Hydroxyapatite deposition disease (HADD) of the spring ligament: an unusual cause of medial foot pain.

Foot pain is one of the most common presenting complaints in orthopaedic clinical practice and can be attributed to a multitude of pathologies in the various osseous structures, ligaments, and tendons of the foot. The spring ligament complex (SLC) between the calcaneum and navicular supports the talus and plays a major role in the static stability of the medial longitudinal arch of the foot. Although calcific ligamentous enthesopathy around the ankle has been described in the literature, we report the first case of its kind affecting the SLC in a 51-year-old male with medial foot pain and no history of trauma. We highlight the role of radiological interventions in the diagnosis and effective management using ultrasound (US)-guided barbotage.

The Broken "Ring of Fire": A New Radiological Sign as Predictor of Syndesmosis Injury?

BACKGROUND: Subcircumferential periosteal edema above the ankle joint is frequently present on magnetic resonance imaging (MRI) with syndesmosis injuries but has not been previously reported. Fluid height within the interosseous membrane also has not previously been shown to be associated with syndesmosis injury severity. PURPOSE: To investigate whether a new sign on MRI and measurement of the length of fluid within the interosseous membrane above the ankle may be used to enable identification of a syndesmosis injury and allow differentiation from lateral ligament injury. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Three groups of patients (those with an isolated syndesmosis injury [SI group], isolated lateral ligament injury [LLI group], and no injury [NI group]) who had an ankle MRI for another reason were identified from a patient notes database and the MRI scans retrieved. The scans were anonymized and independently assessed by 8 clinicians (surgeons and radiologists) who were blinded to the diagnosis. The maximum length of fluid above the ankle within the intraosseous membrane was measured for each patient. The presence or absence of distal anterior, lateral, and posterior tibial periosteal edema was recorded (broken "ring of fire"). RESULTS: Measurement of the length of fluid above the ankle had excellent intraobserver reliability (intraclass correlation coefficient, 0.97; 95% CI, 0.93-0.99) but poor interobserver reliability. Fluid extended higher in both the LLI group (P = .0043) and SI group (P = .0058) than the NI group, but there was no significant difference between the LLI and SI groups (P = .3735), indicating that this measurement cannot differentiate between the injuries. The presence of the broken "ring of fire" around the distal tibia was significantly more frequent in the SI group when compared with both LLI and NI groups (P < .00001). The sensitivity of this sign is 49%, but when present, this sign has a 98% specificity for syndesmosis injury. CONCLUSION: The presence of tibial subcircumferential periosteal edema 4 to 6 cm above the ankle joint (the "ring of fire") is highly suggestive of a syndesmosis injury. This new radiological sign can assist with early identification of such injuries. The measurement of height of fluid above the ankle within the interosseous membrane is variable and cannot differentiate severe ankle sprains from high ankle sprains involving the syndesmosis.

Complex ankle arthrodesis with step-cut osteotomy in Charcot arthropathy with bone loss.

We report a case of a complex limb salvage ankle arthrodesis in a patient with Charcot arthropathy. A step-cut osteotomy was performed in order to tackle the issues of anterior tibial bone loss; worsening leg length discrepancy; soft tissue contraction; joint instability and high risk of non-union. The construct formed by the step-cut allowed for the preservation of good bone stock; avoidance of further limb shortening; increased torsional stability and increased surface area for bony union. This resulted in a patient with a stable, plantigrade foot appropriate for footwear. We use this case to highlight this technique as an option in the operative management of complex ankle fusions with sagittal or coronal plane deformity with bone loss and subluxation of the ankle joint.

Posterior Endoscopic Excision of Os Trigonum in Professional National Ballet Dancers.

Previous studies have compared the outcomes after open and endoscopic excision of an os trigonum in patients of mixed professions. No studies have compared the differences in outcomes between the 2 procedures in elite ballet dancers. From October 2005 to February 2010, 35 professional ballet dancers underwent excision of a symptomatic os trigonum of the ankle after a failed period of nonoperative treatment. Of the 35 patients, 13 (37.1%) underwent endoscopic excision and 22 (62.9%) open excision. We compared the outcomes, complications, and time to return to dancing. The open excision group experienced a significantly greater incidence of flexor hallucis longus tendon decompression compared with the endoscopic group. The endoscopic release group returned to full dance earlier at a mean of 9.8 (range 6.5 to 16.1) weeks and those undergoing open excision returned to full dance at a mean of 14.9 (range 9 to 20) weeks (p = .001). No major complications developed in either group, such as deep infection or nerve or vessel injury. We have concluded that both techniques are safe and effective in the treatment of symptomatic os trigonum in professional ballet dancers. Endoscopic excision of the os trigonum offers a more rapid return to full dance compared with open excision.

Histological evaluation of calcaneal tuberosity cartilage--A proposed donor site for osteochondral autologous transplant for talar dome osteochondral lesions.

