Epidemiological Characteristics of Foot and Ankle Injuries in 2 Professional Ballet Companies: A 3-Season Cohort Study of 588 Medical Attention Injuries and 255 Time-Loss Injuries

Background

The foot and ankle are often reported as the most common sites of injury in professional ballet dancers; however, epidemiological research focusing on foot and ankle injuries in isolation and investigating specific diagnoses is limited.

Purpose

To investigate the incidence rate, severity, burden, and mechanisms of foot and ankle injuries that (1) required visiting a medical team (medical attention foot and ankle injuries; MA-FAIs) and (2) prevented a dancer from fully participating in all dance-related activities for at least 24 hours after the injury (time-loss foot and ankle injuries; TL-FAIs) in 2 professional ballet companies.

Study Design

Descriptive epidemiological study.

Methods

Foot and ankle injury data across 3 seasons (2016-2017 to 2018-2019) were extracted from the medical databases of 2 professional ballet companies. Injury-incidence rate (per dancer-season), severity, and burden were calculated and reported with reference to the mechanism of injury.

Results

A total of 588 MA-FAIs and 255 TL-FAIs were observed across 455 dancer-seasons. The incidence rates of MA-FAIs and TL-FAIs were significantly higher in women (1.20 MA-FAIs and 0.55 TL-FAIs per dancer-season) than in men (0.83 MA-FAIs and 0.35 TL-FAIs per dancer-season) (MA-FAIs, P = .002; TL-FAIs, P = .008). The highest incidence rates for any specific injury pathology were ankle impingement syndrome and synovitis for MA-FAIs (women 0.27 and men 0.25 MA-FAIs per dancer-season) and ankle sprain for TL-FAIs (women 0.15 and men 0.08 TL-FAIs per dancer-season). Pointe work and jumping actions in women and jumping actions in men were the most common mechanisms of injury. The primary mechanism of injury of ankle sprains was jumping activities, but the primary mechanisms of ankle synovitis and impingement in women were related to dancing en pointe.

Conclusion

The results of this study highlight the importance of further investigation of injury prevention strategies targeting pointe work and jumping actions in ballet dancers. Further research for injury prevention and rehabilitation strategies targeting posterior ankle impingement syndromes and ankle sprains are warranted.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

RESULTS

A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.

DESIGN

A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.

RESULTS

Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.

CONCLUSIONS

This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.

PROSPERO REGISTRATION NUMBER

CRD42020176641.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

SARS-CoV-2 viability on sports equipment is limited, and dependent on material composition

The control of the COVID-19 pandemic in the UK has necessitated restrictions on amateur and professional sports due to the perceived infection risk to competitors, via direct person to person transmission, or possibly via the surfaces of sports equipment. The sharing of sports equipment such as tennis balls was therefore banned by some sport's governing bodies. We sought to investigate the potential of sporting equipment as transmission vectors of SARS-CoV-2. Ten different types of sporting equipment, including balls from common sports, were inoculated with 40 μl droplets containing clinically relevant concentrations of live SARS-CoV-2 virus. Materials were then swabbed at time points relevant to sports (1, 5, 15, 30, 90 min). The amount of live SARS-CoV-2 recovered at each time point was enumerated using viral plaque assays, and viral decay and half-life was estimated through fitting linear models to log transformed data from each material. At one minute, SARS-CoV-2 virus was recovered in only seven of the ten types of equipment with the low dose inoculum, one at five minutes and none at 15 min. Retrievable virus dropped significantly for all materials tested using the high dose inoculum with mean recovery of virus falling to 0.74% at 1 min, 0.39% at 15 min and 0.003% at 90 min. Viral recovery, predicted decay, and half-life varied between materials with porous surfaces limiting virus transmission. This study shows that there is an exponential reduction in SARS-CoV-2 recoverable from a range of sports equipment after a short time period, and virus is less transferrable from materials such as a tennis ball, red cricket ball and cricket glove. Given this rapid loss of viral load and the fact that transmission requires a significant inoculum to be transferred from equipment to the mucous membranes of another individual it seems unlikely that sports equipment is a major cause for transmission of SARS-CoV-2. These findings have important policy implications in the context of the pandemic and may promote other infection control measures in sports to reduce the risk of SARS-CoV-2 transmission and urge sports equipment manufacturers to identify surfaces that may or may not be likely to retain transferable virus.

Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates

BACKGROUND

An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling.

PURPOSE

To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 1.

METHODS

Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I² < 25%) and by random-effects models if heterogeneity was moderate to high (I²≥ 25%).

RESULTS

Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications.

CONCLUSION

This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.

