Gouty tophus as a rare cause of a Hepple stage V osteochondral lesion of the talus.

BACKGROUND: Talus osteochondral lesion is commonly associated with trauma, avascular necrosis or even genetic factors, but gouty tophus as a cause of Hepple stage V type talus osteochondral lesion is rare. CASE PRESENTATION: Here, we report a case of an 18-year-old man who complained of left medial deep ankle pain on ambulation. This young man had an extreme liking of sea food rich in purines and also sugar-sweetened drinks. He was diagnosed with a Hepple stage V type talus osteochondral lesion and was treated with medial malleolus osteotomy and an osteochondral graft. The talus osteochondral lesion was found to be a gouty tophus and was completely removed. Hypouricemic therapy was prescribed for 2 months, which allowed the patient to walk with a visual analogue score (VAS) score of 1. He was followed up for 12 months. CONCLUSIONS: Young people with an extreme liking of sea food rich in purines and also sugar-sweetened drinks may be at a risk of developing gout. Acute onset of ankle atraumatic pain, swelling with a high level of serum uric acid and a talus osteochondral lesion with cyst formation should make physicians consider a diagnosis of gout.

Osteochondral Lesions of the Talar Dome.

Osteochondral lesion of the talar dome (OCLT) can be a devastating injury that affects mobility. Etiology of these lesions is debated but trauma seems the most supported etiology. Diagnosis of lesions is based on imaging. Conservative management, including weight-bearing restrictions, physical therapy, and supportive measures, often is first-line treatment. Nonsurgical modalities have mixed results and surgical measures often are necessitated for symptom relief. Surgical treatments vary in invasiveness and often are dictated by OCLT size. Studies show patient satisfaction increases substantially after having these procedures performed after failing nonsurgical measures. Results are encouraging, although thorough work-up and discussion should be undertaken.

Non-Small Cell Lung Carcinoma: Clinical Reasoning in the Management of a Patient Referred to Physical Therapy for Costochondritis.

Background and Purpose: Chest pain, a frequent complaint for seeking medical care, is often attributed to musculoskeletal pathology. Costochondritis is a common disorder presenting as chest pain. Initial physical therapist examination emphasizes red flag screening. Reexamination throughout the episode of care is critical, particularly when patients are not progressing and/or in the presence of complex pain presentations. The purpose of this case report is to describe the clinical reasoning process in the management of a patient referred to physical therapy with a medical diagnosis of costochondritis. Case Description: A 59-year-old woman presented with a 5-month history of left-sided chest pain that had progressed to include the cervical and shoulder regions. She reported multiple psychosocial stressors; a depression screen was positive. She reported a history of asthma and smoking and improvement in recent fatigue, coughing, dyspnea, and sweating. At the initial visit, shoulder, cervical, and thoracic active and passive range of motion and joint mobility testing reproduced her pain. Allodynia was present throughout the painful areas in the left upper quarter. Outcomes: The patient demonstrated improvement over 30 days (4 visits). On her fifth visit (day 35), she reported an exacerbation of her chest and upper extremity pain and noted increased fatigue, sweating, dyspnea, and loss of appetite. Even though her pain was again reproduced with musculoskeletal testing, the physical therapist contacted the patient's physician regarding the change in presentation. A subsequent chest computed tomography scan revealed a non-small cell lung adenocarcinoma. Discussion: Cancer can masquerade as a musculoskeletal condition. This case highlights the importance of screening, clinical reasoning, and communication throughout the episode of care, particularly in the presence of chronic pain and psychosocial stressors.

Arthroscopic Management of Osteochondral Lesions of the Talus.

Osteochondral fractures of the ankle are typically caused by traumatic injuries of the ankle. Repetitive trauma can lead to further cartilage damage with subsequent increasing size of the lesion, ultimately leading to severe cartilage disorder and degenerative arthritis of the ankle. Arthroscopic bone marrow stimulation has been shown to be a highly successful option for patients with small osteochondral lesions. Studies show a higher failure rate for larger lesions and cystic changes that disrupt the subchondral plate. The threshold size seems to be 150 mm(2).

