Arthroscopic treatment of anterior ankle impingement

Ankle arthroscopy has recently allowed the elaboration of less invasive techniques for the treatment of anterior impingement. Its indications, advantages, and drawbacks in this application are discussed. Between 1987 and 1994, 133 patients were treated for ankle impingement. Among them, 58 patients, 37 men and 21 women (mean age, 28.5 years), who had failed a trial of conservative treatment were treated by means of tibiotalar arthroscopy. Twenty-seven were athletes engaged in sports with abnormal stressing of the ankle. According to McDermott's radiological classification, there were 15 stage I cases, 23 stage II, 13 stage III, and 7 stage IV. Preoperative evaluation with a modified version of McGuire's scoring system gave 50 cases rated as "poor" (< 60 points) and 8 cases rated as "fair" (60-67 points). Treatment consisted of removal of adhesions, cartilage shaving, and removal of the bone impingement with powered instruments, curettes, or small osteotomes. Follow-up was from 8 to 62 months (mean, 21.5 months). The postoperative McGuire ratings were 37 good, 13 fair, and 8 poor. There were no major complications. Recurrence of impingement was observed in four cases of stage III and IV. The conclusion is drawn that ankle arthroscopy is a sound method for the treatment of anterior impingement. Even in cases with severe joint cartilage impairment, it plays a therapeutic role as a means of postponing a possible arthrodesis.     

Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging

OBJECTIVE: This study was performed to elucidate the MR imaging findings and pitfalls for the diagnosis of anterolateral soft-tissue impingement in the ankle, a cause of chronic ankle pain that can be relieved by arthroscopic resection. MATERIALS AND METHODS: We retrospectively reviewed MR imaging examinations of 18 patients with arthroscopically confirmed anterolateral ankle impingement. The MR images of 18 additional subjects with symptoms that could mimic anterolateral impingement, but who had a surgically confirmed alternate diagnosis (instability, peroneal tendon injury, osteochondral defect, normal arthroscopy) and no evidence of impingement at arthroscopy, served as controls. RESULTS: On the MR imaging studies, nine patients had an ankle effusion, eight of whom showed an abnormal soft-tissue structure in the anterolateral gutter, 2-15 mm in maximal diameter. No soft-tissue mass was seen in the patients without joint fluid. Four control subjects with instability had a similar soft-tissue structure in the anterolateral gutter, but in the control subjects the finding represented a portion of the torn anterior talofibular ligament. CONCLUSION: Anterolateral soft-tissue impingement of the ankle can be suggested by MR imaging when fluid in the lateral gutter outlines an abnormal soft-tissue structure separate from the anterior talofibular ligament.     

Arthroscopic ankle arthrodesis

We performed arthrodesis of the ankle in eight patients by arthroscopic joint excision and fixation with crossed tibiotalar compression screws. Two patients had rheumatoid arthritis and six had post-traumatic osteoarthritis. None had a serious deformity of the ankle. Clinical ankylosis was achieved in all cases and there was radiological evidence of bone fusion in four.     

Arthroscopic stabilization of the ankle

Arthroscopic lateral ankle stabilization is a method for repair of the anterior talofibular ligament which involves decreased morbidity and minimal soft tissue disruption while restoring function and stability to the joint. This technique utilizes soft tissue anchoring systems that reinforce or repair the anterior talofibular ligament. Several techniques are described for the various types of ligamentous injuries. These methods are compared and contrasted with standard open reconstructive and reparative techniques. Advantages of the newer anchoring systems are discussed.     

Arthroscopic findings in ankle ligament reconstruction

The author believes that there are several reasons that justify the use of a preliminary diagnostic and therapeutic arthroscopic examination in conjunction with an ankle ligament reconstruction. First, a high percentage of symptomatic unstable ankles demonstrate associated intra-articular pathologic conditions. Second, not all of these conditions are appreciated on preoperative clinical examination. Third, these pathologic conditions are addressed easily with standard arthroscopic techniques. Fourth, this technique addresses all of the periarticular problems that cause dysfunction. Last, ankle arthroscopy adds minimal time to the procedure and does not appear to confer significant morbidity.     

Arthroscopic treatment of partial rotator cuff tears in young athletes. A preliminary report

A cluster of four cases of haemolytic uraemic syndrome in children occurred in Northern Bohemia, Czech Republic, between 15 June and 7 July, 1995. All the cases had significantly elevated titres of anti-O157 lipopolysaccharide (LPS) antibodies as detected by the indirect haemagglutination assay. All but one of them had drunk unpasteurized goat's milk from the same farm within the week before the disease. Evidence of E. coli O157 infection was subsequently found in 5 of 15 regular drinkers of the farm's raw goat's milk; four of them were asymptomatic, 1 had mild diarrhoea at the end of June. Verocytotoxin 2-producing E. coli O157:H7 strains of phage type 2 and of identical pulsed-field gel electrophoresis patterns were isolated from 1 of 2 farm goats and from 1 of the asymptomatic goat's milk drinkers. The frequency of anti-O157 LPS antibodies found among regular drinkers of the farm's raw goat's milk (33%; 5 of 15) was significantly higher than that found in control population (0%; none of 45) (P = 0.0005; Fisher's exact test). Our findings indicate that goats may be a reservoir of E. coli O157:H7 and a source of the infection for humans; raw goat's milk may serve as a vehicle of the pathogen transmission.     