Limited Evidence for Biological Adjuvants in Hindfoot Arthrodesis: A Systematic Review and Meta-Analysis of Clinical Comparative Studies

BACKGROUND

The purpose of the present study was to evaluate the efficacy of biological adjuvants in patients managed with hindfoot arthrodesis.

METHODS

A systematic review of the PubMed and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with use of specific search terms and eligibility criteria. Assessment of evidence was threefold: level of evidence by criteria as described in The Journal of Bone & Joint Surgery, quality of evidence according to the Newcastle-Ottawa scale, and conflicts of interest. Meta-analysis was performed with fixed-effects models for studies of low heterogeneity (I2 < 25%) and with random-effects models for studies of moderate to high heterogeneity (I2 ≥ 25%).

RESULTS

A total of 1,579 hindfeet were recruited across all studies, and 1,527 hindfeet were recorded as having completed treatment and follow-up visits. The duration of follow-up ranged from 2.8 to 43 months. Twelve of the 17 included studies comprised patients with comorbidities associated with reduced healing capacity. Based on the random-effects model for nonunion rates for autograft versus allograft, the risk ratio was 0.82 (95% CI, 0.13 to 5.21; I2 = 56%; p = 0.83) in favor of lower nonunion rates for autograft. Based on the random-effects model for rhPDGF/β-TCP versus autograft, the risk ratio was 0.90 (95% CI, 0.74 to 1.10; I2 = 59%; p = 0.30) in favor of lower nonunion rates for rhPDGF/β-TCP.

CONCLUSIONS

There is a lack of data to support the meaningful use of biological adjuvants as compared with autograft/allograft for hindfoot arthrodesis. The meta-analysis favored the use of autograft when compared with allograft but favored rhPDGF/β-TCP when compared with autograft in the short term.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Autologous Osteochondral Transplantation for Large Osteochondral Lesions of the Talus Is a Viable Option in an Athletic Population

BACKGROUND

Autologous osteochondral transplantation (AOT) has been shown to be a viable treatment option for large osteochondral lesions of the talus. However, there are limited data regarding the management of large lesions in an athletic population, notably with regard to return to sport. Our investigation focused on assessing both qualitative and quantitative outcomes in the high-demand athlete with large (>150 mm²) lesions.

HYPOTHESIS

AOT is a viable option in athletes with large osteochondral lesions and can allow them to return to sport at their preinjury level.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The study population was limited to professional and amateur athletes (Tegner score, >6) with a talar osteochondral lesion size of 150 mm² or greater. The surgical intervention was AOT with a donor site from the lateral femoral condyle. Clinical outcomes at a minimum of 24 months included return to sport, visual analog scale (VAS) for pain score, and Foot and Ankle Outcome Score (FAOS). In addition, graft incorporation was evaluated by magnetic resonance imaging (MRI) using MOCART (magnetic resonance observation of cartilage repair tissue) scores at 12 months after surgery.

RESULTS

A total of 38 athletes, including 11 professional athletes, were assessed. The mean follow-up was 45 months. The mean lesion size was 249 mm². Thirty-three patients returned to sport at their previous level, 4 returned at a lower level compared with preinjury, and 1 did not return to sport (mean return to play, 8.2 months). The VAS improved from 4.53 preoperatively to 0.63 postoperatively (P = .002). FAOSs improved significantly in all domains (P < .001). Two patients developed knee donor site pain, and both had 3 osteochondral plugs harvested. Univariant analysis demonstrated no association between preoperative patient or lesion characteristics and ability to return to sport. However, there was a strong correlation between MOCART scores and ability to return to sport. The area under receiver operating characteristic of the MOCART score and return to play was 0.891 (P = .005), with a MOCART score of 52.50 representing a sensitivity of 0.85 and specificity of 0.80 in determining ability to return to one's previous level of activity.

CONCLUSION

Our study suggests that AOT is a viable option in the management of large osteochondral talar defects in an athletic population, with favorable return to sport level, patient satisfaction, and FAOS/VAS scores. The ability to return to sport is predicated upon good graft incorporation, and further research is required to optimize this technique. Our data also suggest that patients should be aware of the increased risk of developing knee donor site pain when 3 osteochondral plugs are harvested.

Strength of Interference Screw Fixation to Cuboid vs Pulvertaft Weave to Peroneus Brevis for Tibialis Posterior Tendon Transfer for Foot Drop

BACKGROUND

Tibialis posterior (TP) tendon transfer is an effective treatment for foot drop. Currently, standard practice is to immobilize the ankle in a cast for 6 weeks nonweightbearing, risking postoperative stiffness. To assess whether early active dorsiflexion and protected weightbearing could be safe, the current study assessed tendon displacement under cyclic loading and load to failure, comparing the Pulvertaft weave (PW) to interference screw fixation (ISF) in a cadaveric foot model.

