Osteochondral lesions of the distal tibial plafond: localization and morphologic characteristics with an anatomical grid.

BACKGROUND: The aim of this study was to evaluate the incidence and morphologic characteristics of osteochondral lesions of the distal tibial plafond (OLTP) by location and morphologic characteristics on MRI. MATERIAL AND METHODS: We assigned 9 zones to the distal tibial plafond articular surface in an equal 3 x 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all 9 zones being equal in surface area. Two observers reviewed MRI examinations of 38 patients (12 males and 26 females; mean age, 38.7 years; age range, 10 to 68 years) with reported OLTPs. We recorded the frequency of involvement and size of lesion for each zone. A chart review was performed. RESULTS: Of the 38 OLTP found in this study, 14 (37%) of the lesions were on the medial tibial plafond [zones 1, 4 and 7] and 11 (29%) involved the lateral tibial plafond [zones 3, 6 and 9]; 13 lesions (34%) localized to the center third of the plafond [zones 2, 5 and 8]. Nine of the lesions (24%) were on the anterior tibial plafond [zones 1, 2 and 3], 15 lesions (39%) predominately involved the posterior plafond [zones 7, 8 and 9], and 14 lesions (37%) localized to the central third of the plafond [zones 4, 5 and 6]. The medial central tibial plafond was most frequently involved site with 8 of the 38 (21%) lesions located there; the posterior medial tibial plafond was second most frequently involved with six of the 38 lesions (16%). Six of 38 ankles had both a talar osteochondral lesion and an OLTP. Of these, only one was a ;kissing' lesion. Chart review revealed that all subjects had ankle pain at time of MRI examination. CONCLUSION: We conclude that osteochondral lesions of the distal tibial plafond must be considered in the differential diagnosis of patients with symptomatic ankles and that no location had a significantly higher incidence.

Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings.

BACKGROUND: The objective of the present study was to assess the utility of magnetic resonance imaging for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional magnetic resonance imaging is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard. METHODS: Magnetic resonance images of twenty-one feet in twenty patients (ten women and ten men with a mean age of 33.6 years [range, twenty to fifty-six years]) were evaluated with regard to the integrity of the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal-metatarsal ligaments, and the medial-middle cuneiform ligament. Furthermore, the presence of fluid along the first metatarsal base and the presence of fractures also were evaluated. Radiographic observations were compared with intraoperative findings with respect to the stability of the Lisfranc joint, and logistic regression was used to find the best predictors of Lisfranc joint instability. RESULTS: Intraoperatively, seventeen unstable and four stable Lisfranc joints were identified. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and positive predictive value of 94%, 75%, and 94%, respectively. Nineteen (90%) of the twenty-one Lisfranc joint complexes were correctly classified on magnetic resonance imaging; in one case an intraoperatively stable Lisfranc joint complex was interpreted as unstable on magnetic resonance imaging, and in another case an intraoperatively unstable Lisfranc joint complex was interpreted as stable on magnetic resonance imaging. The majority (eighteen) of the twenty-one feet demonstrated disruption of the second plantar tarsal-metatarsal ligament, which had little clinical correlation with instability. CONCLUSIONS: Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended. The appearance of a normal ligament is suggestive of a stable midfoot, and documentation of its integrity may obviate the need for a manual stress radiographic evaluation under anesthesia for a patient with equivocal clinical and radiographic examinations.

Outcomes of chronic insertional Achilles tendinosis using FHL autograft through single incision.

BACKGROUND: The purpose of this study was to evaluate the clinical outcomes and objective isokinetic dynamometry on a cohort of patients with chronic insertional Achilles tendinosis, who underwent surgical reconstruction using an FHL tendon autograft transfer through a single incision. MATERIALS AND METHODS: Forty patients (16 male and 24 female; mean age, 57 years; age range, 39 to 76 years) with persistent chronic Achilles tendinosis were evaluated after surgical reconstruction at an average of 27 months after surgery. At the time of final followup, ankle strength and active range of motion (AROM) were evaluated using Biodex isokinetic dynamometry. Additionally, patients were assessed with AOFAS Ankle Hindfoot scores, pain on a Visual Analog Scale (VAS) and their self-reported level of satisfaction (Very Good, Good, Fair, Poor). RESULTS: We found no loss of plantarflexion strength or plantarflexion power in the operated ankles; an average of 4-degree loss of AROM was found. The study population scored an average of 96/100 for the total AOFAS-AH score post-repair. The average VAS decreased from 7.5 pre-op to 0.3 post-op. Thirty-eight of 40 patients (95%) were satisfied with their outcome (rated Very Good or Good), two patients rated their outcome as Fair and none as Poor. CONCLUSION: For individuals with chronic insertional Achilles tendinosis, operative repair using an FHL tendon with the single-incision technique achieved a high percentage of satisfactory results as well as excellent functional and clinical outcomes including significant pain reduction.

