Osteochondritis Dissecans of the Lateral Process of Talus Involving the Subtalar Joint: An Unusual Case.

Osteochondritis dissecans is a fairly recognized entity affecting the talus dome but subtalar joint involvement is not that common. We report a case of a 34-year-old male with osteochondritis dissecans of lateral process talus which was missed on imaging studies and identified intraoperatively. The patient was treated with curettage of the subchondral cyst at talus, followed by bone grafting and fixation of the osteochondral lesion with a 4-mm partially threaded cancellous screw. At the 1-year follow-up evaluation, there were no signs of recurrence and the patient resumed his complete activities including sports. We believe that the threshold for diagnosing these lesions should be low in cases with nonspecific chronic ankle pain, and surgeons are encouraged to consider this diagnosis.

Current concept review of Achilles tendinopathy.

Achilles tendinopathy is a common overuse injury affecting the ankle and foot. It manifests as a clinical condition that includes pain, edema, and decreased functionality. This condition can be broadly categorized into two main types based on anatomical location: insertional and noninsertional tendinopathy. The development of Achilles tendinopathy involves various factors, both internal and external. Patients with Achilles tendinopathy often experience stiffness worsened by prolonged rest, and pain exacerbated by physical activity. These symptoms can limit work activity and sports participation, with many patients facing discomfort while wearing shoes due to heel sensitivity. Diagnosis is primarily clinical, although MRI and ultrasound imaging can aid in differential diagnosis. Identifying risk factors and understanding the patient's biomechanics assist in accurate diagnosis and subsequent management. Management of Achilles tendinopathy involves a range of conservative and surgical options. However, due to varying results in clinical studies, a definitive gold standard treatment has not emerged. Eccentric exercises are a valuable tool in managing the condition. The recommend treatments such as shock wave therapy or nitric oxide patches are sought if symptoms do not improve. Peritendinous injections could be options if physical therapy proves ineffective. Surgical intervention is required after six months of conservative treatment. Recent research on Achilles tendinopathy emphasizes the need for individualized treatment plans that address its multifaceted nature. Combining biomechanical analysis, advanced imaging, and patient-specific factors is key to achieving optimal outcomes. Additionally, preventive strategies focusing on proper training techniques, load management, and addressing modifiable risk factors play a critical role in reducing the incidence of this condition. In conclusion, this article provides a current overview of Achilles tendinopathy. It highlights the importance of a comprehensive approach to understanding its causes, pathophysiology, diagnosis, and management strategies.

Novel Surgical Approach for Large Intraosseous Subchondral Cysts of Talus: A Case Report and Technical Innovation.

Large subchondral bone cysts in the medial talar body and dome are common and can cause persistent pain and swelling during axial loading. Open debridement and bone grafting are often necessary to treat these lesions but can require extensive soft-tissue dissection or malleolar osteotomies. A 40-year-old woman presented with ankle pain and swelling for 1 year, worsening with activity and no history of trauma. X-rays showed a cystic lesion in the medial talar dome with no joint line disruption. CT confirmed the cystic lesion without bone collapse or expansion. An anterior approach to the ankle joint was extended to access the talar neck. A window was created in the talar neck to debride and curette the medial talar dome, and the void was filled with allograft. The patient was non-weight-bearing for 6 weeks, followed by gradual weight-bearing and ankle range of motion exercises starting on postoperative day 1. The patient returned to her pre-injury status within 3 months and was asymptomatic at the 6-year follow-up, with good bone graft integration and no symptoms. This technical note presents a novel approach to lesions of the medial talar body and dome through the talar neck, avoiding the need for malleolar osteotomy or disruption to the tibiotalar joint, and resulting in good functional outcomes.

Anterior Tarsal Tunnel Syndrome: Entrapment of the Articular Branch of Deep Peroneal Nerve: A Case Report.

CASE: A 28-year-old male patient who injured his ankle 2 years ago presented with unilateral ankle pain, tingling, and numbness for 1 year. Clinically, tenderness and positive Tinel sign were localized on anterior aspect of ankle. On exploration, deep peroneal nerve and mainly its articular branch were encased in fibrotic tissue. Decompression of both nerves resulted in symptomatic relief after surgery. CONCLUSION: High index of suspicion, a thorough medical history, meticulous clinical examination, complete knowledge of nerve anatomy, proper radiological studies, and careful surgical decompression are all necessary for the diagnosis and management of such atypical cases.