METHODS

Twenty-four cadaveric ankles had TP tendon transfer performed, 12 with the PW technique and 12 with ISF to the cuboid. The TP tendon was cycled 1000 times at 50 to 150 N and then loaded to failure in a materials testing machine. Tendon displacement at the insertion site was recorded every 100 cycles. An independent t test and 2-way analysis of variance were performed to compare techniques, with a significance level of P < .05.

RESULTS

Mean tendon displacement was similar in the PW group (2.9 ± 2.5 mm [mean ± SD]) compared with the ISF group (2.4 ± 1.1 mm), P = .35. One specimen in the ISF group failed early by tendon pullout. None of the PW group failed early, although displacement of 8.9 mm was observed in 1 specimen. Mean load to failure was 419.1 ± 82.6 N in the PW group in comparison to 499.4 ± 109.6 N in the ISF group, P = .06.

CONCLUSION

For TP tendon transfer, ISF and PW techniques were comparable, with no differences in tendon displacement after cyclical loading or load to failure. Greater variability was observed in the PW group, suggesting it may be a less reliable technique.

CLINICAL RELEVANCE

The results indicate that early active dorsiflexion and protected weightbearing may be safe for clinical evaluation, with potential benefits for the patient compared with cast immobilization.

Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Diagnosis: History, Physical Examination, Imaging, and Arthroscopy" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus: 51 - 74%; strong consensus: 75 - 99%; unanimous: 100%.

RESULTS

A total of 12 statements on the diagnosis of cartilage injuries of the ankle reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support and 10 reached strong consensus (greater than 75% agreement). All statements reached at least 86% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians in the diagnosis of cartilage injuries of the ankle.

Differential Motion and Compression Between the Plantaris and Achilles Tendons: A Contributing Factor to Midportion Achilles Tendinopathy?

BACKGROUND

The plantaris tendon (PT) has been thought to contribute to symptoms in a proportion of patients with Achilles midportion tendinopathy, with symptoms improving after PT excision.

HYPOTHESIS

There is compression and differential movement between the PT and Achilles tendon (AT) during ankle plantarflexion and dorsiflexion.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eighteen fresh-frozen cadaveric ankles (mean ± SD age: 35 ± 7 years, range = 27-48 years; men, n = 9) were mounted in a customized testing rig, where the tibia was fixed but the forefoot could be moved freely. A Steinmann pin was drilled through the calcaneus, enabling a valgus torque to be applied. The soleus, gastrocnemius, and plantaris muscles were loaded with 63 N with a weighted pulley system. The test area was 40 to 80 mm above the os calcis, corresponding to where the injury is observed clinically. Medially, the AT and PT were exposed, and a calibrated flexible pressure sensor was inserted between the tendons. Pressure readings were recorded with the ankle in full dorsiflexion, full plantarflexion, and plantargrade and repeated in these positions with a 5 N·m torque, simulating increased hindfoot valgus. The pressure sensor was removed and the PT and AT marked with ink at the same level, with the foot held in neutral rotation and plantargrade. Videos and photographs were taken to assess differential motion between the tendons. After testing, specimens were dissected to identify the PT insertion. One-way analysis of variance and paired t tests were performed to make comparisons.

RESULTS

The PT tendons with an insertion separate from the AT demonstrated greater differential motion through range (14 ± 4 mm) when compared with those directly adherent to the AT (2 ± 2 mm) ( P < .001). Mean pressure between the PT and AT rose in terminal plantarflexion for all specimens ( P < .001) and was more pronounced with hindfoot valgus ( P < .001).

CONCLUSION

The PT inserting directly into the calcaneus resulted in significantly greater differential motion as compared with the AT. Tendon compression was elevated in terminal plantarflexion, suggesting that adapting rehabilitation tendon-loading programs to avoid this position may be beneficial.

CLINICAL RELEVANCE

The insertion pattern of the PT may be a factor in plantaris-related midportion Achilles tendinopathy. Terminal range plantarflexion and hindfoot valgus both increased AT and PT compression, suggesting that these should be avoided in this patient population.

Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review

BACKGROUND

The critical lesion size treated with bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) has been 150 mm² in area or 15 mm in diameter. However, recent investigations have failed to detect a significant correlation between the lesion size and clinical outcomes after BMS for OLTs.

PURPOSE

To systematically review clinical studies reporting both the lesion size and clinical outcomes after BMS for OLTs.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the MEDLINE and EMBASE databases was performed in March 2015 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies were evaluated with regard to the level of evidence (LOE), quality of evidence (QOE), lesion size, and clinical outcomes.

