Management of acute ankle ligament injuries

Ankle sprains are amongst the most common injuries presenting to emergency departments in the UK. They are not one single entity but a heterogeneous group of injuries with a wide spectrum of severity. Most injuries will involve the lateral ankle ligament complex but it is important to ensure injuries to the syndesmotic ligaments or the deltoid ligaments are not missed. Missed injuries or poor management can cause disabling consequences and may occur in as many as 40% of inadequately treated patients. This article focuses on the basic anatomy and biomechanics of the ankle joint, common mechanisms of injury, appropriate diagnostic techniques and the indications for non-operative and operative management.     

Ankle instability and intra-articular injuries in children

Ankle instability is a common problem in children and adolescents. What may seem like an initial, relatively benign ankle injury for a child may lead to chronic pain, chronic instability and gradual loss of the ability to participate in certain activities. The complications of an ankle injury can include osteochondral defects, which may require urgent surgical attention and may be associated with an increased long-term risk of osteoarthritis. This article aims to provide trainees and general orthopaedic surgeons with a systematic approach to the assessment, diagnosis and management of ankle instability in the paediatric population. We explore the mechanisms of the initial injury together with factors that may increase the risk of injury to the child. Guidance on clinical examination and of the ankle joint is provided. Though short periods of immobilization and proprioceptive activities are the mainstay of treatment, there is a small subset of these patients who will benefit from further imaging and surgical intervention to prevent the chronic sequelae of ankle instability.     

The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Management strategies in the treatment of osteochondral lesions of the talus

Osteochondral defects of the talus are a common occurrence and remain a challenge to the orthopaedic surgeon. Commonly found on the medial talar dome, they are usually the sequelae from traumatic injuries and often are delayed in their presentation to the outpatient setting. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Management of these full-thickness cartilage injuries is usually guided by the size, as well as position on the talar dome surface. Arthroscopic microfracture has been the mainstay of first-line surgical treatment as well as for smaller lesions. Larger lesions may need more novel procedures which include scaffold-based therapies or osteochondral transplantation.     

A successful outcome using a minimal invasive approach to manage a severe trauma to the primary maxillary incisor in a toddler

Abstract – Intrusive and lateral luxation are common traumatic injuries in children. The aim of this work is to report the successful conservative management of severe intrusion and lateral luxations of the primary maxillary central incisors in a 27‐month‐old patient.     

Management of tendinopathies of the foot and ankle

Foot and ankle tendinopathies are a significant problem in orthopaedic practice. They represent a failed healing response. Such tendons show increased matrix remodelling, leading to a mechanically less stable tendon which is more susceptible to damage. Diagnosis is based on a careful history and detailed clinical examination and investigations. Initially treatment is by relative rest and modification of physical activity, use of rehabilitative exercises, evaluation and correction of intrinsic and extrinsic causes of injury. Surgical management is indicated if conservative management fails, in stage 3 tendinopathy or if tendon rupture occurs. Randomized controlled trials are awaited to clarify the best therapeutic options.     

Fractures of the talus: where are we now?

The talus provides a crucial role in ankle stability and joint movement. If the talus is damaged, the collective motion of the foot and ankle becomes compromised, and significant disability or chronic pain can result secondary to complications including post-traumatic osteoarthritis, infection, and avascular necrosis. Talus fractures are challenging to treat due to their multiple articulations, precarious vascularity, and confined anatomical location. Long-term outcomes after talar fractures have historically been poor. Surgical management is advised for most displaced fractures of the talus in suitable patients. Goals of surgical treatment focus on meticulous anatomic reconstruction, preservation of blood supply, and stable fixation to encourage fracture union. This review summarizes the literature findings to provide a clearer view of the recommended management for each type of talus fracture. This article addresses individual talus fracture subtypes, including lateral process, posterior process, head, body, neck, and extrusion of the talus. In each section, we address assessment, management options, and known outcomes. The reader is also reminded of how to assess the commonly missed talus subtype fractures, particularly lateral process, posterior process and the talar head, where high index of suspicion is paramount even following a low-energy injury mechanism. Appropriate counselling is recommended to inform and educate patient about the long-term morbidity associated with talar fractures.     

