Image-Guided Intervention of the Postoperative Foot and Ankle After Ligament and Tendon Repair.

This review article describes the potential range of image-guided interventional procedures performed following foot and ankle ligament and/or tendon repair. Diagnosis of the cause of recurrent or persistent pain/symptoms in this postoperative group is challenging and requires a coordinated clinical and radiologic assessment. This directs appropriate treatment including image-guided intervention that may be used both as a diagnostic tool and a therapeutic option. There is a paucity of high-quality studies on the role of image-guided intervention in the foot and ankle after ligament/tendon repair. Many of the procedures used in this group are extrapolated from other areas of the body or the preoperative scenario. We review the role of imaging to identify the cause of postsurgical symptoms and to direct appropriate image-guided intervention. The available injectables and their roles are discussed. Specific surgical procedures are described including lateral ligament repair, Achilles repair, posterior tibialis tendon surgery, and peroneal tendon surgery.

Use of a Proximal Humeral Locking Plate for Complex Ankle and Hindfoot Fusion.

Arthrodesis of the ankle and hindfoot in the setting of major deformity is challenging and associated with substantial risks. Patients often have significant comorbidities that lead to unforgiving soft tissues, poor vascularity, and poor bone quality. This creates the high-risk scenario of poor wound healing and poor implant fixation. Complications can be devastating, leading to loss of the limb and sepsis. The use of locking plate technology might provide biomechanical and operative technique advantages in such patients. We retrospectively assessed the results of the modified use of the PHILOS(™) (Synthes(®), Zuchwil, Switzerland) proximal humeral locking plate in 21 patients (11 males, 10 females; mean age 56.1 years, range 25 to 74 years) who had undergone complex fusions, including tibiotalar (n = 4), tibiocalcaneal (n = 7), or tibiotalocalcaneal (n =10) fusions. The average follow-up period was 14.6 (median 10, range 6 to 49) months. Of the 21 fusions, 18 achieved union (85.7%) at an average period of 4.8 (median 4.3, range 3 to 12) months. The overall deep infection rate was 14.3%. Overall, 17 of the 21 patients (81%) were satisfied with the result (good to excellent), 1 reported the result was fair (4.8%), and 3 patients developed nonunion and were dissatisfied with the procedure (14.3%). The present study is the largest series to date of patients undergoing complex ankle and hindfoot arthrodesis with the use of a proximal humeral locking plate and confirms previous findings that the technique is reliable with union, satisfaction, and complication rates comparable to those of other techniques.

Percutaneous Arthroscopic Calcaneal Osteosynthesis: A Minimally Invasive Technique for Displaced Intra-Articular Calcaneal Fractures.

The management of calcaneal fracture remains challenging. Open surgery has been fraught with high infection rates and soft tissue complications. More minimally invasive procedures have reduced this risk, but the patient outcomes after treatment of displaced calcaneal fractures have remained relatively unsatisfactory. We present a method for the management of Sanders grade II and III calcaneal fractures: percutaneous arthroscopic calcaneal osteosynthesis. Thirty-three fractures in 30 patients who had presented to our tertiary foot and ankle trauma center in central London were treated with percutaneous arthroscopic calcaneal osteosynthesis for calcaneal fractures, and the data were prospectively collected. The mean patient age at injury was 39 years. The mean follow-up period was 24 months. Of our patients, 58% were smokers at injury. Of the 33 fractures, 46% were classified as grade II and 54% as grade III. The mean length of stay was 1.92 days. At the final follow-up visit, the mean Böhler angle had increased from 11.10° (range 2° to 24°) to 23.41° (range 15° to 35°). The modified American Orthopaedic Foot and Ankle Society scale score was 72.18 (range 18 to 100), the calcaneal fracture scoring system score was 79.34 (range 42 to 100), and the visual analog scale score was 29.50 (range 0 to 100). We had a single case of a superficial port site infection and 2 cases of prominent screws, which were removed. No cases of deep infection developed, and no conversion to subtalar fusion was required. This technique significantly reduced the incidence of postoperative wound complications. Direct visualization of the fracture site allowed accurate restoration of the articular surface and correction of heel varus. Furthermore, it was associated with a high self-reported functional outcome and a return to preinjury employment levels. Also, the results did not appear to be influenced by tobacco consumption.