Equol suppresses inflammatory response and bone erosion due to rheumatoid arthritis in mice.

Rheumatoid arthritis (RA) is a chronic and systemic autoimmune inflammatory disease. Typical pathological findings of RA include persistent synovitis and bone degradation in the peripheral joints. Equol, a metabolite of the major soybean isoflavone daidzein, shows superior bioactivity than other isoflavones. We investigated the effects of equol administration on inflammatory response and bone erosion in mice with collagen-induced arthritis (CIA). The severity of arthritis symptoms was significantly low in the equol-administered CIA mice. In addition, equol administration improved the CIA-induced bone mineral density decline. In the inflamed area of CIA mice, equol administration suppressed the expression of interleukin-6 and its receptor. Furthermore, equol reduced the expression of genes associated with bone formation inhibition, osteoclast and immature osteoblast specificity and cartilage destruction. These results suggest that equol suppresses RA development and RA-induced bone erosion by regulating inflammation and bone metabolism.

Lift, drill, fill and fix (LDFF): a new arthroscopic treatment for talar osteochondral defects.

PURPOSE: The purpose of this study was to describe the short-term clinical outcome of a new arthroscopic fixation technique for primary osteochondral talar defects: lift, drill, fill and fix (LDFF). METHODS: Seven patients underwent an arthroscopic LDFF surgery for osteochondral talar defects, the mean follow-up was 12 months (SD 0.6). Pre- and postoperative clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS) and the numeric rating scales (NRS) of pain at rest and during walking. Remodelling and bone ingrowth after LDFF were analysed on weight-bearing radiographs during follow-up. RESULTS: In all patients, LDFF led to an improvement of the AOFAS and NRS of pain. The AOFAS significantly improved from 63 to 99 (p < 0.001). The NRS of pain at rest significantly improved from 2.9 to 0.1 (p = 0.004), and pain with walking significantly improved from 7.6 to 0.1 (p < 0.001). On the final radiographs, five of seven patients showed remodelling and bone ingrowth after LDFF. CONCLUSIONS: The LDFF of an osteochondral talar defect appears to be a promising arthroscopic treatment option for primary talar osteochondral defects. Although the clinical and radiological results of 1-year follow-up are encouraging, more patients and longer follow-up are needed to draw any firm conclusions and determine whether the results stand the test of time. LEVEL OF EVIDENCE: Prospective case series. Therapeutic, Level IV.

Deficiency of cathepsin K prevents inflammation and bone erosion in rheumatoid arthritis and periodontitis and reveals its shared osteoimmune role.

Using rheumatoid arthritis (RA) and periodontitis mouse models, we demonstrate that RA and periodontitis share many pathological features, such as deregulated cytokine production, increased immune-cell infiltration, increased expression of Toll-like receptors (TLRs), and enhanced osteoclast activity and bone erosion. We reveal that genetic deletion of cathepsin K (Ctsk) caused a radical reduction in inflammation and bone erosion within RA joint capsules and periodontal lesions, a drastic decrease in immune-cell infiltration, and a significant reduction in osteoclasts, macrophages, dendritic and T-cells. Deficiency of Ctsk greatly decreased the expression of TLR-4, 5, and 9 and their downstream cytokines in periodontal gingival epithelial lesions and synovial RA lesions. Hence, Ctsk may be targeted to treat RA and periodontitis simultaneously due to its shared osteoimmune role.

[Generalized exanthematous pustular dermatophytid, a rare clinical presentation of dermatophytid reaction]. / La dermatophytide exanthématique et pustuleuse généralisée (DEPG), une présentation clinique rare de dermatophytide.