RESULTS

Twenty-five studies with 1868 ankles were included; 88% were either LOE 3 or 4, and 96% did not have good QOE. The mean area was 103.8 ± 10.2 mm² in 20 studies, and the mean diameter was 10.0 ± 3.2 mm in 5 studies. The mean American Orthopaedic Foot and Ankle Society score improved from 62.4 ± 7.9 preoperatively to 83.9 ± 9.2 at a mean 54.1-month follow-up in 14 studies reporting both preoperative and postoperative scores with a mean follow-up of more than 2 years. A significant correlation was found in 3 studies, with a mean lesion area of 107.4 ± 10.4 mm², while none was reported in 8 studies, with a mean lesion area of 85.3 ± 9.2 mm². The lesion diameter significantly correlated with clinical outcomes in 2 studies (mean diameter, 10.2 ± 3.2 mm), whereas none was found in 2 studies (mean diameter, 8.8 ± 0.0 mm). However, the reported lesion size measurement method and evaluation method of clinical outcomes widely varied among the studies.

CONCLUSION

An assessment of the currently available data does suggest that BMS may best be reserved for OLT sizes less than 107.4 mm² in area and/or 10.2 mm in diameter. Future development in legitimate prognostic size guidelines based on high-quality evidence that correlate with outcomes will surely provide patients with the best potential for successful long-term outcomes.

Management of sports injuries of the foot and ankle: An update

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299-1311.

Plantaris Excision Reduces Pain in Midportion Achilles Tendinopathy Even in the Absence of Plantaris Tendinosis

Background:

It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear.

Purpose:

To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively.

Results:

Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P < .05).

Conclusion:

The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.

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.

Return to sport following acute lateral ligament repair of the ankle in professional athletes

PURPOSE

Recent literature supports early reconstruction of severe acute lateral ligament injuries in professional athletes, suggesting earlier rehabilitation and reduced recurrent instability incidence. Not previously reported, predicting the time to return to training and play is important to both athlete and club. We evaluate the effectiveness and complications of lateral ligament reconstruction in professional athletes. We aim to estimate the time to return to training and sports in both isolated injuries and patients with additional injuries.

METHODS

A consecutive series of 42 athletes underwent modified Broström repair for clinically and radiologically confirmed acute grade III lateral ligament injury. Of 42, 30 had isolated complete rupture of ATFL and CFL. Of 42, 12 had additional injuries (osteochondral lesions, deltoid ligament injuries). All patients received minimum of 2 years post-operative assessment.

RESULTS

The median return to training and sports for isolated injuries was 63 days (49-110) and 77 days (56-127), respectively. However, for concomitant injury results were 86 days (63-152) and 105 days (82-178). This delay was significant (p < 0.001). Despite no difference in pre- and post-op VAS scores between the groups, those with combined injuries had significantly lower FAOS pain and symptoms sub-scores post-operatively (p = 0.027, p < 0.001). Two superficial infections responded to oral antibiotics. No patient developed recurrent instability. All returned to their pre-injury level of professional sports.

CONCLUSION

Lateral ligament reconstruction is a safe and effective treatment for acute severe ruptures providing a stable ankle and expected return to sports at approximately 10 weeks. Despite return to the same level of competition, club and player should be aware that associated injuries may delay return and symptoms may continue. These results may act as a guide to predict the expected time to return to training and to sport after surgical repair of acute injuries and also the influence of associated injuries in prolonging rehabilitation.

LEVEL OF EVIDENCE

III.

Return to Training and Playing After Acute Lisfranc Injuries in Elite Professional Soccer and Rugby Players

BACKGROUND

Lisfranc joint injuries are increasingly recognized in elite soccer and rugby players. Currently, no evidence-based guidelines exist on time frames for return to training and competition after surgical treatment.

PURPOSE

To assess the time to return to training and playing after Lisfranc joint injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive series of 17 professional soccer and rugby players in the English Premier/Championship leagues was assessed using prospectively collected data. All were isolated injuries sustained during training or competitive matches. Each player had clinical and radiological evidence of an unstable Lisfranc injury and required surgical treatment. A standardized postoperative regimen was used. The minimum follow-up time was 2 years.

RESULTS

Clinical and radiological follow-up was obtained in all 17 players. Seven players had primarily ligamentous injuries, and 10 had bony injuries. The time from injury to fixation ranged from 8 to 31 days, and hardware was removed at 16 weeks postoperatively. One athlete retired after a ligamentous injury; the remaining 16 players returned to training and full competition. Excluding the retired player, the mean time to return to training was 20.1 weeks (range, 18-24 weeks) and to full competition was 25.3 weeks (range, 21-31 weeks). There was a significant difference between the mean time to return to competition for rugby (27.8 weeks) and soccer players (24.1 weeks; P = .02) and for ligamentous (22.5 weeks) compared with bony injuries (26.9 weeks; P = .003). Three patients suffered deep peroneal nerve sensation loss, from which 1 patient did not fully recover.

