Numerous metatarsal osteotomies have been developed for the treatment of Freiberg's disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg's disease.
From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg's disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients' subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg's disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed.
VAS showed improvement from 6.2 ± 1.4 to 1.4 ± 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 ± 14.9 to 80.4 ± 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 ± 10.1 to 48.3 ± 13.0 degrees at last follow-up (p < 0.0001). According to Smillie's classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, reporting excellent or good results.
Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg's disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.
Freiberg's disease; Modified Weil osteotomy; Dorsal closing wedge osteotomy
We report the case of a healthy 36 year old man who suffered from foot pain lasting for weeks, without having a specific medical history relating to it. The clinical evaluation was interpreted as a transfer metatarsalgia caused by a splayfoot. The radiographs revealed no pathology except the splayfoot deformity. Due to persistent pain and swelling of the entire forefoot, after two weeks of conventional treatment, magnet resonance images (MRI) and a blood sample were taken. The laboratory investigation showed raised levels of white blood cell count and C-reactive protein. The MRI showed up oedema in the metatarsal heads II-IV, as well as soft tissue swelling of the forefoot without any signs of decomposition.
Because of this atypical inflammation of the forefoot a laboratory investigation to check for rheumatology disease was done and revealed borrelia burgdorferi infection. On the basis of these findings, antibiotic treatment was started and maintained over three weeks. The symptoms disappeared after 2 weeks, and the patient was able to resume his sports activities.
There is evidence that appropriate footwear is an important factor in the prevention of foot pain in otherwise healthy people or foot ulcers in people with diabetes and peripheral neuropathy. A standard care for reducing forefoot plantar pressure is the utilization of orthotic devices such as total contact inserts (TCI) with therapeutic footwear. Most neuropathic ulcers occur under the metatarsal heads, and foot deformity combined with high localized plantar pressure, appear to be the most significant factors contributing to these ulcers. In this study, patient-specific finite element models of the second ray of the foot were developed to study the influence of TCI design on peak plantar pressure (PPP) under the metatarsal heads. A typical full contact insert was modified based on the results of finite element analyses, by inserting 4 mm diameter cylindrical plugs of softer material in the regions of high pressure. Validation of the numerical model was addressed by comparing the numerical results obtained by the finite element method with measured pressure distribution in the region of the metatarsal heads for a shoe and TCI condition. Two subjects, one with a history of forefoot pain and one with diabetes and peripheral neuropathy, were tested in the laboratory while wearing therapeutic shoes and customized inserts. The study showed that customized inserts with softer plugs distributed throughout the regions of high plantar pressure reduced the PPP over that of the TCI alone. This supports the outcome as predicted by the numerical model, without causing edge effects as reported by other investigators using different plug designs, and provides a greater degree of flexibility for customizing orthotic devices than current practice allows.
Finite element analysis; diabetic foot; insole design
Treatment of comminuted fractures of the radial head is controversial, and considerable effort has been made to restore optimal function of the elbows, either by surgical reconstruction or prosthetic replacement. This report presents our experiences in treatment of unreconstructable radial head or neck fractures using osteochondral autografts harvested from the base of the second metatarsal bones.
Five patients with radial head and one with a radial neck fracture underwent treatment with osteochondral autografts. After excision of the unreconstructable radial head, the second metatarsal base was harvested and transplanted to the radius using the intramedullary nailing technique.
The reconstructed elbows were examined clinically and radiographically for a mean period of 44.8 months (range, 24–72 months). At the last follow-up, in flexion-extension, the mean elbow mobility was 130°/10°. In supination-pronation, the mean elbow mobility was 73.3°/66.7°, with a mean loss of supination of 19.2° and loss of pronation of 12.5°. Grip strength was 91%, compared with the contralateral limb. The mean Mayo Elbow Performance Score was 94.2. The mean score of AOFAS rating system to the lesser toe was 93.7 points.
Radial head arthroplasty with an osteochondral autograft from the second metatarsal base appears to be an effective alternative for treatment of unreconstructable radial head fractures. A larger group of patients and a longer follow-up period will be required in order to ease concerns regarding the donor site; however, none of the patients who underwent this procedure showed any complications during follow-up.
Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.
osteochondritis dissecans; knee; cartilage; surgical treatment
Congenital brachymetatarsia, a shortened metatarsal bone, can be corrected surgically by callus distraction or one-stage lengthening using bone graft.
