Sports-related tendon injuries of the foot and ankle

Treatment of major tendon injuries is a complex and challenging subject. It is necessary to have a thorough understanding of the mechanism of injury to successfully treat these soft tissue injuries of the foot and ankle.     

足踝部肌腱损伤的MSCT诊断

目的:探讨足踝部肌腱损伤的MSCT诊断价值,提高对足踝部肌腱损伤的认识,避免漏诊。方法:回顾分析自2009年1月至2010年12月临床疑诊足踝部肌腱损伤的32例患者,其中男24例,女8例;年龄23～68岁,平均43岁;外伤后局部均出现疼痛、压痛、软组织肿胀及功能障碍或伴有骨折。所有病例经手术、MRI、双侧对照或随访证实。外伤后7d内完成MSCT检查,2名高年资CT诊断医师在不知结果的情况下分别评估肌腱的异常,意见不一致时协商确定。结果:失访5例,纳入研究27例,最终证实肌腱损伤23例(31处),4例未见异常。按肌腱数(总243条)计算,CT共诊断35处异常,其中误诊4处,CT诊断敏感性、特异性和准确率分别为88.8%(31/35)、98.1%(208/212)和98.4%(239/243)。其中肌腱脱位11处,表现为肌腱部分或全部离开肌腱沟;肌腱卡压13处,横断面显示肌腱1/2及以上横断面嵌插于骨折缝内,7处VR显示肌腱位于骨折缝内,走形迂曲,6处表现为骨折缝较宽,肌腱仍可显示但与骨折缝关系密切(2处误诊);骨片嵌插4处,横断面表现为骨片部分位于肌腱内,VR显示骨片嵌入肌腱,局部较模糊(1处误诊);肌腱完全断裂4处,横断面表现为断裂处肌腱缺如或伴有周围脂肪间隙模糊,VR显示肌腱连续性中断,长轴方向上肌腱短缩(1处误诊);肌腱损伤3处,横断面表现为肌腱增粗,密度减低,边界不清,周围脂肪间隙模糊,VR显示肌腱增粗,密度减低,结构模糊。结论:足踝部MSCT检查(薄层横断面结合VR评价)能很好地诊断肌腱脱位、肌腱卡压、骨片嵌插、肌腱完全断裂、肌腱损伤等外伤性病变,具有较高的临床应用价值。     

Giant-cell tumour of the tendon sheath in the foot and ankle

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.     

Nerve injuries to the foot and ankle in the industrial setting

Nerve injuries of the foot and ankle are among the most difficult to diagnose and treat. With the added influences of potential secondary gain and poor motivation of the work injured patient, these injuries can be taxing and frustrating to manage in the acute or chronic setting. This article reviews the neuroanatomy, mechanisms of injury, diagnosis and management of these injuries with specific reference to the patient injured in the industrial setting.     

Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity

Total ankle arthroplasty is an alternative to arthrodesis in selected patients with end-stage arthritis of the ankle. We report on the clinical features, radiographic findings, management and results in a 58-year-old man with associated ankle osteoarthritis and drop foot deformity. The patient was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Three years after the procedure, the patient was able to walk, had no pain, and had a stable joint with 5° dorsiflexion and 20° plantar flexion.     

Stress fractures about the tibia, foot, and ankle

In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High-risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high-level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.     

The uses of tendon transfers to correct paralytic deformity of the foot and ankle

Tendon transfers for paralytic foot and ankle deformities can be rewarding in well-selected patients. The goal should be to achieve a stable plantigrade foot which optimally will not require a brace. This is possible if there is adequate preoperative tendon strength, adherence to the basic principles of tendon transfer during surgery, and intensive retraining of the muscle in the recovery phase. The optimal method of tendon fixation remains unclear.     

Diagnostic imaging of trauma to the ankle and foot: I. Fractures about the ankle

Drs. Mitchell et al. provide a valuable radiologic perspective of trauma to the ankle. The review is divided into six parts. The initial presentation deals with ankle fractures. Subsequent dialogues will consist of ligamentous injuries, trauma to the talus, calcaneal fractures, midfoot, and forefoot injuries. Plain x-ray film, as well as sophisticated studies, will assist in recognizing these conditions.     

Sprains about the foot and ankle encountered in the workmans' compensation patient

Soft tissue injury in the workmans' compensation patient population has been previously poorly understood. Injuries that do not show up easily on radiographs are often undertriaged and undertreated. With the advent of improved imaging techniques, an enhanced understanding of soft tissue injuries has evolved over the past few years. Coupled with improved surgical and rehabilitation techniques, severely injured patients are able to experience remarkable recoveries. Many cannot return to previous function. These patients pose challenges to the astute clinician with regards to psychosocial issues relative to secondary gain. In addition, State-to-State variations in the workmans' compensation laws can confuse clinicians. Because of the protections and laws set in place in the United States, these patients can frequently be returned to the workforce as grateful and productive members of society.     