CONCLUSION

Return to competitive elite-level soccer and rugby is possible after surgically treated Lisfranc injuries. Return to training can take up to 24 weeks and return to playing up to 31 weeks, with bony injuries taking longer.

Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery

PURPOSE

To perform a meta-analysis investigating venous thromboembolism (VTE) following isolated foot and ankle surgery and propose guidelines for VTE prevention in this group of patients.

METHODS

Following a PRISMA compliant search, 372 papers were identified and meta-analysis performed on 22 papers using the Critical Appraisal Skills Programme and Centre for Evidence-Based Medicine level of evidence.

RESULTS

43,381 patients were clinically assessed for VTE and the incidence with and without chemoprophylaxis was 0.6% (95% CI 0.4-0.8%) and 1% (95% CI 0.2-1.7%), respectively. 1666 Patients were assessed radiologically and the incidence of VTE with and without chemoprophylaxis was 12.5% (95% CI 6.8-18.2%) and 10.5% (95% CI 5.0-15.9%), respectively. There was no significant difference in the rates of VTE with or without chemoprophylaxis whether assessed clinically or by radiological criteria. The risk of VTE in those patients with Achilles tendon rupture was greater with a clinical incidence of 7% (95% CI 5.5-8.5%) and radiological incidence of 35.3% (95% CI 26.4-44.3%).

CONCLUSION

Isolated foot and ankle surgery has a lower incidence of clinically apparent VTE when compared to general lower limb procedures, and this rate is not significantly reduced using low molecular weight heparin. The incidence of VTE following Achilles tendon rupture is high whether treated surgically or conservatively. With the exception of those with Achilles tendon rupture, routine use of chemical VTE prophylaxis is not justified in those undergoing isolated foot and ankle surgery, but patient-specific risk factors for VTE should be used to assess patients individually.

LEVEL OF EVIDENCE

II.

Calcaneal fractures: selection bias is key

In this paper, we critically appraise the recent publication of the United Kingdom Heel Fracture Trial, which concluded that when patients with an absolute indication for surgery were excluded, there was no advantage of surgical over non-surgical treatment in the management of calcaneal fractures. We believe that selection bias in that study did not permit the authors to reach a firm conclusion that surgery was not justified for most intra-articular calcaneal fractures.

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.

Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes

BACKGROUND

Achilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy.

AIM

To assess whether excising the plantaris tendon improved the symptoms of Achilles tendinopathy in elite athletes.

METHODS

This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preoperative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed.

RESULTS

At a mean follow-up of 22.4 months (12-48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5-27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection.

CONCLUSIONS

The plantaris tendon may be responsible for symptoms in some athletes with non-insertional Achilles tendinopathy. Excision carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite-level sports.

Osteochondral lesions of the talus: aspects of current management

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Achilles tendinopathy: A review of the current concepts of treatment

The two main categories of Achilles tendon disorder are broadly classified by anatomical location to include non-insertional and insertional conditions. Non-insertional Achilles tendinopathy is often managed conservatively, and many rehabilitation protocols have been adapted and modified, with excellent clinical results. Emerging and popular alternative therapies, including a variety of injections and extracorporeal shockwave therapy, are often combined with rehabilitation protocols. Surgical approaches have developed, with minimally invasive procedures proving popular. The management of insertional Achilles tendinopathy is improved by recognising coexisting pathologies around the insertion. Conservative rehabilitation protocols as used in non-insertional disorders are thought to prove less successful, but such methods are being modified, with improving results. Treatment such as shockwave therapy is also proving successful. Surgical approaches specific to the diagnosis are constantly evolving, and good results have been achieved.

Management of acute lateral ankle ligament injury in the athlete

PURPOSE

Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries with special emphasis on a rationale for treatment of these injuries in athletes.

METHODS

A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed.

RESULTS

It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7-10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot.

CONCLUSION

Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4-5 days to reduce pain and swelling. Initially, 10-14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

Stress fractures of the tibia and medial malleolus

Tibial diaphyseal stress fractures are rare in the general population, but are more frequently seen in the athletic and military communities. The diagnosis of this problem may be problematic and needs to be considered in all athletes and military recruits who present with shin or ankle pain. The female triad in athletes (low-energy availability/disordered eating, amenorrhea, and osteoporosis/osteopenia) should be considered in those women who sustain this injury. Management is usually conservative with a variety of rehabilitation programs suggested, but a pragmatic approach is to manage the patient symptomatically.