We asked whether one-stage metatarsal lengthening using metatarsal homologous bone graft could improve forefoot function, lead to metatarsal healing, restore metatarsal parabola, and improve cosmetic appearance.
Patients and Methods
We retrospectively reviewed 29 patients (41 feet) in whom we lengthened 50 metatarsals. Surgery consisted of a transverse proximal osteotomy of the metatarsal shaft and interposition of a metatarsal homologous bone graft (average, 13 mm long) fixed with an intramedullary Kirschner wire. Minimum followup was 3 years (mean, 5 years; range, 3–11 years).
Bone union was achieved in all cases. The mean preoperative American Orthopaedic Foot and Ankle Society score was 37 points (range, 28–53 points) and the mean postoperative score was 88 points (range, 74–96 points), with an average improvement of 51 points. Radiographically, the mean gain in length was 13 mm (range, 10–15 mm), and the mean percentage increase was 23%.
One-stage metatarsal lengthening using interposition of metatarsal homologous bone graft to correct congenital brachymetatarsia has low morbidity for the patient, limited complications, short recovery times, and restores forefoot anatomy.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Joint pain is a common complaint in pediatrics and is most often attributed to overuse or injury. In the face of persistent, severe, or recurrent symptoms, the differential typically expands to include bony or structural causes versus rheumatologic conditions. Rarely, a child has two distinct causes for joint pain. In this case, an obese 15-year-old male was diagnosed with gout, a disease common in adults but virtually ignored in the field of pediatrics. The presence of juvenile idiopathic arthritis (JIA) complicated and delayed the consideration of this second diagnosis. Indeed, the absence of gout from this patient’s differential diagnosis resulted in a greater than two-year delay in receiving treatment. The patients’ BMI was 47.4, and he was also mis-diagnosed with osteochondritis dissecans and underwent medical treatment for JIA, assorted imaging studies, and multiple surgical procedures before the key history of increased pain with red meat ingestion, noticed by the patient, and a subsequent elevated uric acid confirmed his ultimate diagnosis. With the increased prevalence of obesity in the adolescent population, the diagnosis of gout should be an important consideration in the differential diagnosis for an arthritic joint in an overweight patient, regardless of age.
Juvenile idiopathic arthritis; Gout; Obesity; Ankle pain; Adolescent; Joint pain; Autoimmune; Osteochondritis dissecans; Treatment failure
Morton’s neuroma is a common cause of pain that radiates from between the third and fourth metatarsals and which, when symptomatic, creates sensations of burning or sharp pain and numbness on the forefoot. Many conservative and surgical interventions are employed to reduce associated pain, but not enough research has been conducted to recommend patients to any one approach as the most reliable source of pain management.
The objective of this case report is to describe the effect of massage therapy on one woman with symptomatic Morton’s neuroma.
A physically active 25-year-old female with diagnosed symptomatic Morton’s neuroma who has not found relief with previous conservative intervention.
Six session of massage therapy once weekly for 60–75 minutes focused on postural alignment and localized foot and leg treatment. The client also completed an at-home exercise each day. Change was monitored each week by the massage therapist reassessing posture and by the client filling out a pain survey based on a Visual Analog Scale.
The client reported progressive change in the character of the pain from burning and stabbing before the first session to a dull, pulsing sensation after the third session. She also recorded a reduction in pain during exercise from a 5/10 to 0/10 (on a scale where 10 is extreme pain).
This study describes how massage therapy reduced pain from Morton’s neuroma for one client; however, larger randomized control studies need to be done in order to determine the short- and long-term effects of massage therapy on this painful condition.
intermetatarsal neuroma; foot health; entrapment neuropathy; Mulder’s sign; forefoot; deep transverse metatarsal ligaments
In this study, we performed a mechanical analysis of the effect of fibroblast growth factor-2 (FGF-2) on autologous osteochondral transplantation in a rabbit model. A full-thickness cartilage defect (diameter: 5 mm; depth: 5 mm) made in the right femoral condyle was treated with osteochondral transplantation using an osteochondral plug (diameter: 6 mm; depth: 5 mm) taken from the left femoral condyle. The animals were divided into three groups: Group I, the defect was filled with 0.1 ml of gelatin hydrogel containing 1 μg of FGF-2; Group II, the defect was filled with 0.1 ml of gelatin hydrogel only; Group III, the defect was left untreated. Thereafter, osteochondral plugs were transplanted and the transplanted osteochondral grafts were evaluated mechanically and histologically at postoperative weeks 1, 3, 8 and 12. The structural property of the osteochondral graft was significantly greater in Group I than in Groups II and III at postoperative week 3. Histological analysis at 3 weeks revealed a tendency towards increased subchondral bone trabeculae in Group I compared with the other groups. Autologous osteochondral grafts transplanted with gelatin hydrogel containing FGF-2 acquired adequate stiffness at an early postoperative phase.
