Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.     

Combined tibio-talar and subtalar arthrodesis by retrograde nail in hindfoot rheumatoid arthritis

PURPOSE OF THE STUDY: Many techniques for ankle arthrodesis have been described. Some are not applicable to patients with severe rheumatoid arthritis (RA) because of osteopenia and deformities. This study describes a new surgical technique for arthrodesis in painful valgus deformity of the hind-foot in advanced rheumatoid arthritis (RA) with severe osteopenia. MATERIALS: The present series included 9 patients. Eleven talocrural and talocalcaneal arthrodeses were performed for degenerative changes secondary to RA involving hind-foot joints. All patients were reviewed after an average follow-up of 6 years. Mean duration of RA was 34 years. All patients had severe osteopenia, including major deformations of the hind-foot in 5 cases. METHODS: After removal of talocrural and talocalcaneal articular surfaces using an anterolateral approach, deformities were corrected by removal of an appropriate bone wedge. A Küntscher nail was then positioned in the calcaneal plantar cortical through the plantar surface of the foot and driven proximally into the medullary canal of the tibia through the talus. This nail allowed both deformity correction and fixation. Aftercare required immobilization in a short leg cast. Weight bearing was allowed with the cast approximately 5 weeks after surgery. The ankle was immobilized for 7.5 weeks. DISCUSSION: Results showed a 80 per cent fusion rate. Two non-unions occurred (one recurrence of valgus deformity after early nail migration requiring removal of the nail; and the other asymptomatic). A complication occurred in one foot (delayed healing). At follow-up, all patients but one were satisfied with respect to pain relief and residual deformities. Our results are comparable with those of other series and should be considered in the context of severe RA. CONCLUSION: This technique of vertical retrograde transarticular nailing allows an easy control of hind-foot deformities correction. Other techniques are preferable in case of solid bone. This technique is an acceptable alternative in advanced RA.     

Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints

STUDY DESIGN: Prospective randomized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain, with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain. OBJECTIVES: To assess the efficacy of single facet joint anesthesia versus placebo (saline injections) and to determine clinical criteria that are predictive of significant relief of LBP after injection. SUMMARY OF BACKGROUND DATA: There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures. Single or double facet joint anesthesia, and single photon emission computed tomography are expensive and time-consuming procedures for selecting patients in controlled clinical trials with large populations. METHODS: Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not. In the current study, a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria. Patients randomly received injection of either lidocaine or saline into the lower facet joints. The result was considered positive if more than 75% pain relief was determined by visual analog scale. The patient, the radiologist, and the investigator were blinded. An analysis of variance was used to seek an interaction between clinical group effect and injection effect, and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75% after the injection. RESULTS: There was a significant interaction between clinical group and injection effect (P = 0.003). In patients with back pain, lidocaine provided greater lower-back pain relief than saline (P = 0.01). Lidocaine also-provided greater pain relief in the back pain group than in the nonpain group (P = 0.02). The presence of five among seven variables (age greater than 65 years and pain that was not exacerbated by coughing, not worsened by hyperextension, not worsened by forward flexion, not worsened when rising from flexion, not worsened by extension-rotation, and well-relieved by recumbency), always including the last item, distinguished 92% of patients responding to lidocaine injection and 80% of those not responding in the lidocaine group. CONCLUSIONS: A set of five clinical characteristics can be used in randomized studies to select lower back pain that will be well relieved by facet joint anesthesia. These characteristics should not, however, be considered as definite diagnostic criteria of lower back pain originating from facet joints.     

Function of stiff joints may be restored by Ilizarov joint distraction

Three patients with joint stiffness caused by trauma or infection are reported. The involved joints are the interphalangeal joint of the thumb, patellofemoral joint, and ankle joint. As an alternative for the indicated arthrodesis in these patients, treatment with articulating joint distraction was performed. By use of adapted Ilizarov external ring fixators, gradual distraction was applied to loosen the joint, followed after loosening by a period of exercise during distraction. In all three patients this experimental approach led to a decrease in pain and improvement of joint function that persisted for at least 2 years after treatment. With the use of Ilizarov joint distraction, joint function in cases of joint stiffness may be restored, and the need for an arthrodesis can be postponed.     