Combined Deltoid and Spring Ligament Reconstruction Using the Quadrangular Construct: Our Experience and Review of the Literature.

Background A combined reconstruction of chronic deltoid and spring ligament insufficiency is uncommon. Our study aims to share our experience in treating post-traumatic, chronic deltoid, and spring ligament insufficiency using the "quadrangular construct" technique. Material and methods Five patients who had post-traumatic combined deltoid and spring ligament insufficiency were included in the study. All patients reported a "giving-way" sensation. Preoperatively, each patient underwent weight-bearing radiographs of the ankle and foot. The talo-first metatarsal angle and hindfoot alignment angle were noted. The superficial deltoid ligament was repaired using a suture anchor augmented with Internal BraceTM (Arthrex, Naples, USA) FiberTape® to form a quadrangular construct that anatomically mimics various components of the deltoid-spring ligament complex. Due to the associated excessive heel valgus, three patients also underwent medial displacement calcaneum osteotomy. Additionally, one patient required lateral ligament repair, and another patient required syndesmotic stabilization. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to evaluate preoperative and postoperative ankle function. Results All five patients were followed up for a mean of 20 months (range: 12-24 months). The mean preoperative talo-first metatarsal angle improved from 8.46 degrees to 4.84 degrees. The preoperative mean hindfoot alignment angle was reduced from 10.9 to 5.76 degrees postoperatively. One patient had irritation due to the anchor, which needed removal after one year. Postoperatively, no patients re-experienced the feeling of "giving way". The AOFAS scores postoperatively showed two patients as excellent, two as good, and one as fair. All the patients returned to their pre-injury work. Conclusion  We have developed a technique for combined deltoid and spring ligament reconstruction using a quadrangular construct. This technique helps to restore anatomical stability, is safe, easily reproducible, and has shown positive short-term results in follow-up. The level of evidence is one of the methods used to categorize the quality and reliability of research, and our study falls under the category of level IV evidence.

Mal-union of sustentaculum tali fracture with talo-calcaneal coalition leading to tarsal tunnel syndrome: A case report.

Displaced isolated fractures of sustentaculum tali are rare. Inadequate treatment of these injuries can rarely lead to non-union or mal-union and in most cases are treated non-surgically. We report a unique case of undiagnosed mal-union of sustentaculum tali in the setting of underlying tarsal coalition that resulted in symptoms of tarsal tunnel. Osteotomy and excision of the mal-united fragment and coalition along with decompression of the tarsal tunnel was performed. The patient had immediate improvement in pain and the paraesthesia recovered by the end of 6 weeks post-operatively. The Foot and Ankle disability score (FADI) score improved from 26.0 pre-operatively to 96.2 at 3 years' follow-up. This case highlights that isolated fractures of sustentaculum tali warrant advanced imaging and surgical reduction and fixation may be appropriate to avoid long-term disability where displacement compromises the tarsal tunnel or function of the subtalar joint.

Functional outcome in patients with Charcot neuropathy with almost complete loss of talus treated by tibio-talo calcaneal nail: A cross-sectional study.

INTRODUCTION: Tibio-talo-calcaneal (TTC) fusion is a successful surgery for Charcot neuropathy affecting the hindfoot. A case series of Charcot neuropathy is presented with almost complete loss affecting hindfoot treated with tibio-talo-calcaneal nail. MATERIAL AND METHODS: Seven patients with Charcot neuropathy of the hindfoot having varying degrees of talus loss underwent tibio-talo-calcaneal nailing between January 2014 and Feb 2016 at a tertiary care hospital by a single surgeon. All the patients were type 3a as per Brodsky classification. Patients with active infection, fractures and avascular necrosis of talus was excluded from the study. The final outcome was measured using the AOFAS and FADI scores at the end of 2 years. RESULTS: The mean duration of diabetes was 8.16 ± 3.12 years. Two patients (28.6%) had total and 5 (71.4%) patients had subtotal talus loss. Anterior approach was used in four, and lateral approach was used in three cases respectively. The talus was reconstructed by using the iliac crest or the graft from the distal fibula wherever appropriate. The average surgical duration was 93.28 ± 4.84 min. One patient had deep infection, 2 years after the surgery which was treated by implant removal and antibiotics. No patients had non-union. The pre-operative AOFAS scores improved from 32.2 ± 2.58 to 73.4 ± 3.36 at 2-year follow-up (p < 0.0001). Similarly, the pre-operative FADI scores were 31.74 ± 1.98 which improved to 65.94 ± 3.68 at the end of 2 years (p < 0.0001). CONCLUSION: Retrograde tibio-talo-calcaneal nail is a good option for limb salvage in patients with severe talus loss with good functional outcome. LEVEL OF EVIDENCE: Therapeutic IV.

