Does subtalar instability really exist? A systematic review.

BACKGROUND: Subtalar joint instability (STI) is considered as a potential source of chronic lateral hindfoot instability. However, clinical diagnosis of STI is still challenging. This systematic review was conducted to assess the consistency of the clinical entity "subtalar instability", to investigate the reliability of available diagnostic tools and to provide a critical overview of related studies. METHODS: A systematic review of the Medline, Web of Sciences and EMBASE databases was performed for studies reporting on tests to investigate subtalar instability or lesions of the subtalar ligaments. To investigate the relation with chronic STI, studies focusing on sinus tarsi syndrome (STS) or acute lesions of the subtalar ligaments were also included in the search strategy and were assessed separately. RESULTS: This review identified 25 studies focusing on different topics: chronic STI (16), acute lesions of the subtalar ligaments (5) and STS (4). Twelve studies, assessing STI, demonstrated the existence of a subgroup with instability complaints related to abnormal increased subtalar motion (7) or abnormalities of the subtalar ligaments (6). We found insufficient evidence for measuring subtalar tilting using stress radiographs. MRI was able to assess abnormalities of the ligaments and stress-MRI detected abnormally increased motion. CONCLUSION: Complaints of instability can be related to subtalar ligaments injuries and an abnormally increased motion of the subtalar joint. Stress radiographs should be interpreted with caution and should not have the status of a reference test. Clinical diagnosis should rely on several parameters including MRI.

Minimally invasive repair of the tibialis anterior tendon using a semitendinosus autograft.

BACKGROUND: Ruptures of the tibialis anterior tendon are rare but can cause substantial functional deficiencies. The literature regarding the treatment of such injuries is very limited. Atraumatic ruptures often occur in the presence of an abnormal tendon structure, and retraction often makes end-to-end repair impossible. With traumatic lesions, the risk of developing both adhesions and scar tissue is high. METHODS: This study assesses the results of a surgical reconstruction using the interposition of a semitendinosus tendon autograft in 12 patients. Three patients had a traumatic rupture, and 9 patients had an atraumatic rupture. In 8 patients, the procedure was carried out using a minimally invasive technique. RESULTS: The average postoperative American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score was 95.7 in the atraumatic group and 94.7 in the traumatic group. Active dorsiflexion was possible after 2 to 3 weeks. We believe that the interposition of a strong, healthy tendon facilitated healing and allowed early weight bearing. All patients had good recovery of dorsiflexion and gait. CONCLUSIONS: Repairing a ruptured tibialis anterior tendon using a semitendinosus autograft was a reliable technique and offered a good result. With the minimally invasive approach, there was no need to divide the extensor retinaculum, which we believe allowed faster recovery and reduced the risk of adhesions and wound healing problems. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Endoscopic treatment of intrasheath peroneal tendon subluxation.

Intrasheath subluxation of the peroneal tendons within the peroneal groove is an uncommon problem. Open exploration combined with a peroneal groove-deepening procedure and retinacular reefing is the recommended treatment. This extensive lateral approach needs incision of the intact superior peroneal retinaculum and repair afterwards. We treated three patients with a painful intrasheath subluxation using an endoscopic approach. During this tendoscopy both tendons were inspected. The distal muscle fibers of the peroneus brevis tendon were resected in two patients. A partial tear was debrided in the third patient. All patients had a good result. No wound-healing problems or other complications occurred. Early return to work and sports was possible. An endoscopic approach was successful in treatment of an intrasheath subluxation of the peroneal tendons.

Percutaneous bunionette correction.

BACKGROUND: Treatment of tailor's bunion is largely conservative. For severe or refractory cases surgical intervention is necessary. The aim of this study is to evaluate a percutaneous technique for correcting such bunionette deformities. METHODS: Twenty-one procedures were performed on 20 patients using a percutaneous technique. Patients were scored using the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale. RESULTS: No wound healing problems, infections, non-unions or mal-unions occurred. Functional assessments revealed very good results. Radiographic evaluation confirmed good average correction of the fourth-fifth intermetatarsal angle and metatarsophalangeal angle. CONCLUSIONS: This percutaneous technique is a reliable and effective approach for the treatment of bunionette deformity. The results obtained were comparable to those reported using traditional open techniques, but major complications due to soft tissue damage were averted. This technique can be adapted depending on the type of deformity, and does not require internal fixation.

Clinical Outcomes of Characterized Chondrocyte Implantation.

