Operative Outcome of Side-Locking Loop Suture Technique Accompanied by Autologous Semitendinosus Tendon Grafting for Chronic Rupture of Achilles Tendon.

BACKGROUND: The purpose of this retrospective study was to clarify the operative outcomes of the side-locking loop suture (SLLS) technique accompanied by autologous semitendinosus tendon grafting for chronic Achilles tendon rupture. METHODS: A chart review was conducted of consecutive patients treated with the SLLS technique at our department from 2012 to 2017. Postoperatively, a below-knee splint was applied for 2 weeks in 20 degrees of plantar flexion and then active range of motion exercise was started. Partial weightbearing exercise was allowed at 4 weeks according to patient tolerance, and full weightbearing without crutches was allowed at 8 weeks. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale score and the Achilles tendon rupture score (ATRS) were used to evaluate clinical outcomes preoperatively and at the final follow-up. RESULTS: Ten patients (6 men, 4 women) were included in the analysis. Mean AOFAS ankle-hindfoot scale score increased significantly from 64.2 ± 5.6 points preoperatively to 95.0 ± 5.3 points at the final follow-up (P < .001). The mean ATRS also increased significantly from 29.8 ± 4.4 points to 86.2 ± 7.7 points, respectively (P < .001). Mean time between surgery and ability to perform 20 continuous double-leg heel raises of the operated foot was 13.5 ± 3.4 (range 10-18) weeks. One patient complained of postoperative hypoesthesia in the foot, which had spontaneously resolved by 3 months after surgery. CONCLUSION: The SLLS technique accompanied by autologous semitendinosus tendon grafting provided successful operative outcomes for patients with chronic Achilles tendon rupture regardless of the size of the defect, and thus long-term orthotic use was not needed after surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Simultaneous ossicle resection and lateral ligament repair give excellent clinical results with an early return to physical activity in pediatric and adolescent patients with chronic lateral ankle instability and os subfibulare.

PURPOSE: To elucidate surgical outcomes in pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare. METHODS: A retrospective chart review was conducted of pediatric/adolescent patients with chronic lateral ankle instability and os subfibulare following simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active range of motion exercises for the ankle in our department between 2013 and 2017. Clinical outcomes were evaluated by comparing preoperative and final follow-up American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and Karlsson-Peterson ankle function scores. Intervals between surgery and return to physical education in school were determined. RESULTS: 31 feet of 15 male and 16 female patients were examined. Mean postoperative follow-up duration was 40.7 ± 12.7 (range 24-66) months. Mean AOFAS score increased significantly from 66.3 ± 2.5 (range 62-77) preoperatively to 96.5 ± 4.9 (range 87-100) at final follow-up (p < 0.001). Mean Karlsson-Peterson score increased significantly from 51.7 ± 4.0 (range 47-70) preoperatively to 95.3 ± 6.7 (range 80-100) at final follow-up (p < 0.001). Mean interval between surgery and return to physical education in school was 11.4 ± 1.6 (range 10-18) weeks. CONCLUSION: Simultaneous ossicle resection and lateral ligament repair using suture anchors with subsequent immediate full weightbearing and active ankle range of motion exercises may give excellent clinical outcomes with early return to physical activity for chronic lateral ankle instability with os subfibulare in pediatric/adolescent patients desiring an early return to physical activity. Level of evidence III.

Stress fracture of the posterior talar process in a female long-distance runner treated by osteosynthesis with screw fixation via two-portal hindfoot endoscopy: a case report.

BACKGROUND: Stress fracture of the lateral tubercle of the posterior talar process in runners is extremely rare. Here, we describe a case of a female long-distance runner who sustained a stress fracture of the lateral tubercle of the posterior talar process. Osteosynthesis with screw fixation via two-portal hindfoot endoscopy achieved a good surgical outcome with a less invasive procedure. CASE PRESENTATION: An 18-year-old female long-distance runner who belonged to her university's road running club presented to our institution with a half-year history of persistent left hindfoot pain when running. Radiographs revealed a stress fracture of the lateral tubercle of the posterior talar process. Because the fracture showed no signs of healing 3 months after starting conservative therapy, osteosynthesis with screw fixation was performed via two-portal hindfoot endoscopy. Non-contrast computed tomography at 10 weeks postoperatively revealed consolidation of the stress fracture. At 15 weeks postoperatively, the patient was permitted to jog and return to athletic activity while wearing an orthosis. As of this writing 2 years postoperatively, she remains an active competitive runner. CONCLUSIONS: Osteosynthesis with screw fixation via two-portal hindfoot endoscopy was a less invasive procedure that successfully treated stress fracture of the lateral tubercle of the posterior talar process in this female long-distance runner.