Tibiofemoral kinematic analysis of knee flexion for a medial pivot knee.

The performance of total knee arthroplasty in deeply flexed postures is of increasing concern as the procedure is performed on younger, more physically active and more culturally diverse populations. Several implant design factors, including tibiofemoral conformity, tibial slope and posterior condylar geometry have been shown directly to affect deep flexion performance. The goal of this study was to evaluate the kinematics of a fixed-bearing, asymmetric, medial rotation arthroplasty design in moderate and deep flexion. Thirteen study participants (15 knees) with a medial rotation knee arthroplasty were observed performing a weight-bearing lunge activity to maximum comfortable flexion and kneeling on a padded bench from 90 degrees to maximum comfortable flexion using lateral fluoroscopy. Subjects averaged 74 years of age and nine were female. At maximum weight-bearing flexion, the knees exhibited 115 degrees of implant flexion (102 degrees-125 degrees) and 7 degrees (-3 degrees to 12 degrees) of tibial internal rotation. The medial and lateral condylar translated posteriorly by 2 and 5 mm, respectively. At maximum kneeling flexion, the knees exhibited 119 degrees of implant flexion (101 degrees-139 degrees ) and 5 degrees (-2 degrees to 14 degrees) of tibial internal rotation. The lateral condyle translated posteriorly by 11 mm. The medial rotation knee exhibited motion patterns similar to those observed in the normal knee, but less tibial rotation. The medially conforming articulation beneficially controls femoral AP position in deep flexion, in patients who require such motion as part of their lifestyle.

Cost-benefit comparison of the Oxford Knee score and the American Knee Society score in measuring outcome of total knee arthroplasty.

The American Knee Society score (AKSS) and the Oxford Knee score (OKS) are validated outcome measures for evaluation of total knee arthroplasties (TKAs). We investigated whether patient self-assessment using the OKS offers a viable alternative to clinical review using the AKSS. Preoperative, 2-year, 5-year, and 10-year postoperative OKS and AKSS were reviewed from TKA patients. The scores were analyzed using the Pearson correlation. There was good correlation of OKS and AKSS at 2 years. This implies that patient self-assessment is a viable screening tool to identify which patients require clinical review, at 2 years, after TKA. However, the moderate correlation at 5 and 10 years indicates that clinical evaluation remains necessary at these time points.

Correlation between the Oxford Knee and American Knee Society scores at mid-term follow-up.

A sensitive and reproducible measurement of knee surgery outcomes is increasingly needed. However, it has been difficult to compare results because of numerous scoring systems and the publication of data in these systems. Our aim was to compare the more widely used American Knee Society score (AKSS) with the shorter Oxford Knee Score (OKS). The questionnaires were completed preoperatively and at 2, 5, and 10 years postoperatively. A negative correlation of -0.64 (P < .0001) between the OKS and AKSS and the Functional score at 2 years, and a correlation of -0.5 (P < .0001) at 5 and 10 years were found. However, excellent, good, fair, and poor OKS classifications did not correlate well with the AKSS grading (weighted kappa coefficient = 0.06-0.288). This study indicates that the OKS, with its easier analysis and higher compliance rate, can be used more directly to compare studies using the AKSS.

Internal iliac artery pseudoaneurysm in primary total hip arthroplasty.

