Whereas arthroscopic arthrodesis of the ankle is commonplace and of the subtalar joint is established, reports of arthroscopic talo-navicular fusion are a rarity. To review a case series to establish if arthroscopic talo-navicular arthrodesis is a feasible surgical option.Background
Aim
Disability and slow return to sport and work after tendon rupture are major challenges. Platelet Rich Plasma (PRP) is an autologous supraphysiological concentration of platelets from whole blood that has demonstrated positive cellular and physiological effects on healing in laboratory conditions but evidence from adequately powered robust clinical trials is lacking. We aimed to determine the clinical efficacy of PRP for treatment of acute Achilles tendon rupture. In a placebo-controlled, participant- and assessor-blinded, trial at 19 NHS hospitals we randomly assigned 230 adults starting acute Achilles rupture non-surgical management to PRP injection or dry-needle insertion (placebo) to the rupture gap under local anaesthetic. Patients with confounding or contraindicated concurrent medical conditions were excluded. The primary outcome was muscle-tendon function, assessed by the limb symmetry index (LSI, uninjured limb/injured limb × 100, higher scores better) of the work (Joules) performed during the heel-rise endurance test at 24 weeks. Secondary outcomes were: Achilles Tendon Rupture Score (ATRS, 0–100, higher scores better), quality of life (SF-12), pain, and goal attainment. Trial registration: ISRCTN54992179Background
Methods
This study aimed to examine how physical activity and health-related quality of life (HRQoL) evolved over the first year after total knee replacement (TKR) for patients with and without post-operative chronic knee pain. 83 adults participating in the PEP-TALK, a RCT testing the effectiveness of a behaviour change physiotherapy intervention versus usual rehabilitation post-primary TKR, were analysed. UCLA Activity Score and EQ-5D-5L values for participants with and without chronic knee pain (14 points or lower in the Oxford Knee Score Pain Subscale at six months post-TKR) were compared at six and 12 months post-TKR. We evaluated recovery trajectory those with or without chronic pain at these time points.Abstract
INTRODUCTION
METHODS
Traditional open approaches for subtalar arthrodesis have reported nonunion rates of 5–16% and significant incidence of infection and nerve injury. The rationale for arthroscopic arthrodesis is to limit dissection of the soft tissues in order to preserve blood supply for successful fusion, whilst minimising the risk of soft tissue complications. The aim of this study was to determine the outcomes of sinus tarsi portal subtalar arthrodesis. Case records of all patients undergoing isolated arthroscopic subtalar arthrodesis by two senior surgeons between 2004 and 2014 were examined. All patients were followed up until successful union or revision surgery. The primary outcome measure was successful clinical and radiographic union. Secondary outcome measures included occurrence of infection and nerve injury. Seventy-seven procedures were performed in 74 patients, with successful fusion in 75 (97.4%). One (1.3%) superficial wound infection and one (1.3%) transient sural nerve paraesthesia occurred. Fixation with a single screw provided sufficient stability for successful arthrodesis. To our knowledge this is the largest reported series of isolated arthroscopic subtalar arthrodeses to date, and the first series reporting results of the two portal sinus tarsi approach. This approach allows access for decortication of all three articular facets, and obviates the need for a posterolateral portal, features which may explain the high union rate and low incidence of sural nerve injury in our series.
Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet). Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years.Introduction:
Methods:
In a consecutive series of 71 arthroscopic subtalar arthrodeses performed between 2004 and 2011, 14 also involved arthroscopic decortication of the talonavicular joint (double arthrodesis) and 4 the subtalar, talonavicular and calcaneocuboid joints (triple arthrodeses). We examined complications, union rates in all 18 patients and clinical outcomes in 16 for whom this was the sole procedure.Introduction:
Methods:
Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years. Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.