Magnetic resonance imaging findings in bipartite medial cuneiform - a potential pitfall in diagnosis of midfoot injuries: a case series.

INTRODUCTION: The bipartite medial cuneiform is an uncommon developmental osseous variant in the midfoot. To our knowledge, Magnetic Resonance Imaging (MRI) characteristics of a non-symptomatic bipartite medial cuneiform have not been described in the orthopaedic literature. It is important for orthopaedic foot and ankle surgeons, musculoskeletal radiologists, and for podiatrists to identify this osseous variant as it may be mistakenly diagnosed as a fracture or not recognized as a source of non-traumatic or traumatic foot pain, which may sometimes even require surgical treatment. CASE PRESENTATIONS: In this report, we describe the characteristics of three cases of bipartite medial cuneiform on Magnetic Resonance Imaging and contrast its appearance to that of a medial cuneiform fracture. CONCLUSION: A bipartite medial cuneiform is a rare developmental anomaly of the midfoot and may be the source of midfoot pain. Knowledge about its characteristic appearance on magnetic resonance imaging is important because it is a potential pitfall in diagnosis of midfoot injuries.

Intrasheath subluxation of the peroneal tendons.

BACKGROUND: Dislocation or subluxation of the peroneal tendons out of the peroneal groove under a torn or avulsed superior peroneal retinaculum has been well described. We identified a new subgroup of patients with intrasheath subluxation of these tendons within the peroneal groove and with an otherwise intact retinaculum. METHODS: The cases of fifty-seven patients with painful snapping of the peroneal tendons posterior to the fibula were reviewed. Of these, forty-three had tendons that could be reproducibly subluxated out of the groove with a dorsiflexion-eversion maneuver of the ankle. Fourteen patients who could not subluxate the tendons out of the groove underwent a dynamic ultrasound examination of the tendons. While the same dorsiflexion and eversion maneuver was being performed, the tendons were seen to switch their relative positions (the peroneus longus came to lie deep to the peroneus brevis tendon) with a reproducible painful click. All fourteen patients underwent a peroneal groove-deepening procedure with retinacular reefing. Intraoperatively, thirteen patients were found to have a convex peroneal groove and all fourteen had an intact peroneal retinaculum. All patients subsequently underwent a follow-up dynamic ultrasound examination and an American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score evaluation at a minimum of twenty-four months after surgery. RESULTS: All fourteen patients were female, with an average age of thirty-five years. Two subtypes of intrasheath subluxation were found. Type A (ten patients) involved intact tendons with relative switching of their anatomic alignment. Type B (four patients) involved a longitudinal split within the peroneus brevis tendon through which the longus tendon subluxated. Intraoperative confirmation of the ultrasound findings was 100%. At an average follow-up interval of thirty-three months, the average AOFAS score had improved from 61 points preoperatively to 93 points, and the average score on the 10-cm visual analog pain scale had improved from 6.8 to 1.2. Follow-up ultrasound evaluation revealed healed tendons without persistent subluxation in thirteen patients. Nine patients rated the result as excellent, four rated it as good, and one rated it as fair. CONCLUSIONS: Patients with retrofibular pain and clicking of the peroneal tendons may not have demonstrable subluxation on physical examination and may have an intact superior peroneal retinaculum. They may have an intrasheath subluxation of the peroneal tendons, which can be confirmed with use of a dynamic ultrasound. Surgical repair of tendon tears combined with a peroneal groove-deepening procedure with retinacular reefing is a reproducibly effective procedure for this condition.

Bone stress injury of the ankle in professional ballet dancers seen on MRI.

