Ankle fractures are extremely common orthopedic injuries. There is evidence that the deltoid ligament becomes insufficient in the setting of acute ankle fractures. Whether this finding is clinically relevant to address with surgical repair is a topic that has been debated for years. There is literature documenting the repair or reconstruction of the deltoid ligament dating back in the 1950s, although most orthopedists have adopted the mainstay of treating the fibula fracture without directly repairing the deltoid ligament. This current standard of practice is based on the literature from the 1980s, which itself has not been revisited in the current literature. We present an argument and critique of the literature that supported not repairing the deltoid ligament in the setting of ankle fractures. The deltoid ligament has proven to confer at least some element of stability of maintaining a concentric ankle mortise. At any rate, the literature that supports not repairing the deltoid has significant limitations and needs to be investigated further to provide clarity to this difficult yet common orthopedic injury.
Deltoid ligament ruptures are frequently associated with ankle fractures. Poor outcomes are associated with inadequate healing of the deltoid ligament. Repair of the deltoid ligament has potential to improve outcomes in a subset of patients with ankle fractures where medial ankle instability persists and medial ankle space remains wide even after the ankle fracture is stabilized.
Aim: To analyze the effectiveness of nonoperative modern management in patients with ruptured tendo-Achilles when compared with operative management. Background: Ruptured tendo-Achilles is a common pathology presenting to the orthopedic department. It mostly occurs during spontaneous activity in active male patients between the age of 30 and 40. Traditional nonoperative management consisted of a period of nonweight-bearing in an equinus cast for 6 weeks. When comparing this nonoperative management regime with operative repair of tendo-Achilles ruptures, many studies found that rerupture rates increased, and peak strength decreased in the nonoperative group. We look at the results of nonoperative management when the accelerated functional rehabilitation protocol is used compared to operative management. Review results: In a patient with a ruptured tendo-Achilles, employing nonoperative management using the accelerated functional rehabilitation protocol was comparable with operative management. In multiple high-level studies, both groups showed no difference in rerupture rates, peak strength, return to work, return to sport, patient satisfaction, range of movement, and clinical and functional outcome. One study demonstrated improved exercise at high velocity in the operative group in the short-term; however, the clinical significance of this is yet to be analyzed. Conclusion: Operative management of ruptured tendo-Achilles carries risks that are difficult to manage, in particular wound breakdown requiring subsequent revision surgery and tendon transfers. It was previously proven that operative management had decreased rerupture rates and improved strength. It has now been proven that when using the accelerated functional rehabilitation protocol, results are comparable to the operative group, without going through the risks of surgery. Clinical significance: Our group recommends strong consideration toward employing nonoperative management of ruptured tendo-Achilles using the accelerated functional rehabilitation protocol over operative management. Exceptions to consider are open injuries from lacerations, avulsion from the calcaneal attachment, or strong wishes from the patient, such as an elite athlete.
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Wenxian P, Thien KK. Open vs Percutaneous TOPAZ Coblation for the Management of Plantar Fasciitis: Comparison of the Two Techniques in Obese Patients. J Foot Ankle Surg Asia-Pacific 2020; 7 (1):14-20.
Introduction: Plantar fasciopathy is known to be the most common cause of heel pain. Obese patients are known to have an increased probability of suffering from this condition. The technique of radiofrequency (RF) coblation, comparing open vs percutaneous methods, and its outcomes, has not been studied in the subgroup of patients. Materials and methods: Patients treated operatively by RF coblation in our institution for plantar fasciitis between 2007 and 2015 were grouped into whether they received the open or percutaneous microtenotomy. The patients were interviewed at baseline and 3 months, 6 months, and 12 months postoperatively using the American Orthopedic Foot and Ankle Society (AOFAS) and 36-item Medical Outcomes Short Form (SF-36) questionnaires. Results: Patients in both arms had an overall improvement in the visual analog scale (VAS) pain score and AOFAS ankle–hindfoot scores. The SF-36 scores also showed improvement across all areas postoperatively. There was also a significant improvement in expectation and satisfaction scores. However, those who had open RF microtenotomy fared better at 3 months, with regard to the visual analog score and both at 3 months and 6 months for the AOFAS hindfoot scores. There were no difference comparing both techniques with regard to the SF-36 scores. Conclusion: Radiofrequency microtenotomy is a safe and effective procedure for the treatment of plantar fasciitis even in the obese group of patients. Both open and percutaneous methods have achieved good patient outcomes and expectation, although the open group showed superior pain and functional outcomes at early follow-up.
