Ankle Arthroscopy Without Tourniquet: A Mid-Term Follow-Up.

Ankle arthroscopy is a surgical technique still most commonly performed with a tourniquet. In 2017, we published a randomized controlled trial comparing anterior ankle arthroscopy with and without the tourniquet use. The results showed feasibility of performing the anterior ankle arthroscopy without the tourniquet, as well as comparable functional outcomes at 3- and 6-month follow-up visits, regardless of the tourniquet use. The aim of the current study was to evaluate mid-term functional outcomes after a 5-year period and to document patient satisfaction with the surgery. All 49 available patients from the original study were asked to attend examination at the 60-month follow-up visit. Patients were assessed with the same functional scores, as well as with additional Munich Ankle Questionnaire (MAQ) to assess the postoperative subjective and objective outcome and Abdelatif questionnaire to evaluate patient satisfaction. Any new complications were noted. At the 60-month follow-up visit, 39 (79.6%) patients were available for examination. No significant difference was found between the groups regarding the functional outcomes or the MAQ. In comparison with the 3- and 6-month follow-up visits, no further improvement or decline of functional outcomes was present. High patient satisfaction was found in both groups. No new complications were noted during the follow-up period. Similar improvement in both groups reveals that the anterior ankle arthroscopy can be performed without the tourniquet with no negative impact on mid-term functional outcomes. In addition, high patient satisfaction can be expected even after 5 years from surgery, regardless of the tourniquet use.

Arthroscopic resection of localized tenosynovial giant cell tumor in the deep infrapatellar bursa: a case report.

Tenosynovial giant cell tumor (TGCT) is a rare disease characterized by the proliferation of the synovial membrane of a joint, tendon sheath, or bursa. TGCTs in joints are subdivided into the diffuse or localized type. The localized TGCT most frequently affects the knee and may occur in any knee compartment. The most common localization is the Hoffa's fat pad, followed by the suprapatellar pouch and the posterior capsule. Here, we describe a case of a histopathologically proven TGCT of the knee, found in an unusual localization in the deep infrapatellar bursa, which was diagnosed by magnetic resonance imaging. The tumor was entirely arthroscopically resected. The patient had no further complaints following the operation, and there was no recurrence at the 18-month follow-up. Even though TGCT of the knee is uncommon, it should not be overlooked by orthopedic and trauma surgeons, and excision should be regarded as a reliable treatment option. The form of surgical treatment, either open or arthroscopic, should be determined based on a combination of the surgeon's preference and the best approach to the anatomical location of the disease.

Comparison of arthroscopy versus percutaneous radiofrequency thermal ablation for the management of intra- and juxta-articular elbow osteoid osteoma: case series and a literature review.

BACKGROUND: Today, intra-articular and juxta-articular osteoid osteomas are treated with arthroscopy and radiofrequency thermal ablation. However, for the case of an elbow joint, arguments are made for the use of a minimally invasive technique to be the optimal choice. This study aims to analyse our experiences of arthroscopically treated elbow osteoid osteomas and to compare it with the published results of both techniques. METHODS: The retrospective study analyses the patients who underwent elbow arthroscopy ablation of an elbow osteoid osteoma at a single institution from January 2014 until March 2020. Clinical and diagnostic features, success and treatment failure rates, complications and tumour recurrence rates were all compared to 13 studies of intra-articular elbow osteoid osteoma arthroscopic ablation and 15 studies involving radiofrequency thermal ablation of intra-articular osteoid osteoma within different joints. RESULTS: Four males and two females, with a mean age of 19.3 years, were encompassed. All the patients had immediate postoperative pain relief and improved range of motion. No tumour recurrences were observed during a median of 21.7 months. The literature review yielded 86.4% success rate, 68.2% successful biopsies, one minor complication and no recurrences following the arthroscopic ablation of an elbow osteoid osteoma; while radiofrequency thermal ablation of an intra-articular elbow osteoid osteoma yielded 96.3% success rate, 33.3% successful biopsies, no complications and 3.7% recurrence rate. CONCLUSIONS: Our results are consistent with the published literature proving that arthroscopic ablation is an efficient method with low treatment failure rates and no recurrences in treating intra- and juxta-articular elbow osteoid osteomas. Advantages of arthroscopic ablation stem from the ability to visualise and safely deal with the lesion and the joint's reactive changes resulting in high biopsy rates, no recurrences and better postoperative elbow's range of motion. Still, the technique selection should be personalised considering the medical expertise of every institution.

