Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study.

BACKGROUND: Complete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle. METHODS: A prospective case series study with patients operated between 2005-2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire. RESULTS: A total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13-107) were studied. The MFS increased a mean of 21 points (p=.001), the AOFAS score a mean of 25 points (p=.001), and the VAS decreased a mean of 8.89 points (p=.001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11-34) preoperatively to 19.3° (range 11-34) at the end of follow-up (p=.05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients. CONCLUSIONS: Percutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.

Minor or occult ankle instability as a cause of anterolateral pain after ankle sprain.

PURPOSE: The aim of this study was to determine which intra-articular injuries are associated with chronic anterolateral pain and functional instability after an ankle sprain. METHODS: From 2008 to 2010, records of all patients who underwent ankle joint arthroscopy with anterolateral pain and functional instability after an ankle sprain were reviewed. A systematic arthroscopic examination of the intra-articular structures of the ankle joint was performed. Location and characteristics of the injuries were identified and recorded. RESULTS: A total of 36 ankle arthroscopic procedures were reviewed. A soft-tissue occupying mass over the lateral recess was present in 18 patients (50%). A partial injury of the anterior talofibular ligament (ATFL) was observed in 24 patients (66.6%). Cartilage abrasion due to the distal fascicle of the anteroinferior tibiofibular ligament coming into contact with the talus was seen in 21 patients (58.3%), but no thickening of the ligament was observed. Injury to the intra-articular posterior structures, including the transverse ligament in 19 patients (52.7%) and the posterior surface of the distal tibia in 21 patients (58.3%), was observed. CONCLUSION: Intra-articular pathological findings have been observed in patients affected by anterolateral pain after an ankle sprain. Despite no demonstrable abnormal lateral laxity, morphologic ATFL abnormality has been observed on arthroscopic evaluation. An injury of the ATFL is present in patients with chronic anterolateral pain and functional instability after an ankle sprain. A degree of microinstability due to a deficiency of the ATFL could explain the intra-articular pathological findings and the patients' complaints. LEVEL OF EVIDENCE: IV.

Iatrogenic articular cartilage injuries during ankle arthroscopy.

PURPOSE: The purpose of this study was to assess the incidence of iatrogenic articular cartilage injuries during ankle arthroscopy and to determine the factors that caused them. The hypothesis of this study was that the incidence of iatrogenic cartilage injuries produced during ankle arthroscopic procedures is high and directly related to the arthroscopic technique. METHODS: All consecutive records from ankle arthroscopies performed between 2008 and 2010 were reviewed. Arthroscopic arthrodesis of the ankle was excluded from the study. Iatrogenic articular cartilage injury was defined as any cartilage injury that occurred during the arthroscopic procedure. RESULTS: The final number of ankle arthroscopic procedures reviewed was 74. There were a total of 23 iatrogenic lesions of the cartilage, for an overall complication rate of 31%. The two most common injury locations were the anterolateral and central area of the talus. The cartilage lesion was superficial in 78.2% of injuries (24.3% of all patients), and deep in 21.8% of injuries (6.7% of all patients). Of the 23 injuries found, 65% of them were sustained during the therapeutic portion of the arthroscopic procedure and the remaining 35% occurred during the portal creation portion of the procedure. CONCLUSION: The incidence of cartilage injury during ankle arthroscopy is high. However, severe damage was found in only 6.7% of ankle arthroscopies. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Identification of the superficial peroneal nerve: Anatomical study with surgical implications.

PURPOSE: To prevent iatrogenic damage to the superficial peroneal nerve during ankle arthroscopy, it needs to be identified. The purpose of the present study was to determine which clinical test identified the superficial peroneal nerve most frequently and which determinants negatively affected the identification. METHODS: A total of 198 ankles (99 volunteers) were examined for identification of the superficial peroneal nerve. Race, gender, body mass index (BMI), shoe size and frequency of physical activity were collected. RESULTS: The best method to identify the superficial peroneal nerve was the maximal combined ankle plantar flexion and inversion test. In this position, the nerve was identified in 57% of the ankles by palpation. BMI was the only independently influential factor in the identification of the superficial peroneal nerve. CONCLUSION: Since in nearly six out of the ten ankles the superficial peroneal nerve can be identified, it is advised to assess its anatomy prior to portal placement. A higher BMI negatively influences the identification of the superficial peroneal nerve. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Anatomy of the ankle ligaments: a pictorial essay.