Intraarticular corticosteroid injection in the management of children with chronic arthritis

OBJECTIVE: Intraarticular (IA) corticosteroid injection is a common therapeutic approach in the management of adult rheumatoid arthritis. This study examined the safety and efficacy of IA corticosteroid injection in 71 patients with juvenile arthritis who were being seen at the Sheba Medical Center during the years 1991-1996. METHODS: Sixty-one patients fulfilled the American College of Rheumatology revised criteria for the diagnosis of juvenile rheumatoid arthritis (JRA), 6 patients had reactive arthritis, and 4 patients had various other arthritic conditions. The mean +/- SD age was 9.4 +/- 5.6 years (range 0.5-18 years); 47 were female (mean age 8.1 +/- 5.5 years) and 24 were male (mean age 10.8 +/- 5.4 years). A total of 300 joints were injected with triamcinolone hexacetonide. The most common sites of injection were the knees (124 injections), ankles (71 injections), wrists (46 injections), shoulders (10 injections), and elbows (7 injections). Children under the age of 6 (n = 17), or older children who received more than 4 joint injections at one time (n = 10) were sedated with either ketamine HCI or propofol. All other children received their joint injections under local anesthesia. RESULTS: Full remission of the joint inflammation lasting >6 months following injection was achieved in 246 of the 300 injections (82.0%). In 54 (18.0%) of the injected joints, the inflammation recurred within 6 months of injection. In patients with pauciarticular arthritis, 115 of 141 injections (81.6%) resulted in full remission. Discontinuation of all oral medications was accomplished in 43 patients (60.6%) of the total group of 71 patients and in 32 of the 43 patients with pauciarticular disease (74.4%). Correction of joint contraction was achieved in 42 children (55 joints). In all 11 patients with Baker's cyst and in 12 patients with tenosynovitis, complete remission was achieved following injection. No infection or other serious complications occurred in any of the patients following the procedure. CONCLUSION: IA corticosteroid joint injection in children with juvenile arthritis is a safe and effective mode of therapy. It may be the only therapy needed in patients with pauciarticular JRA, obviating the need for prolonged oral medications, and is effective in correcting joint contractions and deformities.     

Significant reduction of UVB caused by smoke from biomass burning in Brazil

We report six caucasian patients who had acute pain in the hip and marked limitation of all movement of the joint. Plain radiographs and CT of the pelvis showed calcification within the reflected head of rectus femoris. All six responded to accurate CT-controlled injections of corticosteroid and local anaesthetic with dramatic and prolonged pain relief, although one required a second injection for recurrence of symptoms after two months.     

Talonavicular arthrodesis for the painful adult acquired flatfoot

Twenty-seven consecutive patients with posterior tibial tendon insufficiency were treated with talonavicular arthrodesis as the primary stabilizing procedure. Twenty-six patients were followed a minimum of 12 and an average of 27 months. Twenty-four patients had either no pain or pain only after heavy usage. Eleven patients were completely satisfied with postoperative foot function, 13 were satisfied, with minor reservations, and 2 were satisfied, with major reservations. Results were rated as excellent in 10 patients, good in 14 patients, and fair in 2 patients. Successful arthrodesis was achieved in all patients, although one patient required two additional bone grafts. Progressive arthrosis in adjacent joints was noted in five patients, four of whom had arthrosis preoperatively. No deterioration of foot position was seen in any patient with follow-up as long as 5 years. An isolated talonavicular arthrodesis seems to offer patients with this disorder both reliable pain improvement and lasting stability.     

Modification of the standard method used in the United Kingdom for counting Escherichia coli in live bivalve molluscs

Surgical fusion of the subtalar, talonavicular, and calcaneocuboid joints historically evolved for the treatment of paralytic deformities of the foot where there was often notable bone deformity. Today most of these procedures are performed in adults for posttraumatic arthritis, rheumatoid arthritis, or end-stage posterior tibial tendon rupture with fixed bone deformity. Triple arthrodesis is a technically demanding procedure that generally involves a prolonged recovery time. When proper alignment is obtained, predictable and significant improvement in symptoms occurs, but the resultant loss of hindfoot motion is not without consequence. Residual discomfort and secondary arthrosis of the ankle and tarsometatarsal joints should be expected. Because of the complications of residual deformity, pseudarthrosis, avascular necrosis of the talus, and ankle and midtarsal arthritis, it has been recommended that it be used only as a salvage operation in older patients who have a painful, fixed deformity or disabling instability refractory to other treatment options. Despite these caveats, most patients who undergo triple arthrodesis for appropriate indications report significant improvement in their symptoms and level of function.     