Anatomic structures at risk: curved hindfoot arthrodesis nail--a cadaveric approach.

Retrograde intramedullary nailing of the hindfoot and ankle is an established procedure for salvage of severe foot and ankle deformity, arthritis, tumor, and instability. In the present study, retrograde hindfoot (tibiotalocalcaneal) arthrodesis nailing was performed using a standardized technique on 7 cadaver specimens by trained senior surgeons. The specimens were then dissected to determine the distance of the subcalcaneal structures at risk from the insertion point of the nail. The findings showed that the distance of the lateral neurovascular bundle from the edge of the nail was 6.5 (range 3.5 to 8, 95% confidence interval 5.9 to 7.1) mm. No neurovascular bundle was compromised, and all were within a previously described "safe window."

Lisfranc injuries: an update.

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

Ankle arthroscopy: is preoperative marking of the superficial peroneal nerve important?

The aim of this study was to see whether preoperative marking of the superficial peroneal nerve and its branches before anterior ankle arthroscopy reduced the incidence of nerve injury compared with the available evidence reported in the literature. We reviewed 100 consecutive cases of anterior ankle arthroscopy that had been performed between February 2005 and April 2009. The medical records for all of the patients were reviewed for any documented complications related to the arthroscopic procedure. The patients were interviewed by telephone to find out if they had experienced any temporary or long-term neurologic symptoms after the surgery, and any patient with symptoms suggestive of a neurologic complication was thereafter physically examined in the clinic. A total of 96 (96%) of the patients were followed up for a mean of 15.3 (range 1 to 39) months, and the incidence of post-arthroscopy injury to the superficial peroneal nerve or its branches was 1.04% (1 out of 96 cases). Based on our observations, we believe that marking the superficial peroneal nerve and its branches before anterior ankle arthroscopy is an important and effective way to decrease the risk of iatrogenic nerve injury.

Surgical approaches to the forefoot for common sports-related pathologies: a review of the literature and cadaveric dissection.

This article reviews the published literature regarding the surgical approaches to pathologies encountered within the forefoot, including arthroscopic and open techniques, and their treatment. We have demonstrated these surgical approaches with cadavers, to identify the key anatomical landmarks and safe zones for these surgical techniques, to prevent the complications associated with their treatment.

First metatarsophalangeal arthrodesis using a dorsal plate and a compression screw.

BACKGROUND: Fusion of the first metatarsophalangeal joint is considered a `gold standard' procedure for arthritis and as a salvage procedure for previous failed surgeries. Recent biomechanical studies have shown that a combination of a plate and screw is the most stable construct. Only a few studies have evaluated this combination and they have small cohorts so we are presenting our larger series of patients. MATERIALS AND METHODS: Forty-six consecutive cases of first metatarsophalangeal joint fusion performed between April 2006 and April 2008 were performed using a dorsal plate and a compression screw. We analyzed the outcome in terms of fusion rate, patient satisfaction and complication rates. The average followup period was 23 (range, 14 to 37) months. The most common indications were hallux rigidus and severe hallux valgus. RESULTS: Ninety-eight percent of the cases fused uneventfully by four months. The average time to fusion was 3.1 months. There was one non-union, which remained asymptomatic after metal removal which was the only case requiring removal of metal. There was no hardware failure. The patient satisfaction was 100%. The average AOFAS score was 82.1 (maximum, 90). CONCLUSION: These results show that arthrodesis of the first MTP joint with spherical reamers and a low-profile contoured dorsal titanium plate and compression screw is highly successful, with excellent patient satisfaction and functional outcomes. We recommend the use of specially designed plates against improvised plates as bending leads to poor control over dorsiflexion and may increase the incidence of plate failure.

Use of Fat-Suppressed T2-Weighted MRI Images to Reduce the Magic Angle Effect in Peroneal Tendons.