Fifth metatarsal fractures in the athlete: evidence for management

Shortest time to union, and to return to sporting activity, are the goals of management of fifth metatarsal fractures in the athlete. Whereas zone 1 injuries are largely treated conservatively, zone 2 and 3 injuries are best treated with surgical fixation in athletes, most commonly with intramedullary screw fixation. Fixation with the addition of bone graft has also yielded good results. In the chronic setting, good results have been shown with intramedullary screw fixation, surgical debridement and bone grafting alone, and tension band wiring. Shock wave therapy and pulsed electromagnetic fields may have a place in chronic and acute injury.

Syndesmosis and deltoid ligament injuries in the athlete

PURPOSE

Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete.

METHODS

A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed.

RESULTS

The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete.

CONCLUSION

Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.

Posterior ankle impingement in dancers and athletes

The diagnosis of posterior ankle impingement requires an accurate history and specific examination. Computed tomography is a useful investigation to diagnose bony impingement, especially where plain radiography and/or magnetic resonance imaging are sometimes inconclusive. Accurate ultrasound-guided steroid/anesthetic injections are useful interventions to locate the symptomatic lesions and reduce symptoms and occasionally prove curative. If surgical debridement or excision is deemed necessary, arthroscopic surgery via a posterior approach is recommended to excise impingement lesions with a quicker return to sport expected and minimal complications. Open surgical excision, however, remains a viable treatment option.

Is there an anatomical marker for the deep peroneal nerve in midfoot surgical approaches?

The deep peroneal nerve (DPN) passes over the dorsum of the foot and is susceptible to injury during surgical approaches. The purpose of this anatomical study is to examine the relationship of the extensor hallucis brevis (EHB) as it passes over the DPN. Ten cadaver feet specimens were dissected and the anatomical structures surrounding the neurovascular bundle containing the DPN were examined. In nine out of the ten specimens the DPN was under the EHB musculotendinous junction. In one case it passed through the musculotendinous junction. This cadaver study has found a consistent easily identifiable landmark for protecting the neurovascular bundle containing the DPN during dorsal midfoot surgery.

Lateral column lengthening osteotomies

Lateral column lengthening procedures, either an Evans-type procedure or a calcaneocuboid distraction arthrodesis, clearly have a role to play in the management of a pes planovalgus foot deformity, as is evident from clinical outcome studies. Despite an abundance of literature intricately detailing the biomechanical effects of different operative procedures on the hindfoot, there is no clear consensus as to the best procedure or procedures to perform for a flexible pes planovalgus foot deformity. There is, therefore, no single solution to this problem; the surgeon must treat each patient as an individual and choose the procedure that will work best in their hands for any given foot pathology they are presented with. The surgeon must also be aware that to improve the kinematics of a planovalgus foot deformity, one may often have to perform multiple procedures and not a lateral column lengthening in isolation.

Incidence of venous thromboembolism in elective foot and ankle surgery with and without aspirin prophylaxis

The incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE) is thought to be low following foot and ankle surgery, but the routine use of chemoprophylaxis remains controversial. This retrospective study assessed the incidence of symptomatic venous thromboembolic (VTE) complications following a consecutive series of 2654 patients undergoing elective foot and ankle surgery. A total of 1078 patients received 75 mg aspirin as routine thromboprophylaxis between 2003 and 2006 and 1576 patients received no form of chemical thromboprophylaxis between 2007 and 2010. The overall incidence of VTE was 0.42% (DVT, 0.27%; PE, 0.15%) with 27 patients lost to follow-up. If these were included to create a worst case scenario, the overall VTE rate was 1.43%. There was no apparent protective effect against VTE by using aspirin. We conclude that the incidence of VTE following foot and ankle surgery is very low and routine use of chemoprophylaxis does not appear necessary for patients who are not in the high risk group for VTE.

The epidemiology of foot injuries in professional rugby union players

BACKGROUND

Foot injuries represent a small but important proportion of injuries to professional rugby union players. There are no detailed epidemiological studies regarding these injuries. The aim of this study was to describe the epidemiology of foot injuries sustained by a cohort of professional rugby union players and identify areas that may be targeted for injury prevention in the future.

METHODS

Medical personnel prospectively recorded injuries in professional Premiership rugby union players in England over four seasons. Injuries to the foot were identified and the time away from training and playing was reported.

