Operative management of distal tibialis anterior tendinopathy.

BACKGROUND: The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the literature. We present the results of 12 operative procedures. MATERIALS AND METHODS: Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed 11 patients who underwent surgery for failure of nonoperative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring, at a mean followup of 29 months. RESULTS: Ten women (ten feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean preoperative AOFAS score was 52. Preoperative MRI showed tendinosis in two tendons and tendinosis with longitudinal split tears in ten tendons. Six of the twelve cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Six tendons were augmented with an extensor hallucis longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 33 and the mean postoperative pain VAS of 0.9 out of 10. Two patients underwent concomitant procedures on the same foot. Three of the six treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In six cases the patient was completely satisfied. Three were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery. CONCLUSION: Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provided a high level of patient satisfaction after nonoperative management failed in this series.

The clinical relevance of Tarlov cysts.

OBJECTIVE: The sacral perineural cyst was first described by Tarlov in 1938 as an incidental finding at autopsy. There are very few data in the literature regarding the role of Tarlov cysts in causing symptoms, however. Most studies report low numbers, and consequently, the recommendations for treatment are vague. Our aim, therefore, is to present further detail regarding the clinical relevance of Tarlov cysts and to identify whether or not they are a cause of lumbosacral spinal canal stenosis symptoms. METHODS: Over a 5-year period, 3535 patients underwent magnetic resonance imaging (MRI) scan for lumbosacral symptoms. Fifty-four patients were identified as having Tarlov cysts, and their clinical picture was correlated with the findings on MRI. RESULTS: The majority of Tarlov cysts (n = 38) cannot be held responsible for patients' symptoms and are clinically unimportant. However, we encountered several patients in whom Tarlov cysts (n = 9) occurred at the same level as another pathology. In these cases, the cyst itself did not require any specific therapy; treatment was directed at the other pathology, and uneventful symptom resolution occurred. A smaller subgroup of cysts (n = 7) are the main cause of patients' symptoms and may require specific treatment to facilitate local decompression. CONCLUSIONS: The majority of Tarlov cysts are incidental findings on MRI. Where confusion exists as to the clinical relevance of a Tarlov cyst, treatment of the primary pathology (ie, non-Tarlov lesion) is usually sufficient. Tarlov cysts may, however, be responsible for a patient's symptoms; possible mechanisms by which this may occur and treatment strategies are discussed.

Spontaneous rupture of the popliteus tendon in a 74-year-old woman and review of the literature.

Spontaneous rupture of the popliteus tendon has not previously been reported. We report the case of a 74-year-old patient, discuss its diagnosis and management, and review the current literature on isolated popliteus lesions. A multi-database electronic literature review suggests that the injury is invariably traumatic and has essentially been reported only in young, active individuals. It should be suspected in a patient with acute lateral knee pain who, on examination, has a hemarthrosis and a stable, possibly locked knee. The diagnosis is readily made using arthroscopy. While both conservative treatment with physiotherapy and open repair have been advocated, we describe a successful outcome of arthroscopic resection in an elderly patient and propose that popliteus injury is not confined to a younger age group. The balance of opinion in the current literature is that acute traumatic rupture in the young patient is managed by primary surgical repair, but successful outcome is also reported with nonoperative treatment.