvement of multiple epiphyses of both feet.

A 17-year-old boy reported left second and third toe pain after axial loading injury to his left foot. Radiographs showed collapse of the second metatarsal heads and epiphysial irregularities of the fifth metatarsal heads and the condyle of the proximal phalanx of the hallux of both feet. The patient was diagnosed to have Thompson and Hamilton type IV Freiberg's disease. He was screened for epiphysial dysplasia of the other sites. He had on and off bilateral hip and knee pain. Radiographs showed bilateral symmetrical epiphysial abnormalities with morphological change as focal concavity in bilateral femoral heads and fragmentation of the patellar articular surface with preservation of the patellofemoral joint space.

Osteochondral lesions of the talus.

In a retrospective study of thirty-one ankles in twenty-nine patients with osteochondral lesions, we found that lateral lesions were associated with inversion or inversion-dorsiflexion trauma, were morphologically shallow, and were more likely to become displaced in the joint and to have persistent symptoms. Medial lesions were both traumatic and atraumatic in origin, morphologically deep, and less symptomatic. Using the classification system of Berndt and Harty, it appeared that Stage-I and Stage-II lesions should be treated non-operatively, regardless of location. Stage-III medial lesions should be treated non-operatively initially but if symptoms persist surgical excision and curettage are indicated. Stage-III lateral lesions and all Stage-IV lesions should be treated by early operation. Long-term results indicated that few lesions unite when treated non-operatively. Degenerative changes in the ankle joint, whether symptomatic or not, were common (50 per cent of the ankles) regardless of the type of treatment.

The Catterall classification of Perthes' disease: an assessment of reliability.

The reliability of the Catterall grouping of Perthes' disease was examined by determining the agreement between pairs of observers using weighted kappa statistics. Anteroposterior and lateral radiographs of 100 hip joints were grouped independently by four experienced observers. There was a low, and in our opinion, unacceptable degree of inter-observer agreement even when Groups 2 and 3 were combined.

Osteochondritis dissecans and other lesions of the femoral condyles.

We reviewed lesions of the femoral condyles seen in 5,000 knee arthroscopies, recording the findings and the age and sex of the patients. We were able to distinguish the characteristics of developing and late osteochondritis dissecans, acute and old osteochondral fractures, chondral separations, chondral flaps and idiopathic osteonecrosis, and suggest that these are separate distinct conditions. Haemarthrosis was associated only with acute osteochondral fractures. The characteristic feature of osteochondritis dissecans was an expanding concentric lesion at the 'classical' site on the medial femoral condyle which appeared during the second decade of life and progressed to a concave steep-sided defect in the mature skeleton. Caffey's (1958) classification of epiphyseal dysplasias could not be applied to osteochondritis dissecans, which appeared to have a gradual onset without acute trauma. Much of the controversy about the cause of osteochondritis dissecans is the result of imprecise nomenclature.

Kienböck's disease: conservative management versus radial shortening.

Avascular necrosis of the lunate, first described by Kienbock, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9). Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease. We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse.

Kienböck's disease.

Recent anatomic and biomechanical studies have contributed to a better understanding of Kienb ock 's disease. The operative alternative, if based on a classification of the severity of disease, should provide a more logical and systematic approach to patients with this difficult problem.

Osteochondral lesions of the talus: a revised classification.

Osteochondral lesions of the talus present a numerically small but therapeutically significant problem to the foot surgeon. The diagnosis and investigation of such lesions have been greatly enhanced by modern high resolution magnetic resonance imaging capabilities, which have provided far greater detail of the pathological anatomy. We have reviewed our experience in this area and suggest a revised classification for osteochondral lesions appropriate to the detail available on magnetic resonance imaging scans. The cause of osteochondral lesions is also discussed.

[A new classification of semilunar bone necrosis]. / Eine neue Klassifikation der Mondbeinnekrose.