RESULTS

A total of 147 foot injuries were sustained resulting in 3542 days of absence in total. Acute events accounted for 73% of all foot injuries, with chronic, mostly overuse conditions, accounting for 25% (undiagnosed 2%). Chronic conditions led to proportionately more time away from training and playing (p=<0.001). Specifically, stress fractures in the foot accounted for 8% of the total foot injuries but 22% of the absence. Navicular stress fractures had the longest recovery time with the mean return to training and match play of 188 days.

CONCLUSION

In collision sports such as rugby, some injuries may be inevitable but clinicians should always be seeking ways to minimise their occurrence and impact. This study revealed a high proportion of morbidity associated with chronic and overuse foot injuries in these professional athletes. With greater attention paid to risk factors, some of these injuries, and importantly, recurrent injuries may be avoided.

Stress fracture of the anterior process of the calcaneus associated with a calcaneonavicular coalition: a case report

Level of Evidence: V, Expert Opinion

Tarsal coalitions

A tarsal coalition is an aberrant union between 2 or more tarsal bones and can be classified as osseous (synostosis) or nonosseous (cartilaginous [synchondrosis] or fibrous [syndesmosis]). This union may be complete or partial and the joints in the hindfoot and midfoot are most commonly affected. The resulting abnormal articulation presents as a noncorrectable flat foot, usually during adolescence, leading to accelerated degeneration within adjacent joints. An understanding of the condition and presenting symptoms enable the clinician to correctly diagnose and initiate appropriate treatment. This review discusses the evidence-based literature on the cause, diagnosis, and current management of tarsal coalition.

Sciatic nerve blockade: a survey of orthopaedic foot and ankle specialists in North America and the United Kingdom

BACKGROUND

Sciatic nerve blocks are used to reduce post-operative pain and allow early discharge for patients undergoing foot and ankle surgery. This study aimed to identify the utilization of this procedure in the US and UK and to establish the standard of care with respect to the level of anesthesia that the patient is under and use of ultrasound localization when performing sciatic nerve blocks.

MATERIALS AND METHODS

A survey of current committee members of AOFAS and members of BOFAS.

RESULTS

Two hundred sixty-three surgeons were contacted with a response rate of 44%. Eighty-two percent commonly used a sciatic nerve blockade. Sixty-nine percent never or only sometimes used ultrasonography and variable levels of nerve stimulation were used. Forty-two percent where happy to have the block performed under full anesthesia. There were significant differences between British and American practices regarding the level of nerve stimulation and the level of anesthesia used. The most common complication cited was prolonged anesthesia of which the vast majority spontaneously resolved. Performing blocks awake or sedated did not seem to alter number of complications seen.

CONCLUSION

This study represents a current practice review of sciatic nerve blocks performed amongst senior foot and ankle surgeons. Although no absolute consensus has been reached as to the use of ultrasound or whether the patient needs to be awake for the procedure, it is clear that the standard of care does not mandate either of these. The differences between US and UK practice are probably cultural and do not appear to affect the number of complications encountered.

Treatment of a distal tibial osteochondral lesion with a synthetic osteochondral plug: a case report

Level of Evidence: V, Expert Opinion

Topical glyceryl trinitrate and noninsertional Achilles tendinopathy: a clinical and cellular investigation

BACKGROUND

Topical glyceryl trinitrate (GTN) therapy has been advocated in the treatment of Achilles tendinopathy. The mechanism of action is unknown but may be related to modulation of local nitric oxide levels.

HYPOTHESIS

Topical GTN therapy for noninsertional Achilles tendinopathy will significantly enhance clinical improvement and will be associated with increased collagen synthesis within the tendon.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Forty patients were recruited. Twenty underwent standard nonoperative physical therapy, and 20 underwent physical therapy and topical GTN daily. Clinical outcome was assessed using the Ankle Osteoarthritis Scale (AOS) visual analog score. Patients who failed to improve with conservative measures and who underwent surgical decompression had histological and immunohistochemical examination of samples from the Achilles tendon.

RESULTS

Glyceryl trinitrate did not offer any additional clinical benefit over standard nonoperative treatment for noninsertional Achilles tendinopathy. After 6 months of treatment, there was no significant difference in scores between the groups for pain (3.0 vs 3.1, P = .42) or disability (2.15 vs 2.25, P = .38). Histological examination did not show any difference in neovascularization, collagen synthesis, or stimulated fibroblasts between the 2 groups. There was no evidence of modulation of nitric oxide synthase, a marker of nitric oxide production, in those tendons treated with GTN.

CONCLUSION AND CLINICAL RELEVANCE

This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperative therapy.

The Thompson hemiarthroplasty

The Thompson hemiarthroplasty is a popular hip prosthesis. We present two case reports highlighting a significant alteration in the design of the implant which compromised the success of the operations.

In recent years the manufacturing process of this prosthesis has changed, with a resultant increase in the volume of the stem of 10 ml.

