Anatomic validation of the lateral malleolus as a cutaneous marker for the distal insertion of the calcaneofibular ligament

PURPOSE

An anatomic study was performed to confirm whether the lateral malleolus could serve as a simple and reproducible anatomic reference for the distal insertion of the calcaneofibular ligament (CFL).

METHODS

Dissection was performed after placement of a Kirschner wire to simulate the calcaneal tunnel for the distal insertion of the CFL. The skin was penetrated 1 cm distal and posterior to the tip of the lateral malleolus. The main information recorded was the distance from the Kirschner wire to the centre of the distal insertion of the CFL. Other elements were noted (characteristics of the CFL, distance between the distal insertion of the CFL-peroneal tubercle, nerve or tendon injuries).

RESULTS

Thirty ankles were dissected. The mean distance from the Kirschner wire to the centre of the distal insertion of the CFL was 2.4 ± 1.8 mm. Only one case of peroneal injury was noted. The sural nerve was usually located a mean 1.8 ± 1.1 mm from the Kirschner wire. The posterior tibial vascular pedicle was a mean 27.8 ± 3.5 mm from the point of exit of the Kirschner wire.

CONCLUSION

Using the lateral malleolus as the cutaneous reference for the distal insertion of the CFL seems to be more reliable than the pure arthroscopic technique. This study describes a percutaneous technique to obtain a calcaneal tunnel for distal insertion of the CFL. The sural nerve is at the greatest risk of injury with this technique and requires careful subcutaneous incision to prevent injury. This new percutaneous technique is less invasive than a purely arthroscopic technique and more accurately identifies the location of the tunnel. It can be used to do calcaneal tunnel in clinical practice during anatomic ligament reconstruction for chronic ankle instability.

Early strength recovery after anterior cruciate ligament reconstruction using the fascia lata

INTRODUCTION

After undergoing anterior cruciate ligament (ACL) reconstruction, patients must recover at least 80% of their hamstring and quadriceps strength to be able to return to sports without risk to the graft. Harvesting of the patellar tendon leads to large deficits in quadriceps strength, while harvesting the hamstring tendons leads to large deficits in hamstring strength. However, there are no published studies on the strength deficit after ACL reconstruction with the fascia lata. The objective of this study was to evaluate the results of isokinetic testing in patients who underwent ACL reconstruction with a fascia lata graft and to analyze the individual factors affecting these results. The hypothesis was that preserving the quadriceps and hamstrings would lead to satisfactory isokinetic testing results by preserving the physiological balance between the flexor and extensor mechanisms in the leg.

MATERIALS AND METHODS

In this retrospective, single-center study, 53 patients had their quadriceps and hamstring strength recovery evaluated 6 months and 1 year post-ACL reconstruction by concentric isometric testing at a slow (90°/s) and fast velocity (240°/s). These results were analyzed as a function of individual characteristics such as age, sex, preinjury level and type of sports activity, and IKDC and Lysholm scores.

RESULTS

The quadriceps strength deficit at the slow and fast velocities was 27.5% and 22.5% at 6 months and 15.5% and 11% at 1 year, respectively. The hamstring strength deficit at the slow and fast velocities was 12.1% and 7% at 6 months and 8% and 6.4% at 1 year, respectively. The quadriceps to hamstring ratio at the slow and fast velocities was 66.7±16.5 and 71.3±15.5 at 6 months, and 61.1±14.9 and 67.6±12.5 at 1 year. Being less than 25 years of age, having a subjective IKDC grade or Lysholm score above 90, and being a professional athlete were significant predictors of better muscle strength recovery.

DISCUSSION

Isokinetic testing at 6 months and 1 year after ACL reconstruction surgery using the fascia lata showed that the quadriceps to hamstring ratio is close to physiological standards.

LEVEL OF EVIDENCE

IV retrospective study.

Localized and diffuse forms of tenosynovial giant cell tumor (formerly giant cell tumor of the tendon sheath and pigmented villonodular synovitis)

Tenosynovial giant cell tumor (TSGCT) is a rare benign tumor arising from joint synovia, bursae and tendon sheaths. Their variable clinical presentation is related to variations in site and progression. Localized forms are most frequent in the hands, and diffuse forms in the knee. MRI is necessary and sometimes sufficient for diagnosis. Treatment strategy is guided by progression, symptomatology, location and diathesis. Optimally complete resection is the principle of first-line treatment. Radiation therapy is effective and targeted therapies are promising; both should especially be considered in case of relapse.

