Anatomy of the inferior extensor retinaculum and its role in lateral ankle ligament reconstruction: a pictorial essay.

The inferior extensor retinaculum (IER) is an aponeurotic structure, which is in continuation with the anterior part of the sural fascia. The IER has often been used to augment the reconstruction of the lateral ankle ligaments, for instance in the Broström-Gould procedure, with good outcomes reported. However, its anatomy has not been described in detail and only a few studies are available on this structure. The presence of a non-constant oblique supero-lateral band appears to be important. This structure defines whether the augmentation of the lateral ankle ligaments reconstruction is performed using true IER or only the anterior part of the sural fascia. It is concluded that the use of this structure will have an impact on the resulting ankle stability.

Is there an anatomical marker for the deep peroneal nerve in midfoot surgical approaches?

The deep peroneal nerve (DPN) passes over the dorsum of the foot and is susceptible to injury during surgical approaches. The purpose of this anatomical study is to examine the relationship of the extensor hallucis brevis (EHB) as it passes over the DPN. Ten cadaver feet specimens were dissected and the anatomical structures surrounding the neurovascular bundle containing the DPN were examined. In nine out of the ten specimens the DPN was under the EHB musculotendinous junction. In one case it passed through the musculotendinous junction. This cadaver study has found a consistent easily identifiable landmark for protecting the neurovascular bundle containing the DPN during dorsal midfoot surgery.

Primary hyperparathyroidism presenting as delayed fracture union.

We describe a case of delayed union in a tibial fracture secondary to primary hyperparathyroidism. A closed intra-articular proximal tibia fracture was stabilized with a hybrid external fixator. At 5 months clinical and radiological evaluation failed to demonstrate evidence of fracture healing. Fixation was stable and inflammatory markers ruled out infection. Further questioning revealed symptoms of anorexia, nausea and constipation. Plasma biochemistry showed an elevated corrected calcium and parathyroid hormone concentration. Further investigation included a sestamibi scan which confirmed a diagnosis of hyperparathyroidism secondary to a parathyroid adenoma. Six weeks following partial parathyroidectomy the fracture site was pain free, non-tender and the fracture had united radiologically. In cases of delayed-union, once an infective cause has been excluded with a mechanically stable fracture, other causes of delayed union like primary hyperparathyroidism should be ruled out.

Percutaneous and mini-open repair of acute Achilles tendon rupture.

Treatment of acute Achilles tendon rupture is slowly evolving, but a lack of prospective, randomized trials leaves insufficient evidence for a definitive recommendation as to the best treatment. Percutaneous and mini-open techniques certainly have roles in treating the acutely ruptured Achilles tendon, and some trials suggest that these techniques can give results equivalent to or better than those of an open repair, with the added benefit of fewer complications. These findings have been backed up by a recent meta-analysis.

The Thompson hemiarthroplasty: a new problem for an old favourite.

The Thompson hemiarthroplasty is a popular hip prosthesis. We present two case reports highlighting a significant alteration in the design of the implant which compromised the success of the operations. In recent years the manufacturing process of this prosthesis has changed, with a resultant increase in the volume of the stem of 10 ml. It is essential that manufacturers inform orthopaedic surgeons of any alteration in the design of the implant and supply compatible instrumentation to minimise surgical errors. Surgeons must remain vigilant when checking the compatibility of the trial and definitive prostheses.

Independent evaluation of a recently described Achilles tendon repair technique.

BACKGROUND: We investigated a previously reported technique for the repair of acute Achilles tendon ruptures using the percutaneous Achillon suture system (Intega Life Sciences Corporation, Plainsboro, NJ). METHODS: Twenty-five patients with Achilles tendon ruptures were studied prospectively with a minimum of 12 months followup. A single 2- to 3-cm horizontal incision and the Achillon suture system were used. Early rehabilitation and an active range-of-motion brace were instituted. RESULTS: There were no wound problems, sural nerve injuries, or re-ruptures. All patients were able to return to their previous sporting activities by 6 months. CONCLUSIONS: This independent study confirms that the technique offers patients a safe operative procedure for repair of acute Achilles tendon ruptures that allows early active rehabilitation.

Management of sports injuries of the foot and ankle: an update.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874-83.

Management of sports injuries of the foot and ankle: An update.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299-1311.

Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study.

OBJECTIVE: To assess the use of a supervised active rehabilitation program following repair of acute Achilles tendon ruptures using a minimally invasive suture system. METHODS: We performed a prospective study on 46 patients undergoing surgical repair of acute Achilles tendon ruptures using the Achillon suture system. All patients began a supervised active rehabilitation program from 2 weeks postoperatively. Patients were placed in a range of motion brace fixed at 20 degrees equinus for 2 weeks to allow wound healing followed by active movement from neutral to full plantar flexion for 4 weeks. RESULTS: At a minimum follow up of 12 months there were no re-ruptures. All patients were able to return to their previous sporting activities by 6 months post operation. The average American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months was 98, with 42 patients having excellent and four patients good Leppilahti scores. The average time to return to work was 22 days. One patient had a superficial wound infection which settled with 5 days of oral antibiotics. Two patients had altered sensation in the distribution of the sural nerve which settled spontaneously within 3 months. CONCLUSION: The Achillon suture system appears to allow a safe early active rehabilitation program and achieves a high rate of success. Further evaluation is necessary with regard to potential damage to the sural nerve.