OBJECTIVE: To assess the clinical outcome of patients treated with autologous chondrocyte implantation using ChondroCelect in daily practice. METHODS: The study is a cross-sectional analysis of an open-label, noninterventional cohort. The setting was a compassionate use program, involving 43 orthopaedic centers in 7 European countries. The participants were patients treated with ChondroCelect between October 13, 2004 and July 2, 2008. The measurements used were Clinical Global Impression-Improvement and -Efficacy and solicited adverse event reports. RESULTS: Safety data were collected from 334 patients (90.3%), and effectiveness data were from 282 (76.2%) of the 370 patients treated. Mean age at baseline was 33.6 years (range, 12-57 years), 57% were male, and mean body mass index was 25 kg/m(2). Mean follow-up was 2.2 years (range, 0.4-4.1 years). A femoral condyle lesion was reported in 66% (288/379) and a patellar lesion in 19% (84/379). Mean lesion size was 3.5 cm(2); a collagen membrane was used in 92.4% (328/355). A therapeutic effect was reported in 89% (234/264) of patients overall and in 87% (40/46) of patellar lesion patients. Rates of much or very much improved patients were similar in patients with short- (<18 months: 71% [115/163]) and long-term follow-up (>18 months: 68% [70/103]) (P = 0.68) and were independent of lesion size (>4 cm(2): 75.5% [37/49]; ≤4 cm(2): 67.7% [111/164]) (P = 0.38). Adverse events were similar to those reported in the randomized trial with the same product, with more arthrofibrosis, more reduced joint mobility, and more crepitations reported in patellar lesions. Overall, less cartilage hypertrophy was noted, probably due to the use of a biological membrane cover. CONCLUSIONS: Implantation of ChondroCelect appeared to result in a positive benefit/risk ratio when used in an unselected heterogenous population, irrespective of the follow-up period, lesion size, and type of lesion treated.

Arthroscopic subtalar arthrodesis after a calcaneus fracture covered with a forearm flap.

Surgical treatment of intraarticular calcaneal fractures is often associated with postoperative wound problems. Soft tissue necrosis, bone loss and uncontrollable infection are a challenge for the surgeon and amputation may in some cases be the ultimate solution. A free flap can be very helpful to cover a significant soft tissue defect and help in fighting the infection. However, the free flap complicates the surgical approach if subtalar arthrodesis and bone reconstruction are needed. This study demonstrates the value of an arthroscopic technique to resect the remaining articular cartilage in preparation for subtalar arthrodesis and bone grafting. This approach avoids compromising the soft tissues and minimizes damage to the free flap.

Characterized chondrocyte implantation results in better structural repair when treating symptomatic cartilage defects of the knee in a randomized controlled trial versus microfracture.

BACKGROUND: As the natural healing capacity of damaged articular cartilage is poor, joint surface injuries are a prime target for regenerative medicine. Characterized chondrocyte implantation uses an autologous cartilage cell therapy product that has been optimized for its biological potency to form stable cartilage tissue in vivo. PURPOSE: To determine whether, in symptomatic cartilage defects of the femoral condyle, structural regeneration with characterized chondrocyte implantation is superior to repair with microfracture. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Characterized chondrocyte implantation was compared with microfracture in patients with single grade III to IV symptomatic cartilage defects of the femoral condyles in a multicenter trial. Patients aged 18 to 50 years were randomized to characterized chondrocyte implantation (n = 57) or microfracture (n = 61). Structural repair was blindly assessed in biopsy specimens taken at 1 year using (1) computerized histomorphometry and (2) evaluation of overall histological components of structural repair. Clinical outcome was measured using the self administered Knee injury and Osteoarthritis Outcome Score. Adverse events were recorded throughout the study. RESULTS: Characterized chondrocyte implantation resulted in better structural repair, as assessed by histomorphometry (P = .003) and overall histologic evaluation (P = .012). Aspects of structural repair relating to chondrocyte phenotype and tissue structure were superior with characterized chondrocyte implantation. Clinical outcome as measured by the Knee injury and Osteoarthritis Outcome Score at 12 to 18 months after characterized chondrocyte implantation was comparable with microfracture at this stage. Both treatment groups had a similar mean baseline overall Knee injury and Osteoarthritis Outcome Score (56.30 +/- 13.61 and 59.53 +/- 14.95 for microfracture and characterized chondrocyte implantation, respectively), which increased in both groups to 70.56 +/- 12.39 and 72.63 +/- 15.55 at 6 months, 73.26 +/- 14.66 and 73.10 +/- 16.01 at 12 months, and 74.73 +/- 17.01 and 75.04 +/- 14.50 at 18 months, respectively. Both techniques were generally well tolerated; the incidence of adverse events after characterized chondrocyte implantation was not markedly increased compared with that for microfracture. CONCLUSION: One year after treatment, characterized chondrocyte implantation was associated with a tissue regenerate that was superior to that after microfracture. Short-term clinical outcome was similar for both treatments. The superior structural outcome may result in improved long-term clinical benefit with characterized chondrocyte implantation. Long-term follow-up is needed to confirm these findings.