BACKGROUND: Ballet dancers have been shown to have a relatively high incidence of stress fractures of the foot and ankle. It was our objective to examine MR imaging patterns of bone marrow edema (BME) in the ankles of high performance professional ballet dancers, to evaluate clinical relevance. METHODS: MR Imaging was performed on 12 ankles of 11 active professional ballet dancers (6 female, 5 male; mean age 24 years, range 19 to 32). Individuals were imaged on a 0.2 T or 1.5 T MRI units. Images were evaluated by two musculoskeletal radiologists and one orthopaedic surgeon in consensus for location and pattern of bone marrow edema. In order to control for recognized sources of bone marrow edema, images were also reviewed for presence of osseous, ligamentous, tendinous and cartilage injuries. Statistical analysis was performed to assess the strength of the correlation between bone marrow edema and ankle pain. RESULTS: Bone marrow edema was seen only in the talus, and was a common finding, observed in nine of the twelve ankles imaged (75%) and was associated with pain in all cases. On fluid-sensitive sequences, bone marrow edema was ill-defined and centered in the talar neck or body, although in three cases it extended to the talar dome. No apparent gender predilection was noted. No occult stress fracture could be diagnosed. A moderately strong correlation (phi = 0.77, p= 0.0054) was found between edema and pain in the study population. CONCLUSION: Bone marrow edema seems to be a specific MRI finding in the talus of professional ballet dancers, likely related to biomechanical stress reactions, due to their frequently performed unique maneuvers. Clinically, this condition may indicate a sign of a bone stress injury of the ankle.

Incidence and morphologic characteristics of benign calcaneal cystic lesions on MRI.

BACKGROUND: Since we have frequently noted osseous cyst-like lesions within the calcaneus on MRI studies, we sought to systematically evaluate this finding to determine the incidence and morphologic characteristics on MRI. METHODS: Three observers blinded to age evaluated 198 MRIs of the ankle (74 males, 124 females; mean age 47 years, range 13 to 99 years), recording the presence and size of calcaneal cyst-like foci. Statistical analysis was performed to determine if there was an association with age. Additionally, MRI of 12 ankles precontrast and postcontrast were reviewed for the presence of blood vessels in the calcaneus corresponding to the location of the cyst-like lesions and 24 ankle MR arthrograms were reviewed to evaluate communication of the cyst with the adjacent joint. RESULTS: Of the 198 ankle MRI examinations, 81 (40%) had hyperintense foci, all within the mid-calcaneal body. The size ranged from 0.01 cm(2) to 2.47 cm(2), with a mean size of 0.36 cm(2) (+/- 0.45 cm(2)). Thirty-seven (46%) were linear or elongated, whereas 44 (54%) were ovoid or round. Seven of the 81 foci (8.6% or 3.5% of the total population) were 1 cm(2) or larger. There was no significant association of patient age and presence (p = 0.49) or size (p = 0.48) of the focus. Location of the cyst-like foci, which often are ovoid or linear, corresponds to penetrating microvessels on precontrast and postcontrast MRI. One MR arthrogram showed communication of a cyst-like focus and the subtalar joint. CONCLUSIONS: Calcaneal lesions are relatively common incidental findings on MRI. These lesions appear to represent intraosseous ganglion cysts that arise from the anterior margin of the posterior facet of the subtalar joint in the anatomical neighborhood where vessels penetrate the superior calcaneal cortex. The lesions can vary is size; however, there is no correlation between patient age and lesion size and no significant association between age and presence of these foci.

Recurrent burner syndrome due to presumed cervical spine osteoblastoma in a collision sport athlete - a case report.

We present a case of a 35-year-old active rugby player presenting with a history of recurrent burner syndrome thought secondary to an osteoblastoma involving the posterior arch of the atlas. Radiographically, the lesion had features typical for a large osteoid osteoma or osteoblastoma, including osseous expansion, peripheral sclerosis and bony hypertrophy, internal lucency, and even suggestion of a central nidus. The patient subsequently underwent an en bloc resection of the posterior atlas via a standard posterior approach. The surgery revealed very good clinical results. In this report, we will discuss in detail, the presentation, treatment, and return to play recommendations involving this patient.

Osteochondral lesions of the talus: localization and morphologic data from 424 patients using a novel anatomical grid scheme.