INTRODUCTION: Peroneal tendon disorders pose a diagnostic conundrum to the clinician. Magnetic resonance imaging (MRI) is widely used to assess tendon pathology. A recognized artifact of MRI, the magic angle effect (MAE), can lead to spurious results and inappropriate management. The aim of this study is to assess whether T2 fat-suppressed sequences (T2FSs) reduce the frequency of MAE compared with proton density fat-suppressed (PDFS) images. METHODS: MRI scans of 18 patients were prospectively assessed for MAE. The peroneal tendons were assessed at 5 defined levels on PDFS and T2FS images. The frequency of MAE in the peroneal tendons were compared between the 2 scan sequences. RESULTS: In the peroneus brevis tendon, 17/72 levels, on PDFS scans, showed MAE compared with 2/72 levels on the T2FS scans, demonstrating a reduction in the MAE by 85% (P = .0003). In the peroneus longus tendon 14/72 levels, on PDFS scans, demonstrated MAE compared with 4/72 on T2FSs, demonstrating a reduction of 71% (P = .02). CONCLUSION: The inclusion of T2-weighted sequences is useful in MRI scanning for peroneal tendons to mitigate the MAE artifact, avoid potential misdiagnosis, and guide subsequent management of peroneal tendon disorders. Levels of Evidence: Level IV: Case series.

A comprehensive review of subtalar arthrodesis.

BACKGROUND: The aim of this study was to evaluate the results of a series of subtalar arthrodeses done by a single surgeon using a standard technique. METHODS: A retrospective review of 95 primary isolated subtalar arthrodeses in 92 patients was done. Original diagnoses included post-traumatic subtalar arthrosis, primary osteoarthrosis, talocalcaneal coalition, and inflammatory joint disease. In all arthrodeses, a single 7.0-mm partially-threaded cancellous screw was used for fixation, and autogenous bone graft was used. Structural iliac crest autograft was required to restore heel height in three feet with post-traumatic arthrosis. In these three, autograft was harvested from the iliac crest with the remainder receiving morcellized autograft either from the tibia, fibula, or calcaneus. RESULTS: No patients were lost to followup. Ninety-five percent (87) of patients went on to bony union radiographically. Using the Angus and Cowell rating system, 93% (88 feet) of patients had a good or fair outcome. There were seven poor results: four arthrodeses failed to unite, two patients had persistent hindfoot pain in spite of radiographic union, and one developed post-traumatic ankle arthrosis. CONCLUSIONS: The results of isolated subtalar arthrodesis using a single screw for fixation are comparable to other fixation methods. Bone graft from local sites obviates the need for iliac crest autograft in most patients.

Acute and chronic peroneal tendon dislocations.

Peroneal tendon dislocation is an infrequent sports injury and can be difficult to diagnose. Posterior fibula tenderness and pain with eversion are useful signs to discriminate this from an ankle sprain. In the acute setting, a direct repair provides good results but may need to be augmented with additional soft tissue or bony restraints. For chronic injuries there are several methods of reconstruction, all with acceptable outcomes, although bone block procedures have the highest rate of secondary procedures.

Clinical accuracy outcomes of splinted and nonsplinted implant impression methods in dental residency settings.

OBJECTIVE: The splint technique of implant-supported restorations is a popular impression method; however, in-vivo studies showing the advantage of this method are scarce. The objective was to compare radiographic fit of the metal frameworks fabricated according to splinted or nonsplinted impression techniques. The null hypothesis was that splinting techniques would result in more accurate impressions. METHOD AND MATERIALS: A retrospective analysis was performed on 71 patients who had undergone multi-implant-supported rehabilitation in the years of 2012 to 2013. The treatment was carried out by three senior dentists or by residents in the department of Oral Rehabilitation at the Hebrew University Hadassah Medical Center. Each senior and the residents under his guidance treated patients consistently by only one different impression method: (1) no splint; (2) splinted transfers with pattern resin over dental floss scaffold; (3) splinting of transfers to impression tray with pattern resin. Orthoradial radiographs were used to determine if the metal framework fit the implant abutments. RESULTS: In total, 81 impressions and 285 implants were included in the study; 56 impressions were done by seniors and 25 by residents. There was no difference in success between the three methods when done by seniors (P = .76). The fixation to tray method was found to be significantly unsuccessful in the hands of residents (P = .01). CONCLUSION: Because the splint methods were not found to be more accurate, splinting the transfers might be an unnecessary step. Splinting of transfers to the impression tray is not recommended for inexperienced dentists.

