Treatment of moderate hallux valgus by percutaneous, extra-articular reverse-L Chevron (PERC) osteotomy.

AIMS: The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. PATIENTS AND METHODS: A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. RESULTS: The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. CONCLUSION: Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. TAKE HOME MESSAGE: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion.

The hamstring muscle complex.

PURPOSE: The anatomical appearance of the hamstring muscle complex was studied to provide hypotheses for the hamstring injury pattern and to provide reference values of origin dimensions, muscle length, tendon length, musculotendinous junction (MTJ) length as well as width and length of a tendinous inscription in the semitendinosus muscle known as the raphe. METHODS: Fifty-six hamstring muscle groups were dissected in prone position from 29 human cadaveric specimens with a median age of 71.5 (range 45-98). RESULTS: Data pertaining to origin dimensions, muscle length, tendon length, MTJ length and length as well as width of the raphe were collected. Besides these data, we also encountered interesting findings that might lead to a better understanding of the hamstring injury pattern. These include overlapping proximal and distal tendons of both the long head of the biceps femoris muscle and the semimembranosus muscle (SM), a twist in the proximal SM tendon and a tendinous inscription (raphe) in the semitendinosus muscle present in 96 % of specimens. CONCLUSION: No obvious hypothesis can be provided purely based on either muscle length, tendon length or MTJ length. However, it is possible that overlapping proximal and distal tendons as well as muscle architecture leading to a resultant force not in line with the tendon predispose to muscle injury, whereas the presence of a raphe might plays a role in protecting the muscle against gross injury. Apart from these architectural characteristics that may contribute to a better understanding of the hamstring injury pattern, the provided reference values complement current knowledge on surgically relevant hamstring anatomy. LEVEL OF EVIDENCE: IV.

Endoscopic resection of a calcaneonavicular coalition.

Calcaneonavicular coalition is a congenital anomaly characterized by a connection between the calcaneus and the navicular. Surgery is required in case of chronic pain and after failure of conservative treatment. The authors present here the surgical technique and results of a 2-portals endoscopic resection of a calcaneonavicular synostosis. Both visualization and working portals must be identified with accuracy around the tarsal coalition with fluoroscopic control and according to the localization of the superficial peroneus nerve, to avoid neurologic damages during the resection. The endoscopic procedure provides a better visualization of the whole resection area and allows to achieve a complete resection and avoid plantar residual bone bar. The other important advantage of the endoscopic technique is the possibility to assess and treat in the same procedure-associated pathologies such as degenerative changes in the lateral side of the talar head with debridement and resection.

Dolor fémoro-rotuliano. Tratamiento mediante denervación rotuliana artroscópica / Patellofemoral pain: treatment by arthroscopic patellar denervation

Introducción. El objetivo de este estudio es presentar una nueva técnica artroscópica que permite el tratamiento de pacientes con dolor fémoro-rotuliano, y nuestra experiencia y los primeros resultados de la denervación rotuliana artroscópica.Material y método. Se presentan 10 pacientes (8 mujeres y2 hombres; media de 33 años) con dolor fémoro-rotulianoy sin causas evidentes que justifiquen su clínica, tratados mediante denervación rotuliana artroscópica.Resultado. Se ha conseguido una mejoría significativa clínica y funcional en todos los casos. A los 6 meses todos los pacientes habían vuelto a sus actividades cotidianas sin dificultad, incluida la práctica deportiva sin limitaciones. A los dos años de evolución no se han observado cambios clínicos.Conclusiones. La denervación rotuliana artroscópica es una alternativa válida de tratamiento para aquellos casos que presentan dolor fémoro-rotuliano sin alteraciones evidentes. La técnica que se describe es sencilla y segura; al igual que todas las técnicas artroscópicas presenta una escasa morbilidad. A pesar de los buenos resultados el número de pacientes es escaso y es necesario completar el estudio

Introduction. This study presents a new arthroscopic technique for the treatment of patients with patellofemoral pain together with our experience of the procedure and the preliminary results of arthroscopic patellar denervation in patients with intractable patellofemoral pain we have obtained.Materials and methods. Ten patients with patellofemoralpain and no evident alterations (8 women, 2 men; mean age33 years) were treated by arthroscopic patellar denervation, involving a thermal lesion to the peripatellar soft tissue.Results. Considerable functional improvement was obtainedin all cases. At six months after the procedure, all patients had resumed their normal daily activities and the younger patients were able to do sports without difficulty. None of the patients showed any clinical changes during the two-year follow-up period.Conclusions. Patellar denervation may be the solution forcases of intractable patellofemoral pain without evident alterations. The technique described in this study is simple to perform and safe. As with other arthroscopic procedures, morbidity is low. This is a preliminary study in a small number of patients, but the results warrant further study with a control group and long-term follow up

An arthroscopic bone graft procedure for treating anterior-inferior glenohumeral instability.