BACKGROUND: Osteochondral Autologous Transplant (OATs) as a treatment option for Osteochondral lesions (OCLs) of the talar dome frequently uses the distal femur as the donor site which is associated with donor site morbidity in up to 50%. Some studies have described the presence of hyaline cartilage in the posterior superior calcaneal tuberosity. The aim of this study was to evaluate the posterior superior calcaneal tuberosity to determine if it can be a suitable donor site for OATs of the talus METHODS: In this cadaveric study, we histologically evaluated 12 osteochondral plugs taken from the posterior superior calcaneal tuberosity and compared them to 12 osteochondral plugs taken from the talar dome. RESULTS: In the talar dome group, all samples had evidence of hyaline cartilage with varying degrees of GAG staining. The average hyaline cartilage thickness in the samples was 1.33 mm. There was no evidence of fibrocartilage, fibrous tissue or fatty tissue in this group. In contrast, the Calcaneal tuberosity samples had no evidence of hyaline cartilage. Fibrocartilage was noted in 3 samples only. CONCLUSIONS: We believe that the structural differences between the talus and calcanium grafts render the posterior superior clancaneal tuberosity an unsuitable donor site for OATs in the treatment of OCL of the talus.

Rotational and peak torque stiffness of rugby shoes.

OBJECTIVE: Sports people always strive to avoid injury. Sports shoe designs in many sports have been shown to affect traction and injury rates. The aim of this study is to demonstrate the differing stiffness and torque in rugby boots that are designed for the same effect. METHODS: Five different types of rugby shoes commonly worn by scrum forwards were laboratory tested for rotational stiffness and peak torque on a natural playing surface generating force patterns that would be consistent with a rugby scrum. RESULTS: The overall internal rotation peak torque was 57.75±6.26 Nm while that of external rotation was 56.55±4.36 Nm. The Peak internal and external rotational stiffness were 0.696±0.1 and 0.708±0.06 Nm/deg respectively. Our results, when compared to rotational stiffness and peak torques of football shoes published in the literature, show that shoes worn by rugby players exert higher rotational and peak torque stiffness compared to football shoes when tested on the same natural surfaces. There was significant difference between the tested rugby shoes brands. CONCLUSION: In our opinion, to maximize potential performance and lower the potential of non-contact injury, care should be taken in choosing boots with stiffness appropriate to the players main playing role.

Functional outcome of primary hamstring anterior cruciate ligament reconstruction in patients with different body mass index classes.

PURPOSE: We compared functional outcomes after primary hamstring-graft anterior cruciate ligament (ACL) reconstruction in patients with different body mass index (BMI) classes. METHODS: Functional outcomes after ACL reconstruction were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm score. The procedures were carried out by a single surgeon between 2001 and 2009 in 2 groups of patients with different BMI classes: a normal-BMI group (BMI 18.5 to 24.9) and a high-BMI group (BMI ≥ 25), with a minimum of 2 years' follow-up. Rolimeter readings for ligament laxity as well as complications between the 2 groups were also analyzed. RESULTS: A total of 92 patients were reviewed, with the normal-BMI group consisting of 49 patients, whereas there were 43 patients in the high-BMI group. There were no significant differences between the groups in any of the preoperative and postoperative scores or ligament laxity. Both groups showed comparable clinically significant improvement in their postoperative scores compared with their preoperative scores. Patients in the high-BMI group had a slightly increased postoperative complication rate when compared with the normal-BMI group. CONCLUSIONS: Primary hamstring ACL reconstruction is an effective treatment option in patients irrespective of preoperative BMI. High BMI does not adversely affect functional outcomes as measured by the KOOS and Lysholm scores up to and at 2 years postoperatively, and these patients benefit in a manner comparable to that of patients with normal BMI. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effects of tranexamic acid on blood loss during total hip arthroplasty.

PURPOSE: To assess the effects of tranexamic acid (TA) in patients undergoing total hip arthroplasty (THA) for osteoarthritis. METHODS: 42 patients underwent primary THA for osteoarthritis by a single surgeon. 10 men and 11 women who did not receive TA were controls, whereas 9 men and 12 women who received TA constituted the treatment group. Both groups were matched for age, gender, body mass index, and American Society of Anesthesiologists grading. The type of prosthesis used (cemented or uncemented) was based on the surgeon's preference and patient age, activity level and demands. No hybrid prosthesis was used. 10 minutes prior to incision, a single dose of intravenous TA (10 mg per kg body weight) was given to patients in the treatment group. Comparison was made between both groups with regard to intra-operative blood loss, postoperative reduction in haemoglobin and haematocrit levels, blood transfusion, incidence of deep vein thrombosis, and the length of hospital stay. RESULTS: The mean intra-operative blood loss (489 [SD, 281] vs. 339 [SD, 184] ml, p = 0.048) and the decrease in haemoglobin level (38 [SD, 12] vs. 29 [SD, 10] g/l, p=0.014) were significantly higher in the control than the treatment group. Two patients among the controls received a transfusion, compared to none in the TA group (p = 0.49, Fisher's exact test). The 2 patients who needed blood transfusion had blood losses of 600 and 690 ml, compared to a mean of 489 ml in the whole group. No patient in either group developed deep vein thrombosis or pulmonary embolism up to 3 months. CONCLUSION: A single dose of intravenous TA (10 mg per kg body weight) given 10 minutes prior to THA is a cost-effective and safe means of minimising blood loss and reduction in haemoglobin concentrations as well as the need for allogenic blood transfusion, without increasing the risk of thromboembolic events.

