Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis

Background and purpose A retrocalcaneal bursitis is caused by repetitive impingement of the bursa between the Achilles tendon and the posterosuperior calcaneus. The bursa is situated in the posteroinferior corner of Kager's triangle (retrocalcaneal recess), which is a radiolucency with sharp borders on the lateral radiograph of the ankle. If there is inflammation, the fluid-filled bursa is less radiolucent, making it difficult to delineate the retrocalcaneal recess. We assessed whether the radiographic appearance of the retrocalcaneal recess on plain digital (filmless) radiographs could be used in the diagnosis of a retrocalcaneal bursitis. Methods Whether or not there was obliteration of the retrocalcaneal recess (yes/no) on 74 digital weight-bearing lateral radiographs of the ankle was independently assessed by 2 observers. The radiographs were from 24 patients (25 heels) with retrocalcaneal bursitis (confirmed on endoscopic calcaneoplasty); the control group consisted of 50 patients (59 heels). Results The sensitivity of the test was 83% for observer 1 and 79% for observer 2. Specificity was 100% and 98%, respectively. The kappa value of the interobserver reliability test was 0.86. For observer 1, intraobserver reliability was 0.96 and for observer 2 it was 0.92. Interpretation On digital weight-bearing lateral radiographs of a retrocalcaneal bursitis, the retrocalcaneal recess has a typical appearanc

Novel metallic implantation technique for osteochondral defects of the medial talar dome: A cadaver study

BACKGROUND AND PURPOSE: A metallic inlay implant (HemiCAP) with 15 offset sizes has been developed for the treatment of localized osteochondral defects of the medial talar dome. The aim of this study was to test the following hypotheses: (1) a matching offset size is available for each talus, (2) the prosthetic device can be reproducibly implanted slightly recessed in relation to the talar cartilage level, and (3) with this implantation level, excessive contact pressures on the opposite tibial cartilage are avoided. METHODS: The prosthetic device was implanted in 11 intact fresh-frozen human cadaver ankles, aiming its surface 0.5 mm below cartilage level. The implantation level was measured at 4 margins of each implant. Intraarticular contact pressures were measured before and after implantation, with compressive forces of 1,000-2,000 N and the ankle joint in plantigrade position, 10 dorsiflexion, and 14 plantar flexion. RESULTS: There was a matching offset size available for each specimen. The mean implantation level was 0.45 (SD 0.18) mm below the cartilage surface. The defect area accounted for a median of 3% (0.02-18) of the total ankle contact pressure before implantation. This was reduced to 0.1% (0.02-13) after prosthetic implantation. INTERPRETATION: These results suggest that the implant can be applied clinically in a safe way, with appropriate offset sizes for various talar domes and without excessive pressure on the opposite cartilag

Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy

Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented

Achilles tendinopathy. New insights in cause of pain, diagnosis and management

Maayke van Sterkenburg deed onderzoek naar chronische achillespeesklachten. Deze klachten komen wereldwijd veel voor; vaak bij sporters, maar soms ook bij niet-sporters. Globaal kunnen de verschillende klachten worden onderverdeeld in klachten van het middengedeelte van de pees en klachten bij de aanhechting aan het hielbeen. Er zijn veel therapeutische mogelijkheden, de meeste met matige uitkomst. Bij klachten in het middengedeelte van de pees wordt vaak als een van de laatste opties de degeneratieve afwijking in het peeslichaam chirurgisch verwijderd. Dit terwijl bij proefpersonen zonder klachten ook vaak een dergelijke afwijking in de achillespees wordt gevonden. Moeten deze dan wel worden verwijderd? Komt de pijn niet van buiten de pees? Van Sterkenburg onderzocht deze en andere vragen

Arthroscopy and Endoscopy of the Ankle and Hindfoot

Ankle arthroscopy provides the surgeon with a minimally invasive treatment option for a wide variety of indications such as impingement, osteochondral defects, loose bodies, ossicles, synovitis, adhesions, and instability. Posterior ankle pathology can be treated using endoscopic hindfoot portals. These posteromedial and lateral hindfoot portals provide excellent access to the posterior aspect of the ankle and subtalar joint. Also extra-articular structures in the hindfoot, for instance recurrent peroneal tendon dislocation. can be treated by creating an additional portal. The endoscopic hindfoot portals are safe and reliable, both anatomically and clinically. It compares favorably to open surgery with regard to less morbidity and a quicker recover

Less promising results with sclerosing ethoxysclerol injections for midportion achilles tendinopathy: a retrospective study

BACKGROUND: Local injections of the sclerosing substance polidocanol (Ethoxysclerol) have shown good clinical results in patients with chronic midportion Achilles tendinopathy. After training by the inventors of the technique, sclerosing Ethoxysclerol injections were applied on a group of patients in our center. HYPOTHESIS: Sclerosing Ethoxysclerol injections will yield good results in the majority of patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In 113 patients (140 tendons) with Achilles tendinopathy, we identified 62 patients (70 tendons) showing neovascularization on color Doppler ultrasound. Fifty-three Achilles tendons (48 patients) were treated with sclerosing Ethoxysclerol injections, with intervals of 6 weeks and a maximum of 5 sessions. Treatment was completed when neovascularization or pain had disappeared, or when there was no positive treatment effect after 3 to 4 sessions. RESULTS: Forty-eight patients (20 women and 28 men) with a median age of 45 years, (range, 33-68 years) were treated. Median symptom duration was 23 months (range, 3-300 months). Fifty-three tendons were treated with a median of 3 sessions of Ethoxysclerol injections. Six weeks after the last injection, 35% of patients had no complaints, 9% had minimal symptoms, 42% were the same, and 14% had more complaints. Women were 3.8 times (95% confidence interval: 1.1-13.8) more likely to have unsatisfactory outcome than men. Pain correlated positively with neovessels on ultrasound (P < .01). At 2.7 to 5.1 year follow-up, 53% had received additional (surgical/conservative) treatment; 3 of these patients (7.5%) still had complaints of Achilles tendinopathy. In 6 patients, complaints that were still present 6 weeks after treatment had resolved spontaneously by final follow-up. CONCLUSION: Our study did not confirm the high beneficial value of sclerosing neovascularization in patients with midportion Achilles tendinopathy. Despite the retrospective design of our study, we consider it important to stress that injection of Ethoxysclerol may not be as promising as was though

Good outcome after stripping the plantaris tendon in patients with chronic mid-portion Achilles tendinopathy

Achilles tendinopathy is a problem that is generally difficult to treat. The pain is frequently most prominent on the medial side of the mid-portion of the tendon, where the plantaris tendon is running parallel to the Achilles tendon. The purpose of this study was to assess whether excision of the plantaris tendon would relieve symptoms. Three patients with pain and stiffness at the mid-portion of the Achilles tendon were treated by excision of the plantaris tendon. Preoperatively, these patients experienced recognizable tenderness on palpation of the medial side of the mid-portion of the Achilles tendon with localized nodular thickening at 4-7 cm proximal to the insertion. MRI indicated Achilles tendinopathy with the involvement of the plantaris tendon. The plantaris tendon was bluntly retrieved and excised with a tendon stripper through a 4-cm incision in the proximal calf. We report a good-to-excellent outcome of this novel procedure in three patients with chronic mid-portion Achilles tendinopathy The medial pain might be based on the involvement of the plantaris tendon in the process. I