Decompressive Medial Cuneiform Exostectomy for Resistant Tibialis Anterior Insertional Tendinopathy.

Distal tibialis anterior tendinopathy, as a clinical entity, has only recently been documented in foot and ankle studies. We report our experience with medial cuneiform decompressive exostectomy and superficial tendon debridement in 14 cases of recalcitrant tibilalis anterior insertional pain. We reviewed 13 patients (14 feet; 12 females, 1 male; mean age 67.9 ± 7.5; range 55 to 80 years) in whom conservative treatment had failed who had undergone debridement of the insertional tibialis anterior tendon and decompressive exostectomy of the medial cuneiform. Pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale and visual analog scale (VAS) pain scores, local clinical findings, and dorsiflexion power at an average follow-up period of 28 ± 17.9 (range 6 to 55) months were assessed. All patients had experienced burning, nocturnal, medial midfoot pain and disability. The symptom longevity preoperatively was 8.5 ± 3.1 (range 6 to 17) months. Peritendinous or intrasubstance signal changes were noted on magnetic resonance imaging in 10 feet (71%). The mean preoperative VAS pain score was 8.7 ± 1.3 (range 5 to10), whereas postoperative it was 0.4 ± 0.5 (range 0 to1) (p = .001). The mean preoperative and postoperative AOFAS midfoot scale score was 54 ± 14.5 (range 20 to 70) and 91 ± 6.8 (range 79 to 100), respectively (p = .001). Postoperative ankle dorsiflexion power was normal and local tenderness had resolved in all patients. One patient (7.1%) stumbled at 2 weeks, resulting in avulsion of the tibialis anterior tendon, requiring transosseous fixation and gastrocnemius recession. All patients reported satisfaction with the surgical outcome and willingness to undergo the surgery again if necessary. A combination of medial cuneiform mechanical decompression and insertional tendon debridement can offer successful outcomes in resistant insertional tibialis anterior tendinopathy.

Statins attenuate polymethylmethacrylate-mediated monocyte activation.

BACKGROUND: Periprosthetic osteolysis precipitates aseptic loosening of components, increases the risk of periprosthetic fracture and, through massive bone loss, complicates revision surgery and ultimately is the primary cause for failure of joint arthroplasty. The anti-inflammatory properties of HMG-CoA reductase inhibitors belonging to the statin family are well recognized. We investigated a possible role for status in initiating the first stage of the osteolytic cycle, namely monocytic activation. METHODS: We used an in vitro model of the human monocyte/macrophage inflammatory response to poly-methylmethacrylate (PMMA) particles after pretreat-ing cells with cerivastatin, a potent member of the statin family. Cell activation based upon production of TNF-alpha and MCP-1 cytokines was analyzed and the intracellular Raf-MEK-ERK signal transduction pathway was evaluated using western blot analysis, to identify its role in cell activation and in any cerivastatin effects observed. RESULTS: We found that pretreatment with cerivastatin significantly abrogates the production of inflammatory cytokines TNF-alpha and MCP-1 by human monocytes in response to polymethylmethacrylate particle activation. This inflammatory activation and attenuation appear to be mediated through the intracellular Raf-MEK-ERK pathway. INTERPRETATION: We propose that by intervening at the upstream activation stage, subsequent osteoclast activation and osteolysis can be suppressed. We believe that the anti-inflammatory properties of statins may potentially play a prophylactic role in the setting of aseptic loosening, and in so doing increase implant longevity.

Vacuum-assisted closure therapy: a new treatment option for recurrent pilonidal sinus disease. Report of three cases.

No single treatment option available for symptomatic pilonidal disease is entirely satisfactory. In our department, we have treated successfully three cases of pilonidal disease with vacuum-assisted closure therapy. We describe our initial experience with this technique. In two cases, the pilonidal sinus was primarily excised, a split skin graft applied to cover the defect, and the vacuum-assisted closure pump applied over the skin graft for a period of four days on a continuous negative pressure of 50 mmHg. The third case was treated and completely healed with vacuum-assisted closure therapy alone. To our knowledge, this is the first report in the literature describing the use of vacuum-assisted closure therapy for this condition. We propose this therapy as an alternative adjunctive treatment for pilonidal disease.

Segmental femoral cement extraction at revision hip arthroplasty - a safe technique.

Conventional methods of femoral cement extraction at revision hip arthroplasty may be associated with incomplete cement removal, excessive sacrifice of cancellous bone stock, inadvertent cortical perforation, or fracture. Segmental femoral cement extraction is a technique, first introduced in the early 1990s to optimise cement removal while minimising the potential complications of this procedure. It involves the instilling of fresh polymethylmethacrylate (PMMA) into the carefully prepared cement mantle after implant removal. Segments of new cement bound to the old mantle are then extracted. Since its initial description, few subsequent series have been published to validate or discredit this technique. We report on 25 consecutive femoral revisions employing this system. Complete cement removal was achieved in 88%. The integrity of the femoral cortex was preserved in all cases with no perforations or fractures.