Segmental fracture of the femur with concomitant genu valgum: a one-stage solution.

Segmental fractures of the femur are high energy injuries usually treated with internal fixation. We present the case of such a fracture in which the femur had a preexisting genu valgum deformity from an earlier distal femur physeal arrest. This prevented standard intramedullary nailing or minimally invasive plate fixation. A technique of simultaneous correction of the distal femoral deformity coupled with stabilization of the segmental fracture is reported. Surgery involved an external fixator-assisted corrective osteotomy of the deformity and simultaneous minimally invasive plating of the segmental fracture. The advent of modern concepts of deformity correction has allowed a combination with present day internal fixation techniques to achieve correction, stabilization and union in a problem that would otherwise require two stages of surgery.

Nonunion of the ulna after elastic stable intramedullary nailing for unstable forearm fractures: a case series.

Elastic stable intramedullary nailing (ESIN) for displaced forearm fractures in children has shown good results over the last two decades. To our knowledge, nonunion as complications after ESIN fixation of displaced forearm fractures is not well reported in English literature. In our institute, and over a period of 10 years, we identified three cases of nonunion of the ulna after ESIN fixation of unstable and displaced forearm both bone fractures. Two patients had closed fractures and one patient had an open fracture. There was no deep infection in any case. All cases after revision surgery went into union.

Use of elastic stable intramedullary nailing for treating unstable forearm fractures in children.

BACKGROUND: The majority of the pediatric diaphyseal forearm fractures are treated with closed reduction and the application of an above elbow cast for a varying period, depending on the age of the child. Some forearm diaphyseal fractures require osteosynthesis mainly because of the presence of an unacceptable angular deformity, fracture instability, presence of an open injury or failure of conservative management in the form of redisplacement in the cast after manipulation. METHODS: We present our experience with elastic stable intramedullary nailing (ESIN) for displaced and unstable pediatric diaphyseal fractures. A consecutive series of 21 patients treated with ESIN between 1997 and 2005 have been reviewed retrospectively. There were 14 boys and 7 girls with a median age of 11.8 years. All fixations were protected in an above elbow plaster cast. Patients were followed up for an average of 12.8 months (Range, 12-21.5 months). RESULTS: Clinical and radiologic union was achieved within 13 weeks after the procedure in 19 children. One patient had delayed union of the ulna which finally united at 9 months after operation without any further intervention. Another patient had nonunion of ulna that required autologous bone marrow injection after 1 year before full consolidation occurred. Complications were all modest and transient and eventually all patients achieved a good functional clinical outcome. CONCLUSION: We think that the technique has many merits over a more traditional plating technique including a minimally invasive technique, a less time consuming procedure and easier metal work removal. We think that cosmesis is perhaps the most important to our patients because the wounds are small and less conspicuous than the traditional Henry approach for plating which leaves a long unsightly volar forearm scar. We think that ESIN is an attractive treatment option for displaced and unstable diaphyseal forearm fractures in children.

Comparison between collar and cuffs and above elbow back slabs in the initial treatment of Gartland type I supracondylar humerus fractures.

We compared two commonly used methods of immobilization of Gartland type I supracondylar humeral fractures, with respect to pain control, use of analgesia and sleep interruption. Forty patients were included in the study, collar and cuff immobilization (group 1, n=20) and above elbow back slab immobilization (group 2, n=20). Diagnosis was made in the accident department and patients were immobilized (collar and cuff or back slab) according to the preference of the treating doctor. Patients were then reviewed in the next available fracture clinic where they were assessed. The Wong-Baker faces scale was used to measure pain. Patients immobilized with a collar and cuff had an average pain score of 7.2 compared with 3.4 for those immobilized with a back slab (P<0.0001). Children in the collar and cuff group used analgesia at regular intervals nearly four times more often than those in the back slab group (P=0.005), and 85% of children immobilized with a collar and cuff had interrupted or no sleep throughout the night following the injury (P=0.008) compared with 45% of children in the back slab group. We conclude that immobilization of Gartland type I fractures with an above elbow back slab provides better pain relief and is more comfortable for paediatric patients than collar and cuff immobilization.