Painful Medial Ankle in a Young Dancer: A Case Report of a Symptomatic Secondary Ossification Center of the Medial Malleolus.

An osseous fragment at the distal tip of the medial malleolus in a skeletally immature individual may represent a secondary ossification center and should not always be interpreted as a fracture. In this case study of a young dance student presenting with bilateral medial ankle pain, we postulated that hindfoot valgus, in combination with extreme loads placed on the foot during ballet training, increased stresses at the medial malleolus and accessory physis. Our patient was treated conservatively for symptomatic secondary ossification of medial malleolus and she returned to dance class at 6 months.

Percutaneous reduction and injection of Norian bone cement for the treatment of displaced intra-articular calcaneal fractures.

The treatment of intra-articular calcaneal fractures remains controversial. Although open reduction and fixation are favored by many authors, increased risk of soft tissue complications makes this method of treatment a challenge. Conversely, conservative treatment frequently leads to severe functional impairment and disability. Percutaneous surgical techniques have been employed to reduce the incidence of soft tissue complications but carry the risk of inadequate reduction and fracture stabilization. Norian SRS bone cement is an injectable calcium phosphate cement. Recent clinical studies have demonstrated the safe use of Norian SRS bone cement to augment standard plate fixation of calcaneal fractures. The authors describe their method of combining a percutaneous technique of fracture reduction with stabilization using Norian SRS bone cement. A total of 10 patients with 12 displaced intra-articular calcaneal fractures underwent this method of treatment. All 12 cases achieved adequate reduction on postoperative radiographs. Full weight bearing was started at 1 month postoperation, and none of the cases demonstrated loss of reduction on serial postoperative radiographs. No wound complications or cement-related soft tissue reactions were encountered. A 6-month assessment using the visual analog scale, the Maryland Foot Score, and the Short Form 36 general health survey showed encouraging results. Early results of treating displaced intra-articular calcaneal fractures using this method of a percutaneous technique of fracture reduction combined with Norian SRS bone cement stabilization are encouraging and promising.

Osteochondral lesions of the talus.

Osteochondral lesions of the talus can present as a late complication of ankle injuries. As the talus is largely covered by articular cartilage, it has a limited ability for repair. Early and accurate diagnosis is important as talar integrity is required for optimal function of the ankle. The common presentation is chronic ankle pain with a history of ankle trauma. Conservative treatment involving a period of casting and non-weight-bearing is recommended for acute, non-displaced osteochondral lesions. Surgical management is recommended for unstable lesions or failed conservative management.

Modification of lesser metatarsophalangeal joint arthroplasty using flexor digitorum longus transfer.

The authors present a modification of an interposition arthroplasty using the flexor digitorum longus for degeneration of the metatarsophalangeal joint with an associated hammer toe deformity. This procedure is simple to perform and allows for relief of pain and stiffness associated with metatarsophalangeal joint arthrosis.

'Snapping' knee secondary to a tibial osteochondroma.

INTRODUCTION: Osteochondroma is the most common bone tumour and is usually found around the knee. Typical presentations range form painless masses around the joint to mechanical irritation caused by direct pressure over surrounding muscles. Snapping of the knee caused by an osteochondroma however has not been described in literature. METHOD: An active 19-year-old gentleman presented with snapping of the left medial hamstring tendon for over 5 years, but with recent increase in frequencies of attack. The patient was initially diagnosed to have a sporting injury. Radiological investigation showed an opaque lesion on the medial border of the proximal tibia, which was suggestive of an osteophyte. RESULTS: The lump was surgically excised and the patient made good recovery with resolution of symptoms. Histological results revealed the lesion to be that of an osteochondroma. CONCLUSION: Although rare, osteochondroma should be considered as a differential when approaching a case of snapping knee pain.

Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study.

BACKGROUND: Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait. The purpose of this study was to analyze the kinematic effect of a simulated contraction of the abductor hallucis muscle on a cadaver lower limb specimen. METHODS: Eight below-knee cadaver specimens were prepared. The abductor hallucis muscle was exposed and the entire muscle-tendon unit excised. A suture secured to the calcaneal origin of the muscle and tendon was passed through a pulley at the ABH sesamoid attachment. The specimen was mounted on an experimental rig in a 'standing' position. Motions in the first metatarsal, tibia, and calcaneus were tracked using the 'Flock of Birds' motion analysis system (Ascension Technology, Burlington, VT). Muscle contraction was simulated by applying tension on the suture. RESULTS: All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted 'V' shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch. CONCLUSIONS AND CLINICAL RELEVANCE: The abductor hallucis muscle acts as a dynamic elevator of the arch. Understanding this mechanism may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and Charcot neuroarthropathy.

Myotonia congenita in a young active man: symptoms and physique tip the diagnosis.

A 19-year-old man had a 7-year history of leg cramps and a tendency for his legs to "seize up" when he participated in sports. The condition was initially mild, and clinical examination revealed an extremely muscular physique and percussion and action myotonia. Electromyography was consistent with myotonic discharges, and myotonia congenita was the diagnosis. Carbamazepine therapy relieved all symptoms, except for a short time when the patient stopped taking medication. Physicians should carefully document family history and symptom triggers to facilitate making the correct diagnosis.

Post-traumatic paroxysmal exercise-induced dystonia: case report and review of the literature.

A young Chinese man sustained a back injury in a motorcycle accident in 2000 and had left lower limb weakness due to a lumbosacral plexopathy, diagnosed clinically and electromyographically. With rehabilitation, he recovered full function, but developed paroxysmal dystonia of the left leg only with prolonged exertion. He responded well to oral baclofen, relapsed when he stopped taking it, and remains well on low dose maintenance therapy. Dystonia occurring after trauma is well documented, but paroxysmal exercise-induced dystonia occurring after trauma has yet to be described. Paroxysmal exercise-induced dystonia responds variably to anticonvulsant therapy, but the literature does not report response to baclofen, especially in low doses.

Osteolysis of structural autograft after calcaneocuboid distraction arthrodesis for stage II posterior tibial tendon dysfunction.

Surgical treatment of stage II posterior tibial tendon dysfunction that fails nonoperative treatment is amenable to operative treatment. This commonly consists of a medial soft-tissue reconstruction and lateral column lengthening. We report on 32 patients undergoing distraction calcaneocuboid arthrodesis using an autogenous tricortical iliac crest graft. Almost 50% of patients did not go on to complete and uneventful incorporation of the graft at the arthrodesis site. Two different types of failure were noted. The first was classic nonunion which maintained structural integrity of the graft. The second was osteolysis and collapse of the graft accompanying the nonunion. Risk factors included smoking, K-wire fixation and possibly larger deformities requiring Achilles tendon lengthening. Complications of nonunion were salvageable with reoperation.

Complications of total ankle replacement.

Total ankle arthroplasty with second-generation prostheses is gaining popularity. Complications do and will occur with this group of replacements, just as they do with all other arthroplasties, whether at the knee, hip, elbow, shoulder, or wrist. Even if the complications are understood and the preventative measures or solutions are well thought out, there is occasionally no clear-cut answer to the problem. Although there are many obstacles to a successful outcome, most of the complications reported here are preventable with good patient selection and technique or at least treatable once they occur.