Large variation in management of talar osteochondral lesions among foot and ankle surgeons: results from an international survey.

PURPOSE: Surgeons management of osteochondral lesions of the talus (OLT) may be different to the published guidelines because not all treatment recommendations are feasible in every country. This study aimed to assess how OLT are managed worldwide by foot and ankle surgeons. METHODS: A web-based survey was distributed to the members of 21 local and international scientific societies focused on foot and ankle or sports medicine surgery. Answers with a prevalence greater than 75% of respondents were considered a "main tendency", whereas where prevalence exceeded 50% of respondents they were considered a "tendency". RESULTS: A total of 1804 surgeons from 79 different countries returned the survey. The responses to 19 of 28 questions (68%) regarding management and treatment of OLT achieved a main tendency (> 75%) or a tendency (> 50%). Symptoms reported to be most suspicious for OLT were pain on weight-bearing (WB) and after activity (83%), deep localization of the pain (62%), and any history of trauma (55%). 89% of surgeons routinely obtain an MRI, 72% routinely get WB radiographs, and 50% perform a CT scan. When treated surgically, OLTs are managed in isolation by only 7% of surgeons, and combined with ligament repair or reconstruction by 79%; 67% report simultaneous excision of soft-tissue or bony impingements (64%). For lesions less than 10-15 mm in diameter, bone marrow stimulation (BMS) represents the first choice of treatment for 78% of surgeons (main tendency). No other treatment was recorded as a tendency. For lesions greater than 15 mm in diameter no tendencies were recorded. The BMS represented the most preferred treatment being the first choice of treatment for 41% of surgeons. OLT depth had little influence on treatment choice: 71% of surgeons treating small lesions and 69% treating large lesions would choose the same treatment regardless of whether the lesion had a depth lesser or greater than 5 mm. CONCLUSION: The management of OLT by foot and ankle surgeons from around the world remains extremely varied. The main clinical relevance of this study is that it provides updated information with regard to the management of OLT internationally, which could be used by surgeons worldwide in their decision-making and to inform the patient about available surgical options. LEVEL OF EVIDENCE: Level IV.

Partial anterior tunnel syndrome: a retrospective analysis of ultrasound findings in four surgically proven cases.

We present the cases of four patients (two men and two women, mean age of 48.5 years) with surgically confirmed partial anterior tarsal syndrome, diagnosed by ultrasound. All patients reported pain in the dorsal aspect of the forefoot radiating to the first intermetatarsal space. Ultrasound showed compression of the medial branch of the deep fibular nerve by the extensor hallucis brevis tendon at the level of the Lisfranc joint, associated with a hypoechoic neuroma. The ultrasound allowed a correct diagnosis to be obtained, which was not evident from clinical examination or by standard radiographs (four patients) or MRI (three patients). Surgery confirmed the sonographic findings, and all patients showed complete recovery.

Ultrasonography of the Sural Nerve: Normal and Pathologic Appearances.

Ultrasonography (US) of peripheral nerves has gained wide popularity because of the increased definition of modern high-frequency electronic transducers, as well as the well-known advantages of US, which include easy availability, low cost, and the possibility of realizing a dynamic examination. Traditionally, US has been deployed to assess the major nerves of the limbs. More recently, US has also been used to assess the normal appearance and pathologic changes of smaller subcutaneous nerves. The sural nerve is a small sensory nerve in the subcutaneous tissues of the calf that can be affected by a variety of disorders. This pictorial essay illustrates the normal anatomy of the sural nerve, the technique for its examination by US, as well as the US appearance of its main pathologic changes.

Ultrasound of peroneal tendons.