The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.
hip dislocation; osteochondral autograft transplant; femoral head; osteochondral defect; osteochondral injury; mosaicplasty
Autologous platelet-rich plasma (PRP) may enhance wound healing through the formation of a platelet plug that provides both hemostasis and the secretion of biologically active proteins, including growth factors such as platelet-derived growth factor, transforming growth factor (TGF)-β, TGF-β2, and epidermal growth factor. The release of these growth factors into the wound may create an environment more conducive to tissue repair and could accelerate postoperative wound healing. To our knowledge, there are no reports of combining the use of PRP with curative diabetic foot surgery. This article provides a summary of the literature regarding PRP and wound healing and presents a case of a 49-year-old man with diabetes and a three-month history of a deep, nonhealing plantar hallux wound in which PRP was combined with a first metatarsophalangeal joint arthroplasty. Through the use of the PRP and bioengineered tissue to supplement curative diabetic foot surgery, the patient healed uneventfully at seven weeks.
diabetic; foot surgery; platelet rich plasma; wound
To present the case of a collegiate athlete with an atraumatic osteochondral fracture influenced by the presence of osteoarthritis.
Osteochondral fractures are fairly common occurrences in athletes, although it can be difficult to recognize such an injury in the absence of a traumatic event. Osteoarthritis is 1 condition that can increase an athlete's susceptibility to an atraumatic osteochondral fracture. However, because of the atraumatic nature of the injury, the possibility of an osteochondral fracture may be overlooked.
Meniscal damage, osteochondritis dissecans, patellofemoral disorders.
The osteochondral fragment was surgically removed, and fibrous growth was encouraged by drilling and laser smoothing.
Osteochondral fractures are usually associated with some type of traumatic mechanism, such as a rotational and compressive force. Also, osteoarthritis is not common in young collegiate athletes. However, this 20-year-old volleyball player had no apparent injury and lacked the usual signs and symptoms (eg, locking, giving way, crepitus, loss of range of motion) associated with an osteochondral fracture. The athlete's susceptibility to an osteochondral fracture was increased by the presence of osteoarthritis.
The athletic trainer should consider the possibility of an osteochondral fracture in an athlete with persistent effusion and pain in the absence of a traumatic mechanism of injury.
osteochondritis dissecans; knee injury
Patellofemoral chondral lesions are unique and difficult-to-treat entities often affecting a young and active patient population. Recent advances in our understanding of cartilage injuries, surgical techniques, and surgical technology have provided treatment options for symptomatic patients with lesions of the patellofemoral compartment. A number of surgical treatment options are available, including surgical microfracture, autologous or juvenile chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft implantation. Management decisions are based on a number of patient- and lesion-related factors in an effort to relieve pain, restore function, and preserve the patellofemoral articulation. The present article reviews the evaluation and management of cartilage injuries affecting the patellofemoral joint.
Patellofemoral; Chondromalacia; Osteochondral lesion; ACI; Osteochondral autograft; Osteochondral allograft
Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.
diabetic foot; osteomyelitis; ulcer; amputation; neuropathy
Large symptomatic osteochondral defects in a young active population represent a therapeutic challenge for orthopedic surgeons, since standard interventions such as debridement, microfracture and autologous osteochondral transfer are not suitable for the treatment of these larger lesions. Fresh osteochondral allograft transplantation provides a surgical option for these challenging defects, both as a primary procedure and for salvage of prior failed treatment attempts. This article reviews the basic science, indications, technique, and evidence for osteochondral allograft transplantation in the knee.