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Safety and efficiency of posterior arthroscopic ankle arthrodesis.

PURPOSE: To study the safety and efficiency of posterior arthroscopic ankle arthrodesis. METHODS: Ten fresh-frozen human lower leg specimens without evidence of previous surgery to the foot and ankle were selected. Arthroscopic debridement of the tibiotalar joint was performed in all specimens using a standardized protocol. Anatomical dissections were regarded the gold standard for safety analysis. To evaluate the efficacy of the posterior ankle arthroscopic arthrodesis, the debrided articular tibiotalar parts were resected and subsequently analysed using Image-analysis software, Image J (Wayne Rasband, National Institutes of Health, Bethesda, MD). RESULTS: In none of the specimens, iatrogenic damage was detected during the anatomical dissection following the posterior ankle arthroscopic procedure. A total talar joint surface area of 95 % and total tibial joint surface area of 96 % was addressed during the arthroscopic debridement. CONCLUSIONS: The posterior ankle arthroscopic arthrodesis can be regarded safe and is also highly effective in the debridement of cartilage, resulting in optimal biology for fusion to occur. Therefore, this new arthroscopic technique potentially will diminish existing non-union rates for the fusion of the ankle joint.

Evaluation and management of injuries of the tibiofibular syndesmosis.

INTRODUCTION: Injury to the tibiofibular syndesmosis often arises from external rotation force acting on the foot leading to eversion of the talus within the ankle mortise and increased dorsiflexion or plantar flexion. Such injuries can present in the absence of a fracture. Therefore, diagnosis of these injuries can be challenging, and often stress radiographs are helpful. Magnetic resonance imaging scans can be a useful adjunct in doubtful cases. The management of syndesmotic injuries remains controversial, and there is no consensus on how to optimally fix syndesmosis. This article reviews the mechanism of injury, clinical features and investigations performed for syndesmotic injuries and brings the reader up-to-date with the current evidence in terms of the controversies surrounding the management of these injuries. SOURCES OF DATA: Embase, Pubmed Medline, Cochrane Library, Elsevier and Google Scholar (January 1950-2014). AREAS OF CONTROVERSY: The management of syndesmotic injuries remains controversial, and there is no consensus on: (i) which ankle fractures require syndesmotic fixation, (ii) the number or the size and the type of screws that should be used for fixation, (iii) how many cortices to engage for fixation, (iv) the level of screw placement above the ankle plafond, (v) the duration for which the screw needs to remain in situ to allow the tibiofibular syndesmosis to heal and (vi) when should patients weight bear. AREAS OF AGREEMENT: (i) A high proportion of syndesmotic fixations demonstrates malreduction of the syndesmosis, (ii) no need to remove screws routinely, (iii) two screws appear to better one alone and (iv) if syndesmosis injury is not detected or not treated long term, it leads to pain and arthritis. GROWING POINTS: (i) How to assess the adequacy of syndesmotic reduction using imaging in the peri-operative period, (ii) the use of bio-absorbable materials and Tightrope and (iii) evidence is emerging not to remove syndesmotic screws unless symptomatic. AREAS OF TIMELY FOR DEVELOPMENT RESEARCH: (i) A bio-absorbable material that can be used to fix the syndesmosis and allow early weight bearing, and (ii) there is a need for developing a surgical technique for adequately reducing the syndesmosis without the exposure to radiation.

Hindfoot endoscopy for the treatment of posterior ankle impingement syndrome: a safe and reproducible technique.

INTRODUCTION: Posterior ankle impingement is a clinical syndrome characterized by posterior ankle pain that is mainly presented on plantar flexion. The aim of this study is to compare and evaluate the results of posterior ankle impingement treated by endoscopic hindfoot posterior portals. MATERIALS AND METHODS: Between 2004 and 2009, a total of 38 endoscopic hindfoot procedures were performed to treat posterior ankle impingement. The indication for procedure was posterior ankle impingement syndrome in all cases. There were 38 patients, 17 females and 21 males. Mean age was 27.6 years (16-59 years). Mean follow-up was 27.6 months (12.5-52 months). The results were evaluated following the AOFAS score. Data statistical analysis was performed using the Student's t-test. RESULTS: The main preoperative AOFAS score increased from 67.42 (range 41-91) to 97.13 (range 84-100) at follow-up. No complications were reported in any case. CONCLUSION: Hindfoot endoscopy is a reproducible and safe procedure which offers excellent outcomes in posterior ankle impingement syndrome.