We report a single surgeon series of 33 arthroscopic subtalar fusions performed through a 2-portal sinus tarsi approach on 32 patients between March 2004 and February 2009. Background pathologies included primary arthrosis, post-traumatic arthritis, planovalgus foot, rheumatoid disease, sinus tarsi syndrome and CTEV. 97% [32/33] of fusions as assessed by both clinical and radiological means were achieved within 16 weeks [76% [25/33] within 12 weeks] with only a single outlier which had fused by 22 weeks. There were no deep infections, thrombotic events or neuromas. Five patients suffered complications of which four were successfully treated with a satisfactory outcome. One patient developed persistent pain and was eventually referred to another centre for further management. In our experience arthroscopic subtalar fusion surgery has been demonstrated to give excellent outcomes with minimal complications. Furthermore, it is a technique allowing surgery even in patients with significant hindfoot deformity. It is a suitable operation even for patients with a compromised soft tissue envelope which would normally preclude an open procedure.
We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit. Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose. Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis
DDH incidence falls from 5–20 per 1000 at birth to 1–2 per 1000 by 3 weeks. Some patients present late and frequently require surgical intervention. If the hip cannot be contained without tension, these children undergo open reduction +/− a femoral shortening, varus and derotation osteotomy. Salter’s osteotomy, may be performed either at index surgery or later in the presence of persisting acetabular dysplasia. Our aim was to see if we could predict which cases of persistent DDH would require both femoral and pelvic surgery to contain the affected hip, using a single plain AP radiograph of the pelvis in the outpatient setting. We performed a retrospective study of all children older than 18 months with persistent DDH of one or both hips, over the last 5 years, who had undergone femoral and/or pelvic surgery to contain the hip. Plain AP pelvic radiographs were standardised according to the method described by Tonnis. From these radiographs the acetabular indices and child’s age in months, were recorded. Syndromic and children with non-standard x-rays were excluded. Thirty nine hips (34 female, 5 male), age range of 18–102 months, formed our study group. 53% of hips having femoral surgery later required pelvic surgery for persisting acetabular dysplasia. Examining the data in these cases, the difference between the acetabular index of the normal and affected hip was always greater than 20 degrees and the child’s age in months. Using this method we conclude that it is possible to predict which cases of persistent DDH will require pelvic surgery to fully contain the affected hip and that this can be done with one AP pelvic radiograph in the outpatient clinic. The benefit is avoidance of unnecessary pelvic osteotomies, and being able to determine the cases which should have a pelvic osteotomy at index procedure.
Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis.
Arthroscopy of the ankle and subtalar joints are established techniques in foot and ankle surgery. Arthroscopic ankle arthrodesis is well described and is useful in patients with a poor soft tissue envelope. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. 22 patients, made up of 9 males and13 females were operated on from March 2004 to present day with 12 to 36 months follow up. Indications for surgery included primary osteoarthritis and degeneration secondary to previous calcaneal fracture, tibialis posterior insufficiency, neurological conditions and previous ankle fusion. 8 Patients had a concurrent arthroscopic ankle fusion and 4 patients also had a talonavicular fusion. All patients had surgery by the senior author and followed the same postoperative course. Patients were protected in plaster for 12 weeks with gradual increase to fully weightbearing at 6 weeks and x-rays taken at 6 and 12 weeks. Successful outcome was taken as clinical and radiological evidence of fusion. 21 patients (95.5%) achieved fusion by 12 weeks. There has been 1 nonunion but there have been no wound breakdowns, deep infections or other serious complications. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. These early results suggest that arthroscopic subtalar fusion is a safe and reliable method with a high success rate and a low complication rate. Correspondence should be addressed to Major M Butler RAMC, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Exeter, Devon.
Patients’ who had consulted both mainstream and CAM practitioners reported the poorest health outcomes (EQ 5D = 0.55), followed by those who consulted just mainstream practitioners (EQ 5D = 0.61), and those who had consulted no one (EQ 5D = 0.72). The best health outcomes were reported amongst those who had just consulted CAM practitioners (EQ 5D =0.78). In multivariate analyses, the most powerful predictors of consulting both mainstream and CAM practitioners were working and having high levels of pain related disability.