Hindfoot Endoscopy for the Treatment of Localized Pigmented Villonodular Synovitis.

Introduction: Pigmented villonodular synovitis (PVNS) is a rare and benign proliferative lesion affecting synovial lining of joints, bursae, and tendon sheaths. Depending on the extent of synovial involvement, two forms are distinguished, diffuse, and localized. Intra-articular localized form of PVNS (LPVNS) presents as a nodular, well circumscribed, pedunculated, or sessile soft-tissue mass. Case Presentation: We report a case of an unusual localization of LPVNS in posterior ankle recess in a 42-year-old male with concomitant anterior ankle impingement syndrome. To address both the posterior and the anterior ankle disorders the patient was treated with combined two-portal endoscopic hindfoot approach and anterior ankle arthroscopy within the same operative session. The hindfoot endoscopy encompassed complete removal of the localized mass, partial synovectomy of the area at the base of the lesion, removal of os trigonum, and a loose body impinged in the interval between tibia and fibula. The anterior ankle arthroscopy included removal of the osteophytes from the anterior distal tibia and dorsal talus. Patient continued his normal daily and sporting activities without any restrictions and no recurrence of LPVNS 2 years after the surgery. Conclusion: PVNS is an important clinical entity that should always be thought of as a differential diagnosis when treating patients with ankle disorders. Hindfoot endoscopy, when performed by an experienced ankle surgeon, is a safe and effective procedure for LPVNS of the posterior ankle recess, when deemed amenable to complete resection.

Arthroscopic removal as an effective treatment option for intra-articular osteoid osteoma of the knee.

BACKGROUND: Intra-articular osteoid osteoma (iaOO) can be found in 5.2% up to 10% of cases. They may cause non-specific symptoms, mimicking degenerative or traumatic pathologies. If iaOO is left untreated, it may lead to severe muscle atrophy, tenderness, swelling, and limited range of motion. Therefore, surgical treatment is recommended. The main goal of surgical treatment is complete removal or destruction of iaOO. AIM: To evaluate the efficiency of arthroscopic removal of iaOO of the knee in our cases and cases available in the literature. METHODS: Analysis of available hospital records of four patients with iaOO of the knee treated by arthroscopic removal from August 2005 to December 2015 at our Department was performed. All patients had a diagnosis of iaOO confirmed by histopathologic analysis. Additional literature review of cases of iaOO of the knee available on PubMed and Google Scholar was made. All cases of iaOO of the knee treated by arthroscopic or arthroscopically assisted removal were reviewed in order to further evaluate the efficiency of the method. RESULTS: The average age of patients included in our study was 23.2 (range 16-37) years. The average duration of the symptoms prior to surgery was 14.2 (range 6-24) months. All of the patients had persistent knee pain. Three patients reported worsening of pain during the night, while two reported worsening of pain during activity. Three patients reported alleviation of pain on non-steroidal anti-inflammatory drugs (NSAIDs), while one patient reported partial alleviation of pain on NSAIDs. No intraoperative complications were noted, and the postoperative period was uneventful in all patients. The patients reported immediate pain relief in the postoperative period. No recurrence of the disease was noted in any of the patients during the follow-up period of at least 24 mo. The literature review revealed 14 cases with an average age of 27.6 (range 16-48) years and onset of symptoms 27.7 (range 6-108) months prior to surgery, with recurrence of the disease noted in a single case. CONCLUSION: Arthroscopic removal is an efficient treatment method that allows excision of iaOO that is neither insufficient nor excessive, thus avoiding disease recurrence while obtaining adequate material for histopathologic analysis.

Anterior and Posterior Arthroscopic Treatment of Primary Synovial Chondromatosis of the Ankle.

