A case of arthroscopic ankle arthrodesis for hemophilic arthropathy of the bilateral ankles

INTRODUCTION: Hemophilic arthropathy can affect multiple joints including ankle. However, only one report has been published regarding both arthroscopic ankle arthrodesis with hemophilic arthropathy. PRESENTATION OF CASE: The patient was a 23-year-old man with hemophilia A and a 3-year history of recurrent hemarthrosis in both ankles. We undertook surgery to treat arthropathy. His left ankle was treated first and the right ankle 6 months later. In both ankles, the cartilage was worn and eburnated. The remaining cartilage was removed and more dimples were created to fuse the tibia and talus. The ankle was fixed using 3 cannulated screws. Postoperatively, the patient wore an immobilization cast with no weight-bearing for 2 weeks. Thereafter, weight-bearing was allowed and the cast was removed 4 weeks after surgery. DISCUSSION: At the 1-year follow-up, bony union was satisfactory, functional outcome was acceptable, and pain relief was good. The Japanese Society for Surgery of the Foot ankle-hindfoot scale score increased from 24 preoperatively to 87 postoperatively. CONCLUSION: We report successful treatment with arthroscopic arthrodesis in a case of hemophilic arthropathy in both ankles

Temporary Kirschner wire fixation of the first metatarsophalangeal joint before osteotomy for hallux valgus

Introduction: Numerous operative procedures have been described for correction of hallux valgus, including distal step-cut osteotomy such as the Mitchell osteotomy. However, overcorrection can occur due to technical problems with the initial metatarsal osteotomy. Here, we describe a modified Mitchell osteotomy with a novel method, the temporary Kirschner wire fixation of the first metatarsophalangeal joint (TeKFiM) method (Tonogai method), that can be used before osteotomy for hallux valgus to avoid incongruency and overcorrection. Operative technique: A skin incision and Y-shaped capsulotomy are performed and the medial exostosis is excised. Lateral capsule release is done if the first metatarsophalangeal (MTP) joint cannot be reduced manually. Next, a Kirschner wire (K-wire) is inserted subcutaneously through the medial side of the first proximal phalanx to the lateral side of the first metatarsal to preserve the correct congruency of the first MTP joint during surgery. To correct pronation of the distal fragment, step-off transverse cuts are made in the distal fragment, as described by Mitchell, reaching one-second to two-thirds of the transverse diameter of the neck from the plantar medial side. After the osteotomies are completed, the lateral spike of the proximal fragment is flattened. The distal fragment is displaced laterally and slightly plantarward, and the pronation deformity of the distal fragment is corrected by inserting a K-wire to act as a joystick. The osteotomy site is stabilized using two Herbert-type screws. After removal of the K-wire, the operation is completed by closing the medial capsule of the first MTP joint and the skin. A plantar cast is applied for 2 weeks, followed by a special heel brace for 4–6 weeks. Sutures are removed 2 weeks after surgery. Patients are allowed to start weightbearing gradually as tolerated from 2 weeks after surgery. Discussion: After osteotomy, it is difficult to maintain the correct congruency of the first MTP joint due to instability of the distal fragment. The TeKFiM method (Tonogai method) reliably maintains this congruency during surgery. Also, by using a K-wire as a joystick to fix the joint in correct congruency, the first toe is rotated and pronation is corrected by supinating the distal fragment. The K-wire also serves as a landmark for determining how far the distal fragment is shifted plantarward. Conclusions: We have developed a modified Mitchell osteotomy with the novel TeKFiM method (Tonogai method) before osteotomy for hallux valgus to avoid incongruency and overcorrection. This method also provides a landmark to correct pronation and plantarward shifting

A case of ankle osteoarthritis associated with lateral premalleolar bursitis caused by chronic ankle instability

INTRODUCTION: Lateral premalleolar bursitis develops on the dorsolateral aspect of the foot anterior to the lateral malleolus, distinct from lateral malleolar bursitis located just around the lateral malleolus. PRESENTATION OF CASE: A 71-year-old woman visited an orthopedic clinic about 40 years after an episode of ankle sprain and was diagnosed with lateral premalleolar bursitis and osteoarthritis of the left ankle. Stress radiography revealed left ankle anterolateral malleolar bursitis with varus and anterior instability. We opted for less invasive arthroscopic ankle arthrodesis over open resection to stop the communication of the bursitis with the ankle joint. The lateral premalleolar bursitis was located just over the anterolateral portal. The remaining cartilage in the talotibial joint was removed and the subchondral surface was exposed and curetted down to a bleeding surface by ankle arthroscopy. The talotibial joint was fixed with 3 6.0-mm cannulated cancellous screws. The foot and ankle were immobilized by cast for 4 weeks. Bony union was achieved about 8 weeks postoperatively. The patient could perform daily activities without pain and with no recurrence of the lateral premalleolar bursitis at the 1.5-year follow-up. DISCUSSION: To our knowledge, this is the first report on arthroscopic arthrodesis for ankle osteoarthritis with recalcitrant lateral premalleolar bursitis caused by the check valve mechanism of chronic ankle instability after old ankle sprain. CONCLUSION: We report a case of arthroscopic arthrodesis for osteoarthritis of the ankle associated with lateral premalleolar bursitis caused by the check valve mechanism of chronic ankle instability after old ankle sprain