It is essential that manufacturers inform orthopaedic surgeons of any alteration in the design of the implant and supply compatible instrumentation to minimise surgical errors. Surgeons must remain vigilant when checking the compatibility of the trial and definitive prostheses.

Independent evaluation of a recently described Achilles tendon repair technique

BACKGROUND

We investigated a previously reported technique for the repair of acute Achilles tendon ruptures using the percutaneous Achillon suture system (Intega Life Sciences Corporation, Plainsboro, NJ).

METHODS

Twenty-five patients with Achilles tendon ruptures were studied prospectively with a minimum of 12 months followup. A single 2- to 3-cm horizontal incision and the Achillon suture system were used. Early rehabilitation and an active range-of-motion brace were instituted.

RESULTS

There were no wound problems, sural nerve injuries, or re-ruptures. All patients were able to return to their previous sporting activities by 6 months.

CONCLUSIONS

This independent study confirms that the technique offers patients a safe operative procedure for repair of acute Achilles tendon ruptures that allows early active rehabilitation.

Early, active rehabilitation following mini-open repair of Achilles tendon rupture: a prospective study

OBJECTIVE

To assess the use of a supervised active rehabilitation program following repair of acute Achilles tendon ruptures using a minimally invasive suture system.

METHODS

We performed a prospective study on 46 patients undergoing surgical repair of acute Achilles tendon ruptures using the Achillon suture system. All patients began a supervised active rehabilitation program from 2 weeks postoperatively. Patients were placed in a range of motion brace fixed at 20 degrees equinus for 2 weeks to allow wound healing followed by active movement from neutral to full plantar flexion for 4 weeks.

RESULTS

At a minimum follow up of 12 months there were no re-ruptures. All patients were able to return to their previous sporting activities by 6 months post operation. The average American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months was 98, with 42 patients having excellent and four patients good Leppilahti scores. The average time to return to work was 22 days. One patient had a superficial wound infection which settled with 5 days of oral antibiotics. Two patients had altered sensation in the distribution of the sural nerve which settled spontaneously within 3 months.

CONCLUSION

The Achillon suture system appears to allow a safe early active rehabilitation program and achieves a high rate of success. Further evaluation is necessary with regard to potential damage to the sural nerve.

Apoptosis--a significant cause of bone cell death in osteonecrosis of the femoral head

Osteonecrosis of the femoral head usually affects young individuals and is responsible for up to 12% of total hip arthroplasties. The underlying pathophysiology of the death of the bone cells remains uncertain. We have investigated nitric oxide mediated apoptosis as a potential mechanism and found that steroid- and alcohol-induced osteonecrosis is accompanied by widespread apoptosis of osteoblasts and osteocytes. Certain drugs or their metabolites may have a direct cytotoxic effect on cancellous bone of the femoral head leading to apoptosis rather than purely necrosis.

Results of isolated Lisfranc injuries and the effect of compensation claims

The results of treatment of Lisfranc injuries are often unsatisfactory. This retrospective study investigated 46 patients with isolated Lisfranc injuries at a minimum of two years after surgery. Thirteen patients had a poor outcome and had to change employment, or were unable to find work as a result of this injury. The presence of a compensation claim (p = 0.02) and a delay in diagnosis of more than six months were associated with a poor outcome (p = 0.01). There was no association between poor functional outcome and age, gender, mechanism of injury or previous occupation. This study may have medico-legal implications on reporting the prognosis for such injuries, and highlights the importance of prompt diagnosis and treatment.

Osteochondritis of the navicular: a case report

Brailsford's disease and Kohler's disease are two conditions of uncertain etiology affecting the navicular in adults and children, respectively. Kohler's disease has been universally agreed to have an excellent outcome in all cases. There have been no recorded cases of a child with Kohler's disease having persistent clinical and radiological abnormalities into adulthood and no cases of patients with Brailsford's disease having had abnormalities in childhood. This case report presents a teenage patient with osteochondritis of the navicular bone with symptoms that persisted into skeletal maturity.

Treatment of mucous cysts of the toes

The outcome of surgically treated mucous cysts of the foot is poorly documented in the orthopaedic literature. This study reports on the treatment of mucous cysts of the toes by simple excision and joint debridement. This is in contrast to treatment of similar lesions in the fingers which is often treated by excision of the cyst, joint debridement, and rotational flap. Following this procedure on 15 patients (15 cysts), at a minimum of 2 years postoperatively, only one cyst had recurred at 9 months. All patients were satisfied by the cosmetic appearance of their toe. The authors reviewed the available literature on this condition and suggest that this method of treatment provides good functional and cosmetic results with a minimal rate of recurrence.