Non-surgical management of infected type III dens invaginatus with vital surrounding pulp using contemporary endodontic techniques

This paper reports on the conservative non-surgical endodontic management of an upper right lateral incisor diagnosed with infected dens invaginatus (Oehlers' type III) and associated acute apical abscess, while maintaining vitality of the surrounding pulp. The use of contemporary endodontic techniques in the diagnosis, treatment planning and management of the case is highlighted.     

Conservative management of dens in dente

Dens Invaginatus (DI) or dens in dente is an uncommon anomaly which mostly affects permanent lateral incisors, and it is very rare in molars. This article presents the conservative endodontic management of four different cases of DI and a discussion of the endodontic literature for this malformation. Three upper lateral incisors Type II, IIIa and IIIb, and an upper first molar Type II are shown. The most conservative approach possible was carried out. Three of the cases were obturated using the continuous wave technique. In one of the cases, it was possible to treat only the invagination with MTA and preserve the pulp vitality of the main canal. To make a correct diagnosis and to treat in the most conservative way possible, a DI is necessary to know its classification and use tools such as CBCT and magnification.     

(iii) Entrapment neuropathies of the foot and ankle

Any of the 5 nerves supplying the foot and ankle (tibial, superficial & deep peroneal, sural, saphenous) can suffer compression neuropathy. The diagnosis is usually made clinically, supported by imaging and electrodiagnostic studies. Treatment is conservative or surgical. The known nerve entrapments about the foot and ankle are presented with a discussion of their aetiology, clinical findings and treatment options.     

An update on tarsal coalitions

Tarsal coalitions are anomalous connections between two or more bones in the hindfoot or midfoot secondary to embryonic failure of segmentation and differentiation of the mesenchyme. Calcaneonavicular and talocalcaneal coalitions are the most common. Although it is a congenital deformity, presentation is usually in adolescence which coincides with ossification of the coalition. Patients typically present with diffuse foot pain, calf muscle pain, recurrent ankle ligament sprains and a rigid hindfoot valgus deformity. Initial management is non-operative and may involve activity reduction, a trial of immobilization in a walking boot or cast, physiotherapy, corticosteroid injections and regular analgesia. Close to a third of patients experience symptom relief but the remaining patients with persistent symptoms will require operative intervention. Patients without degenerative joint disease undergo resection of the coalition. It is now established that an associated severe hindfoot valgus foot should be addressed at this stage to prevent inevitable future joint degeneration. The indications for joint fusion remain unclear and the tendency is to postpone this when possible until a later age. In recent years, arthroscopic resection of talocalcaneal coalitions has gained popularity, despite being technically demanding. It gives good visualization of the coalition, better postoperative pain relief and quicker improvement of the hindfoot stiffness.     

The sporting ankle: an update

The ankle is one of the most commonly injured joints during sport, accounting for almost 30% of all musculoskeletal injuries. These result in a spectrum of pathology varying in severity and involving a number of structures around the hind foot. The most common pathologies include lateral ligament and syndesmosis injuries, impingement and osteochondral lesions of the talus. Most of these injuries will resolve with non-operative management, however, more severe injuries may never fully settle and will require surgical intervention. There have been recent developments in the surgical management of these conditions and this review article will focus on the recent advances in the understanding of these injuries and aim to discuss the up-to-date management options.     

Charcot Marie Tooth Disease

Charcot Marie Tooth (CMT) disease was first described in 1886. It describes a spectrum of genetic disorders that affects peripheral nerves, either by slowing action potential transmission along the axons, or by reducing the amplitude, or both.It is this variety of underlying genetic findings and subtleties of clinical presentation that has resulted in the varying nomenclature over the years. Patients with CMT commonly present to orthopaedic surgeons with lower and upper limb symptoms including ankle sprains, cavus feet and weakness of the intrinsic hand muscles. More rarely, they present with spinal and hip manifestations. It is not usually a life threatening or painful condition and therefore lends itself to the FRCS (Tr & Orth) exam.     