Cartilage repair; Osteochondral allograft transplantation; Biologic joint reconstruction
We investigated quantitative changes over time in ultrasound signal intensity (an index of stiffness), signal duration (an index of surface irregularity), and interval between signals (an index of thickness) of plug cartilage in an animal model of autologous osteochondral grafting. A full-thickness osteochondral plug was surgically removed and replaced in male Japanese white rabbits (n = 22). Specimens obtained at day 0 and weeks 2, 4, 8, 12 and 24 postoperatively were assessed using an ultrasound system and by macroscopic and histological evaluation (modified Mankin's score). Histology revealed that the plug sank until 2 weeks postoperatively, and that newly formed cartilage-like tissue covered the plug, but at 24 weeks the tissue detached. The plug itself survived well throughout the period of observation. Although the signal intensity at the plug site was same as that in the sham operated contralateral knee at day 0, from 2 to 24 weeks postoperatively it was less than that in the sham knee. At 8 weeks, this difference was significant (P < 0.05). Modified Mankin's score revealed early degenerative changes at the site, but macroscopic examination did not. Signal intensity correlated significantly with score (both at day 0 and at the five postoperative time points [P < 0.05, r = -0.91] and as a whole [P < 0.05, r = -0.36]). Signal intensity also significantly correlated with the individual subscores for 'cartilage structure' (P < 0.05, r = -0.32) and 'cartilage cells' (P < 0.05, r = -0.30) from the modified Mankin's score, but not significantly with subscores for 'staining' and 'tidemark'. Signal duration correlated significantly with total score (as a whole [P < 0.05, r = 0.34]), but not significantly with the score for cartilage structure (P = 0.0557, r = 0.29). The interval between signals reflected well the actual thickness of the plug site. The significant relationships between ultrasound signal intensity and scores suggest that early degenerative changes in plug cartilage and cartilage-like tissue, especially in the superficial layer, are detectable by high-frequency ultrasound assessment.
articular cartilage; high-frequency ultrasound; histology; osteochondral grafting surgery
No head-to-head comparisons of different orthoses for patients with stage II posterior tibial tendon dysfunction (PTTD) have been performed to date. Additionally, the cost of orthoses varies considerably, thus choosing an effective orthosis that is affordable to the patient is largely a trial-and-error process.
A 77-year-old woman was seen with complaints of abnormal foot posture (“my foot is out”), minimal medial foot and ankle pain, and a 3-year history of conservatively managed stage II PTTD. The patient was not able to complete 1 single-limb heel rise on the involved side, while she could complete 3 on the uninvolved side. Ankle strength testing revealed a mild to moderate loss of plantar flexor strength (20%–31% deficit on the involved side), combined with a 22% deficit in isometric ankle inversion and forefoot adduction strength. To assist this patient in managing her flatfoot posture and PTTD, 3 orthoses were considered: an off-the-shelf ankle-foot orthosis (AFO), a custom solid AFO, and a custom articulated AFO. The patient’s chief complaint was partly cosmetic (“my foot is out”). As decreasing flatfoot kinematics may unload the tibialis posterior muscle, thus prevent the progression of foot deformity, the primary goal of orthotic intervention was to improve flatfoot kinematics. Given the difficulties in clinical approaches to evaluating flatfoot kinematics, a quantitative gait analysis, using a multisegment foot model, was used.
In the frontal plane, all 3 orthoses were associated with small changes toward hindfoot inversion. In the sagittal plane, between 2.7° and 6.1°, greater forefoot plantar flexion (raising the medial longitudinal arch) occurred. There were no differences among the orthoses on hindfoot inversion and forefoot plantar flexion. In the transverse plane, the off-the-shelf design was associated with forefoot abduction, the custom solid orthosis was associated with no change, and the custom articulated orthosis was associated with forefoot adduction.
Based on gait analysis, the higher-cost custom articulated orthosis was chosen as optimal for the patient. This custom articulated orthosis was associated with the greatest change in flatfoot deformity, assessed using gait analysis. The patient felt it produced the greatest correction in foot deformity. Reducing flatfoot deformity while allowing ankle movement may limit progression of stage II PTTD.
biomechanics; PTTD; tendinopathy
Osteochondritis dissecans of the knee primarily affects subchondral bone, with a secondary effect on the overlying articular cartilage. This process can lead to pain, effusions, and loose body formation. While stable juvenile lesions often respond well to nonoperative management, unstable juvenile lesions, as well as symptomatic adult lesions, often require operative intervention. Short-term goals focus on symptomatic relief, while long-term expectations include the hope of preventing early-onset arthritis. Surgical options include debridement, loose body removal, microfracture, arthroscopic reduction and internal fixation, subchondral drilling, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Newer single-stage cell-based procedures have also been developed, utilizing mesenchymal stem cells and matrix augmentation. Proper treatment requires evaluation of both lesional (size, depth, stability) and patient (age, athletic level) characteristics.