Endoscopic plantar fascia release via a suprafascial approach is effective for intractable plantar fasciitis.

PURPOSE: To evaluate the medium-term clinical results of endoscopic plantar fascia release (EPFR) using a suprafascial approach for recalcitrant plantar fasciitis. METHODS: Twenty-four feet of twenty-three patients who underwent EPFR using a suprafascial approach were followed up for more than 2 years using the American Orthopedic Foot and Ankle Society (AOFAS) score. The AOFAS score at final follow-up was compared between patients who participated in athletic activity (group A) and those who were sedentary (group S) and between those with and those without calcaneal spur (group with CS and group without CS, respectively). The ability of patients to return to athletic activity, and if so, the time interval between surgery and return to athletic activity, were investigated in group A. Complications were recorded. RESULTS: The median follow-up duration was 48 months. The mean AOFAS score in all patients increased significantly between before surgery and final follow-up (P < 0.001). The mean score in group A at final follow-up was significantly higher than that in group S (P < 0.05). However, there was no significant difference in the mean score at final follow-up between the groups with and without CS. In group A, all patients could return to athletic activity after a median 8 weeks. Injury to the first branch of the lateral plantar nerve occurred in three feet. CONCLUSION: EPFR using a suprafascial approach was effective for recalcitrant plantar fasciitis. However, the prognosis of sedentary patients was inferior to that of patients engaged in athletic activity. LEVEL OF EVIDENCE: IV.

Surgical outcome of posterior ankle impingement syndrome with concomitant ankle disorders treated simultaneously in patient engaged in athletic activity.

BACKGROUND: It is unclear whether simultaneous surgery for posterior ankle impingement syndrome (PAIS) and concomitant ankle disorders, such as anterior ankle impingement syndrome (AAIS), lateral ankle instability (LAI), and osteochondral lesion of the talus (OLT), allows for early return to athletic activity. METHODS: Ninety-seven patients who engaged in athletic activity (mean age 27 [range 18-43] years) and were treated by a hindfoot endoscopic approach for PAIS alone or simultaneously for PAIS and concomitant ankle disorders were included in this study. The patients were divided into four groups: PAIS alone (group A, n = 61), PAIS with AAIS (group B, n = 8), PAIS with LAI with or without AAIS (group C, n = 20), and PAIS with OLT with or without AAIS/LAI (group D, n = 8). In all patients, the concomitant ankle disorder was treated simultaneously by arthroscopic debridement for AAIS, bone marrow stimulation or autologous cancellous bone transplantation for OLT, and anterior talofibular ligament repair or reconstruction for LAI. American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores before and 2 years after surgery and times from surgery to resuming training and athletic activity were compared between the groups. RESULTS: Mean AOFAS score improved significantly after surgery in all groups (groups A and C, P < .0001; groups B and D: P < .05). The time taken to return to training was significantly longer in group D than in groups A, B, and C (all P < .01) as was the time taken to return to athletic activity in groups C and D when compared with group A (P < .01); however, there were no significant differences in this regard between groups B and C. CONCLUSION: Concomitant surgery for AAIS and LAI with PAIS did not delay the postoperative start of training, however, concomitant surgery for LAI and OLT delayed the return to athletic activity when compared with PAIS surgery alone. STUDY DESIGN: Clinical Retrospective Comparative Study.

Midterm clinical results of osteochondral autograft transplantation for advanced stage Freiberg disease.

PURPOSE: We aimed to evaluate the midterm clinical results of osteochondral autograft transplantation (OAT) for advanced stage Freiberg disease. METHODS: This study included consecutive patients who underwent OAT for advanced stage Freiberg disease and were followed postoperatively for more than five years. In all cases, the autograft was harvested from the ipsilateral knee joint. Clinical evaluation was performed based on the American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal-Interphalangeal Scale (AOFAS) score and visual analogue scale (VAS) score, which were done pre-operatively and at the most recent follow-up. Radiological evaluation was performed at two years after the operation. Furthermore, the most recent six patients underwent magnetic resonance imaging (MRI) five years after the operation to assess the configuration of the articular surface. RESULTS: A total of 13 patients (all female; mean age 16.7 years; range 10-38 years) were included and followed up for a mean duration of 67.2 months (range 60-100 months). The mean AOFAS significantly improved from a score of 66.9 ± 5.3 (range 59-77) to 93.0 ± 7.6 (range 82-100) (p < 0.0001). Likewise, the mean VAS significantly improved from a score of 72.7 ± 10.3 (range 60-90) to 7.8 ± 7.2 (range 0-20) (p < 0.0001). Radiographs at two years after the operation revealed no osteoarthritic change in all cases. MRI at five years after the operation showed consolidation of the transplanted autograft and smooth configuration of the articular surface in the six cases. CONCLUSIONS: OAT may be effective for advanced stage Freiberg disease. Further studies are necessary before this technique can become the standard operative treatment.