Vascular injury is one of the rare complications of primary total hip arthroplasty (THA). We report an unusual case of lobulated pseudoaneurysm arising from one of the branches of the left internal iliac artery during acetabulum preparation in THA, which was successfully treated with coil embolization and multidisciplinary care. After 6 years follow up, patient did not have any symptoms related to the hip replacement. We recommend that surgeons should be extremely cautious while drilling medial wall of the acetabulum for depth assessment. Aggressive multidisciplinary approach, including possible support from an interventional radiologist is required for the treatment of such vascular injuries.

Caveats of bisphosphonate abuse.

BACKGROUND: Bisphosphonates (BPs) are the common drugs used for the treatment of postmenopausal osteoporosis. Short term benefits of the BPs are well known. However, there are concerns regarding their long term use. The aim of the study was to analyze the association between atypical femoral fractures and BP misuse/abuse as well as study the outcome of management of these fractures. MATERIALS AND METHODS: A retrospective study of a prospectively studied patients who presented with atypical femoral fractures between January 2010 and August 2012 and were followed up upto June 2014. The cohort consisted of nine female patients (12 fractures) with an average age of 71 years (range 58-85 years). Analysis was done for the indications, duration of BP use, configuration of associated fractures and method of treatment. RESULTS: The mean duration of BP use was 6.6 years (range 4-10 years). BP treatment was initiated without sufficient indication and continued without proper review and followup in most cases. Most patients did not followup and continued to consume BPs without any review by the doctors. All patients had prodromal thigh pain of various duration, which was inadequately investigated and managed before the presentation. Two cases with an incomplete fracture and no thigh pain were managed successfully with conservative treatment. The rest were treated by surgery with intramedullary nailing. The average union time was longer and two fractures went into nonunion which required further surgical intervention. CONCLUSION: Atypical femoral fractures appear to be strongly related to abuse of BPs. Great care is to be exercised at initiation as well as the continuation of BP therapy, and regular review is required. There is a need for improved awareness among physicians about the possibility of such fractures, and interpretation of thigh pain and radiological findings, especially if the patient has been on BPs therapy. Internal fixation for complete fractures and for incomplete fractures with thigh pain is needed. Delayed union is common.

A rare case of giant cell tumour arising from anterior cruciate ligament: Its diagnosis and management.

Tenosynovial giant cell tumour is a locally aggressive tumour arising from the synovia of the fibrous tissue surrounding the joints, tendon sheaths and tendons. Areas of predilection are the hand, and in the case of synovial joints, the knee joint is particularly affected. We describe a rare case of an intra-articular localized tenosynovial giant cell tumour arising from the anterior cruciate ligament (ACL) in a 27 year male who presented with pain and giving way of his left knee without prior history of any trauma. Tests for internal derangement of knee were negative. MRI reported an ACL tear with a heterogeneous fibrous mass attached to the distal part, most probably an organized haematoma. It was decided to do a diagnostic arthroscopy before proceeding for ACL reconstruction. Arthroscopy revealed a purple coloured mass attached to distal part of ACL. The mass was removed piecemeal using an additional posterolateral portal. ACL was found intact. Histopathology reported it to be tenosynovial giant cell tumour. The patient was asymptomatic at each subsequent follow up. It is a rare diagnosis which presented as an ACL tear; in such suspected cases it is prudent to perform a diagnostic arthroscopy before going for ACL reconstruction.

Radiographic Features of Acute Patellar Tendon Rupture.

OBJECTIVE: The purpose of our study was to assess soft tissue features of acute patellar tendon rupture on lateral knee radiograph that would facilitate early diagnosis. METHODS: The participants were divided into two groups of 35 patients each. There were 28 men and seven women with a mean age of 46 years in the control group and 26 men and nine women with a mean age of 47 years in the rupture group. The lateral knee radiograph of each patient was evaluated for Insall-Salvati ratio for patella alta, increased density of the infrapatellar fat pad, appearance of the soft tissue margin of the patellar tendon and bony avulsions. RESULTS: In the rupture group there were three consistent soft tissue radiographic features in addition to patellar alta. These were increased density of infrapatellar fat pad; loss of sharp, well-defined linear margins of the patellar tendon and angulated wavy margin of the patellar tendon while in the control group these features were not observed. CONCLUSIONS: The soft tissue radiographic features described in the rupture group are consistent and reliable. When coupled with careful clinical assessment, these will aid in early diagnosis and further imaging will be seldom required.

