Retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis: a short-term, prospective study.

In this prospective study, tibiotalocalcaneal arthrodesis was performed in 29 patients with a retrograde femur nail (Interlocking Compression Nail; Stryker Trauma, Schönkirchen, Germany) inserted through a plantar approach. Patients were evaluated by a standardized follow-up examination using the American Foot and Ankle Society ankle-hindfoot scale and the main criteria of the short-form health survey (36 items). Special emphasis was placed on surgical approach, bony consolidation, and postoperative quality of life. Solid fusion was achieved in 90% of the patients after a mean follow-up of 25 months. Twenty-two patients (76%) showed primary bone healing after an average of 5.2 months; a delayed union was observed in 7 patients. In 79% of the patients, pain was reduced effectively and quality of life substantially improved with the intramedullary nail arthrodesis. The average ankle-hindfoot score improved from 46 (range, 41-53) to 71 (range, 49-83) points. Complications occurred in 6 patients (21%), including 2 deep infections, 3 nonunions, and 1 case of postoperative flexion deformity. The authors found retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis to be an effective technique in obtaining solid fusion, an effective relief from pain, and an improvement of quality of life.

Tumoral calcinosis-like lesion of the foot. A case report.

Tumoral calcinosis-like lesions of the foot are a pedal manifestation of end-stage renal disease. Although they are benign, they have the potential to cause significant morbidity because of their invasive nature. Following a brief description of tumoral calcinosis-like lesions, the authors provide an illustrative case presentation including radiographs, magnetic resonance images, surgical photographs, and histopathology.

Intra-articular soft-tissue masses of the ankle. Meniscoid lesions and transarticular fibrous bands.

Meniscoid lesions and fibrous bands are unique lesions, most likely of differing origin. Although they are similar in clinical presentation, their appearance at arthroscopy is clearly different. The meniscoid lesion is attached only at its origin at the inferolateral gutter on the anterior talofibular ligament. Fibrous bands are attached at two ends and may be found anywhere in the joint but are most common extending dramatically over the anterior joint line. Unexpected encountering of a fibrous band should alert the surgeon to carefully inspect the joint for other associated (occult) pathology. Because of the frequent association of bands with antecedent fracture, the observation of this lesion should lead the clinician to consider antecedent intra-articular fracture (transchondral fracture, malleolar fracture, and tibial pilon fracture) as a likely co-pathology. Careful examination of the ankle and review of the radiographs and other available images may be helpful in assessing the joint for these injuries when fibrous bands are encountered. The association of meniscoid lesion with prior soft tissue injury (sprain) is also important to understanding this lesion. Excision of both these abnormal lesions in concert with repair of coexistent pathology is associated with improvement of symptoms. Finally, both fibrous bands and meniscoid lesions are associated with symptoms that warrant closer inspection and observation. Whether the operative intervention is open or closed, the reader can benefit from the information presented.

Anterior ankle impingement arthropathy. The role of anterolateral arthrotomy and arthroscopy.

The choice of anterior ankle arthroplasty conducted by anterolateral arthrotomy versus arthroscopic techniques depends on the severity of the osteophytosis and the dominance type. This can be determined in most cases by conventional radiology, contrast arthrography, or MRI. Diagnostic arthroscopy may be required when noninvasive means fail to provide the answer to anterior frontier joint pain. Thorough arthroplasty must be performed and the joint placed through its end range of motion to verify reduction of all impingements. Extensive bony impingements are most effectively treated by conventional anterolateral arthrotomy. This is particularly true in posttraumatic cases with considerable arthrofibrosis infiltrate. Lesser degrees of osteophytosis confined, in particular, to the leading tibial edge are effectively reduced by arthroscopic technique. Anterior ankle arthroplasty by either technique offers symptomatic relief of pain with minimal morbidity. It can serve as a definitive treatment protocol for many patients or simply represent a temporary step along the way to more aggressive salvage surgery such as arthrodesis.

Complications in ankle arthroscopy.

The advantages of arthroscopy are limited soft tissue injury and a microsurgical approach to manipulation of tissue. The benefits of this approach can be enjoyed by the patient and physician as earlier return to function and activity. Surgical ankle arthroscopy, like any other invasive ankle procedure, has complications. When it is compared to ankle arthrotomy, diminished morbidity and earlier return to function are usually realized for almost all procedures. Complications range from relatively inconsequential surface injury to substantial and morbid injury to fatal events. As with any surgery, the complications possible from arthroscopy must be weighted against the advantages of performing these procedures. Avoiding preventable complications is important to the success of ankle arthroscopy. The use of appropriate technique and the arthroscopist's experience can play a significant role in reducing the incidence of complications. Experience has been shown to reduce the frequency of complications. Appropriate technique appears to be particularly important in portal development and instrument manipulation. The portal creation maneuver is the source of many encountered complications. The learning curve for arthroscopic technique is steep. An inexperienced arthroscopist should expect complications. With appropriate indications and skills, the benefits of ankle arthroscopy are great. As with all invasive procedures, risks can never be eliminated. Maximizing and enhancing technique and controlling risk factors allow ankle arthroscopy the greatest potential for success with the least potential for complications.

Objective diagnosis of equinus during gait prior to and following a tibial nerve block.

A quantitative evaluation technique has been developed to assist the clinician in the diagnosis and treatment of ankle equinus deformity. Specifically, the work focuses on accomplishing two major goals: 1) to develop a reliable set of quantitative criteria to assess the degree of dysfunction of the ankle joint during locomotion in patients with equinus deformity; and 2) to determine the effect of various treatment modalities on the ambulatory performance of patients with equinus deformity. A statistically significant difference in two key gait parameters has been demonstrated between healthy subjects and those with equinus deformity.

Objective identification of ankle equinus deformity and resulting contracture.

A quantitative diagnostic technique is described for identifying contracture at the ankle joint in patients with equinus deformity, hence addressing the shortcoming of the conventional clinical diagnostic procedure. To gain a better understanding of how contracture contributes to equinus deformity, a study was designed that compared the torque about the ankle joint before and after administering a tibial nerve block to equinus patients and to a control group. Functional equinus, manifested by walking and early heel rise, is defined as inadequate dorsiflexion for normal gait. The ability to accurately identify an equinus condition, and contracture as the contributing factor in equinus deformity, has important implications for the type of treatment prescribed and the evaluation of treatment effectiveness.

Closed reduction of a proximal interphalangeal joint dislocation.

A case report involving the closed reduction of a simple dislocation of a lesser digit is presented. The technique of reduction is illustrated and discussed. Classification of both simple and complex dislocations are reviewed.

Normal and abnormal arthroscopic anatomy of the ankle joint.

Normal and abnormal intraarticular anatomy of the ankle is presented from an arthroscopist's perspective. Pathologic anatomy including synovitis, transchondral fracture, impingement lesions, osteochondral bodies, and erosions are described. A classification of chondromalacia and current concepts of its pathogenesis are presented.