BACKGROUND: The primary aim of this study was to evaluate the true incidence of osteochondral lesions on the talar dome by location and by morphologic characteristics on MRI. Because no universally accepted localization system for talar dome osteochondral lesions currently exists, we established a novel, nine-zone anatomical grid system on the talar dome for an accurate depiction of lesion location. METHODS: We assigned nine zones to the talar dome articular surface in an equal 3 x 3 grid configuration. Zone 1 was the most anterior and medial, zone 3 was anterior and lateral, zone 7 was most posterior and medial, and zone 9 was the most posterior and lateral. The grid was designed with all nine zones being equal in surface area. Two observers reviewed MRI examinations of 428 ankles in 424 patients (211 males and 213 females; mean age 43 years; age range 6 to 85 years) with reported osteochondral talar lesions. We recorded the frequency of involvement and size of lesion for each zone. Statistical analyses were performed using ANOVA and Scheffe tests. RESULTS: Four hundred and twenty-eight lesions were identified on MRI. The medial talar dome was more frequently involved (n = 269, 62%) than the lateral talar dome (n = 143, 34%). In the AP direction, the mid talar dome (equator) was much more frequently involved (n = 345, 80%) than the anterior (n = 25, 6%) or posterior (n = 58, 14%) thirds of the talar dome. Zone 4 (medial and mid) was most frequently involved (n = 227, 53%), and zone 6 (lateral and mid) was second most frequently involved (n=110, 26%). Lesions in the medial third of the talar dome were significantly larger in surface area involvement and deeper than those at the lateral talar dome. CONCLUSIONS: Our established nine-grid scheme is a useful tool for localizing and characterizing osteochondral talar lesions, which are most frequently located in zone 4 at the medial talar dome, and second most in zone 6 at the lateral talar dome near its equator. Medial talar dome lesions are not only more common but are larger in surface area and in depth than lateral lesions. Posteromedial and anterolateral lesions rarely were found.

Reconstruction for missed or neglected Achilles tendon rupture with V-Y lengthening and flexor hallucis longus tendon transfer through one incision.

BACKGROUND: The purpose of this study was to introduce a novel operative technique and to evaluate the clinical outcomes in a cohort of patients with missed or neglected Achilles tendon ruptures. METHODS: Fifteen consecutive patients with missed complete Achilles tendon ruptures and 5-cm or larger gaps had reconstruction with V-Y lengthening and flexor hallucis longus tendon transfer through a single incision. The patients were evaluated at an average of 106 weeks after surgery. At the time of followup, all patients were assessed with regard to their self-reported level of satisfaction and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Ankle strength and active range of motion were evaluated using Biodex (Biodex Medical Systems, Shirley, NY) isokinetic dynamometry. In addition, seven patients were evaluated using diagnostic ultrasound. RESULTS: We found a 7.7 N-m (-22.3%) loss of plantarflexion torque at 60 degrees/sec and a 3.5 N-m (-13.5%) loss of plantarflexion torque at 120 degrees/sec, as well as a 5 degrees loss of active range of motion. AOFAS scores were all good to excellent, with an average score of 94.1 of 100. All patients were satisfied with their outcomes (rated good or very good). Excellent exposure of the Achilles tendon repair was obtained with ultrasound. CONCLUSIONS: For patients with missed or neglected Achilles tendon rupture with a rupture gap of at least 5 cm, operative repair using V-Y lengthening and flexor hallucis longus tendon transfer through a single incision technique achieved a high percentage of satisfactory results.

Osteochondral lesions of the talus: change in MRI findings over time in talar lesions without operative intervention and implications for staging systems.

BACKGROUND: MRI findings are used in several staging systems to help determine appropriate treatment. The purposes of this study were to evaluate longitudinal changes in MRI characteristics of osteochondral lesions of the talus (OLT) and to evaluate published staging systems in a cohort of nonoperatively treated patients. METHODS: Twenty-nine patients were identified; MR images were reviewed for location, size, and interface signal of OLT as well as cysts, marrow edema and osteoarthritis. Lesions were classified as unchanged, progressed, or improved based on changes in size or interface signal. Each lesion was assigned a stage based on four different staging systems. RESULTS: Of the 29 lesions, 13 progressed, seven improved, and nine were unchanged over an average followup of 13.7 months. In the 13 that progressed, marrow edema remained present in ten and developed in two. Four had persistent cysts and four developed new cysts. Two had progression of osteoarthritis and two developed it anew. In the seven that improved, six had some degree of marrow edema that persisted and one had a persistent cyst. Initial staging changed for at least one classification system in 16 (55%) of the 29 lesions at followup. Change in stage was primarily due to development (four of 16) or disappearance of cysts or progression of the lesion in the extent of bone marrow edema (five of 16). CONCLUSIONS: OLT did not invariably progress over the short-term without operative intervention. Because some cysts and bone marrow edema resolved on MRI, they may not be reliable signs of lesion severity nor show progression of degenerative changes. Since these findings determine the stage and severity of OLT in some staging systems, they may require reconsideration and adjustment of the current staging systems.