Percutaneous foot joint needle placement using a C-arm flat-panel detector CT

Purpose: Image guidance is valuable for diagnostic injections in foot orthopaedics. Flat-detector computed tomography (FD-CT) was implemented using a C-arm, and the system was tested for needle guidance in foot joint injections. Methods: FD-CT—guided joint infiltration was performed in 6 patients referred from the orthopaedic department for diagnostic foot injections. All interventions were performed utilising a flat-panel fluoroscopy system utilising specialised image guidance and planning software. Successful infiltration was defined by localisation of contrast media depot in the targeted joint. The pre- and post-interventional numeric analogue scale (NAS) pain score was assessed. Results: All injections were technically successful. Contrast media deposit was documented in all targeted joints. Significant relief of symptoms was noted by all 6 participants. Conclusions: FD-CT—guided joint infiltration is a feasible method for diagnostic infiltration of midfoot and hindfoot joints. The FD-CT approach may become an alternative to commonly used 2D-fluoroscopically guidanc

Muscular atrophy of the lower leg in unilateral post traumatic osteoarthritis of the ankle joint

Purpose: Muscle atrophy is a commonly encountered problem in osteoarthritis (OA). The aim of this study was to estimate the amount of muscle atrophy and fatty degeneration of the lower leg muscles related to ankle OA by magnetic resonance imaging (MRI). Methods: Twenty-one patients with unilateral ankle OA were included in this cohort study. Calf circumference of the affected and healthy lower leg was documented. The degree of OA was classified in conventional radiographs. The cross-sectional areas and fatty degeneration of the muscles of the lower leg were measured in bilateral MRI. Results: We found a significantly reduced calf circumference of the affected vs. healthy leg (p = 0.016). MRI showed a significantly lower cross-sectional area of the entire lower leg musculature in OA (p = 0.013). Sub-analysis of muscle groups revealed that only the M. soleus had a significant cross-sectional area decrease (p < 0.01). All muscles showed a significant fatty degeneration (p < 0.01). Conclusions: We conclude that unilateral ankle joint osteoarthritis leads to an overall lower leg muscle atrophy, but significant atrophy of the M. soleus. All muscles of the affected leg undergo a fatty degeneratio

Facilitating the interpretation of pedobarography: the relative midfoot index as marker for pathologic gait in ankle osteoarthritic and contralateral feet

Background Pedobarography offers dynamic information about the foot, but the interpretation of its large data is challenging. In a prior study it was shown that attention can be restricted to pedobarographic midfoot load data. We aim to verify this observation in ankle osteoarthritic and contralateral feet. Methods We assessed both feet of 120 patients with end-stage ankle osteoarthritis (OA) and 35 healthy volunteers with AOFAS-score and dynamic pedobarography in barefoot condition. We introduce a new parameter, the Relative Midfoot Index (RMI), representing the depth of the midfoot weighted by the maximal force (MF) in the hindfoot and forefoot. Main outcome measures were the RMI, MF and contact times in the hindfoot, midfoot and forefoot. Ankle OA, contralateral and healthy feet were compared with ANOVA. Results The RMI was significantly smaller in OA feet (0.65 ± 0.19) and contralateral feet (0.69 ± 0.15) than in healthy feet (0.84 ± 0.08, p < 0.0001). There was no significant difference between OA and contralateral feet. The RMI showed a correlation of 0.48 with the AOFAS score. Contralateral and OA feet were significantly different from healthy feet (p < 0.001) in all parameters except the hindfoot MF. An RMI <0.8 showed a positive predictive value of 80% and sensitivity of 78% for being unhealthy. Conclusion The RMI assists the interpretation of pedobarographic parameters and provides a user-friendly indicator for unhealthy foot conditions with a cut-off value of 0.8. The contralateral feet of ankle OA patients differed significantly from healthy feet and are therefore not suitable as control group

Autologous matrix-induced chondrogenesis aided reconstruction of a large focal osteochondral lesion of the talus

The aim of this case report is to describe a novel technique for treatment of large osteochondral lesions of the talus using autologous matrix-induced chondrogenesis with a collagen I/III membran

Bony periosteum-covered iliac crest plug transplantation for severe osteochondral lesions of the talus: a modified mosaicplasty procedure

Purpose: This study reports first evidence of a modified procedure for osteochondral autologous transplantation where bony periosteum-covered plugs are harvested at the iliac crest and transplanted into the talar osteochondral lesion. Methods: Thirteen out of 14 patients, average age 39.6 (SD 14.4) years, were followed clinically and radiographically for a median of 25 (24-28) months (minimal follow-up, 24months). Results: For these 13 patients, the American Orthopaedic Foot and Ankle Society hindfoot score increased from 47 (SD 11) points pre-operatively, to 81 (SD 14) points postoperatively (p<0.0001). The average pain score decreased from 6.6 (SD 1.3) points pre-operatively, to 1.4 (SD 1.9) points postoperatively (p<0.0001). Seven patients returned to sports activity. Radiographically good plug osteointegration was observed in nine out of 11 ankles. Follow-up arthroscopy showed fibrous cartilage in four ankles, periosteum hypertrophy in five ankles, and partial or total missing of coverage of the bone in three ankles. Three revision surgeries had to be performed. Conclusions: This modified mosaicplasty might be recommended for severe and recurrent osteochondral lesions of the talus and may lead to restoration of the subchondral bone stock, formation of fibro-cartilage, and stable joint function. Level of evidence: IV