Flexor tendon transfer for metatarsophalangeal instability of the second toe

Flexor to extensor transfer was used to treat painful second metatarsophalangeal joint instability in thirteen feet in eleven patients. All patients had their pain reproduced with vertical stress motion of 50% to 100% at the metatarsophalangeal joint. Seven feet had concomitant hallux valgus correction, two feet had no hallux valgus, and four feet underwent no correction for asymptomatic hallux valgus. Results at an average of 33.4 months followup showed that all patients had substantial pain relief, with eight patients becoming pain-free, and five patients experiencing mild pain. All but one were satisfied with their result. Stiffness appeared to be the source of the mild residual pain. All toes, including six toes with preoperative medial crossover toe deformity, were corrected into valgus alignment with adjacent toes. All toes operated on for the first time were able to touch the ground with grasp postoperatively. Flexor to extensor transfer is successful in reducing the second toe and relieving pain caused by instability of the second metatarsophalangeal joint, but may require rapid postoperative mobilization to ensure passive dorsiflexion equal to that of the adjacent toes to reduce postoperative uncomfortable stiffness.     

Apparent feeding behaviour of ensheathed third-stage infective larvae of human hookworms

We examined 16 feet, 33 to 133 months (mean 83) after simultaneous calcaneocuboid and talonavicular fusions performed for a variety of painful disorders of the hindfoot. Objectively, four feet were rated excellent, eight good, four fair and none poor. There was one asymptomatic nonunion of the talonavicular joint. Progressive degenerative arthritis of the ankle was seen in six patients and of the naviculocuneiform joint in seven. Biomechanically, simultaneous calcaneocuboid and talonavicular arthrodesis is better than an isolated talonavicular fusion and is a simple and effective alternative to triple arthrodesis.     

The painful arc syndrome. Clinical classification as a guide to management

Ninety-seven patients suffering from painful arc syndrome of the shoulder were studied. Local anaesthetic and radiographic contrast investigations were carried out. One-third of the patients had lesions in the posterior part of the rotator cuff which resolved after injections of local anaesthetic and steroid. One-third had anterior lesions in the subscapularis tendon: almost all resolved under the same regime but two required division of the coraco-acromial ligament. The remaining third had lesions of the supraspinatus tendon, usually associated with degeneration of the acromio-clavicular joint: most of these failed to gain relief from the local anaesthetic and steroid. Twenty-two operations were performed either by a transcromial or by a deltoid splitting approach. Excision of the outer end of the clavicle and division of the coraco-acromial ligament abolished the pain in most cases.     

Lunotriquetral arthrodesis

Lunotriquetral arthrodesis has been recommended for the treatment of disabling pain at the lunotriquetral joint after more conservative measures have failed. We retrospectively analyzed a series of 22 patients treated with a lunotriquetral arthrodesis for presence of fusion, method of fixation, duration of immobilization, carpal alignment, pain relief, and ability to return to work. Fixation with a Herbert screw supplemented with a Kirschner wire (K-wire) was superior to fixation with K-wires alone. Immobilization longer than 6 weeks was superior to immobilization less than 6 weeks. Combined use of a Herbert screw supplemented with a K-wire and immobilization longer than 6 weeks resulted in union in all patients, even when performed for nonunion after a prior attempted arthrodesis. Pain was improved in all patients; all patients who previously were working returned to work. Routine posteroanterior and lateral x-ray films often failed to adequately profile the arthrodesis site. We recommend using a Herbert screw supplemented with a K-wire for lunotriquetral arthrodesis and keeping the patient in a cast until fusion is documented, usually at least 8 weeks. Fluoroscopic spot views or tomograms are recommended to demonstrate bone fusion.     

Access to alcohol from licensed premises during adolescence: a longitudinal study

Sixty-two consecutive patients with painful limited dorsiflexion of the ankle not responding to nonoperative treatment participated in a prospective study. All 42 men and 20 women (average age, 31 years) underwent arthroscopic surgery. Preoperative radiographs were graded according to an osteoarthritic and an impingement classification. Standardized followup took place at 4 months and 1 and 2 years after surgery. Results showed that the degree of osteoarthritic changes is a better prognostic factor for the outcome of arthroscopic surgery for anterior ankle impingement than size and location of the spurs. The hypothesis is that osteophytes without joint space narrowing are not a manifestation of osteoarthritic changes but rather the result of local (micro)trauma. After 2 years, 73% of the patients experienced overall excellent or good results; 90% of those without joint space narrowing had good or excellent results, and 50% of those with joint space narrowing had good or excellent results. At the 2-year followup, the group without joint space narrowing showed significantly better scores in pain, swelling, ability to work, and engagement in sports. This study also revealed that patients with less than 2 years of ankle pain before surgery and spurs located anteromedially were more satisfied with the outcome than when longer periods of preoperative pain were involved and when spurs were located anterolaterally.     