The purpose of this study is twofold: to present an arthroscopic method for treating anterior-inferior glenohumeral instability, and to evaluate its feasibility in a cadaveric model. This arthroscopic technique was performed in ten fresh frozen cadaver shoulder specimens. Quality of the results following the procedure were evaluated subjectively by assessing how the bone block graft was placed respect glenoid rim. We also evaluated adjacent axillary nerve and the neuro-vascular structures medial to the coracoid. We had six 'good' results, two 'fair' results, and two 'poor' results. The present study indicates that an anterior bone graft procedure for treating anterior bone defects of the glenoid in anterior inferior shoulder instability can be successfully performed. The worst results occurred during our first five procedures, suggesting a learning curve. However, the learning curve doesn't appear to be steep, as the good results gained in the last five procedures confirm.

Fracturas osteocondrales del astrágalo: posibilidades artroscópicas y técnicas de reparación condral / Osteochondral fractures of the talus: arthroscopic possibilities and chondral repair techniques

Introducción. La artroscopia de tobillo ha experimentadoen estos últimos años un avance importante como consecuencia de la mejora de la tecnología y la experiencia quirúrgica acumulada. Actualmente es posible acceder artroscópicamente al tobillo y a los huesos del retropié, como a las lesiones condrales del astrágalo. No obstante, la técnica exige una adecuada curva de aprendizaje y la suficiente experiencia en otras regiones más habituales. La colocación de una tracción estable, los conocimientos anatómicos, lasistemática de los abordajes, la vía de agua accesoria y el instrumental adecuado vuelven a ser, como siempre, losprotagonistas de una historia que se repite en cada articulación.Astrágalo. Con respecto a las lesiones del astrágalo, lasprincipales indicaciones de la artroscopia son el control de la reducción de los fragmentos en las fracturas articulares y el tratamiento de lesiones condrales y osteocondrales, tantopara su extirpación como para su osteosíntesis. Así mismo, es útil en el tratamiento de secuelas, como sinovectomías, limpiezas articulares o artrodesis.Tratamiento. A nivel del tratamiento o reparación de las lesiones osteocondrales del astrágalo, actualmente disponemos de diversas técnicas, como el desbridamiento y estimulación de la médula ósea, las técnicas de fijación del fragmento y los métodos de regeneración de nuevo cartílago hialino, entre los que se encuentran el autoinjerto osteocondral o mosaicoplastia, el aloinjerto y la implantación de condrocitos autólogos cultivados

Introduction. In the last few years, significant advances have been made in ankle arthroscopy as a result of improvements in technology and the surgical experience accumulated. It is currently possible to arthroscopically approach the ankle andthe hindfoot bones in an attempt to address chondral injuries of the talus. However, the technique requires a considerable learning curve and enough experience of other more usual regions. The creation of stable traction, the anatomical knowledge, the mastery of the different surgical techniques, the use of accessory portals and of the appropriate instruments are allprotagonists of a story that repeats itself no matter which of the joints we may want to approach.Talus. As regards talar injuries, the main indications for arthroscopy are controlling the reduction of fragments in joint fractures and the treatment of chondral and osteochondral lesions, with a view to both excision and osteosynthesis.Likewise, it is useful for the treatment of such sequelaeas synovectomies, joint lavage or arthrodesis.Treatment. A series of techniques are currently availablefor the treatment or repair of osteochondral lesions of the talus, like debridement and bone marrow stimulation, as well as fragment fixation techniques and the new methods for new hyaline cartilage regeneration like osteochondral autografting or mosaicplasty, allografting and cultured autologous chondrocyte implantation

Fracturas osteocondrales del astrágalo: posibilidades artroscópicas y técnicas de reparación condral / Osteochondral fractures of the talus: arthroscopic possibilities and chondral repair techniques

Introducción. La artroscopia de tobillo ha experimentadoen estos últimos años un avance importante como consecuencia de la mejora de la tecnología y la experiencia quirúrgica acumulada. Actualmente es posible acceder artroscópicamente al tobillo y a los huesos del retropié, como a las lesiones condrales del astrágalo. No obstante, la técnica exige una adecuada curva de aprendizaje y la suficiente experiencia en otras regiones más habituales. La colocación de una tracción estable, los conocimientos anatómicos, la sistemática de los abordajes, la vía de agua accesoria y elinstrumental adecuado vuelven a ser, como siempre, losprotagonistas de una historia que se repite en cada articulación.Astrágalo. Con respecto a las lesiones del astrágalo, lasprincipales indicaciones de la artroscopia son el control de la reducción de los fragmentos en las fracturas articulares y el tratamiento de lesiones condrales y osteocondrales, tanto para su extirpación como para su osteosíntesis. Así mismo, es útil en el tratamiento de secuelas, como sinovectomías,limpiezas articulares o artrodesis.Tratamiento. A nivel del tratamiento o reparación de las lesiones osteocondrales del astrágalo, actualmente disponemos de diversas técnicas, como el desbridamiento y estimulación de la médula ósea, las técnicas de fijación del fragmento y los métodos de regeneración de nuevo cartílago hialino, entre los que se encuentran el autoinjerto osteocondral o mosaicoplastia, el aloinjerto y la implantación de condrocitos autólogos cultivados