BACKGROUND: Dermatophytids are immunologically mediated dermatologic presentations secondary to sensitization to a dermatophyte infection. They are most frequently associated with toe-web intertrigo and usually present as localized, palmar, pruriginous vesicular eruptions. We report three original cases of generalized exanthematous pustular dermatophytid associated with kerions. PATIENTS: Two boys aged 11 and 6 years, and one girl aged 6 years initially presented with kerion secondary to Trichophyton tonsurans (case 1), Trichophyton soudanense (case 2) and Trichophyton mentagrophytes (case 3), respectively. Two to three days after initiation of griseofulvin treatment, all patients presented with a pustular eruption extending from the head to the trunk, associated in one case with fever of 39°C and inflammatory chondritis. Samples obtained from the pustular lesions were sterile, serum inflammatory markers were within the normal range and skin lesions resolved on oral corticosteroid treatment (prednisone 0.75 mg/kg, case 1) or high-potency topical steroids (cases 2 and 3) given as an adjunct to griseofulvin treatment (19 to 23 mg/kg/d). DISCUSSION: Dermatophytids occur during the acute phase of infection or within a few days of treatment initiation. Lesions are remote from the infection site, contain no dermatophyte, and resolve after treatment of the infection. We report three original cases of generalized exanthematous pustular dermatophytid, associated in one case with fever and inflammatory chondritis. The main differential diagnosis is acute generalized exanthematous pustulosis secondary to antifungal drugs. Differences in clinical presentation between the two enable the appropriate diagnosis to be made as well as continued use of the antifungal medication needed to cure the patient. General or topical steroids may also be used in combination.

Horse-, training- and race-level risk factors for palmar/plantar osteochondral disease in the racing Thoroughbred.

REASONS FOR PERFORMING STUDY: Palmar/plantar osteochondral disease (POD) is a common, debilitating condition in Thoroughbred racehorses; however, training- and racing-related factors associated with this disease are unknown. OBJECTIVES: To determine horse-, racing- and training-related risk factors for POD. The general hypotheses were that early training and racing, and increased intensity of racing and training, lead to increased severity of POD. METHODS: The metacarpo/metatarsophalangeal joints of 164 Thoroughbred racehorses were examined at post mortem and graded for third metacarpal and metatarsal POD. The relationships between training- and racing-related factors and grade of POD in each condyle were determined using multilevel, multivariable, ordinal logistic regression models. RESULTS: A total of 1288 condyles were graded. Factors associated with higher grades of POD were the total lifetime number of races, an increase in gallop sessions in the previous season, racing before import to Hong Kong and an increase in the number of short (8-16 weeks) between-race intervals per season. Horses in their first racing season were more likely to have lower POD grades, while horses that had a long between-race interval (greater than 16 weeks) in the season prior to euthanasia were also more likely to have lower POD grades. Lower POD grades were significantly more likely as days since last race increased up to 400 days. Age at first race was not significantly associated with grade of POD. CONCLUSIONS AND POTENTIAL RELEVANCE: Cumulative racing exposure and training intensity in the previous season were associated with higher grades of POD, supporting the hypothesis that the disease is due to repetitive loading. Longer between-race intervals and increased time since racing were associated with lower POD grades, which may indicate that lesions heal. Further work is required to enable optimisation of racing and training programmes to reduce the frequency and severity of this disease.

A simple surgical technique for treatment of Freiberg's disease.

BACKGROUND: Of all the osteochondrosis, Freiberg's disease is reported to be the fourth most common, exceeded by Köhler's disease, Panner's disease, and Sever's disease. This disease usually occurs in the 2nd metatarsal head and relatively in the 3rd and 4th metatarsal heads. OBJECTIVE: The purpose of this study was to evaluate the outcome of debridement, synovectomy, dorsal closing wedge osteotomy and pin fixation for Freiberg's disease treatment. METHODS: Ten female patients, mean age 18.3 years; (ranged 14-24 years) were treated by the above mentioned technique. The main presenting symptom was pain on walking or sport; affected their daily life and activities and was not improved by non-surgical treatment. The second metatarsal head was affected in all patients. Halve of patients had a history of trauma. According to Smillie's classification, four patients were type V and six patients were type IV. Mean follow-up period was 19.2 months (range 6-36 months). RESULTS: Were assessed by the Lesser Metatarsophalangeal-Interphalangeal (LMPI)Scale by Kitaoka et al. At the final follow up, scoring was changed from (44-76) with an average 57 to (66-100) with an average 80. There was no case of infection, avascular necrosis, arthritis or pseudoarthrosis. CONCLUSION: We founded that dorsiflexion osteotomy of the metatarsal head is presented as a logical procedure that is simple, reliable, not destructive, and capable of good results regardless of the stage of the disease.