Osteochondritis dissecans; Knee; Microfracture; Osteochondral autologous transplant; Drilling; Internal fixation; Allograft; Autologous chondrocyte implantation; Loose body; Surgical treatment; Cartilage
While injuries of the upper extremity are widely discussed in rock climbers, reports about the lower extremity are rare. Nevertheless almost 50 percent of acute injuries involve the leg and feet. Acute injuries are either caused by ground falls or rock hit trauma during a fall. Most frequently strains, contusions and fractures of the calcaneus and talus. More rare injuries, as e.g., osteochondral lesions of the talus demand a highly specialized care and case presentations with combined iliac crest graft and matrix associated autologous chondrocyte transplantation are given in this review. The chronic use of tight climbing shoes leads to overstrain injuries also. As the tight fit of the shoes changes the biomechanics of the foot an increased stress load is applied to the fore-foot. Thus chronic conditions as subungual hematoma, callosity and pain resolve. Also a high incidence of hallux valgus and hallux rigidus is described.
Rock climbing; Sport climbing; Feet injuries; Hallux valgus; Overstrain injuries
Fresh osteochondral allograft transplantation is an increasingly common treatment option for chondral and osteochondral lesions in the knee, but the long-term outcome is unknown.
We determined (1) pain and function, (2) frequency and types of reoperations, (3) survivorship at a median of 13.5 years, and (4) predictors of osteochondral allograft failure in the distal femur.
We evaluated 122 patients (129 knees) who underwent osteochondral allograft transplantation of the femoral condyle. Mean age was 33 years and 53% were male. Clinical evaluation included the modified Merle d’Aubigné-Postel (18-point), IKDC, and Knee Society function (KS-F) scores. We defined graft failure as revision osteochondral allografting or conversion to arthroplasty. We determined whether patient characteristics or attributes of the graft influenced failure. Minimum followup was 2.4 years (median, 13.5 years); 91% had more than 10 years of followup.
Mean modified Merle d’Aubigné-Postel score improved from 12.1 to 16, mean IKDC pain score from 7.0 to 3.8, mean IKDC function score from 3.4 to 7.2, and mean KS-F score from 65.6 to 82.5. Sixty-one knees (47%) underwent reoperations. Thirty-one knees (24%) failed at a mean of 7.2 years. Survivorship was 82% at 10 years, 74% at 15 years, and 66% at 20 years. Age of more than 30 years at time of surgery and having two or more previous surgeries for the operated knee were associated with allograft failure.
Followup of femoral condyle osteochondral allografting demonstrated durable improvement in pain and function, with graft survivorship of 82% at 10 years.
Level of Evidence
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
The Tripod Index (TI) has been created to allow assessment of complex foot deformities. It utilizes tripod relationship between center of the heel, medial/lateral borders of the forefoot, and compare it to the center of the talar head. This study aimed to verify diagnostic accuracy of the TI in symptomatic flatfoot and cavovarus foot.
Weightbearing radiographs including foot AP with a hemispherical marker around the heel, lateral, and hindfoot alignment views were obtained on 91 patients (110 feet) presenting with medial foot and ankle pain and on 89 patients (90 feet) presenting with lateral foot and ankle pain between June 2010 and May 2011. Radiographs were evaluated blindly for the TI, AP talonavicular coverage angle, lateral talo-first metatarsal angle, calcaneal pitch angle, medial cuneiform-fifth metatarsal height, and coronal plane hindfoot alignment. The sensitivity, specificity, likelihood ratios, and predictive values were calculated. Clinically diagnosed flatfoot and cavovarus foot deformity indicated for surgical reconstruction by one of our foot and ankle orthopaedic surgeons was used as the accepted standard for diagnosis.
In flatfoot, sensitivity of the TI was 100%, comparable with lateral talo-first metatarsal angle (100%), and medial cuneiform-fifth metatarsal height (100%). Specificity of the TI was 93%, comparable with coronal plane hindfoot alignment (98%), but superior to other parameters. Positive likelihood ratio of the TI was 14.29, which was less than coronal plane hindfoot alignment (47.5), but more than other parameters. In cavovarus foot, sensitivity of the TI was 96%, comparable with coronal plane hindfoot alignment (100%), but superior to other parameters. Specificity of the TI was 95%, comparable with lateral talo-first metatarsal angle (94%), but superior to other parameters. Positive likelihood ratio of the TI was 19.2, which was more than other parameters.
The Tripod Index showed high accuracy as a quantitative assessment in diagnosis of a symptomatic flatfoot and cavovarus foot.