BACKGROUND: Primary synovial chondromatosis (PSC) is a progressive disorder of unknown etiology resulting in formation of multiple loose bodies. If left untreated, it may lead to degenerative changes or malignant transformation to chondrosarcoma. METHODS: Seventeen patients who underwent combined posterior and anterior ankle arthroscopy within the same operative session and had histologically confirmed PSC were included in this retrospective study. American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score was used to evaluate ankle function preoperatively and at a final follow-up. A 3-question survey was used to evaluate patient's satisfaction at the final follow-up. RESULTS: In 14 patients, loose bodies were found in both compartments of the ankle, in 2 only in the anterior compartment, and in 1 only in the posterior compartment. All patients had evident signs of synovial inflammation in both compartments. The AOFAS Ankle-Hindfoot score increased from the preoperative median score of 65 (range, 29-90) to 95 (range, 65-100) at the final follow-up. Fourteen patients reported they were extremely satisfied with the outcome, 1 was moderately satisfied, and 2 were dissatisfied. No cases of recurrence of synovitis or loose body formation were noted, nor any signs of malignant transformation during the follow-up period. CONCLUSION: We believe the risk of recurrence of PSC, which is in close relation to malignant transformation, can be minimized by performing a complete synovectomy of the ankle. Our experience and review of literature makes us believe that ankle PSC should be regarded as a whole joint disorder. Performing a combined posterior and anterior arthroscopic procedure within the same operative session should always be considered in patients with ankle PSC. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Importance of Space-Occupying Anatomical Variations in Peroneal Tendoscopy.

BACKGROUND: We hypothesized that peroneal tendons disorders are more commonly associated with anatomical variations, which could overcrowd the retrofibular groove. METHODS: This single-center retrospective case study covered 84 consecutive cases that had undergone peroneal tendoscopy. Peroneal tendoscopy was performed on 82 patients, predominantly female (3:1) with a median age of 46 years. The preoperative evaluation and all the procedures were performed by a single surgeon using a standardized technique. RESULTS: Two patients required revision surgery 8 and 52 months after the index procedure due to persistent posterolateral ankle pain. Peroneal tendoscopy was performed as a solitary procedure in 45.1% (37/82) of cases, while the remaining cases involved peroneal tendoscopy as a supplementary procedure. Low-lying peroneus brevis muscle belly (LLMB) was the most common finding in this series in 53.7% (44/82) of cases. In 41.5% (34/82) of cases, longitudinal tears of the peroneus brevis tendon were noted. Some patients presented with more than 1 concomitant peroneal tendon pathology. The LLMB was observed in 23.5% (8/34) of cases with a longitudinal tear of the peroneus brevis tendon. CONCLUSION: Peroneal tendon anatomical variations, especially LLMB, were associated with the presence of peroneus brevis tendon ruptures and intrasheath peroneal tendon subluxations as well as posttraumatic posterolateral ankle pain. Due to high rates of undiagnosed and misdiagnosed cases of LLMB preoperatively, we believe special care should be taken to recognize it during tendoscopy. Peroneal tendoscopy is a high-efficiency, low-complication method to treat some peroneal tendon conditions. LEVEL OF EVIDENCE: Level IV, case series.

Accessory Soleus Muscle: Two Case Reports with a Completely Different Presentation Caused by the Same Entity.

Accessory soleus muscle (ASM) is a rare supernumerary anatomical variant that commonly presents as a posteromedial ankle swelling, which may become painful during physical activity. As it may mimic a soft tissue tumor, it is essential to differentiate this condition from ganglion, lipoma, hemangioma, synovioma, and sarcoma. However, ASM may also present with a painful syndrome, characterized by pain and paresthesia of the ankle and foot, mimicking the tarsal tunnel syndrome (TTS). Two cases of ASM are presented in this article. The first case had a typical presentation with painful posteromedial ankle swelling. After the initial assessment, the diagnosis was confirmed by magnetic resonance imaging (MRI), and ASM was treated by complete resection. The second case presented with pain and paresthesia in the right ankle and foot, but no swelling was noticeable. It was initially misdiagnosed by a rheumatologist and afterward overlooked on an MRI by a musculoskeletal radiology specialist and therefore mistreated by numerous physicians before being referred to our outpatient clinic. After further assessment, the diagnosis has been confirmed, and ASM was treated by complete resection combined with tarsal tunnel decompression. To the best of our knowledge, this is the first case reported in which ASM caused symptoms but presented without posteromedial swelling. This might be due to a proximally positioned belly of the ASM, followed by a tendinous insertion on the medial side of the calcaneus.