Introduction. In the last few years, significant advances have been made in ankle arthroscopy as a result of improvements in technology and the surgical experience accumulated. It is currently possible to arthroscopically approach the ankle and the hindfoot bones in an attempt to address chondral injuriesof the talus. However, the technique requires a considerable learning curve and enough experience of other more usual regions. The creation of stable traction, the anatomical knowledge, the mastery of the different surgical techniques, the use of accessory portals and of the appropriate instruments are allprotagonists of a story that repeats itself no matter which of the joints we may want to approach.Talus. As regards talar injuries, the main indications for arthroscopy are controlling the reduction of fragments in joint fractures and the treatment of chondral and osteochondral lesions, with a view to both excision and osteosynthesis. Likewise, it is useful for the treatment of such sequelae as synovectomies, joint lavage or arthrodesis.Treatment. A series of techniques are currently availablefor the treatment or repair of osteochondral lesions of the talus, like debridement and bone marrow stimulation, as well as fragment fixation techniques and the new methods for new hyaline cartilage regeneration like osteochondral autografting or mosaicplasty, allografting and cultured autologous chondrocyte implantation

Tratamiento quirúrgico percutáneo del hallux valgus mediante osteotomías múltiples / Percutaneous hallux valgus repair by multiple osteotomies

Objetivo. Se presenta la experiencia del tratamiento del hallux valgus mediante la realización de osteotomía distal del primer metatarsiano y osteotomía de la falange con liberación del abductor por técnicas percutáneas.Material y método. Desde junio de 1996 hasta junio de l997 han sido intervenidos 64 pacientes, la mayor parte mujeres con hallux valgus de grado moderado con un ángulo intermetatarsiano medio de 14,5° y un ángulo del complejo articular proximal (PASA) de 17,7° de media.Resultados. Los resultados obtenidos desde el punto de vista radiológico pusieron de manifiesto una corrección media de 5° del ángulo intermetatarsal y se obtiene un valor medio del PASA de 8,2°. La consolidación de las osteotomías se consiguió en el 100 por ciento de los pies sin retardos de consolidación significativos, salvo en un caso que precisó más de tres meses. Por lo que se refiere a las complicaciones, al no utilizar ningún medio de fijación, el desplazamiento de las osteotomías fue muy frecuente, pero sólo en un 8 por ciento de la serie tuvieron repercusión clínica. El acortamiento del primer metarsiano fue la norma alcanzando como media 0,7 cm, lo que se intentó compensar con un descenso de la cabeza del primer metatarsiano; la metatarsalgia por trasferencia en esta serie ocurrió en el 25 por ciento de los casos. No se presentaron alteraciones neurológicas, infección ni síndromes flebíticos postquirúrgicos. Conclusión. Parece que la técnica de Reverdin-Isham, por vía percutánea, es un buen método para el tratamiento del hallux valgus, ya que proporciona unos resultados clínicos muy aceptables, sin presentar complicaciones importantes; en el momento actual hay que asociar con mucha más frecuencia la realineación metatarsal a la cirugía del hallux valgus para evitar las metatarsalgias por trasferencia (AU)

Vascularity and neuroreceptors of the pes anserinus: anatomic study.

The primary aim of this work was to evaluate the neurovascular network of the pes anserinus (PA) at its tibial insertion because the PA is often used for anterior cruciate ligament (ACL) reconstruction. Four fresh cadaver knees were injected with India ink gelatin solution and the arteries that supply blood to the PA were identified; microscopic studies of vessels and nerve fibers were also performed. Superficial and deep branches of the inferior medial genicular artery contribute to an arterial arch that courses deep to the PA insertion. A widespread array of small vessels and nerve fibers penetrate the PA insertion and course along the length of the gracilis and semitendinosus tendons. Computer analysis revealed that the mean diameter of the vessels decreased from 2201 microm at the insertion to 661 microm midway along the length of the tendon (mean tendon length = 17 cm; range = 13-21 cm); the cross-sectional area of the vessels per histologic section decreased from 336.37-137.05 microm(2). This study demonstrates that the PA insertion is well vascularized and richly innervated and that these morphological features continue along the length of the tendons.

A cadaveric study of endoscopic decompression of the cubital tunnel.

A cadaveric study of endoscopic decompression of the cubital tunnel was performed. Four fresh-frozen upper limbs were used for dissection, with a focus on the relationship between the ulnar nerve and Osborne's band. The endoscopic procedure was performed with the Ectra II system (Smith & Nephew, Andover, MA). After the surgical procedure, further dissection was done to evaluate the effectiveness and safety of the endoscopic cut of Osborne's band. Our conclusion is that endoscopic release is not a technically difficult procedure, and may be limited to certain clinical situations.