Functional outcome following a large head total hip arthroplasty: A retrospective analysis of mid term results.

BACKGROUND: One of the reasons that hip resurfacing and large head metal on metal (MOM) total hip arthroplasty (THA) became popular in Asia was the possible increased range of movement and thereby improved function of the hip joint. Due to concerns of MOM articulation an alternative bearing was sought. Hence, a shift from large head MOM to large head ceramic on ceramic (COC) was made. The aim of this study was to compare the functional outcome including range of motion (ROM) and dislocation rates following large head MOM and large head COC THA. MATERIALS AND METHODS: Retrospectively, 39 primary THA with large head MOM with a mean age of 56 years (range 36-72 years) and average followup of 54 months (range 38-70 months) were compared with 23 primary THA with large head COC bearing with a mean age of 48 years (range 36-68 years) and an average followup of 18 months (range 12-26 months). Functional outcome was assessed using the Modified Harris Hip Score. Dislocation rate and ROM were compared. RESULTS: Global ROM averaged 248 degrees with MOM group and 252 degrees with the COC group. One patient with metal bearing had dislocation at an average 3 year followup which required revision THA while there were no complications in the COC group. MHHS averaged 89 points in MOM and 94 in COC THR. CONCLUSION: This study has shown that large head ceramic on ceramic THA is a good alternative to large head metal on metal THA with comparable dislocation rates and range of movements and without complications of metallosis in Asian patients.

Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing?

BACKGROUND: The aim of our study was to identify whether there was any correlation between the outcome of secondary patellar resurfacing and malrotation of either the femoral or tibial component. METHODS: We identified patients that underwent secondary patellar resurfacing following previous primary total knee arthroplasty (TKA) at a single, large orthopaedic department. Patients were reviewed for range of movement, satisfaction, health status and knee function. CT scanning was performed, assessing rotational alignment of the components. RESULTS: Twenty-one patients (23 knees) were reviewed. Nine out of 21 (39%) were satisfied while 14 (61%) remained dissatisfied after the secondary patellar resurfacing. There were no complications after the secondary procedure. All knees were internally rotated. The mean femoral internal rotation in the satisfied group was 0.92°, and in the dissatisfied group was 2.88° of internal rotation. In the dissatisfied group eight out of 14 TKAs were in >3° femoral internal rotation compared with only one in nine TKAs in the satisfied group (p<0.05). CONCLUSIONS: Investigation for malrotation should be considered in patients with post-operative pain, especially anteriorly, causing significant dissatisfaction amongst patients following TKA. This is especially true if the patella has not been primarily resurfaced and secondary resurfacing is being considered. Patients with more than 3(°) of femoral internal rotation undergoing secondary patella resurfacing should be warned of the possibility of a poor outcome. It may well be that if the underlying problem is component malrotation, revision knee replacement may lead to a more satisfactory outcome than secondary resurfacing alone. LEVEL OF EVIDENCE: Level of Evidence III.

In vivo weight-bearing kinematics with medial rotation knee arthroplasty.

Knee arthroplasties are designed to accommodate flexion, axial rotation and anteroposterior (AP) translation. Axial rotation during extension varies, with some rotating platform devices allowing unrestricted rotation while some conforming fixed-bearing designs almost none. The purpose of this study was to examine in vivo kinematics of a fixed-bearing medial rotation-type arthroplasty (MRK) during weight-bearing activities. Fifteen knees with a medial pivot TKA design were studied during step and pivot activities using lateral fluoroscopy and model-image registration. Average knee kinematics during the step activity showed little AP translation or rotation from 0 degrees -100 degrees flexion. During the pivot activity, the mean tibial internal rotation in individual knees was 7 degrees (3 degrees -19 degrees ). Mean condylar translations for individual knees were 3mm medially and 5mm laterally. The medial pivot prosthesis design provides anteroposterior stability during demanding activities, and exhibits a medial pivot motion pattern when subjected to twisting.