The deltoid ligament: an in-depth review of anatomy, function, and treatment strategies.

PURPOSE: A literature review of the deltoid ligament was conducted, examining the current literature on anatomy, function, and treatment strategies. In particular, anatomical inconsistencies within the literature were evaluated, and detailed anatomical dissections are presented. METHODS: A literature search was conducted on PubMed using keywords relevant to the deltoid ligament in the ankle and medial ankle instability. Primary research articles, as well as appropriate summary articles, were selected for review. RESULTS: While it is well defined that the deltoid is contiguous and divided into one superficial and one deep portion, the creation of the individual fibres may be artificial. Furthermore, while improvements in imaging techniques and arthroscopy have not led to a consensus on the anatomy of the ligament, they may help improve recognition of deltoid injuries. Once identified, the majority of deltoid injuries can be treated via conservative treatment. However, reparative and reconstructive treatment strategies can also be used for complex acute injuries or chronic medial ankle instability. CONCLUSION: Given the continuing evolution of the anatomical understanding of the ligament, the current treatment protocol for deltoid injuries requires further standardization, with an emphasis on proper diagnosis.

"Web impingement" of the ankle: a case report.

This case report presents two patients with persisting anterior ankle impingement pain after an ankle distortion. A web-like intra-articular fibrous band was discovered and resected. The patients presented were, after a 1-year follow-up, pain free.

Tendoscopic groove deepening for chronic subluxation of the peroneal tendons.

INTRODUCTION: Recurrent subluxation of the peroneal tendons over the lateral malleolus is an uncommon disabling condition in young people involved in sports. Injury to the superior peroneal retinaculum, sometimes in association with a shallow fibular groove, can lead to this condition. There are several surgical treatments for recurrent peroneal tendon subluxation, but no tendoscopy technique has been reported to date. The aim of this study was to describe a tendoscopic groove-deepening technique and its results for treating patients with recurrent subluxation of the peroneal tendons. METHODS: Seven patients (3 women and 4 men; mean age 26.4 [21-32] years) with chronic subluxation of the peroneal tendons were treated with a tendoscopic procedure. All patients experienced pain at the lateral retromalleolar area and recurrent subluxation of the peroneal tendons. The right ankle was affected in 4 patients. Mean follow-up was 15.4 (8-25) months. RESULTS: On tendoscopic examination, all patients had a flat fibular groove, and the superior peroneal retinaculum was found to be detached in 4 cases. Three patients had a superficial injury of the peroneus brevis tendon which was debrided. Tendoscopic deepening of the peroneal groove without superior peroneal retinaculum repair was performed in all cases. None of the patients experienced recurrent subluxation during follow-up. The AOFAS score increased from 75 preoperatively to 93 at final follow-up. No complications were reported in any case. CONCLUSION: Tendoscopic deepening of the fibular groove was a reproducible, minimally invasive technique that provided a favorable outcome for recurrent subluxation of the peroneal tendons in our limited number of patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Articular chondral damage of the first metatarsal head and sesamoids: analysis of cadaver hallux valgus.

BACKGROUND: Evidence of successful correction on postoperative hallux valgus imaging studies may not always correlate with patient satisfaction. Recent attention to the association of cartilaginous degeneration and hallux valgus may provide new insight into treatment algorithms and patient expectations. The purpose of this cadaveric study was to evaluate the degree of chondral damage as it relates to increasing hallux valgus deformity. METHODS: A total of 39 cadaver first metatarsophalangeal joints were evaluated by radiography, and then dissected to evaluate for chondral damage. Chondral lesion grade, size, and location were recorded and then analyzed based on patient demographics and hallux valgus angle. RESULTS: Twenty-nine of 39 specimens were considered to have hallux valgus characterized by a hallux valgus angle of 15 degrees or greater. Four of 39 (10%) specimens revealed absence of chondral lesions, and 3 of those were found in the group with a hallux valgus angle of less than 15 degrees. Chondral lesions of increasing size and grade were seen more commonly with a more severe hallux valgus deformity. Particular locations on the metatarsal head appeared to be more prone to cartilaginous lesions when compared to other locations. CONCLUSION: Assessment of first metatarsophalangeal joint articular damage with regard to hallux valgus may be an important clinical parameter for consideration. CLINICAL RELEVANCE: Operative intervention to realign the first metatarsophalangeal joint may correct malalignment and relieve pressure on the widened forefoot, but residual pain within the joint may emanate from preexisting articular cartilaginous lesions. These findings support the concept that earlier intervention with operative realignment of a hallux valgus deformity and specifically the sesamoid complex may diminish degenerative changes.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study.