Traumatic problems of the patella

This article will outline the clinical presentation and management of patellar instability and fracture. Patellar instability is a generic term that describes anything from symptomatic apprehension to patellar subluxation and through to patellar dislocation. It can result from osseous abnormalities such as patella alta or patellofemoral dysplasia or it can arise secondary to soft tissue abnormalities such as a torn medial patellofemoral ligament. Failing conservative management, surgical treatment is directed to the underlying cause(s) of the instability, and can include medial patellofemoral ligament reconstruction or a bony realignment procedure.Patellar fracture is a common injury caused by excessive tension through the extensor mechanism or a direct blow. Such injury can lead to stiffness, extension weakness and patellofemoral arthritis. Non-surgical management is indicated for non-displaced fractures with an intact extensor mechanism. Surgical fixation is recommended for fractures that either disrupt the extensor mechanism or that demonstrate over 2–3 mm of step-off and/or over 1–4 mm of displacement. Anatomic reduction and fixation with a tension-band technique is associated with the best outcomes; however, symptomatic hardware is a frequent complication.     

Osteoarthritis of the ankle

Ankle arthritis is a debilitating condition. Primary ankle joint osteoarthritis is much rarer than hip or knee arthritis. The majority of cases are post-traumatic secondary to previous articular trauma or ligamentous instability. Treatment methods available are guided by disease severity and the patient's functional demands. Weight loss, activity modification, the wearing of an ankle brace or high-topped lace-up boots and orthoses should be the first line of treatment. Joint-sparing procedures such as arthroscopic debridement, supramalleolar osteotomy and distraction arthroplasty have been trialled with low levels of supporting evidence. The demand for joint preservation has led to the development of total ankle allografting procedures, but these have fallen out of favour. Despite advancements, the gold standard for end-stage arthritis remains arthrodesis, although evidence for total ankle arthroplasty in certain groups of patients is increasing. The current third-generation implants have improved survivorship although their results remain inferior to arthroplasty of the hip and knee. There is currently a UK randomized control trial of ankle replacement versus arthrodesis under way as well as several national joint registries, which will hopefully better define those patients who will gain most benefit from replacement as opposed to fusion.     

Surgical management of bisphosphonate induced osteonecrosis of the jaws

Recent literature contains numerous articles on osteonecrosis of the jaws (ONJ) associated with bisphosphonate treatment (BPT), with most advocating a conservative approach to management. A prospective study was designed to review the surgical management of cases of ONJ that did not respond to conservative management. Forty patients, referred with ONJ that did not respond to conservative management, were treated surgically and followed up for 6 months to 4 years. Four patients were taking i.v. BPT as part of their bone cancer management and 16 were taking oral BPT for osteoporosis. The surgical management of ONJ involved antibiotic therapy, surgical debridement of all necrotic bone and tension-free primary closure. All 40 cases healed uneventfully with no wound breakdown during follow-up. Most of the literature supports the conservative management of ONJ, but the condition leaves the patient debilitated. Many cases do not respond to conservative management and the infection and bone destruction is progressive. The conservative management of ONJ is to be supported, but this prospective study has shown that those cases that do not respond may be managed surgically. It should be recognized that while the results of this paper are encouraging, some cases will be resistant to all treatments.     