Surgical treatment of an osteochondral lesion associated with stress fracture of the tarsal navicular: a case report.

We surgically treated an osteochondral lesion associated with a stress fracture of the tarsal navicular. The surgical procedure involved the confirmation and complete resection of the lesion under direct vision, followed by the transplantation of block-shaped iliac bone grafts. The postoperative computed tomography scan showed that the lesions had disappeared, the grafted bone had fused, and the stress fracture had healed. However, the tarsal navicular joint surface was slightly irregular. The patient was able to resume her sports activities 15 weeks after surgery. We have described a novel method to reconstruct the tarsal navicular after osteochondral lesion resection.

Freiberg's disease.

Freiberg's disease is a relatively uncommon disorder of the metatarsal head. Although trauma and circulatory disturbances likely contribute major roles in its development, it is widely accepted that Freiberg's etiology is multifactorial. Conservative treatment, focused on offloading and relieving stress, is uniformly accepted as the appropriate initial management. Surgical management can broadly be categorized as procedures which attempt to correct the pathophysiology and halt its progression, and procedures which address the sequelae of later stage disease. Newer strategies, including osteochondral transplantation, attempt to restore the damage metatarsal cartilage with a viable osteochondral plug.

Incidence of meniscal and osteochondral lesions in patients undergoing delayed anterior cruciate ligament reconstruction.

OBJECTIVE: Unreconstructed anterior cruciate ligament (ACL) tears cause repeated incidences of giving-way and rotational-translational instability. The aim of this study was to test our hypothesis that delayed surgical treatment of patients with ACL tears, especially those with high Tegner activity levels, results in more severe and complicated meniscal and osteochondral lesions with potential affect on the outcome. METHODS: This study included 385 patients who underwent arthroscopic ACL reconstruction between 2001 and 2009. Patients arthroscopic video records or MRI scans and patient files at the time of surgery were analyzed. We defined severe meniscal and osteochondral lesions which could negatively affect the outcome and labeled them meniscal lesions affecting outcome (MLAO) and osteochondral lesions affecting outcome (OLAO). The relation between MLAO, OLAO, time since injury and Tegner activity levels were statistically analyzed. RESULTS: The incidences of MLAO and OLAO grew statistically higher as time elapsed between the injury and surgery increased (p=0.001, p<0.05; p=0.001, p<0.05). The relation between the Tegner activity score, MLAO and OLAO risk were found to be statistically insignificant (p=0.317, p=0.184, p>0.05). CONCLUSION: Delays in ACL reconstruction surgery result in an increase in the incidence of meniscal and osteochondral lesions which have the potential to negatively affect the surgical outcome.

Pediatric running injuries.

As more children have become involved in athletic activities and running, there has been a significant increase in overuse injuries. The young athlete with open growth plates is vulnerable to unique overuse injuries involving the apophyses, articular cartilage, and growth plate. The physician caring for these young athletes needs to be aware of these conditions to diagnose and treat them appropriately. Physicians should also be aware of the risk of overtraining and overuse injury in athletes participating in year-round sports and competition. Current guidelines for overuse injury prevention in young athletes are primarily based on consensus and expert opinion. Further research is needed to provide evidence-based guidelines for overuse injury prevention in young athletes and runners.

The natural history of osteochondral lesions in the ankle.

Most osteochondral lesions (defects) of the talar dome are caused by trauma, which may be a single event or repeated, less intense events (microtrauma). A lesion may heal, remain asymptomatic, or progress to deep ankle pain on weight bearing, prolonged joint swelling, and the formation of subchondral bone cysts. During loading, compression of the cartilage forces water into the microfractured subchondral bone. The increased flow and pressure of fluid in the subchondral bone can cause osteolysis and the slow development of a subchondral cyst. The pain does not arise from the cartilage lesion but most likely is caused by repetitive high fluid pressure during walking and a concomitant decrease in pH produced by osteoclasts, which sensitize the highly innervated subchondral bone. Prevention of further degeneration depends on several factors, including the repair of the subchondral bone plate and the correct alignment of the ankle joint.