Charcot neuroarthropathy of the foot and ankle

The goal of this study was to characterize Charcot neuroarthropathy of the foot and ankle by specific sites of involvement (ankle, hindfoot, midfoot, and forefoot), modes of presentation, methods of management, and outcome. A summary of treatment and results for 50 ankles, 22 hindfeet, 131 midfeet, and 18 forefeet is presented. Nondisplaced neuropathic ankle fractures typically healed uneventfully with casting and bracing. For displaced ankle fractures, closed reduction and casting generally resulted in loss of reduction and progressive deterioration; better results were obtained with open reduction and internal fixation, using supplemental Kirschner wires and screws. Ankles with Charcot neuroarthropathy and preexisting arthritis typically required arthrodesis. Of the ankles with neuropathic avascular talar necrosis, approximately 1/3 did well with nonoperative intervention and 2/3 required surgery. Chronic, unstable, malaligned Charcot ankles often required arthrodesis. Neuropathic calcaneal fractures were managed successfully nonoperatively. For feet with transverse tarsal joint involvement (Schon Type IV), management was more complex. Nonoperative treatment was successful for less than 1/2. Two thirds of the feet with midtarsus involvement (Schon Types I, II, and III) were managed successfully nonoperatively; 1/3 required surgery for recurrent ulceration, instability, or osteomyelitis. Half of the feet with forefoot neuroarthropathy required surgery for malalignment, ulceration, and/or difficulty with shoewear or braces. This review has established patterns of Charcot involvement of the foot and ankle with corresponding methods of treatment and subsequent responses. From this extensive clinical experience with 221 neuropathic fractures or Charcot joints, recommendations were derived to assist in selecting appropriate management options.     

Injuries in Australian Army recruits. Part II: Location and cause of injuries seen in recruits

Simple and reliable diagnostic aids need to be available for clinicians to consider sacroiliac joint dysfunction in the differential diagnosis of low back pain. The Fortin finger test was used as a means to identify patients with low back pain and sacroiliac joint dysfunction. Provocation-positive sacroiliac joint injections were used to ratify or refute the applicability of this new clinical sign for identification of patients with sacroiliac joint dysfunction. Sixteen subjects were chosen from 54 consecutive patients by using the Fortin finger test. All 16 patients subsequently had provocation-positive joint injections validating sacroiliac joint abnormalities. A subset of 10 individuals underwent additional evaluation to exclude the possibility of confounding discogenic or posterior joint pain sources. All 10 patients had no indication of either discogenic or zygapophyseal joint pain generators. These results indicate that positive findings of the Fortin finger test, a simple diagnostic measure, successfully identifies patients with sacroiliac joint dysfunction.     

Salvage operation for neglected ankle fractures

From 1986 to 1993, 49 cases of untreated or poorly treated ankle fractures who received salvage surgery were followed up for an average of 36.4 months. The patients included 31 males & 18 females with an average age of 41.6y/o and the time interval from initial injury to reconstructive surgery average due 17.6 months. They were classified and treated according to their grade of reduction and degree of arthrosis. The surgical methods included arthrotomy & joint debridement, revised open reduction, lower tibial osteotomy and ankle arthrodesis, depending on different individual conditions. After surgery, all cases had symptomatic relief and functional improvement with an average score increased from 26.3 preoperatively to 86.8 at follow up. The goals of ankle fractures is as articular fractures, they are treated by surgical anatomic reduction with rigid fixation as early as possible in order to provide good functional results. Nevertheless they are varied in neglected ankle fractures according to their individual conditions: open reductions were performed on cases with no or little arthritic change even though arthrosis might occur later because, if necessary, future conversion to osteotomy or arthrodesis would be easier. As for late cases with advanced arthritis, ankle arthrodesis were done by compressive arthrodesis with necessary bone graft to secure fusion in an optimal position.     

Botulinum toxin for the treatment of hyperfunctional lines of the face

OBJECTIVE: To determine the effectiveness of botulinum toxin injections for the management of hyperfunctional facial lines in patients with dystonia. DESIGN: Twenty-six patients were included in the study: 24 patients had dystonic movement of the face as either a primary or secondary component, and two patients were treated for purely hyperfunctional lines. Botulinum toxin type A was injected via a monopolar hollow-bore Teflon-coated electromyography needle into the facial muscles associated with the hyperfunctional lines. Doses were divided into 1.25- to 10-U aliquots. Qualitative assessments by the patient and physician were made before injection and 2 to 3 weeks after injection. PATIENTS: Twenty-six patients (two male and 24 female) with hyperfunctional lines were included. The ages were from 32 to 84 years with an average age of 59 years. Twenty had dystonia, four had hemifacial spasm, and two had pure hyperfunction without neuromuscular disease. RESULTS: All of the patients had an effect of toxin within the first 24 to 72 hours. All of the patients experienced benefit from the toxin injections with partial or total resolution of painful contractions or unsightly hyperfunctional lines and spasms. The effects of the injection lasted 3 to 6 months. No systemic side effects were noted. Adverse effects included mild, temporary eyelid or lip weakness. CONCLUSION: Based on this initial pilot study, botulinum toxin may be an important new option for the treatment of patients with hyperfunctional facial lines.     

