Split lesions of the peroneus brevis tendon in chronic ankle laxity.

Between 1993 and 1995, we operated on 18 patients for split lesions of the peroneal brevis tendon associated with chronic ankle instability. Five patients were competitive athletes, seven were recreational athletes, and six were persons. Symptoms developed in three phases: ankle sprain, chronic instability, and posterolateral pain. The mean delay between sprain and posterolateral pain was 6 years. At the time of surgery the main complaint was retromalleolar pain in nine patients, pain and instability in eight patients, and instability only in one patient. Diagnosis of tendinous lesions was based on clinical examination in three cases, preoperative magnetic resonance imaging in eight cases, preoperative tenography in one case, and surgical exploration in six cases. The lesion was localized at the tip of the lateral malleolus and was visible only after opening the peroneal retinaculum. In three cases an accessory peroneal muscle was present. A Chrisman-Snook procedure was performed in 13 cases and a simple tendinous repair in 5 cases. The split lesion of the peroneus brevis tendon may be the result of chronic ankle laxity. This lesion needs a specific surgical treatment and the peroneal tendon must be checked in case of surgical procedure for ankle laxity. After ligamentous repair, residual pain can be due to a neglected peroneus brevis tear.

Deformation of the adult rheumatoid rearfoot. A radiographic study.

Three hundred ninety-seven adult rheumatoid feet were examined. Those in whom pain had been present since the onset of the disease were compared radiographically with the painless feet in standing position: examination of the talar angle and of the internal arch showed flattening on the affected feet. The calcaneal angle, on the other hand, showed no difference between the two groups, but this latter parameter is little affected by the valgus pronation deformity of the hindfoot most often seen in patients who had experienced foot pain.

Rheumatoid metatarsus. The original evolution of the first metatarsal.

Three hundred and eight unselected rheumatoid feet underwent a weight-bearing X-ray examination. If the malformations of the forefoot studied here present a statistical association, the primus metatarsus adductus is closely connected with tarsal arthritis and flattened foot but does not depend on the duration of the disease. The spread forefoot is indeed related to the duration of the disease and the presence of a metatarsal erosion at the foot level, but is not affected by the lesions of the midfoot. It appears then that an early orthopaedic treatment should be prescribed, once the first signs of involvement of the first ray or pronounced pronation of the hindfoot are noticed; it must affect the hindfoot, the midfoot and the first ray which progress together.

CT and MRI evaluation of tenosynovitis of the rheumatoid hindfoot.

Thirty-nine patients with rheumatoid arthritis who had presented with tarsitis before, were investigated at the level of the rearfoot. The first 17 patients had CT with previous tenography when it was possible; the following 22 patients had MRI with gadolinium injection. Tendon involvement appeared in 52.9% of the cases on CT, and in 90% of the feet on MRI; therefore, in case of clinical or radiological signs of tarsitis, it appears that tendon involvement must be suspected. With the two procedures the tibialis posterior tendon lesions were very predominant. In the majority of the patients (31/39), there was associated involvement of two or more tendons. If there is a ruptured tendon, the authors think that one must be cautious with surgical tendinous transfer; indeed, the long-term results of this surgical procedure present a strong probability of being compromised in rheumatoid arthritis which is a progressive disease.

The rheumatoid heel: its relationship to other disorders in the rheumatoid foot.

Four-hundred and eight rheumatoid feet are studied. The percentage of talalgia is 3.7%; for inferior exostosis it is 29.6%, and 30.8% for posterior exostosis. Posterior demineralisation is present in 12%, whereas for bony erosion it is 8.1%. Plantar spurs are very closely associated to flattened feet (p less than 0.0001). Likewise a very noticeable statistical association is noted between postero-superior calcaneitis and tarsal arthritis (p less than 0.0001), and calcaneitis was more frequent among marked valgus (p less than 0.001). These results are compared with findings of other works. Therapeutic consequences are evoked.

Arthroscopy of the ankle: analysis of results and indications on a series of 75 cases.

The purpose of this study was to evaluate the results of arthroscopy of the ankle. Of the 114 arthroscopies of the ankle that we performed between 1991 and 1996, 13 were for diagnosis, 6 were associated with open surgery, and 10 were ankle arthrodeses. We report the results of the remaining 85 therapeutic arthroscopies. We identified five groups according to preoperative indications: (1) anterolateral synovitis after a sprained ankle (33 cases), (2) sequelae of fractured ankles (17 cases), (3) anterior impingement as a result of osteophytes (12 cases), (4) loose foreign bodies as a result of avulsion of fragments of bone (6 cases), and (5) osteochondral lesions of the talar dome (17 cases). In anterolateral synovitis, results were better when the pain followed a single sprain than when after chronic instability. In osteochondral lesions of the talar dome, results were better in anterolateral lesions than in posteromedial lesions.

[Longitudinal splitting syndrome of the short fibular tendon. . Imaging and classification by MRI]. / Syndrome fissuraire du tendon court fibulaire. Mise en évidence et classification en IRM.