Current concepts in the diagnosis and treatment of osteochondral lesions of the ankle.

Osteochondral lesions of the ankle are a more common source of ankle pain than previously recognized. Although the exact pathophysiology of the condition has not been clearly established, it is likely that a variety of etiological factors play a role, with trauma, typically from ankle sprains, being the most common. Technological advancements in ankle arthroscopy and radiologic imaging, most importantly magnetic resonance imaging, have improved diagnostic capabilities for detecting osteochondral lesions of the ankle. Moreover, these technologies have allowed for the development of more sophisticated classification systems that may, in due course, direct specific future treatment strategies. Nonoperative treatment yields best results when employed in select pediatric and adolescent patients with osteochondritis dissecans. However, operative treatment, which is dependent on the size and site of the lesion, as well as the presence or absence of cartilage damage, is frequently warranted in both children and adults with osteochondral lesions. Arthroscopic microdrilling, micropicking, and open procedures, such as osteochondral autograft transfer system and matrix-induced autologous chondrocyte implantation, are frequently employed. The purpose of this article is to review the history, etiology, and classification systems for osteochondral lesions of the ankle, as well as to describe current approaches to diagnosis and management.

Posterior tibial tendon dislocation: a systematic review of the literature and presentation of a case.

OBJECTIVE: In contrast to posterior tibial tendon lesions, dislocations of the posterior tibial tendon are thought to be 'extremely rare'. Diagnostic criteria for this condition have not yet been established. METHODS: A systematic literature review revealed 61 published cases with posterior tibial tendon dislocation in 36 reports, including eight (12 patients) in French and five (7 patients) in German. We add one more case, which was complicated by a longitudinal tibial tendon tear and a lateral talar dome osteochondral lesion. Fifty-nine cases were descriptively analysed regarding initial injury, subjective symptoms, clinical presentation and findings on different imaging modalities. Treatment and outcome were additionally evaluated. RESULTS: 58.5% of the initial injuries were induced by sport. Initially most cases were misdiagnosed (53.1%). 35.6% of the patients felt a recurrent snapping phenomenon at the medial ankle. Physical examination exhibited a cord-like structure over the medial malleolus in 58.6%, and a posterior tibial tendon (sub)luxation could be provocated in 54.2%. MRI, ultrasound and plain radiography (medial malleolar chip fracture) detected specific findings in 75.0%, 66.7% and 14.7%, respectively. Surgery was done in 83.1% of the patients using varying techniques. The authors judged the treatment result as excellent or asymptomatic in 80%, as good in 12% and as fair or moderate in 8% of the patients. CONCLUSIONS: Posterior tibial tendon dislocation occurs more frequently than was previously thought. Misdiagnosis can be avoided, if the surgeon is aware of the condition and combines findings from history, physical investigation and imaging modalities.

Cartilage degeneration is associated with augmented chemically-induced joint pain in rats: a pilot study.

BACKGROUND: Osteoarthritis arising from cartilage degeneration is the most common cause of joint pain. However, the relationship between joint pain and cartilage degeneration is not well understood. QUESTIONS/PURPOSES: We asked whether the inflammatory mediators participate in the joint pain in the presence of cartilage degeneration. METHODS: We observed electromyographic responses of hindlimb flexors to four inflammatory mediators (bradykinin, ATP, acetylcholine, and serotonin) injected in normal rat knees and in those with monosodium iodoacetate (MIA)-induced arthritis. RESULTS: Joint cartilage of all the rats with MIA-induced arthritis histologically showed severe degeneration. We observed greater magnitude and longer duration responses in the MIA-induced arthritis than normal joints with all four mediators. CONCLUSIONS: The data suggested nociceptors in osteoarthritic joints are more sensitive to inflammatory mediators than in normal joints. Such nociceptive sensitization to inflammatory mediators may participate in the joint pain in osteoarthritis.