Implantation of a collagen matrix for an AMIC repair during dry arthroscopy

Several arthroscopic cartilage repair techniques in the knee joint require the insertion of a cut-to-shape matrix. Depending on the location and accessibility of the cartilage lesion, this procedure can be challenging. To overcome the limitations of currently used techniques, a novel matrix insertion technique was developed. This technique utilizes an inserter rod and a dedicated guide which can be used in a dry arthroscopy setup. Level of evidence: Expert opinion, Level V

Dry Arthroscopy With a Retraction System for Matrix-Aided Cartilage Repair of Patellar Lesions

Several commercially available cartilage repair techniques use a natural or synthetic matrix to aid cartilage regeneration (e.g., autologous matrix–induced chondrogenesis or matrix-induced cartilage implantation). However, the use of matrix-aided techniques during conventional knee joint arthroscopy under continuous irrigation is challenging. Insertion and fixation of the matrix can be complicated by the presence of fluid and the confined patellofemoral joint space with limited access to the lesion. To overcome these issues, we developed a novel arthroscopic approach for matrix-aided cartilage repair of patellar lesions. This technical note describes the use of dry arthroscopy assisted by a minimally invasive retraction system. An autologous matrix–induced chondrogenesis procedure is used to illustrate this novel approach

Realignment osteotomy in fibular malunion

Category: Ankle Arthritis Introduction/Purpose: The incidence of fibula fractures continues to increase. The exact incidence of distal fibula malunions after fibular reconstructions is not known, but incidence up to 33% is described in the literature. The most frequent malunions of the fibula are shortening and malrotation, resulting in the widening of the ankle mortise and talar instability. It has been demonstrated that substantial fibular displacement may substantially increase the contact pressures in the ankle joint. Therefore distal fibular malunion is a risk factor for development of posttraumatic ankle osteoarthritis. The objectives of this study were to (1) describe our treatment algorithm and surgical technique in patients with posttraumatic fibula malunions; (2) determine intra- and postoperative complications rates, (3) to describe mid-term clinical and radiological outcomes and quality of life. Methods: 21 consecutive patients (12 male, 9 female, mean age 42 years) with symptomatic fibular malunions were included into this prospective study. The initial injury was Weber B and C fracture in 7 and 14 ankles. The mean time between the injury and reconstructive surgery was 17.5 months. In all patients a z-shaped osteotomy of the fibula was performed to achieve the appropriate length/rotation of the fibula. Fixation was performed using a plate. If necessary, supramalleolar and inframalleolar deformities were corrected by supramalleolar tibial and calcaneal osteotomies, respectively. Prior to the osteotomies an anterior ankle arthroscopy was performed in all patients. All patients were evaluated pre- and postoperatively (mean follow-up 5.6 years). Radiological outcomes were assessed using standardized weight-bearing radiographs. Clinical outcomes were assessed using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, SF-36 questionnaire. Results: There were no intraoperative complications. In two patients early wound healing problems were observed, and resolved with i.v. antibiotics. Osseous healing was observed in all ankles within 10 weeks after surgery. The length and rotation of the fibula was improved in all patients, according to Weber criteria. All patients experienced significant pain relief (VAS: 6.5 ± 1.1 to 1.1 ± 0.9, P < 0.001) and functional improvement (AOFAS hindfoot scale: 47.1 ± 14.5 to 85.0 ± 7.5, P < 0.001; ROM:37° ± 6° to 45° ± 5°, P < 0.001). The SF-36 score also significantly increased in all 8 subgroups. In 11 patients hardware was removed due a discomfort after a mean of 11.7 months (range 7.2 – 22.8). Conclusion: A z-shaped osteotomy is an efficient and successful method to restore fibula length and rotation in patients with posttraumatic malunion. Our findings in this series of 19 ankles confirm that this realignment surgery results in significant pain relief and functional improvement

Pain in osteochondral lesions.

Pain is the key symptom of patients suffering from osteochondral lesions (OCLs) of the ankle joint. Routine radiographic imaging methods for diagnosis and staging of OCL fail to visualize the pain-inducing focus within the joint. SPECT-CT (Single-photon emission computed tomography-computed tomography) is a new hybrid imaging technique allowing exact digital fusion of scintigraphic and computer tomographic images. This allows precise localization and size determination of an OCL within the joint. Using this novel imaging method, we conducted a study to evaluate the correlation between pathological uptake within an OCL and pain experienced by patients suffering from this condition; 15 patients were assessed in the orthopaedic ambulatory clinic for unilateral OCL of the ankle joint. Pain status was measured with the Visual Analogue Scale (VAS). A SPECT-CT was performed. All patients underwent CT-guided ankle injection with a local anesthetic and iodine contrast medium. The VAS score assessed immediately postinfiltration was compared with the preinterventional VAS score obtained in the outpatient clinic. Pain relief was defined as a reduction of the VAS score to ?50% of the preinterventional score, if expected immediately after infiltration. Pain relief was found in all 15 patients. The results of our study show that there is a highly significant correlation between pain and pathological uptake seen on SPECT-CT, indicating that pathologically remodeled bone tissue is an important contributor to pain in OCL. Adequate addressing of involved bone tissue needs to be taken into consideration when choosing a surgical treatment method