The currently accepted classifications of Kienböck's disease by Decoulx and coworkers (1957) as well as Lichtman and coworkers (1977) resp. Lichtman and Degnan (1993) do not take into account early changes in MRI or changes in carpal architecture. A recent publication by Lichtman and Ross (1994) did not solve the problems of precisely describing the disease. This necessitates a new, reliable classification based on the true nature course of the disease. In a prospective study with 49 patients and in a retrospective review of 125 cases of lunate necroses, the regular natural course of the disease was analysed. It begins with normal X-ray appearance but a typical extinguished T1-signal in MRI; a fracture line is part of the later course and not seen in the beginning. Later, collapse of the lunate and the carpus can be observed. A new classification based on the natural course of the disease is proposed. This classification divides the natural course of Kienböck's disease into four stages, subdividing stage I, II and III by A and B. The disease commences with pathology only detectable by MRI (extinguished signal in T1-weighted sequence-stage I A), followed by first changes in the X-ray (condensation or mosaic-like appearance), while the outer form remains preserved (stage I B); the disease proceeds with partial deformation of the lunate with proximal or radial indentation (stage II A), later with a fracture line, while the lunate index of Ståhl remains normal (stage II B); the collapse of the lunate follows, and Ståhl's lunate index becomes pathologic (stage III A); the subsequent collapse of the carpus is characterized by a pathologic Youm-index (stage III B); Kienböck's disease, finally, leads to arthrosis of the wrist.

[Radiologic diagnosis of lunate necrosis]. / Radiologische Diagnostik der Lunatumnekrose.

In the literature little is to be found concerning diagnosis and differential diagnosis of Kienböck's disease. Because of technical development in radiological imaging, we now possess very detailed pictures. However, there are many radiological findings within the lunate bone, which can be misinterpreted as Kienböck's disease. Pathological findings of the lunate bone are demonstrated, which are not Kienböck's disease. These findings were compared to different stages of Kienböck's disease and identified. The early stages of Kienböck's disease show changes especially in the MRI, which are very similar to acute bone bruise, ulnar impaction syndrome, synovialitis or gout. Vessel tubes or an intraosseous ganglion can be mistaken for Kienböck's disease. In the late stages of Kienböck's disease, it can be difficult to differentiate this from pseudarthrosis of the lunate bone. The differentiation between Kienböck's disease and other pathological findings is at times very difficult--even with MRI. However, sometimes diagnosis can only be verified by MRI. We therefore suggest that Kienböck's disease must be correctly diagnosed with help of the MRI before commencing with any therapeutic steps.

[Kienboeck's disease: comparative study of magnetic resonance tomography and roentgenologic imaging]. / Kienböck'sche Erkrankung: Kernspintomographische und röntgenologische Vergleichsstudie.

Magnetic resonance imagine of the carpus is helpful in diagnosing or ruling out even early stages of lunatomalacia. MRI is capable of providing information on the vitality of the lunate and is thus helpful in developing a proper therapy plan.

[Diagnosis and staging of lunate necrosis. A current review]. / Diagnostik und Stadieneinteilung der Lunatumnekrose. Eine aktuelle Ubersicht.

Recently, early diagnosis and staging of Kienböck's disease was mainly influenced by imaging techniques (CT and MRI). New findings led to the staging classification of Lichtman and Ross (1994) which is recommended in the following. MRI allows diagnosis of the reversible bone marrow edema (stage I), which often is equivocal in conventional radiography. High-resolution CT facilities a more precise imaging of later stages in Kienböck's disease including spongiosal sclerosis (stage II), fractures at the proximal pole (stage III A), and initial osteoarthrosis (stage IV). For therapeutic considerations, contrast-enhanced MRI is extremely useful in stages II and III A, whereas MRI is redundant in stages III B and IV. Carpal instability (stage III B) is sufficiently visualized using conventional radiograms exposed in the neutral position. This review article reveals the value and indications of CT and MRI.

[Graner operation in therapy of semilunar bone necrosis. Review of the literature and personal results]. / Operation nach Graner zur Therapie der Lunatumnekrose. Literaturübersicht und eigene Ergebnisse.

Intercarpal arthrodesis with interposition of the capitate osteotomized in Graner's technique is performed in the treatment of stage III Kienböck's disease. Although clinical results are satisfactory, there are complications such as necrosis of the capitate, pseudarthrosis of the capitate, and arthrosis of the radiocarpal joint. From 1992 to 1995, twenty patients were treated for Kienböck's disease by Graner's technique in the Clinic of Hand Surgery II in Bad Neustadt/Saale. Seventeen patients were submitted to follow-up studies. The range of motion (extension/flexion) of the wrist was 55 degree. The grip strength was 67% of the other hand. Four patients continued to complain of pain. Necrosis of the capitate was found in four cases, pseudarthrosis in two cases, and arthrosis of the radiocarpal joint in five cases. Based on the poor X-ray results found in this review, the authors feels there is no indication for Graner's technique. They favor STT arthrodesis in stage III of Kienböck's disease.