Ultrasound evaluation of flexor tendon lacerations

Thirteen injured digits in 10 patients (10 hands) with 20 potentially injured flexor tendons were preoperatively evaluated using real-time ultrasonography. The time interval between injury and ultrasonographic evaluation averaged 22 days. If a complete tendon laceration was found, the location of the proximal tendon stump was determined. Surgery was performed an average of 4 days after the ultrasonographic evaluation to determine the accuracy of the ultrasound study. Ultrasonography accurately identified the status of the flexor tendon in 11 of 13 digits and in 18 of 20 flexor tendons (12 intact, 2 partial lacerations, and 6 complete tendon lacerations). With complete tendon lacerations the location of the proximal tendon stump was accurately identified in 5 of 6 digits. There were 2 false ultrasound findings, including incorrectly identifying a 75% laceration in an intact index flexor and a complete tendon laceration in a 75% lacerated index finger flexor. Ultrasonography can help to evaluate the preoperative status of injured flexor tendons and, in cases of completely lacerated tendons, can help identify the location of the proximal tendon stump.     

Bone grafting in surgery about the foot and ankle: indications and techniques

Bone grafting is a common procedure in foot and ankle surgery. Historically, autogenous bone graft has most often been harvested from the ipsilateral iliac crest. However, other sites offer similar volumes of cancellous bone and are associated with fewer complications. The ipsilateral proximal tibia, distal tibia, and calcaneus provide adequate amounts of bone graft material for most arthrodesis procedures about the foot and ankle. Emerging techniques have enabled the development of a seemingly unlimited supply of alternative bone graft materials with osteoconductive properties. The osteoprogenitor cells in bone marrow aspirates can be concentrated by use of selective retention systems. These aspirate-matrix composites may be combined with allograft preparations, resulting in a product that promotes osteoconduction, osteoinduction, and osteogenesis with limited morbidity.     

Tendoscopies in the foot and ankle

Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders. Most common foot and ankle tendoscopies are for the Achilles, peroneals, and posterior tibial tendon. Tendoscopy may be used as an adjacent procedure to other techniques, such as calcaneal osteotomies. The technique allows for an unrivalled view of the entire length of tendons while also providing a dynamic evaluation of their movement inside the sheath. Therefore, it is a useful tool both for the diagnosis and the minimally invasive treatment of different tendon disorders around the foot and ankle. In this paper we will review the techniques, indications, results, and existing evidence and outcomes and complications of foot and ankle tendoscopies. The original techniques will be presented together with tips and tricks to optimize the tendoscopic experience. We will also conducted a search of the biomedical literature to look for results and outcomes of posterior tibial tendoscopy, peroneal tendoscopy, and Achilles tendoscopy.     

Fractures of the foot and ankle

Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan.     

Scintigraphy in the foot and ankle

Nuclear medicine provides a number of sensitive, although unfortunately not always specific techniques, for the evaluation of foot pain and suspected infection. In most patients the 3 phase bone scan is the initial means of evaluation, with a labeled white cell scan included when osteomyelitis is suspected. Nuclear medicine studies must be interpreted with knowledge of the patient's history and symptoms and with close correlation to plain film findings. Attention to detail when acquiring images, possibly with the addition of SPECT or pinhole images in difficult patients, results in excellent anatomic localization in most patients.     

Fractures of the foot and ankle

Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Open fractures should be treated urgently with a combined approach with the plastic surgeons. Temporary external fixation may be required to stabilize the fracture before definitive fixation and subsequent soft tissue cover. Foot elevation is essential to reduce swelling after major fractures or crush injuries. Compartment syndrome should be considered in anyone with disproportionate pain. Mild forms of compartment syndrome are easily missed and can result in clawing of the toes. Patients suffering fractures to the foot and ankle also require deep vein thrombosis prophylaxis whilst in plaster or until mobile.     

Tuberculosis of the foot and ankle

Tuberculosis of the foot and ankle is an uncommon presentation of skeletal tuberculosis. The uncommon site, lack of awareness, and ability to mimic other disorders clinically and on radiographs, leads to diagnostic and therapeutic delays. In the early stages and when the disease is limited to bone, medical treatment leads to excellent healing and limited residual disabilities. Joint involvement occurs because of spread from a periarticular bony focus, and in the midfoot, the disease may spread to involve all the interconnected joints, leading to a stiff foot and residual deformities. Of 74 cases reviewed, the calcaneus was involved most commonly, followed by infection of the midtarsal, Lisfranc joints, and ankle. The most common radiologic finding is that of osteoporosis, which may be intense: cancellous bone involvement may present as a cystic lesion with or without sequestrum. Computed tomography scans and magnetic resonance imaging are helpful examinations. Because the disease is paucibacillary, a positive acid fast bacilli culture is rare and the diagnosis usually is confirmed by obtaining granulomatous tissue on biopsy. The treatment basically is medical, with surgical intervention being reserved for patients with intractable disease or as a salvage procedure for patients with deformed hindfoot joints.