Posterosuperior glenoid rim impingement in athletes: the diagnostic value of traditional radiology and magnetic resonance

First described by Walch in 1991, the posterosuperior glenoid rim impingement syndrome is a major condition in the differential diagnosis of shoulder pain occurring in the athletes engaged in repetitive and loading movements of abduction and extra-rotation of the dominant upper limb. Thirty-eight athletes with these dynamic athletic characteristics, referred for unexplained shoulder pain and with a clinical diagnosis of posterosuperior glenoid rim impingement syndrome, underwent radiography and MR examinations, with excellent final results. Radiography was capable of depicting the abnormal skeletal features of this kind of impingement, thus allowing a preliminary diagnosis to be made. MRI excelled in diagnosing the lesions in the deep surface of the supraspinatus tendon and in the posterior labrum secondary to impingement. The static and the kinematic sequences with the arm in abduction and extrarotation proved to be the best ones to define the physiopathologic phases of impingement. Thus, we conclude that invasive diagnostic procedures are not necessary for the correct and unquestionable diagnosis of posterosuperior glenoid rim impingement syndrome.     

The treatment problems of soft-tissue infections

The authors analysed retrospectively a reproductive function among female workers of chemical plant. The subjects were exposed to mutagenic and carcinogenic chemicals before pregnancy and during early term pregnancy. Occurrence of complications during pregnancy and delivery was significantly higher in the exposed group vs. the reference one. Incidence of congenital abnormalities among children in the exposed group tended to increase. Cytogenetic alterations were reliably more frequent in peripheral WBC and in embryonal tissues obtained during abortions in workers of the plant, if compared to the parameters of the reference group.     

Some biomechanical aspects of the foot and ankle in athletes with and without shin splints

Thirteen adult male athletes (long-distance runners and orienteerers without foot problems) and 35 male athletes with shin splints were compared with respect to: 1) the position of the lower leg and the heel while standing, 2) the passive range of mobility in the subtalar joint, and 3) the angular displacement between the calcaneus and the midline of the lower leg (Achilles tendon angle) while running with bare feet on a treadmill. In standing, the two groups differed statistically significantly in the Achilles tendon angle, which values were greater in the shin splint group. With respect to passive mobility, the athletes with shin splints had significantly greater (P less than 0.05-0.01) angular displacement values in inversion, eversion, and in their sum than the control group. While running, the Achilles tendon angle of the shin splint group was significantly greater (P less than 0.01) at the heel strike. Further, the shin splints group had a significantly greater (P less than 0.01) angular displacement between the heel strike and the maximal everted position. The results suggest structural and functional differences in the feet and ankles between healthy athletes and those with shin splints.     

Arthroscopic treatment of metacarpophalangeal arthropathy in haemochromatosis

A 37-year-old sports teacher suffering from idiopathic haemochromatosis with arthropathy of the MP joints has been treated and followed-up by us for 4 years. Three out of four affected MP joints were treated with arthroscopic operations; one of these had been treated elsewhere previously by arthrotomy. This article presents a brief review of the condition and its treatment by arthroscopic surgery with detailed technique. We believe that MP joint arthroscopy in certain cases is an alternative to open surgery and gives excellent results. No specific instruments are needed apart from a standard small joint arthroscopy set.     

Arthroscopic treatment of cysts of the lateral meniscus

We have treated 69 patients with 72 cystic lateral menisci by arthroscopic surgery. Meniscal tears were observed in all cases, and 69 of these had a horizontal cleavage component. Three types of tear were identified and may be progressive. Treatment was by arthroscopic resection of the meniscal tear, and decompression of the cyst through the substance of the meniscus. After a mean follow-up of 34 months the results were good or excellent in 64 knees (89%) and there were few complications. We recommend this technique as the treatment of choice for cysts of the lateral meniscus.     

Arthroscopic treatment of rotator cuff disorders

The past 2 decades have seen rapid advancement in the field of shoulder arthroscopy in general and of rotator cuff disorders in particular. Arthroscopy allows superior visualization of pathologic conditions with less soft-tissue trauma than open exposures. Arthroscopic surgical techniques also are being applied to the actual treatment of many forms of rotator cuff disorders with clinical results similar to more traditional, open procedures. Although these techniques and their indications continue to evolve, it remains clear that, in carefully selected patients, arthroscopy has become a highly useful and effective tool in the diagnosis, evaluation, and surgical management of common disorders of the rotator cuff.     

Surgical treatment of Freiberg's infraction in athletes

Ten patients with 11 cases of Freiberg's infraction were studied retrospectively. The patients had varying amounts of sports participation. All cases were treated surgically, most after some form of nonoperative intervention. Surgery consisted of metatarsophalangeal joint debridement, except in 1 patient where the metatarsal head was resected. All patients had improvement of their symptoms and 80% of normal joint range of motion was restored. No patient had joint space narrowing or major arthritic changes on follow-up roentgenographic studies.     