[STT arthrodesis as therapy of lunate necrosis in an advanced stage]. / Die STT-Arthrodese als Therapie der Lunatumnekrose im fortgeschrittenen Stadium.

The results of STT-fusion for treatment of advanced Kienböck's disease were investigated in a retrospective study. The follow-up included 25 of 28 patients, the average follow-up time was 39 months. Pain relief, range of motion, grip strength and X-ray findings were the most important criteria for rating the results. On the one hand, there was a decrease of range of motion, but on the other hand, grip strength improved markedly. Of course, one part of the decrease of pain is caused by the performed partial denervation of the wrist. However, the decrease of pain was impressive.

[Stress on the wrist joint in semilunar bone necrosis--a morphologic study in vivo]. / Uber die Beanspruchung des Handgelenks bei Mondbeinnekrose--Eine morphologische Untersuchung am Lebenden.

The distribution of subchondral mineralization of the distal articular surface of the radius was examined by CT osteoabsorptiometry in both wrists of twelve patients showing different stages of Kienböck's disease. The pattern of density distribution had already been demonstrated in previous studies to be an adequate parameter for assessing axial loading across the wrist joint in the patients. Contrary to the anticipated presence of predominant stress in the lunate compartment, some patients showed identical stress in the compartment of the scaphoid, and the balanced loading of both compartments, as before. Even when in early stages of the disease the lunate type of mineralization appeared more often, it was still not possible to demonstrate general excessive stress on the lunate. We have therefore concluded that the main stress in the scaphoid compartment might be a secondary effect, which is to be regarded as the expression of the advancing destruction of the lunate and consequent loss of load transmission through this compartment. This hypothesis is also supported by the fact that, in progressive stages of Kienböck's disease, the density maximum in the fovea lunata, generally present in healthy people, is absent. Furthermore, in patients with necrosis of the lunate, the total mineralization in terms of the maximal density values in the distal joint surface of the radius is in the majority of cases less than in the normal subject. In two cases, even the density maximum was absent from the fovea lunata of the contralateral wrist joint, without there being any clinical signs suggesting a possible lunate necrosis on this side. We interpret these pathological changes in the unaffected wrist joint as a further indication that we are dealing with a congenital predisposition which affects both wrist joints.

[Radiological appearances of osteochondritis of the hip in children]. / Aspects radiologiques de l'ostéochondrite de hanche chez l'enfant.

Radiological examinations are of primary importance in the diagnosis of osteochondritis of the hip in the children, and enable appropriate therapy to be selected. The classification described by Catterall is preferred to that of Taillard, which describes the classical stages of the disease, as it has prognostic value when frontal and profile hip x-rays are taken.

[Radiological appearances in Blount's disease]. / Aspects radiologiques de la maladie de Blount.

The radiological appearances in 16 Antilles patients with Blount's disease are described, and a classification is proposed according to the modifications noted during the course of the disease. Six stages can be identified during growth. A decisive stage appears to be that of stage IV when spontaneous epiphysiodesis occurs in the internal part of the epiphysial cartilage. Corrective osteotomy at this stage is always followed by recurrence of the tibia varum. The results of arthrography are defined as well as possible associated pathological affections.

Osteochondral lesions of the talar dome. A comprehensive review with retrospective study.

The incidence of osteochondral lesions of the talus is increasing because of a greater awareness of this injury following ankle trauma. The treating physician should view the so-called simple ankle sprain as a potential for fractures of the talar dome, especially in patients who are recalcitrant to treatment. It has been the authors' experience that talar dome lesions respond well to arthrotomy with removal of the fracture fragment and subchondral drilling, and yield generally good results. A high index of suspicion following ankle trauma allows for the early recognition and treatment of talar dome lesions.

A case of Freiberg's disease in an adult patient.

Freiberg's disease is an osteochondrosis of the IInd metatarsal head that prevalently develops during the second decade of life and that is the cause of important painful symptoms that resist conservative treatment. The disease is quite rare and must be treated surgically during its early phase in order to prevent progression that may result in permanent changes in the metatarsal head. It is the purpose of this study to describe the clinical case of a patient aged 30 years affected with Freiberg's disease, diagnosed at the age of 15 years, and never submitted to either conservative treatment or surgery.