Adult tarsal scaphoiditis or Mueller Weiss disease is a rare condition characterized by collapse of lateral half of the navicular bone. It is a spontaneous adult onset osteonecrosis of navicular bone with unclear etiology. Mueller Weiss disease is not sequelae to childhood onset Kohler\'s disease. Middle-aged women complain of midfoot and hindfoot pain. A detailed clinical and plain weight-bearing radiograph of foot is often diagnostic. The condition is graded using Maceira classification based on the deformity on lateral radiographs. Numerous surgical options are described for the management but no gold standard. We are presenting three patients, one with bilateral feet involvement, all in Maceira stage III deformity treated with double arthrodesis (talonavicular-cuneiform and calacaneocuboid) and autologous bone grafting achieving solid fusion and good functional outcome.
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Mahjoub S, Mihoubi M, Zaraa M, Hariz L, Abdelkefi M, Mbarek M. Giant Cell Tumor of the Distal Tibiofibular Joint: Extensive Curettage, Reconstruction, and Arthrodesis Using Induced Membrane Technique. J Foot Ankle Surg Asia-Pacific 2020; 7 (1):24-27.
Aim: Masquelet technique may be used successfully for the reconstruction and arthrodesis of distal tibiofibular joint after tumor resection. Background: Giant cell tumors (GCTs) involving both distal tibia and fibula are exceedingly rare. The optimal surgical treatment in these locations is controversial. Reconstruction of cavitary bone loss after resection is challenging. Case description: We describe an unusual presentation of exophytic GCT affecting distal tibiofibular joint in a 35-year-old man. The optimal surgical treatment was controversial. Collapse of the tibial plafond was the major risk of surgical resection. An extensive intralesional curettage was performed. The size of the resulting bone defect measured 5 cm in fibula and 4 cm × 3 cm × 2 cm (24 cm3) in tibia. Reconstruction of the cavitary bone loss was challenging. Induced membrane technique was performed for the reconstruction of both tibia and fibula. A plate and a cement spacer were used in the first-time procedure. Two months later, the induced membrane was opened longitudinally. The cement spacer was removed and the biological space which had been created was filled with cancellous bone graft obtained from the patient\'s iliac crest. Two K-wires were placed in order to avoid tibial plafond collapse and were removed after 6 weeks. Bone union was obtained at 2 months. No recurrence or septic complications were observed. Good functional and anatomic results were obtained at 4 years’ follow-up. Conclusion: Reconstruction and arthrodesis of the distal tibiofibular joint represent an excellent indication of Masquelet technique, especially after GCT resection. Clinical significance: The present case highlights therapeutic difficulties in this exceptional location, particularly regarding cavitary bone loss.
Kerk Hsiang Chua,
Ewe Juan Yeap,
Keen Wai Chong,
Introduction: Gastrocnemius recession was first described by Vulpius and Stoffel in 1913 for gastrocnemius equinus contracture. Equinus contracture alters the biomechanics of the foot–ankle complex and affects other musculotendinous and ligamentous constrains in the ankle, contributing to many foot and ankle pathologies. The commonly used Strayer\'s technique has been modified, with the use of endoscopic approaches, to try to reduce the poor cosmesis and reduce the risk of iatrogenic injury to the sural nerve. This article aims to describe a simple uniportal technique that uses readily available arthroscopic instruments to perform endoscopic gastrocnemius recessions (EGRs). Materials and methods: The leg is prepped and draped with a rolled towel under the lateral malleolus. A 10 mm incision is made over this point. The dissection is carried bluntly to the gastrocnemius aponeurosis. The fascia is opened and a McDonald or Freer elevator is introduced between the aponeurosis and the fascia of the soleus. A 4.0 mm 30° arthroscope is inserted beneath the elevator. A half-pipe (Karl Storz, Tuttlingen) is introduced over the scope which protects the sural nerve. The length of the aponeurosis is identified from proximal to distal. At this point, the sural nerve may be visualized at the end of the pipe. A triangle knife (Smith and Nephew, Andover, MA, USA) is then introduced with the sharp edge facing the half-pipe. The knife is then flipped 180° and tension is applied to the aponeurosis by dorsiflexing the foot. The aponeurosis is then released under direct arthroscopic vision.
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Kumar V, Hooda A. Manual of Fracture Management of Foot and Ankle (AO Trauma: Rammelt S, Swords M, Dhillon MS and Sands AK: Thieme Publishers). J Foot Ankle Surg Asia-Pacific 2020; 7 (1):32-33.