Postero-superior glenoid impingement. Another impingement of the shoulder

Presence of air in acute extradural hematomas has been described by several authors. Little attention has been paid to its significance. We report six pediatric patients with air-containing extradural hematomas. A fracture involving air-containing structures in either anterior or middle cranial fossa was detected on computed tomographic scans of all patients. The pertinent literature was reviewed.     

Early posterior ankle release in the treatment of congenital clubfoot

Eighty-one patients (116 clubfeet) underwent posterior ankle release before the age of two years, following unsatisfactory responses to serial corrective casts applied according to the technique of Kite. Seventy-three per cent of these feet showed no or only mild talar flattening at an average follow-up of 7.5 years. Four years, following posterior ankle release there was a none-mild talar flattening rate of 69 per cent in this group compared to a 40 per cent none-mild rate in ankle release reduces the incidence of recurrent equinus deformity and the necessity for subsequent surgery in comparison to the results obtained with serial plaster casts or with tendo Achillis lengthening alone. Recent trends in clubfoot management have favored increasingly early operative intervention. Denham stated that "In the infant hard tissues (bone and cartilage) should be regarded as soft, and the soft tissues (tendon and ligament) as hard." Our operative experience with posterior ankle release supports this philosophy and indicates that early aggressive surgical management is the treatment of choice for the resistant clubfoot.     

Oncological outcomes of operative treatment of subcutaneous soft-tissue sarcomas of the extremities

We reviewed the cases of sixty-two patients who had had a subcutaneous sarcoma to determine the effect of tumor and treatment-related variables on the rates of survival and local recurrence. Fifty-nine (95 per cent) of the patients had had an operation at another hospital before being referred to us. Twenty-nine (47 per cent) of the sixty-two tumors were high-grade, forty-two (68 per cent) were small (five centimeters or less), and thirty (48 per cent) were malignant fibrous histiocytomas. We followed a treatment strategy that consisted of repeat excision with the goal of obtaining wide margins. Excluding thirteen patients who had had a palpable local recurrence at the time of presentation, twenty (49 per cent) of forty-one patients who had had a marginal excision at another hospital had microscopic residual tumor on repeat excision. At a median of fifty-six months after the repeat excision, fifty (81 per cent) of the sixty-two patients had been continuously disease-free, one had no evidence of disease, eight had died of the disease, and three had died of other causes. The five-year rate of disease-free survival was 85 per cent (fifty-three of sixty-two patients). There were three local recurrences, all in patients who had had a marginal resection. No recurrences were noted in patients who had had a wide local excision of the tumor or of the previous operative field. Multivariate analysis revealed that a large tumor (greater than five centimeters), a marginal excision, and adjuvant radiation therapy were associated with a worse prognosis. Excellent rates of survival for patients who have a subcutaneous sarcoma, including those who have a large or high-grade tumor and those who have residual tumor following a previous operation, can be obtained with carefully planned operative treatment alone. We recommend operative excision or repeat excision with wide margins because of the high prevalence of residual tumor. Size is the most important tumor-related factor, and the operative margin is the most important treatment-related factor. The additional value of adjuvant radiation therapy remains unproved.     

First clinical trial of cat soft-tissue sarcomas treatment by electrochemotherapy

Electrochemotherapy combines bleomycin and local electric pulses that allow cell permeabilization and free access of bleomycin to its intracellular target. We report the first veterinarian clinical trial of electrochemotherapy in 12 cats with spontaneous large soft-tissue sarcomas that suffered relapse after treatment with conventional therapies. Permeabilizing electric pulses were delivered using external surface electrodes, as well as new needle-shaped electrodes that were designed to be inserted in tumours for more effective treatment of several-centimetre-thick tumour nodules. The electric pulses were applied to the tumours several times from 4 to 15-30 min after a bolus intravenous injection of 0.5 mg kg(-1) bleomycin. Tolerance to treatment was excellent without general side-effects. The cats showed local inflammatory reactions for a few days and disease stabilization lasted from 2 weeks to 7 months. One partial regression was observed, and the general absence of nodule volume decrease can be explained by local fibrotic reactions. Histological analysis of biopsies also revealed massive tumour cell death. The cats' lifespan increased (P<0.001), with a mean survival time of 6.1 months (maximum 18 months) compared with 0.8 months (maximum 1.5 months) for a group of 11 untreated control cats displaying similar carcinological features. Electrochemotherapy is clearly effective as a salvage treatment for large spontaneous solid tumours in adverse clinical situations and this is promising for future applications.     

Evaluation of treatment results for lateral ankle fractures

An analysis was performed of 18 lateral ankle fractures with fracture fissure running from above-back forward and down-ward. In this group, 15 cases were treated conservatively and three cases surgically. In eight patients an evident limitation of pronation movements was found, the remaining movement being limited to a lesser degree. In six patients traces after previous separation of tibiofibular syndesmosis were found. The conservative treatment failed to maintain normal conditions in the talocrural joint.