Tripod Index; Diagnostic test; Flatfoot; Cavovarus foot
The objective of this study was to determine the clinical outcome of combined bone grafting and matrix-supported autologous chondrocyte transplantation in patients with osteochondritis dissecans of the knee. Between January 2003 and March 2005, 21 patients (mean age 29.33 years) with symptomatic osteochondritis dissecans (OCD) of the medial or lateral condyle (grade III or IV) of the knee underwent reconstruction of the joint surface by autologous bone grafts and matrix-supported autologous chondrocyte transplantation. Patients were followed up at three, six, 12 and 36 months to determine outcomes by clinical evaluation based on Lysholm score, IKDC and ICRS score. Clinical results showed a significant improvement of Lysholm-score and IKDC score. With respect to clinical assessment, 18 of 21 patients showed good or excellent results 36 months postoperatively. Our study suggests that treatment of OCD with autologous bone grafts and matrix-supported autologous chondrocytes is a possible alternative to osteochondral cylinder transfer or conventional ACT.
Treatment of focal full-thickness chondral or osteochondral defects of the talus remains a challenge. The aim of this study was to evaluate the postoperative success and the long-term efficacy of matrix associated autologous chondrocyte implantation in these defects.
Matrix associated autologous chondrocyte implantation (MACI) was applied in 22 consecutive patients (mean age 23.9 years) with full-thickness chondral or osteochondral lesions of the talus. The average defect-size was 1.94 cm² (range 1–6). In case of osteochondritis dissecans (n = 13) an autologous bone graft was performed simultaneously. Follow-ups were routinely scheduled up to 63.5 (±7.4) months, consisting of clinical evaluation and magnetic resonance imaging.
The AOFAS score improved significantly from 70.1 to 87.9/92.6/93.5/95.0/95.5 and 95.3 points at three, six, 12, 24, 36 and 63.5 months, respectively. On a visual analogue scale, pain intensity decreased from 5.7 (±2.6) to 0.9 (±0.8) while subjective function increased from 5.3 (±2.3) to 8.9 (±0.9) at final follow-up (each p < 0.001). The Tegner score rose significantly from 2.4 (±1.2) to 4.7 (±0.6). The MOCART score improved from 62.6 (±19.4) at three months to 83.8 (±9.4) at final follow-up. No significant differences were found between lesions caused by osteochondritis dissecans or trauma and between first- or second-line treatments. For all scores, the most benefit was seen within the first 12 months with stable results afterwards. No major complications were noted.
Matrix associated autologous chondrocyte implantation is capable of significant and stable long-term improvement of pain and functional impairment caused by focal full-thickness chondral and osteochondral talus lesions.
Gout is a common inflammatory arthritis caused by articular precipitation of monosodium urate crystals. It usually affects the first metatarsophalangeal joint of the foot and less commonly other joints, such as wrists, elbows, knees and ankles.
We report the case of a 75-year-old Caucasian man with tophaceous multiarticular gout, soft-tissue involvement and ulcerated tophi on the first metatarsophalangeal joint of the left foot, on the first interphalangeal joint of the right foot and on the left thumb.
Ulcers due to tophaceous gout are currently uncommon considering the positive effect of pharmaceutical treatment in controlling hyperuricemia. Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain, infection and joint destruction.
Osteochondral transplantation is a successful treatment for full-thickness cartilage defects, which without treatment would lead to early osteoarthritis. Restoration of surface congruency and stability of the reconstruction may be jeopardized by early mobilization. To investigate the biomechanical effectiveness of osteochondral transplantation, we performed a standardized osteochondral transplantation in eight intact human cadaver knees, using three cylindrical plugs on a full-thickness cartilage defect, bottomed on one condyle, unbottomed on the contralateral condyle. Surface pressure measurements with Tekscan pressure transducers were performed after five conditions. In the presence of a defect the border contact pressure of the articular cartilage defect significantly increased to 192% as compared to the initially intact joint surface. This was partially restored with osteochondral transplantation (mosaicplasty), as the rim stress subsequently decreased to 135% of the preoperative value. Following weight bearing motion two out of eight unbottomed mosaicplasties showed subsidence of the plugs according to Tekscan measurements. This study demonstrates that a three-plug mosaicplasty is effective in restoring the increased border contact pressure of a cartilage defect, which may postpone the development of early osteoarthritis. Unbottomed mosaicplasties may be more susceptible for subsidence below flush level after (unintended) weight bearing motion.
Biomechanics; Cartilage; Articular/pathology; Humans; Knee Joint/Surgery; Pressure; Surface Properties; Transplantation; Autologous; Weight-bearing