Plantaris tendon: a novel graft for anterolateral ligament reconstruction and additional reinforcement for anterior cruciate ligament autografts in combined reconstructive procedures.

The anterolateral ligament is recently recognized as an important structure in restoring rotational stability of the anterior cruciate ligament-deficient knee. Biomechanical and clinical studies confirmed the benefits of concurrent anterior cruciate ligament and anterolateral ligament reconstruction. However, present techniques mostly use hamstring tendons autografts and therefore additionally disrupt the knee biomechanics. The plantaris tendon is a well known and accessible graft and has excellent biomechanical properties for anterolateral ligament reconstruction. The present paper describes a new combined anterior cruciate ligament and anterolateral ligament reconstruction technique using plantaris tendon and semitendinosus tendon.Level of evidence V (Case report).

Sport injuries in international masters rowers: a cross-sectional study.

AIM: To estimate the frequency and localization of acute (traumatic) and chronic (overuse) injuries in a population of masters rowers with respect to their age subgroups and assess the association between injury occurrence and different training modalities, rowing experience, previous competition level, and current rowing practice. METHODS: A cross-sectional study was conducted among 743 masters rowers who participated in the 34th International Federation of Rowing Associations (Fédération Internationale des Sociétés d'Aviron, FISA) World Rowing Masters Regatta held in Zagreb, September 2-9, 2007. A rowing-specific questionnaire was used, followed by an interview about the injuries sustained during the 12-month period before the competition. RESULTS: The mean injury rate per year was 0.48 injuries/masters rower (2.25 injuries/1000 training sessions/rower). The majority of injuries were chronic injuries (the ratio of acute to chronic injuries was 1:1.7), and did not lead to the loss of training/competition time. Of all acute injuries, 49.6% were acquired during rowing-specific training, 43.7% during cross-training, and 6.7% in the gym. The most commonly affected region was the low back (32.6%), followed by the knee (14.2%), shoulder/upper arm, and elbow (10.6% each). CONCLUSION: International masters rowers sustained predominantly chronic injuries of low severity, and the most commonly injured region was the low back. The mean injury rate per rower per year was lower than the rates previously reported for juniors and seniors.

Lateral Inverted Osteochondral Fracture of the Talus: Case Reports and Review of the Literature.

Lateral inverted osteochondral fracture of the talus (LIFT) is a rare variant of stage IV osteochondral lesion of the talus (OLT), where the fragment is inverted in situ by 180°. The management of LIFT lesion is very challenging and early recognition crucial, given that treatment options depend on the articular cartilage condition and sufficiency of the adjacent bone of the displaced fragment. We describe two LIFT cases referred from other institutions after unsuccessful conservative treatment of OLT. They presented with pain, swelling and tenderness over the anterolateral aspect of the right ankle. We recognized the LIFT lesion on the magnetic resonance imaging scans in patient 2, while in patient 1 the orientation of the fragment was recognized upon direct visualization during operative treatment. Both patients underwent arthroscopic procedure. Due to articular cartilage damage and insufficiency of the adjacent bone of the fragment, both patients were treated with excision fol-lowed by microfracture. Treatment of the LIFT lesion should start arthroscopically to allow clear evaluation of the osteochondral fragment, assessment of the talar defect and identification, as well as treatment of associated disorders. If the articular cartilage appears intact with sufficient subchondral bone, fixation of the fragment is optimal management, otherwise excision and microfracture can be the treatment of choice.

Clinical and MRI Outcomes After Surgical Treatment of Osteochondral Lesions of the Talus in Skeletally Immature Children.