Calcaneal fractures: selection bias is key.

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures. We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures.

Results of isolated Lisfranc injuries and the effect of compensation claims.

The results of treatment of Lisfranc injuries are often unsatisfactory. This retrospective study investigated 46 patients with isolated Lisfranc injuries at a minimum of two years after surgery. Thirteen patients had a poor outcome and had to change employment, or were unable to find work as a result of this injury. The presence of a compensation claim (p = 0.02) and a delay in diagnosis of more than six months were associated with a poor outcome (p = 0.01). There was no association between poor functional outcome and age, gender, mechanism of injury or previous occupation. This study may have medico-legal implications on reporting the prognosis for such injuries, and highlights the importance of prompt diagnosis and treatment.

Manipulation and injection for hallux rigidus. Is it worthwhile?

Manipulation of the metatarsophalangeal joint and injection with steroid and local anaesthetic are widely practised in the treatment of hallux rigidus, but there is little information on the outcome. We report the results of this procedure carried out on 37 joints, with a minimum follow-up of one year (mean, 41.2 months). Patients with mild (grade-1) changes gained symptomatic relief for a median of six months and only one-third required surgery. Two-thirds of patients with moderate (grade-2) disease proceeded to open surgery. In advanced (grade-III) hallux rigidus, little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are graded before treatment and that manipulation under anaesthetic and injection be used only in early (grades I and II) hallux rigidus.

The extent of osteocyte death in the proximal femur of patients with osteonecrosis of the femoral head.

Our aim was to assess the local extent of osteocyte death in the proximal femur of 16 patients with osteonecrosis of the femoral head. We performed histological examination of the femoral heads and cancellous bone biopsies from four regions of the proximal femur in patients undergoing total hip arthroplasty. A control group consisted of 19 patients with osteoarthritis. All histological specimens were examined in a blinded fashion. Extensive osteonecrosis was shown in the proximal femur up to 4 cm below the lesser trochanter in the group with osteonecrosis. There was an overall statistically significant difference in the extent of osteocyte death distal to the femoral head between the two groups (p < 0.001). We discuss the implications of these findings as possible contributing factors in regard to the early failure of total hip arthroplasty reported in patients with osteonecrosis of the femoral head.

Screw versus suture fixation of Mitchell's osteotomy. A prospective, randomised study.

We studied prospectively 30 patients who had a Mitchell's osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell's osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence.

Apoptosis--a significant cause of bone cell death in osteonecrosis of the femoral head.

Osteonecrosis of the femoral head usually affects young individuals and is responsible for up to 12% of total hip arthroplasties. The underlying pathophysiology of the death of the bone cells remains uncertain. We have investigated nitric oxide mediated apoptosis as a potential mechanism and found that steroid- and alcohol-induced osteonecrosis is accompanied by widespread apoptosis of osteoblasts and osteocytes. Certain drugs or their metabolites may have a direct cytotoxic effect on cancellous bone of the femoral head leading to apoptosis rather than purely necrosis.

Management of paediatric clavicle fractures--is follow-up necessary? An audit of 346 cases.

We investigated the incidence of complications following childhood clavicle fractures and the necessity for follow-up in fracture clinic after the first orthopaedic consultation. We found that review in fracture clinic has no impact upon the outcome of clavicle fractures and complications such as non-union, mal-union or neurovascular problems are exceptionally rare. We concluded that there is no need for follow-up of children with isolated, uncomplicated clavicle fractures. These patients should be discharged after their first assessment in fracture clinic.

Surgical treatment of insertional Achilles tendinosis.

Most patients with insertional Achilles tendinosis can be managed nonoperatively but those who do not respond may require excision of the diseased tendon. Currently, there are no clinical studies indicating how much of the tendon may be excised without predisposing the patient to Achilles tendon rupture. This chart review reports on 52 heels treated surgically for this condition and followed for a minimum of six months postoperatively. When less than 50% of the tendon was excised (49 heels) patients were immediately mobilized free of a cast. There were two failures using this regimen--one patient with psoriatic arthropathy and another who underwent bilateral simultaneous procedures. We suggest that in selected patients it is safe to proceed with early active mobilization immediately postoperatively when less than 50% of the tendon is resected.

Osteochondral lesions of the talus: aspects of current management.

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Achilles tendinopathy: A review of the current concepts of treatment.

The two main categories of Achilles tendon disorder are broadly classified by anatomical location to include non-insertional and insertional conditions. Non-insertional Achilles tendinopathy is often managed conservatively, and many rehabilitation protocols have been adapted and modified, with excellent clinical results. Emerging and popular alternative therapies, including a variety of injections and extracorporeal shockwave therapy, are often combined with rehabilitation protocols. Surgical approaches have developed, with minimally invasive procedures proving popular. The management of insertional Achilles tendinopathy is improved by recognising coexisting pathologies around the insertion. Conservative rehabilitation protocols as used in non-insertional disorders are thought to prove less successful, but such methods are being modified, with improving results. Treatment such as shockwave therapy is also proving successful. Surgical approaches specific to the diagnosis are constantly evolving, and good results have been achieved.