BACKGROUND: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. METHODS: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. RESULTS: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. CONCLUSION: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Introducing 3-dimensional stereoscopic imaging to the study of musculoskeletal anatomy.

The stereoscopic imaging technique is an option for a more realistic understanding of what we normally see in 2 dimensions on paper or on a screen. To produce a 3-dimensional image of an object, it is necessary to register 2 different images of the same object at the same distance and height with the use of cameras that focus on one particular point. A convergence between the left and right images is required for human vision. The distance between the camera and the images necessary to create the stereo pair should be proportional to the normal distance between the pupils. Stereoscopic or polarization techniques are used to create the images, and special glasses are required to view them. In medicine, 3-dimensional images are an extremely effective resource in the study and teaching of anatomy at both the macroscopic and microscopic levels. With advancements in technology and the emergence of new diagnostic imaging techniques and innovative therapeutic modalities, 3-dimensional images can be an excellent educational tool.

An anatomical three-dimensional study of the posteromedial corner of the knee.

PURPOSE: For many years, the anatomy of the medial knee corner has been reported. However, it is not exactly clear how all these structures function together. The purpose of this study is to identify and try to understand the relationship between the posteromedial corners of the knee using three-dimensional visualization techniques. MATERIALS AND METHODS: This study comprises of 10 knees from adult corpses. Images were acquired from the dissection of different layers of the posteromedial compartment of the knee using a camera Nikon D40 and AF-S Nikkor 18-55 mm (Nikon Corp., Japan) placed on a slide bar. The pair of images was processed using Callipyan 3D or Anabuilder software (Ana builder, France) that transforms the two different images of the same structure with the intrapupillary distance proportion into one anaglyphic image. RESULTS: During knee dissection, pictures were taken and transformed into three-dimensional images that become more realistic with the use of special glasses. The images were made during the dissection of the three layers of the posteromedial compartment of the knees. CONCLUSIONS: Posteromedial corner ligament structures are quite complex and are not always clearly described in the literature. Three-dimensional images of these structures can help better understanding its anatomy.

Tendoscopic treatment of intrasheath subluxation of the peroneal tendons.

BACKGROUND: Intrasheath subluxation of the peroneal tendons does not have an injury of the proximal retinaculum. The aim of this study was to describe the tendoscopic technique and preliminary results. METHODS: Six patients with intrasheath subluxation of the peroneal tendons were treated tendoscopically. All patients had preoperative pain and a clicking sensation at the lateral retromalleolar area. Mean followup was 18.3 (range, 14 to 24) months. These six patients included three males and three females, with a mean age of 23.5 (range, 18 to 33) years. The AOFAS and Visual Analog Score for pain were used to evaluate the patients. RESULTS: During tendoscopy, two patients had a peroneus quartus tendon which was removed; three had a low-lying peroneus brevis muscle that was resected; and in two cases deepening of the peroneal groove was performed. At followup, all patients reported excellent results, without pain or clicking sensation. The mean AOFAS score increased from 79 to 99, and Visual Analog Score at followup was 0 in four patients and 1 in two patients. CONCLUSION: Tendoscopic treatment of these pathologies led to improved function in a less aggressive manner than open surgery.

Suprascapular Nerve Release: Technique Based on Anatomic Landmarks.

Dysfunction of the suprascapular nerve (SSN) is closely related to rotator cuff pathology; nerve dysfunction can lead to cuff disease and vice versa. Owing to repetitive microtrauma during overhead sports or massive cuff tears with significant tendon retraction, the SSN may suffer compression or traction neuropathy at the suprascapular notch. The SSN release technique has already been described. However, on the basis of the many hands-on cadaveric laboratories in which we have participated in the past 20 years, only a few instructors and almost none of the attendants have shown the experience and skill set needed to release the SSN at the suprascapular notch. Therefore, a review of the surgical technique following the anatomic descriptions of an expert anatomist (P.G.) of the shoulder girdle is quite valuable.