Outside-in Technique for Transforaminal Full-Endoscopic Lumbar Discectomy Under Local Anesthesia : A Review Article

Transforaminal full-endoscopic lumbar discectomy (TF-FELD) was first introduced more than 20 years ago, followed by interlaminar full-endoscopic lumbar discectomy (IL-FELD). Both TF-FELD and IL-FELD require only an 8-mm skin incision and damage to the back muscles is minimal. Thus, these methods are the least invasive disc surgery at present. However, unlike the interlaminar method, the transforaminal method can be performed under the local anesthesia, which is its biggest advantage. Although an inside-out approach after foraminoplasty was initially recommended, an outside-in approach has recently been proposed for safety reasons. This technique is less invasive and allows an early return to the original level of activity. TF-FELD has also been used in athletes because of its minimal invasiveness. It was initially thought that the transforaminal approach would be difficult to perform at L5/S1, so the interlaminar approach was recommended. However, with the advent of foraminoplasty, TF-FELD is now possible even at L5/S1. This review article explains the TF-FELD technique in detail

Posterior ankle arthroscopy for posterior ankle synovitis with an enlarged posterior talar process caused by a cat bite or scratch : A case report

INTRODUCTION: Legs are sometimes infected and swollen by cat bite or scratch. However, there is no report of synovitis with an enlarged talar posterior process in the posterior ankle caused by a cat bite or scratch which was treated by removal of the enlarged process and synovectomy with release of the flexor hallucis longus tendon via posterior ankle arthroscopy. PRESENTATION OF CASE: The patient was a 58-year-old woman who had started keeping a cat 7 months earlier. She subsequently sustained cat bite and scratch wounds to her lower legs, which gradually became increasingly swollen. On presentation, there was left lower leg swelling, particularly on the posterior aspect of the ankle. Imaging revealed bone marrow edema in the enlarged posterior talar process and inflammation of the adjacent soft tissue. We excised the enlarged posterior talar process, performed synovectomy, and released the flexor hallucis longus tendon using a posterior arthroscopic technique via standard posterolateral and posteromedial portals. Microbial culture was negative. DISCUSSION: The patient returned to daily activities approximately 3 weeks after arthroscopic debridement. There was no recurrence at the 1-year follow-up visit. To our knowledge. CONCLUSION: We report a rare case of posterior ankle synovitis with an enlarged posterior talar process caused by a cat bite or scratch which was treated successfully by posterior ankle arthroscopic debridement

A case of osteophyte excision and arthroscopic arthrodesis for tarsal tunnel syndrome with traumatic osteoarthritis of the ankle

INTRODUCTION: There are some reports of tarsal tunnel syndrome (TTS) entrapment/impingement from bony factors, including exostosis and fragment, but there are no reports on TTS with traumatic osteoarthritis of the ankle that were treated with osteophyte excision for TTS and arthroscopic arthrodesis for osteoarthritis of the ankle. PRESENTATION OF CASE: A 61-year-old woman with left trimalleolar fracture had undergone surgery 3 years earlier and was referred to our hospital for further investigation of persistent left ankle pain and numbness around the left medial malleolus and plantar aspect of the foot. Clinical examination demonstrated plantar hypesthesia and a positive Tinel’s sign at the tarsal tunnel. Imaging showed severe osteoarthritic change in the ankle and an osteophyte of the posteromedial distal tibia that appeared to be impinging on the tibial nerve. We performed arthroscopic ankle arthrodesis, which is less invasive than the open procedure, with removal of the osteophyte as the cause of TTS. Tarsal tunnel exploration revealed a large osteophyte pushing on the tibial nerve, and the osteophyte was removed. DISCUSSION: About 8 weeks after surgery, bony union was achieved. At the 2-year follow-up visit, the patient could perform daily activities with almost no pain or numbness. This case offers further insight into the management of TTS with traumatic osteoarthritis of the ankle. CONCLUSION: We report here successful treatment of a rare case of tarsal tunnel syndrome (TTS) accompanied with traumatic osteoarthritis of the ankle, treated with osteophyte excision for the TTS and arthroscopic for the osteoarthritis

One-stage tibial deformity correction and ankle arthrodesis for ankle osteoarthritis and tibial malalignment after low tibial osteotomy