What type of imaging work-up will help to confirm the diagnosis of gossypiboma in the limb? Review of literature

Gossypiboma imaging features are not well known and are often confused with soft tissue tumours. Publications on this topic mainly consist of case reports and small cohorts. Its appearance on various imaging modalities is not well defined. This led us to carry out a review of literature to determine specifically: (1) which imaging modalities should be used in cases of suspected gossypiboma, (2) what are the most common imaging findings that contribute to the diagnosis of gossypiboma. An exhaustive review of literature was carried out in June 2015 in the Medline, PubMed and Cochrane databases using the keywords "gossypiboma/textiloma/foreign body". We found 205 articles describing one or multiple cases of gossypiboma in various locations. Of these, the 32 articles that had imaging data were chosen - 16 for the limbs and 16 for other locations. The type of imaging carried out, description of the gossypiboma and circumstances of the discovery and occurrence were recorded. Descriptive statistics were generated to define the type of imaging used and the various findings. Imaging consisted of X-rays in 21/32 cases (66%), computed tomography (CT) in 14/32 cases (43%), magnetic resonance imaging (MRI) in 21/32 cases (65%) and ultrasonography in 14/32 cases (43%). On X-rays, bone involvement was found in 9/15 cases (60%); there was peripheral contrast product uptake on the CT scans in 9/14 cases (64%), a hypointense signal on T1-weighted sequences on MRI in 6/13 cases (46%) and lack of vascularisation in 8/13 cases (62%) and a acoustic shadow on ultrasonography in 9/14 cases (64%). In a patient presenting with a soft tissue lump and history of surgery, an imaging work-up including X-rays, ultrasonography and MRI must be performed. Bone involvement on X-rays, acoustic shadowing on ultrasonography and hypointense signal on T1-weighted MRI sequences with lack of vascularisation in combination with a history of surgery can bring up the possibility of gossypiboma. If there is a possibility of soft tissue tumour, the case should be discussed in a multidisciplinary meeting and a biopsy should be performed first.

LEVEL OF EVIDENCE

IV - systematic analysis of published retrospective studies.

Total talar fracture - inter- and intra-observer reproducibility of two classification systems (Hawkins and AO) for central talar fractures

INTRODUCTION

We evaluated the inter- and intra-observer reproducibility of two classification systems for central talar fractures (Hawkins, as modified by Canal and Kelly and then by us; AO/AOT).

HYPOTHESIS

The analysis and classification of these fractures will be better with CT scans than with X-rays.

MATERIAL AND METHODS

Four observers evaluated 39 X-ray and CT scan files twice in the span of six weeks; each evaluation entailed classifying the fractures and describing their main features. Cohen's Kappa coefficient for inter-rater agreement was calculated and analysed.

RESULTS

The inter- and intra-observer reproducibility with CT scans was better with X-rays for most of the parameters evaluated. The modified Hawkins classification provided better reproducibility than the AO/AOT one. However, this classification system was not perfect, even after modifications and use of CT scans.

DISCUSSION

CT scans are an essential tool for the analysis of all talar fractures. We modified the Hawkins classification (as modified by Canal and Kelly) to include a Type 0 (no displacement or less than 2mm), include frontal body fractures that are displaced like neck fractures and take into account comminuted fractures and other trauma in the area.

LEVEL OF PROOF

IV - retrospective clinical study.

Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases

INTRODUCTION

Displaced talar neck and body fractures are rare and challenging for the surgeon. Results are often disappointing due to inadequate reduction or internal fixation and high rates of osteoarthritis and osteonecrosis. Very few published series describe the long-term results after internal fixation of talar factures. One of the goals of the 2011 SOO meeting symposium was to specifically evaluate the long-term results after internal fixation of talar fractures. This study included only central fractures.

MATERIAL AND METHODS

We reviewed the results of 114 central talar fractures that had been treated by internal fixation between 1982 and 2006 in nine hospitals in the Western part of France. The clinical and radiological follow-up was 111 months on average. All the patients with a radiological assessment had at least 5 years of follow-up.

RESULTS

Poor reduction was apparent in 33% of cases. The average Kitaoka score was 70/100, which corresponds to an average functional level. At the last follow-up evaluation, 34% of cases had osteonecrosis and 74% had peritalar osteoarthritis. Secondary fusion was required in 25% of cases with an average follow-up of 24 months.

DISCUSSION

The complication rate for talar fractures was high, mostly due to osteonecrosis and osteoarthritis; these conditions had an impact on the final outcome. The outcome could be improved by better evaluating these fractures with a CT scan, developing dual surgical approaches to best preserve the bone vascular supply and achieve better reduction, and improving the internal fixation hardware, especially the use of plates for comminuted fractures.