True submalleolar accessory ossicles causing impingement of the ankle.

True ossicle in the distal portion of the malleolus is only sporadically observed, and related disease has been rarely reported. We present two cases of atypical ankle impingement resulting from an ankle sprain. Plain radiographs revealed true submalleolar ossicles. Conservative treatment failed, and arthroscopy was performed. Instability of the ossicle and surrounding fibrotic soft tissue was evident; a gap between the ossicle and the tip of the malleolus seen during plantar flexion of the ankle disappeared in dorsal flexion, resulting in compression of the surrounding soft tissue. Arthroscopic excision of the accessory ossicle relieved the symptoms and enabled both patients to return to full preinjury activities.

The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications.

Despite the fact that the superficial peroneal nerve is the only nerve in the human body that can be made visible; iatrogenic damage to this nerve is the most frequently reported complication in anterior ankle arthroscopy. One of the methods to visualize the nerve is combined ankle plantar flexion and inversion. In the majority of cases, the superficial peroneal nerve can be made visible. The portals for anterior ankle arthroscopy are however created with the ankle in the neutral or slightly dorsiflexed position and not in combined plantar flexion and inversion. The purpose of this study was to undertake an anatomical study to the course of the superficial peroneal nerve in different positions of the foot and ankle. We hypothesize that the anatomical localization of the superficial peroneal nerve changes with different foot and ankle positions. In ten fresh frozen ankle specimens, a window, only affecting the skin, was made at the level of the anterolateral portal for anterior ankle arthroscopy in order to directly visualize the superficial peroneal nerve, or if divided, its terminal branches. Nerve movement was assessed from combined 10 degrees plantar flexion and inversion to 5 degrees dorsiflexion, standardized by the Telos stress device. Also for the 4th toe flexion, flexion of all the toes and for skin tensioning possible nerve movement was determined. The mean superficial peroneal nerve movement was 2.4 mm to the lateral side when the ankle was moved from 10 degrees plantar flexion and inversion to the neutral ankle position and 3.6 mm to the lateral side from 10 degrees plantar flexion and inversion to 5 degrees dorsiflexion. Both displacements were significant (P < 0.01). The nerve consistently moves lateral when the ankle is manoeuvred from combined plantar flexion and inversion to the neutral or dorsiflexed position. If visible, it is therefore advised to create the anterolateral portal medial from the preoperative marking, in order to prevent iatrogenic damage to the superficial peroneal nerve.

Anterior ankle arthroscopy, distraction or dorsiflexion?

Anterior ankle arthroscopy can basically be performed by two different methods; the dorsiflexion- or distraction method. The objective of this study was to determine the size of the anterior working area for both the dorsiflexion and distraction method. The anterior working area is anteriorly limited by the overlying anatomy which includes the neurovascular bundle. We hypothesize that in ankle dorsiflexion the anterior neurovascular bundle will move away anteriorly from the ankle joint, whereas in ankle distraction the anterior neurovascular bundle is pulled tight towards the joint, thereby decreasing the safe anterior working area. Six fresh frozen ankle specimens, amputated above the knee, were scanned with computed tomography. Prior to scanning the anterior tibial artery was injected with contrast fluid and subsequently each ankle was scanned both in ankle dorsiflexion and in distraction. A special device was developed to reproducibly obtain ankle dorsiflexion and distraction in the computed tomography scanner. The distance between the anterior border of the inferior tibial articular facet and the posterior border of the anterior tibial artery was measured. The median distance from the anterior border of the inferior tibial articular facet to the posterior border of the anterior tibial artery in ankle dorsiflexion and distraction was 0.9 cm (range 0.7-1.5) and 0.7 cm (range 0.5-0.8), respectively. The distance in ankle dorsiflexion significantly exceeded the distance in ankle distraction (P = 0.03). The current study shows a significantly increased distance between the anterior distal tibia and the overlying anterior neurovascular bundle with the ankle in a slightly dorsiflexed position as compared to the distracted ankle position. We thereby conclude that the distracted ankle position puts the neurovascular structures more at risk for iatrogenic damage when performing anterior ankle arthroscopy.