Introduction: There are no reports on one-stage corrective tibial opening wedge osteotomy and arthrodesis for osteoarthritis of the ankle and tibial malalignment after distal tibial osteotomy. Presentation of case: The patient was a 70-year-old woman who presented with complaints of ankle pain and lower limb deformity after tibial osteotomy performed for ankle arthritis 17–18 years earlier. Clinical examination revealed marked swelling around the ankle joint and pain and tenderness at the joint line. Imaging showed tibial malalignment and severe osteoarthritic changes in the ankle. The patient had valgus deformity of 21° and recurvatum deformity of 4°. In two months, she admitted to Department of Orthopedics at Tokushima University Hospital in Japan and we performed one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis with an anterolateral plate through a lateral longitudinal incision. After removal of the previous implants, the remaining articular cartilage and osteophytes were removed from the tibial and talar surfaces. After debridement of the talar trochlea and tibial plateau, the center of rotation and angular deformity of the tibia was cut transversely and a 1-cm bone graft obtained from the removed fibula was inserted into the osteotomy site, which decreased the tibial malalignment. An anterolateral locking plate was inserted over the anterior and lateral sides of the tibia, and the ankle was fused using 2 cannulated screws. Discussion: The patient wore an above-knee splint for 6 weeks to avoid weight-bearing followed by gradual weightbearing with a brace thereafter. Osseous fusion was achieved after about 3.5 months. Radiographs obtained at the 2-year follow-up visit showed complete union of the tibia and talus. Full correction of valgus and recurvatum deformity was achieved, and the patient was able to perform daily activities with almost no pain. Conclusion: We reported a rare case of ankle osteoarthritis and tibial malalignment that was successfully treated with one-stage corrective tibial opening wedge osteotomy and ankle arthrodesis using an anterolateral plate via a transfibular approach

Arthrodesis for chronic lateral subtalar joint dislocation caused by posterior tibial tendon dysfunction : A case report

INTRODUCTION: Adult acquired flatfoot deformity (AAFD) caused by posterior tibial tendon dysfunction (PTTD) can lead to the development of peritalar subluxation (PTS) and much more rarely to lateral subtalar dislocation. PRESENTATION OF CASE: A 75-year-old woman was referred to our hospital with an approximately 15-year history of pain in her right foot without obvious trauma. The lateral shifting foot deformity had worsened in the previous 5 years. On presentation, she had tenderness over the talonavicular joint, and the skin overlying the talar head on the medial foot was taut. Imaging revealed lateral displacement of the calcaneus with simultaneous dislocation of the talonavicular and talocalcaneal joints. We diagnosed lateral subtalar dislocation including the talonavicular and talocalcaneal joints caused by PTTD, which we treated by reduction and fusion of the subtalar joint complex. The foot and ankle were immobilized with a cast for 6 weeks. DISCUSSION: At the 1-year follow-up visit, the patient reported no pain during daily activities, although flatfoot persisted. CONCLUSION: We report a rare case of chronic lateral subtalar dislocation caused by PTTD that was treated by fusion of the talonavicular and talocalcaneal joints

P. acnes in Modic type 1 change

Propionibacterium acnes (P. acnes) is part of the normal flora of human skin, oral cavity, intestinal tract and external ear canal. However, breach in the mucosa as well as ruptured annulus fibrosus provide favorable pathway for P. acnes to nucleus pulposus where it can proliferate under anaerobic condition. In past two decades many authors have identified P. acnes in routine culture of discs. There studies showed that almost 50% of discs cultured were positive for various organism, and in vast majority of culture positive disc, P. acnes was the primary organism isolated. However, there are few studies that refute the hypothesis that P. acnes has a role in pathogenesis of Modic type 1 changes. Identification of P. acnes in culture indicates the infective patho-mechanism in the pathogenesis of Modic type 1 changes, which may be ameable to antibiotic treatment. However, it is still difficult to identify which subset of these patients (patients with low back pain with type 1 Modic change) are infective in nature. Further investigation and more clinical trails will be required for clear identification of the infective subgroup among low back patient in general

スポーツ センシュ ノ ヨウツウ ト テイシンシュウ シュジュツ : ナゾ ノ ヨウツウ オ トキアカス

Low back pain is commonly occurred among athletes. There are some pathologies causing the pain, and most of the pathology would be based on the overuse of the spine during the sports performance. Thus, the clue to obtain the exact diagnosis of the back pain is the lumbar motion causing the pain. Roughly, the pathology is classified into two ; i.e., flexion pain and extension pain. In flexion, anterior component of the spine such as intervertebral disc and endplate is loaded. Thus, disorders causing flexion pain would be disc herniation, discogenic pain, type １ Modic endplate inflammation and so on. During the lumbar extension motion, posterior element including the facet joints and lamina is loaded. Based on this phenomenon, the lumbar spondylolysis and facet joint arthritis would be the main pathology causing the extension pain. Once the exact diagnosis can be obtained, pin-point intervention is possible including the block therapy and endoscopic surgery. The state of the art minimally invasive disc surgery is the endoscopic surgery. The technique is called the percutaneous endoscopic discectomy （PED）. It only requires ８ mm for the skin incision, and it can be done under the local anesthesia. With utilizing the PED system, we have been treating the athletes with disc herniation and discogenic pain minimally invasively