BACKGROUND: The literature on the osteochondral lesion of the talus (OLT) in skeletally immature children is scarce and little is known about the clinical outcomes and the radiologic appearance of these lesions after surgical treatment. The aim of this study was to assess mid-term clinical and magnetic resonance imaging (MRI) outcomes after arthroscopic microfracture (AM) of OLT in skeletally immature children. METHODS: Thirteen patients with OLT treated by AM before skeletal maturity were included in the study. The Berndt and Harty outcome question, the Single Assessment Numeric Evaluation question, and the Martin questionnaire were used to obtain patients' subjective satisfaction with their operated ankle. Functional outcomes preoperatively and postoperatively were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. MRI scans were performed postoperatively using a magnetic resonance observation of cartilage repair tissue (MOCART) scoring system for 11 ankles. RESULTS: The median age was 15 years (range, 13 to 16 y) and the median follow-up period was 5.6 years (range, 3.8 to 13.6 y). According to the Berndt and Harty outcome question, good clinical results were reported in 10 (76.9%) and fair in 3 (23.1%) patients. The postoperative AOFAS score was significantly improved when compared with the preoperative AOFAS score, with a mean increase of 35 points (P<0.001). The overall MOCART score was 65 (range, 10 to 75). MRI variables of the MOCART scoring system showed no association with clinical outcomes. CONCLUSIONS: AM seems to be an effective surgical method for the treatment of OLT in skeletally immature children. LEVEL OF EVIDENCE: Level IV-therapeutic studies, case series.

Value of Tourniquet Use in Anterior Ankle Arthroscopy: A Randomized Controlled Trial.

BACKGROUND: A tourniquet is usually used during anterior ankle arthroscopy to allow for improved visibility and reduced operation time. However, this has not been demonstrated to be true in clinical studies on knee arthroscopy, while limited tourniquet time has been described as a possible factor to lower the complication rate of ankle arthroscopy. The purpose of this randomized controlled trial was to examine the effect of tourniquet use on arthroscopic visualization, operative time, postoperative intra-articular bleeding, postoperative pain scores, and outcome of anterior ankle arthroscopy. METHODS: A consecutive series of 50 patients who were scheduled for anterior ankle arthroscopy were randomized to have the surgery done either without the tourniquet inflated (25 patients) or with the tourniquet inflated (25 patients). The patients were evaluated by the course of the surgery, postoperative intra-articular bleeding, and pain during the early postoperative period, and subjective and objective functional scores were used to evaluate the condition of the ankle before and 3 and 6 months after the surgery. Forty-nine patients were present at the final follow-up, 6 months after the surgery. RESULTS: The results between the groups were comparable regarding the duration of the operative procedure, consumption of sterile saline, visualization, and functional scores. A notable difference between the groups in favor of the nontourniquet group was present regarding postoperative bleeding but was not statistically significant. A statistically significant difference in favor of the nontourniquet group was found regarding postoperative pain during several days in the early postoperative period. CONCLUSION: Our study showed that anterior ankle arthroscopy was performed adequately without the use of a tourniquet and that it had the same operative course as cases in which the tourniquet was used and functional outcomes that were not worse than cases in which the tourniquet was used. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Localized pigmented villonodular synovitis of the ankle: Expect the unexpected.

BACKGROUND: We present the technique, results and discuss arthroscopic treatment of the localized form of pigmented villonodular synovitis (LPVNS) of the ankle. METHODS: Medical records of five patients diagnosed and treated for ankle LPVNS with a minimum five-year followup were retrospectively reviewed. All patients were treated arthroscopically, altered synovial tissue was resected and a sample of tissue was sent for pathohistological examination for the definitive diagnosis. RESULTS: No recurrence was noted at a mean followup of 6.5 years, both clinically and by MRI at one year postoperatively. Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, and an improvement was noted from an average score of 65.6 prior to treatment to 94.6 at final followup. CONCLUSION: Considering the results of this case series, and the absence of complications, arthroscopy is a viable option for treating LPVNS of the ankle.

Hamate hook nonunion initially mistaken for ulnar nerve compression: a case report with review of literature.