We present a series of 38 cases of longitudinal splitting of the peroneus brevis tendon revealed by MR imaging (12 lesions were confirmed at surgery). MRI enabled classification in four surgical grades. The frequency of such lesions in chronic ankle instability as observed in our series is often reported in the literature. Bilateral cases are common. Asymptomatic cases do occur, especially in grades I and II. MRI has been shown to be a very effective investigation for demonstrating this tendinous lesion; the proton density weighted sequence in the axial plane is the most adequate sequence.

[Inflammatory foot disease]. / Pied inflammatoire.

The pathology of the foot is frequent in the inflammatory rheumatisms. It can finally contribute to the diagnosis. In rheumatoid arthritis, the metatarso-phalangeal joint involvement appears earlier and more obvious. The lesion of the midrearfoot is later and the beginning is more indisious, they often evolve in pes plano valgus deformity. In spondylarthropathies the involvement of the heel and of the toes predominates, but there are more specific symptoms for each disease particularly for the psoriasic rheumatism. Local cares, plantar orthoses, casts, corticosteroid injections, synoviortheses as well as a good hygiene of life are very useful. Surgery helps to keep the functional ability of the patient and its indications must be known.

Flattening of the rheumatoid foot in tarsal arthritis on X-ray.

222 consecutive and unselected patients suffering form classical or definite rheumatoid arthritis wee studied. 397 of their feet were examined. Talonavicular arthritis was the commonest finding (31.5% of all patients), followed by sub-talar (23.3%), cuneo-navicular (20.4%) cuneo-metatarsal (14.9%) and tibio-tarsal arthritis (12.6%). Rheumatoid disease of the tarsus becomes commoner as the disease progresses. The incidences of involvement of the talo-navicular and sub-talar joints show a similar pattern, with a leap of 25% between 5 years of duration of the disease and 10 years. The same is seen with involvement of the cuneo-navicular and cuneo-metatarsal joints, between a duration of 10 years of the disease and 15 years. The percentage of flat foot is greater in feet with tarsal arthritis (p less than 0.001). The authors observed a relationship between tarsal arthritis, the length of history of rheumatoid arthritis, and flat foot. The method of investigation is discussed, and theories about evolution of the rheumatoid foot are considered.

[Erbium 169 synoviortheses and infiltrations of triamcinolone hexacetonide in metatarsophalangeal arthritis of chronic inflammatory rheumatism]. / Synoviorthèses à l'erbium 169 et infiltrations d'hexacétonide de triamcinolone dans les arthrites métatarsophalangiennes des rhumatismes inflammatoires chroniques.

The authors report their experience in the treatment of metatarsophalangeal arthritis of chronic inflammatory rheumatism by Erbium 169 synoviortheses (112 joints treated) and by infiltrations of triamcinolone hexacetonide (53 joints treated). The steroid appears to have a marked early superiority as it gives 85% good results compared to 61.6% for Erbium 169 after a period of one to three months. However, its results then deteriorate more rapidly and after 6 months, the proportion of good results is greater with the radioactive treatment (64% compared to 46.7%). The authors consider it reasonable to use triamcinolone hexacetonide as the first line treatment as it is easier to manage and less expensive, reserving the radioactive synoviortheses for later with the prospect of more lasting results.

[Rheumatoid metatarsals, original development of the first metatarsals]. / Le métatarse rhumatoïde, évolution originale du premier métatarsien.

Weight-bearing roentgenograms of 308 feet of rheumatoid arthritis patients were analyzed. Several angles were determined, including the metatarsus primus adductus angle (between the first and second metatarsals, > or = 10 degrees) and the forefoot spread angle (between the first and fifth metatarsals, > or = 30 degrees). Pes planus was diagnosed when the internal arch angle was equal to or greater than 130 degrees. Tarsal arthritis was defined as the presence of joint space narrowing. Varus of the first metatarsal was correlated with tarsal arthritis and pes planus but not with duration of the disease. Forefoot spread was correlated with duration of the disease and erosive metatarsal disease but not with involvement of the midfoot. These data demonstrate that orthopedic treatment should be initiated as soon as involvement of the first metatarsal is detected and should be directed at the hindfoot, midfoot, and first metatarsal whose deformations occur concomitantly.

[Heel involvement in rheumatoid polyarthritis]. / L'atteinte du talon au cours de la polyarthrite rhumatoïde.

Calcaneus involvement during the course of RA is poorly known. A clinical and radiological study of 408 consecutive rheumatoid feet are then reported. If talalgia was seldomly noted (3.7 p. cent), plantar calcaneitis was found in 29.7 p. cent as plantar spur. Similarly, posterior exostosis was displayed in 30.5 p. cent of patients. These radiological abnormalities are increased in RA but appeared more as a consequence of the statical modification of the foot secondary to RA process than as a direct involvement. Logical orthopedic therapeutics are then proposed.