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction.

BACKGROUND: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). METHODS: Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. RESULTS: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. CONCLUSION: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.

Differential effects of intracerebrally microinjected enkephalin analogs on centrally versus peripherally induced pain, and evidence for a facial versus lower body analgesic effect.

[D-Ala2]-Met-Enkephalin and [D-Ala2]-Met-Enkephalinamide were microinjected (10-30 microgram) into the midbrain ventrolateral central gray of rats. The opiate analogs produced profound analgesia in left and right facial areas, and on the hot plate test. The tail-flick test showed significant analgesia, but in a significantly smaller amount than that obtained with noxious face heating. All effects were blocked by naloxone pre-treatment. The drugs had no effect on thresholds for defense responses to high (200 Hz) and low (20 Hz) frequency aversive stimulation in midbrain areas associated with pain perception.

Differential effects of systemic versus intracranial injection of opiates on central, orofacial and lower body nociception: somatotypy in bulbar analgesia systems.

1 microgram morphine sulfate or 30 microgram [D-Ala2]-met-enkephalin microcannulated into the bulbar nuclei reticularis gigantocellularis and paragigantocellularis produced profound analgesia for orofacial thermal nociception, while having a smaller analgesic effect on tail-flick latency, and no effect on aversive stimulation thresholds in midbrain and in the spinal trigeminal nucleus (subnucleus caudalis). Systemic morphine (10 mg/kg) producing equivalently profound orofacial analgesia, profoundly affected tail-flick latency and trigeminal nuclear stimulation thresholds, while still failing to affect aversive midbrain stimulation threshold.

Differential effect of morphine on trigeminal nucleus versus reticular aversive stimulation: independence of negative effects from stimulation parameters.

Electrodes were implanted in mesencephalic, pontine, and bulbar reticular formation, and in spinal trigeminal nucleus and tract of rats. Central and peripheral aversive response thresholds were studied under normal conditions and with morphine. Peripherally elicited aversive reactions were assessed with tail-flick, hot-plate, and footshock responses. Centrally elicited aversive reaction thresholds were in all cases based on unconditioned behavioral distress signs (non-stereotyped, escape-like movements, vocalization, freezing, excretion, etc.) and confirmed in some cases with avoidance learning. Morphine (10 mg/kg) elevated the unconditioned aversive reaction threshold for brain stimulation in the trigeminal complex and for peripheral aversive stimulation, but failed to affect the thresholds for reticular brain stimulation. The failure to affect reticular thresholds was independent of stimulation frequency. Thresholds for 5 and 200 Hz sinusoidal stimulation were both unaffected as were previously reported thresholds with 333 Hz pulsatile stimulation. Trigeminal nucleus and tract stimulation were affected in similar degrees. The data were discussed as supporting descending inhibitory models of opiate analgesia.

Premenstrual dysphoric disorder and changes in frontal alpha asymmetry.

OBJECTIVE: Since the clinical picture of premenstrual dysphoric disorder (PMDD) in the Luteal phase of the menstrual cycle is characterized by extreme negative affect, we predicted and obtained a change in frontal cortical EEG alpha asymmetry, which has been shown to be an index of affect. METHOD: We observed two monthly cycles for five women diagnosed as having PMDD and one monthly cycle for five non-PMDD control subjects. RESULTS: Asymmetry percent scores for the five PMDD women, and for the five control subjects before and after the Luteal phase were typically within the normal non-depressed range, however the asymmetry scores for the PMDD group fell into the negative range during the Luteal period while the control subjects remained stable. DISCUSSION: We predicted alpha asymmetry scores would be affected by the luteal phase in PMDD cases. This hypothesis was clearly confirmed.