BACKGROUND: Hamate hook (HH) stress fractures are rare, often presenting with misleading symptoms and easily overlooked/misdiagnosed. These fractures occur frequently in individuals participating in sports activities involving racquets, bats, or clubs. Symptoms are non-specific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis. CASE REPORT: A 17-year-old tennis player with no history of trauma presented with dominant hand weakness together with pain and paresthesia on the ulnar side, which exacerbated with tennis play. The patient was treated for ulnar nerve compression with activity cessation and rest for 2 months. After 6 months of persistent symptoms, the patient underwent open Guyon tunnel release, although preoperative electromyoneurography revealed no signs of nerve damage and bone scans showed a small area of increased uptake in the hypothenar region. Postoperatively, symptoms resumed and the patient reported to our department for a second opinion. Point tenderness over HH, hypothenar muscles hypotrophy, paresthesia, hand weakness and pain with ulnar deviation, and flexion of distal phalanges of the two ulnar fingers were observed. HH fracture was suspected. Computerized tomography scan revealed fractured HH and the patient underwent hook excision. One month postoperatively, the pain intensity reduced together with function and strength improvement; 2 months postoperatively, the patient was pain free and had returned to tennis. CONCLUSIONS: In patients involved in racquet sports with hypothenar pain and paresthesia of the ulnar side of the hand, HH fracture should be suspected. Symptoms can mimic ulnar nerve entrapment and may lead to overlooking the correct diagnosis. Treatment of choice is fractured fragment excision.

Removal of Osteoid Osteoma of the Calcaneus Using Subtalar Arthroscopy.

Intra-articular calcaneal osteoid osteoma is a very rare condition and the diagnosis as well as the treatment is extremely challenging. We report a case of a 19-year-old male with intra-articular osteoid osteoma of the calcaneus, initially treated for peroneal tenosynovitis with unsatisfactory results. Thorough diagnostic procedure revealed the superolateral location of a calcaneal osteoid osteoma, near the sinus tarsi. A cherry-red elevated lesion typical of an osteoid osteoma nidus was completely removed arthroscopically using the anterolateral portal and the middle portal for subtalar arthroscopy. Histopathology confirmed the suspected diagnosis. The postoperative clinical course was uneventful with immediate pain relief and full weightbearing and movement allowed soon. The patient had no recurrent pain and normal joint mobility 8 months postoperatively. Considering the accessibility of the lesion, intra-articular osteoid osteoma of the calcaneus can be successfully treated arthroscopically using lateral approach for subtalar arthroscopy. LEVELS OF EVIDENCE: Therapeutic, Level IV: Retrospective, Case report.

Ganglion Cyst of the Knee: A Retrospective Review of a Consecutive Case Series.

The aim of this study was to describe relevant medical history, clinical symptoms and outcomes in 12 patients having undergone surgical treatment of intra-articular ganglion cysts of the knee at our Department from January 2010 to June 2016. Patient demographics, medical history, knee manifestations, management and outcome were evaluated. The mean patient age was 26.4 (range, 16-46) years. Th ere were seven female and five male patients. Duration of symptoms prior to the operation varied from 2 months to 3 years (mean, 17.1 months). All patients had preoperative magnetic resonance imaging work-up of the knee. Pain was the most common clinical presentation. All patients were surgically treated arthroscopically, and an additional open approach was used in only one of the patients. There were no complications during surgery and the postoperative period was uneventful in all patients. The mean follow up period was 43.5 (range, 9-83) months and no recurrence was observed. All patients remained symptom-free with full range of motion at final follow up. Despite a wide range of intra-articular ganglion cyst presentations and symptoms, our cohort demonstrated an excellent remission rate and functional prognosis following surgical treatment of the ganglion cysts of the knee.

Extra-Articular Endoscopy.

With the advent of endoscopy in the last 2 decades, a number of procedures, and modifications to them, have been developed and have advanced exponentially. The list of indications was extended over time because of several reasons: better understanding of the pathophysiology, better diagnostics, and advances in endoscopic technology. In this review article, we summarize the most frequently performed extra-articular endoscopic procedures on the extremities. As there are several methods, some have been described briefly, whereas others have been described in greater detail, such as suprascapular nerve entrapment syndrome and Achilles tendon disorders, as they present our area of interest and subspecialty domain. Recent advances in the treatment of versatile pathologic entities have been described, together with new methods, which currently lack sufficient clinical data but still represent promising techniques for the future.