Disorders of the peroneal tendon (PeT) complex are common and affect patients of many different ages. They can be traumatic, inflammatory, infective, or degenerative. Clinical assessment orients the diagnosis, but an imaging modality is almost always performed to confirm the clinical impression and to obtain additional information that is essential in choosing among different treatments. Due to its peculiar characteristics of high resolution, cost effectiveness, noninvasiveness, and dynamism, ultrasound (US) is now widely considered the first-line imaging modality to assess superficial tendons. US not only allows an optimal evaluation of the PeT complex but can also accurately assess its synovial sheath, retinacula, and adjacent tissues. This article describes the normal anatomy, technique of examination, and normal US anatomy of the PeT complex as well as illustrating the US appearance of its main disorders.

Insufficiency fracture of the calcaneum: Sonographic findings.

We present a case of insufficiency fracture (IF) of the calcaneum diagnosed by sonography (US). An 83-year-old woman consulted because of pain and swelling of the left heel without history of trauma. Standard radiographs showed osteoporosis without fracture. US revealed thickening of the calcaneal periosteum associated with edema of the adjacent soft tissues. Color Doppler imaging showed marked increased vascularity of the periosteum. US changes, together with the clinical and radiographic findings, were consistent with an IF of the calcaneum that was confirmed by MRI. The patient was treated successfully by conservative treatment. In the proper clinical setting, US can suggest the diagnosis of IF of the calcaneum.

Limited open repair of Achilles tendon ruptures: a technique with a new instrument and findings of a prospective multicenter study.

BACKGROUND: Controversy persists regarding the ideal surgical technique for repair of a ruptured Achilles tendon. We propose a limited open procedure with use of an instrument that provides the advantage of an open repair but avoids the soft-tissue problems with which open repair has been associated. METHODS: We first performed a cadaver study in order to develop an instrument and a technique for a limited open repair and then, using this procedure in conjunction with an early functional rehabilitation protocol, we began a prospective multicenter study. We are reporting on the first eighty-seven patients consecutively treated with the new instrument and followed for an average of twenty-six months (range, eighteen to forty-two months). All patients were assessed clinically and with an enhanced American Orthopaedic Foot and Ankle Society (AOFAS) rating score. In addition, all fifty patients who had been followed for at least twenty-four months were further evaluated with isokinetic dynamometry. RESULTS: Four patients were lost to follow-up and one patient died, which left eighty-two patients for evaluation. There were no problems with wound-healing, and there were no infections. No patient noted a sensory disturbance in the sural nerve distribution. All patients returned to their previous professional or sporting activities. The mean AOFAS score was 96 points (range, 85 to 100 points). Isokinetic dynamometry showed no significant difference in strength between the injured and uninjured limbs of the fifty patients who were tested. Complications occurred in three patients. Two of them were noncompliant and removed the orthosis, so that the repair was disrupted by a new injury within the first three weeks postoperatively. One patient fell twelve weeks after the surgery and sustained a rerupture. All three new injuries were repaired with an open surgical procedure. CONCLUSIONS: This new procedure allows the surgeon to precisely visualize and control the tendon ends while avoiding excessive dissection and disturbance of local vascularity and minimizing nerve and wound-healing problems. Such a technique, along with an early functional rehabilitation program, allowed us to achieve a high rate of successful results with minimal morbidity.

Foot and ankle injuries during the Athens 2004 Olympic Games.

BACKGROUND: Major, rare and complex incidents can occur at any mass-gathering sporting event and team medical staff should be appropriately prepared for these. One such event, the Athens Olympic Games in 2004, presented a significant sporting and medical challenge. This study concerns an epidemiological analysis of foot and ankle injuries during the Games. METHODS: An observational, epidemiological survey was used to analyse injuries in all sport tournaments (men's and women's) over the period of the Games. RESULTS: A total of 624 injuries (525 soft tissue injuries and 99 bony injuries) were reported. The most frequent diagnoses were contusions, sprains, fractures, dislocations and lacerations. Significantly more injuries in male (58%) versus female athletes (42%) were recorded. The incidence, diagnosis and cause of injuries differed substantially between the team sports. CONCLUSION: Our experience from the Athens Olympic Games will inform the development of public health surveillance systems for future Olympic Games, as well as other similar mass events.