Acute tumor lysis syndrome after transcatheter chemoembolization of hepatocellular carcinoma

PURPOSE: Thromboprophylaxis with heparins after total joint replacement is well accepted. The aim of this prospective randomized study was to evaluate the thrombo-prophylactical efficiency of an ankle joint moving device (Artroflow) after total knee arthroplasty. METHOD: In this prospective study 160 patients were examined who had undergone total knee arthroplasty (TKA). All of the 160 patients received Enoxaparin 1 x 40 mg subcutaneously per day. In addition to this, 90 patients received Artroflow three times a day for 30 minutes. The passive movements of the ankle joint lead to an emptying of the foot and calf veins. Except for the daily routine, we performed physical examination and ultrasound in colour, compression and duplex technique one day before surgery and at the 7th and 14th day after surgery. If a thrombosis was suspected, an ascending phlebography was carried through. RESULTS: The overall thrombosis rate was 6.3% (n = 10). 11.4% (n = 70) deep vein thromboses (DVT) could be observed in the group without Artroflow. Thrombosis occurred in the group with Artroflow in 2 cases (2.2%, n = 90). A statistical difference was found between the two patient groups (p < 0.05, Chi-Square-test). One patient was excluded from the study because of pain in the ankle joint at the fourth day of treatment. CONCLUSION: In addition to heparins, this ankle joint moving device can be recommended as a physical way to prevent DVTs in the thromboprophylaxis of total knee arthroplasty.     

Technique and clinical evaluation of arthroscopic ankle arthrodesis

Arthroscopic ankle arthrodesis has recently been shown to be an effective procedure with significant advantages when properly indicated. We report on the results of arthroscopic ankle fusion in 16 patients with idiopathic or posttraumatic osteoarthritis and rheumatoid disease. We used standard ankle arthroscopic technique and simple noninvasive distraction with hanging weights. All 16 patients had a successful fusion at an average of 9.5 weeks postoperatively. Complications included 1 lateral cutaneous neuroma, and 1 patient who required removal of screws because of superficial pain. Postoperative evaluation showed complete resolution of pain in 14 of 16 patients and significant improvement in gait. Fourteen of 16 patients were completely satisfied with the result and cosmesis, and only 1 patient required shoe modification. These results substantiate previous reports that arthroscopic ankle arthrodesis is successful, and where indicated, has significant advantages over the open technique.     

Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma

We report the long-term results of arthrodesis of the mid-tarsal and tarsometatarsal joints, performed for osteoarthrosis after dislocation with or without a fracture (seventeen patients [seventeen feet]), for primary degenerative osteoarthrosis (twenty-one patients [twenty-two feet]), or for inflammatory arthritis (two patients [two feet]). All forty patients (forty-one feet) had a severe loss of function because of pain. The average age of the patients who had primary degenerative osteoarthrosis was sixty years (range, twenty-seven to seventy-five years) and that of the patients who had post-traumatic osteoarthrosis was forty years (range, twenty-three to sixty-seven years); the two patients who had inflammatory arthritis were forty-four and seventy years old. Thirty-seven patients (thirty-eight feet; 93 per cent) were satisfied with the results of the procedure after an average duration of follow-up of six years (range, two to seventeen years). Union was achieved after 176 (98 per cent) of the 179 attempted arthrodeses, and only one of the three non-unions necessitated an operative repair. A skin slough developed in two patients, one of whom needed operative débridement. Five patients noted at least one prominent metatarsal head postoperatively, but none of these patients needed débridement because of abnormal callus formation. A stress fracture of the second metatarsal developed in three patients, but all three fractures responded to immobilization of the foot. An incisional neuroma developed in three patients, but none of these patients needed additional treatment. We believe that patients who have a severe loss of function due to osteoarthrosis of the mid-tarsal or tarsometatarsal joints can be managed successfully with tarsometatarsal or mid-tarsal arthrodesis, or both.