Ligament reconstruction with single bone tunnel technique for chronic symptomatic subtle injury of the Lisfranc joint in athletes.

INTRODUCTION: Only few procedures for Lisfranc ligaments reconstruction to treat subtle injury of the Lisfranc joint have been reported. We have developed a novel technique for Lisfranc ligaments reconstruction, which was applied to treat chronic symptomatic subtle injuries that had failed to respond to initial treatment or were misdiagnosed. This article describes the technique and its operative outcome in a small case series. METHODS: Between April 2011 and October 2013, 5 (4 male and 1 female) athletes with a mean age of 19.4 (range 17-21) years were diagnosed with chronic subtle injury of the Lisfranc joint and underwent our novel reconstructive operation. In this technique, only a bone tunnel between the medial cuneiform and the second metatarsal bone is needed for near-anatomical reconstruction of the dorsal and interosseous ligaments. All patients were evaluated before and at 1 year after surgery using the American Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle-midfoot. In addition, the interval between surgery and return to athletic activity, defined as return to near pre-injury performance level, was investigated. RESULTS: Mean duration of postoperative follow-up was 18.8 (range 12-26) months. Mean AOFAS score improved significantly from 74.6 ± 2.5 (range 71-77) preoperatively to 96.0 ± 5.5 (range 90-100) at 1 year after the operation (p < 0.01). All patients were able to return to their previous athletic activities and the interval between surgery and return to athletic activity was 16.8 ± 1.1 (range 15-18) weeks. There was no complication related to the operation. CONCLUSION: The results of this study suggest that our technique of Lisfranc ligaments reconstruction using autologous graft is effective for athletes with chronic subtle injury. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Endoscopic Surgery for Symptomatic Unicameral Bone Cyst of the Proximal Femur.

Recently, surgical treatment of a symptomatic unicameral cyst of the proximal femur has been achieved with less invasive procedures than traditional open curettage with an autologous bone graft. In this article we introduce endoscopic surgery for a symptomatic unicameral cyst of the proximal femur. The presented technique, which includes minimally invasive endoscopic curettage of the cyst and injection of a bone substitute, not only minimizes muscle damage around the femur but also enables sufficient curettage of the fibrous membrane in the cyst wall and the bony septum through direct detailed visualization by an endoscope. Furthermore, sufficient initial strength after curettage can be obtained by injecting calcium phosphate cement as a bone substitute.

Effects of amitriptyline and gabapentin on bilateral hyperalgesia observed in an animal model of unilateral axotomy.

Nociceptive responses in an animal model of peripheral nerve injury were studied. The left common sciatic nerve was exposed, tightly ligated at two locations and transected between the ligatures. A bilateral decrease in the nociceptive threshold to mechanical stimulation was observed within 3 h after the operation. The skin of the lateral dorsal part of the injured paw was hypoalgesic, while the medial dorsal paw innervated by the intact saphenous nerve and the contralateral dorsal paw exhibited hyperalgesia. Amitriptyline, an antidepressant, at 25, 50 and 100 mg/kg per day, p.o., and gabapentin, an anticonvulsant, at 30, 100 and 300 mg/kg per day, p.o., significantly inhibited the decrease in the mechanical nociceptive threshold in the injured and uninjured paws. The effects of amitriptyline at 25 and 50 mg/kg were evident at doses that did not cause neurologic deficits as assessed by the inclined screen test. Indomethacin, a cyclooxygenase inhibitor, and morphine (except at the highest dose of 30 mg/kg, s.c.) showed no analgesic effects in this model. The tail-flick latency was also significantly decreased compared with intact rats. Similar bilateral hyperalgesia was observed when axotomy was performed using silk thread instead of chromic gut. When this axotomy model was applied to mice, the nociceptive thresholds in both paws immediately showed a significant decrease in the same manner as in rats. The bilateral and systemic hyperalgesia observed in this axotomy model, which resembles the clinical features of chronic neuropathic pain, suggests the involvement of the central nervous system in the maintenance of the chronic pain state.