Emerging Concepts in Treating Cartilage, Osteochondral Defects, and Osteoarthritis of the Knee and Ankle.

The management and treatment of cartilage lesions, osteochondral defects, and osteoarthritis remain a challenge in orthopedics. Moreover, these entities have different behaviors in different joints, such as the knee and the ankle, which have inherent differences in function, biology, and biomechanics. There has been a huge development on the conservative treatment (new technologies including orthobiologics) as well as on the surgical approach. Some surgical development upraises from technical improvements including advanced arthroscopic techniques but also from increased knowledge arriving from basic science research and tissue engineering and regenerative medicine approaches. This work addresses the state of the art concerning basic science comparing the knee and ankle as well as current options for treatment. Furthermore, the most promising research developments promising new options for the future are discussed.

The Reliability of Orthopaedic Eponymous Terms.

BACKGROUND: There are approximately 20,000 medical eponymous terms in use today. Familiar eponymous terms serve as shorthand during communication with colleagues. This study tested the reliability of the everyday use of common orthopaedic eponymous terms. METHODS: Using an online survey, 224 orthopaedic surgeons were quizzed on common eponymous terms. The correspondence of each eponymous term with its original description (termed appropriate use) was calculated with 95% confidence intervals. We measured the reliability of the use of eponymous terms using the kappa statistic and the proportion of agreement. RESULTS: The percentage of appropriate use averaged 45% (ranging from 27% [for the Barton fracture eponymous term] to 75% [for the Sever's disease eponymous term]), with greater misuse among European surgeons. The reliability of the use of eponymous terms was low (kappa, 0.11; proportion of agreement, 68%). The support for using eponymous terms in daily practice was significantly lower among surgeons practicing in North America (63%) than among their colleagues in Europe and South America (80%; p < 0.001). Eponymous terms were used more often than anatomical descriptions or classifications. CONCLUSIONS: Using eponymous terms is an inaccurate and unreliable method of communication. Descriptive terms are preferable to eponymous terms.

Arthroscopic Repair of Ankle Instability With All-Soft Knotless Anchors.

In recent years, arthroscopic and arthroscopically assisted techniques have been increasingly used to reconstruct the lateral ligaments of the ankle. Besides permitting the treatment of several comorbidities, arthroscopic techniques are envisioned to lower the amount of surgical aggression and to improve the assessment of anatomic structures. We describe our surgical technique for arthroscopic, two-portal ankle ligament repair using an all-soft knotless anchor, which is made exclusively of suture material. This technique avoids the need for classic knot-tying methods. Thus it diminishes the chance of knot migration caused by pendulum movements. Moreover, it avoids some complications that have been related to the use of metallic anchors and some currently available biomaterials. It also prevents prominent knots, which have been described as a possible cause of secondary complaints.

Prospective Computed Tomographic Analysis of Osteochondral Lesions of the Ankle Joint Associated With Ankle Fractures.

BACKGROUND: Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome. METHODS: 100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year. RESULTS: OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs. CONCLUSIONS: Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS. LEVEL OF EVIDENCE: Level IV, observational study.

The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study.

The source of pain and the background to the pain mechanisms associated with mid-portion Achilles tendinopathy have not yet been clarified. Intratendinous degenerative changes are most often addressed when present. However, it is questionable if degeneration of the tendon itself is the main cause of pain. Pain is often most prominent on the medial side, 2-7cm from the insertion onto the calcaneus. The medial location of the pain has been explained to be caused by enhanced stress on the calcaneal tendon due to hyperpronation. However, on this medial side the plantaris tendon is also located. It has been postulated that the plantaris tendon might play a role in these medially located symptoms. To our knowledge, the exact anatomy and relationship between the plantaris- and calcaneal tendon at the level of complaints have not been anatomically assessed. This was the purpose of our study. One-hundred and seven lower extremities were dissected. After opening the superficial fascia and paratendon, the plantaris tendon was bluntly released from the calcaneal tendon moving distally. The incidence of the plantaris tendon, its course, site of insertion and possible connections were documented. When with manual force the plantaris tendon could not be released, it was defined as a 'connection' with the calcaneal tendon. In all specimens a plantaris tendon was identified. Nine different sites of insertion were found, mostly medial and fan-shaped onto the calcaneus. In 11 specimens (10%) firm connections were found at the level of the calcaneal tendon mid-portion. Clinical and histological studies are needed to confirm the role of the plantaris tendon in mid-portion Achilles tendinopathy.

Anterior and posterior ankle impingement.

Anterior ankle impingement is characterized by anterior ankle pain on activity. Recurrent (hyper) dorsiflexion is often the cause. Typically, there is pain on palpation at the anteromedial or anterolateral joint line. Some swelling or limitation in dorsiflexion are present. Plain radiographs can disclose the cause of the impingement. In the case of spurs or osteophytes, the diagnosis is anterior bony impingement. In the absence of spurs or osteophytes, the diagnosis is anterior soft tissue impingement. In patients with anteromedial impingement, plain radiographs ae often falsely negative. An oblique view (anteromedial impingement view = AMI view) is recommended in these patients. Arthroscopic management with removal of the offending tissue provides good to excellent long-term (5-8 years) results in 83% of patients with grade 0 and grade I lesions. Long-term results are good/excellent in 50% of patients with grade II lesions (osteophytes secondary to arthritis with joint space narrowing). In posterior ankle impingement, patients experience hindfoot pain when the ankle is forcedly plantarflexed. Trauma or overuse can be the cause. The trauma mechanism is hyperplantarflexion or a combined inversion plantarflexion injury. Overuse injuries typically occur in ballet dancers and downhill runners, who report pain on palpation at the posterolateral aspect of the talus. On plain radiographs, an os trigonum or hypertrophic posterior or talar process can be detected. Surgical management involves removal of the os trigonum, scar tissue, or hypertrophic posterior talar process. In the case of combined posterior bony impingement and flexor hallucis longus tendinopathy, a release of the flexor hallucis longus is performed simultaneously. Endoscopic management is associated with a low morbidity, a short recovery time, and provides good/excellent results at 2-5 years follow-up in 80% of patients.

Tendoscopy of the posterior tibial tendon.

Posteromedial ankle complaints are most often caused by a disorder of the posterior tibial tendon. Two predominant groups of patients can be distinguished: the first involves younger patients who have some form of systemic inflammatory disease; the second involves older patients whose dysfunction is caused by chronic overuse. This article illustrates endoscopy of the posterior tibial tendon in a group of patients who had diverse pathology. None of the patients showed postoperative complications. All showed a quick recovery, early mobilization, none or mild postoperative pain, and nice wound healing. Although not all patients were free of complaints, all were satisfied with the intervention itself. Tendoscopy of the poterior tibial tendon offers the advantage of less morbidity, reduction of the postoperative pain, early mobilization, no wound healing problems and outpatient treatment.