One Step Double Augmentation with Human Dermis Allograft and Homologous PRP in Misdiagnosed and or Chronic Achilles Tendon Ruptures.

OBJECTIVE: Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration. METHODS: We treated five patients, four males and one female, with the one-step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin-activated, platelet-rich plasma (H-PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally "biological" augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post-operatively. RESULTS: All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic-sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow-up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports. CONCLUSION: The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin-activated). The same approach can also be exploited in cases of severe tendon destructuring and limited "intrinsic" regenerative potential at any age. The proposed one-step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.

Anterior Ankle Arthroscopy: Advantage of a Preoperative Ultrasound Mapping to Prevent Neurovascular Complications.

PURPOSE: The aim of this study is to verify the usefulness of ultrasound-assisted mapping of the vascular and neurological structures in the anterior compartment of the ankle just before an anterior arthroscopic procedure to reduce these kinds of complications. METHODS: Various complications can be present in anterior arthroscopy of the ankle. The structures most prone to iatrogenic damage are vessels and nerves. They are macroscopically visible and palpable in a little more than 50% of cases, but arterial ramifications are not visible because they are located deeper. RESULTS: The authors have investigated how to reduce potential iatrogenic damage to the complex and variable neuro-vascular network of the anterior aspect of the ankle. They have completed the classic routine marking of the bony and tendinous structures with an ultrasound mapping of the neurovascular structures. CONCLUSIONS: The authors concluded that ultrasound-assisted mapping is a non-invasive, fast, and safe procedure that can help to reduce potential iatrogenic damage when performing anterior arthroscopic surgery.

Haglund's Syndrome: endoscopic or open treatment?

BACKGROUND AND AIM OF THE WORK: With the term "Haglund>s syndrome" we define a condition characterized clinically by pain at the insertion of Achille>s tendon and, anatomopathologically, due to the presence of retrocalcaneal bursitis and at times associated with an insertional Achille>s tendinopathy. The aim of the work is to correlate the most reliable and reproducible treatment possible to the aforementioned variables of Haglund>s syndrome. METHODS: The classic syndromic picture is characterized by pain caused by retrocalcaneal bursitis. In some cases, symptoms of insertional tendinopathy are associated with bursitis pain. In those frameworks where symptoms were mainly exacerbated by the bursitis inflammation we have used an endoscopic technique for the resection of the underlying bone deformation and the bursa. An open technique, described in the literature as bridge sutures, was used for those patients with tendinopathic problems. While a homologous PRP unit was infiltrated in patients with degenerative insertional tendinopathy. RESULTS: The group of patients that participated to the study was heterogeneous in age and functional requirements therefore presenting different anatomopathological characteristics. For these reasons considerations with correct statistical meaning are not possible. Despite different post-operative programs, patients demonstrated optimal clinical and functional recovery. There were no local neurological or skin complications. CONCLUSIONS: Haglund>s syndrome can have different clinical and anatomopathological patterns where conservative treatment is unsuccessful surgical solutions must be adopted. The latter have shown to be reliable and reproducible with a very low rate of complications. (www.actabiomedica.it).

A New Treatment for the Reconstruction of the Medial Compartment of the Ankle: The Combined Use of Biological Materials.

Fractures, especially if articular and periarticular, are frequently associated to functional and clinical disabling outcomes and chronic pain. In particular, the injuries with loss of bone, ligament, and/or tendon tissue in which the full recovery of the wound area is not obtained are the worst anatomical/pathological conditions to heal. In this study, three different biological materials were used as regenerative approaches to rebuild the medial malleolus fracture of the ankle in which loss of bone, ligament, and tendon tissue occur. In particular, the morselized human bone tissue was combined with the human dermis decellularized, both augmented with homologous platelet-rich plasma. The magnetic resonance imaging study with contrast at the follow-up showed a signal compatible with vascularization of the tissue without sign of degeneration. Our new regenerative approach in which different biological materials were combined together showed a good choice of treatment for the reconstruction of not repairable outcome of a fracture.

Giant Cells Osseous Tumor in the Tarsal Canal after Lateral Ankle Sprain.

Ankle sprain can cause injuries to the anatomic structures surrounding the tibiotarsal joint. A possible extra-articular pathology is to be hypothesized and diagnosed as early as possible. The subtalar joint, for anatomical and functional reasons, is one of the most damaged joints following an ankle sprain. In spite of this, its involvement is often underestimated. The clinical case presented in the present article is referred to a giant cells osseous tumor in the tarsal canal that was diagnosed 2 months after an inversion ankle sprain.

Posterior arthroscopic approach to the ankle: an anatomic study.

PURPOSE: The purpose of this study is to verify the safety of a new technique for a posterior arthroscopic approach to the ankle. This technique was recently described in literature. The technique uses a modified posteromedial portal, a different way of introducing the instruments into the portal, and the tendon of the flexor hallucis longus (FHL) as a landmark to work in the posterior compartment. TYPE OF STUDY: Anatomic study. METHODS: The technique was performed on 10 (4 fresh and 6 fresh-frozen) below-knee amputation specimens, which were then dissected. The instruments were left in place, and anatomic dissections were performed to determine the relationship to the surrounding neurovascular structures. Then the instruments were removed, and the distance of the neurovascular structures from the posteromedial portal was recorded. Another medial portal, 1 cm more proximal, was also created to measure the distance of this latter portal from the nervous structures. RESULTS: None of the anatomic dissections showed injuries to the neurovascular bundle either during penetration of the instruments or during procedures in the posterior compartment laterally to the tendon of the FHL. This latter is the landmark to prevent damage to the more medially located nerves and vessels. The new posteromedial portal is located, on average, 13.3 mm (range, 11 to 17 mm) from the posterior tibial nerve, 14.7 mm (range, 8 to 20) from the calcaneal branch (which may be single or multiple, and may vary as needed the height of bifurcation from the posterior tibial nerve), and 17.3 mm (range, 15 to 21 mm) from the posterior tibial artery. A posteromedial portal located 1 cm more proximally is on average 2.9 mm closer to the nervous structures. CONCLUSIONS: Based on these anatomic data, there appears to be relatively little risk to the surrounding neurovascular structures with this new technique. Therefore, this technique appears to be relatively safe in the treatment of intra-articular and extra-articular pathology.