Changing trends in the management of condylar fractures

Our aim was to evaluate the functional outcomes and complications of mandibular condylar fractures managed surgically and non-surgically. Patients were identified retrospectively from audit data and clinical records from 2005-2018, and functional outcomes were evaluated based on the development of complications at clinical follow up. Patients were categorised into three treatment groups: conservative (management with soft diet, analgesia, and monitoring), closed (management with intermaxillary fixation), and open reduction and internal fixation (ORIF). A total of 358 patients were included with a median age of 33 years (mean 38), and a male:female ratio of 2.7:1. A total of 72 patients (20%) were treated conservatively, 177 (49%) were treated with closed management, and 109 (31%) with ORIF. The ORIF group demonstrated better outcomes than the closed group in terms of reduced protrusive and lateral excursive movements, and temporomandibular joint (TMJ) pain; and in terms of occlusal derangement when compared with the conservative group. The ORIF group had poorer outcomes than both the closed and conservative groups in terms of maximum mouth opening, and temporary facial nerve injury occurred in 5/109 (5%) and condylar resorption in 2/109 (2%) of patients in the ORIF group. There was no incidence of permanent facial nerve injury, Frey syndrome, or paraesthesia of the auricular nerve. The trend that favours ORIF can be justified, as it offers improved functional outcomes in severe or displaced condylar fractures. However, this must be evaluated against the risk of potential surgical complications. Careful case selection is therefore necessary to optimise management of these injuries.     

Alterations of mandibular movement patterns after total joint replacement: a case series of long-term outcomes in patients with total alloplastic temporomandibular joint reconstructions

According to recognized guidelines, a total alloplastic replacement may be indicated to resolve temporomandibular pain and functional limitations in cases where conservative and less aggressive surgical management strategies have failed. It is broadly believed that, as a result of the surgical procedure, the function of the lateral pterygoid muscle is lost and so are the laterotrusive and protrusive jaw movements. Furthermore, the joint prosthesis design may not be conducive to lateral and protrusive movements. Using a dynamic stereometry technique, it was possible to perform a quantitative analysis of kinematics in TJR patients. The cases of four patients who showed preserved lateral and/or protrusive motion are presented here. During mouth opening, prosthetic condyle translation ranged from 3.18 mm to 10.09 mm and it was also possible to observe this clinically. It has been suggested that changes in prosthesis design may have improved postoperative jaw kinematics. Considering the large diversity in treatment outcomes, it is recommended that the individual prognosis should always be discussed with the patient prior to surgery.     

Endodontic treatment of dens invaginatus type III with three root canals and open apical foramen

AIM: To describe the conservative endodontic treatment and the 1-year follow-up of a permanent maxillary lateral incisor with dens invaginatus. SUMMARY: Frequently, the root canal treatment of invaginated teeth is challenging because of problems associated with gaining access to the root canals and with variations of canal morphology associated with this type of malformation. The present case describes the complex root canal treatment of dens invaginatus in a maxillary lateral incisor with three root canals (Oehler type III), incomplete apex formation, necrotic pulp and abscess formation. After gaining access to two root canals and the invagination with the help of a dental operating-microscope, the canals and the invagination were instrumented and calcium hydroxide dressing was applied for 6 months. Apexification and osseous bone repair were achieved, and the canals were filled with gutta-percha. A follow-up after 1 year showed that the tooth was free of any clinical symptoms and the periapical condition was normal. KEY LEARNING POINTS: The present case demonstrated that conservative root canal treatment can be performed successfully even in sever cases of dens invaginatus. The use of a dental operating microscope can help in the management of complicated cases of invaginated teeth through conventional root canal treatment.     

Management of supplemental permanent maxillary lateral incisors in association with talon cusp on the primary predecessors: a report of 3 cases

Most of the cases of talon cusp in the primary dentition affected the maxillary central incisors, but have no effect on the permanent successors. Among the 5 cases of a talon cusp in primary maxillary lateral incisors reported in the dental literature, however, one was associated with a supernumerary tooth and 3 with supplemental permanent successors. The purpose of this report was to describe 3 cases of a talon cusp on the primary maxillary lateral incisors of Chinese children, all of which were associated with talon teeth or the permanent successors. A conservative approach was used to manage these supplemental permanent lateral incisors, and the advantages of such an approach are discussed.