Sunday, May 15, 2011

Posterior Impingement of the Ankle

Patients with posterior impingement of the ankle oftentimes complain of pain in the posterior, or back of, the ankle. There may be an associated snap or catching sensation along with it, which may be caused by the tendon which lies next to this area, called the FHL (Flexor Hallucis Longus). Along with physical examination and plain x-rays, an MRI may be useful in making the diagnosis. The nonoperative treatment typically consists of NSAIDS, injections, and rest. If these fail, an endoscopic surgical technique may be used to remove the excess bone (Os trigonum or trigonal process) with release of the FHL (Flexor Hallucis Longus) tendon. This endoscopic technique is a minimally invasive technique that has the potential advantages of less bleeding, faster recovery, less scarring, and less pain.

Internal Snap of the Psoas (Iliopsoas) Tendon

The treatment for internal snapping of the hip may consist of a psoas tendon release in those patients who have failed nonoperative treatments and who have persistent pain. Nonoperative treatment for an internal snap typically consists of injections and avoidance of repetitive snapping if possible. Patients typically complain of a snap or click in the hip and on physical examination the snap can often be reproduced. Oftentimes there are other associated abnormalities in the hip that may be causing pain and that may need to be addressed. If there is no pain associated with the snap, typically no additional treatments are necessary. I have recently added a video to my website through youtube that demonstrates the arthroscopic surgical technique. Once the joint has been accessed arthroscopically, the procedure typically takes about 5 minutes to complete.

Tuesday, November 23, 2010

Types of treatment of hip labral (labrum) tears

There are 4 main treatment options for the treatment of labral tears. The best way to treat specific patterns of damage has not been fully clarified in publications on hip arthroscopy, but here I present some guidelines:
1. Debridement: This has been historically the main treatment for labral injury. This treatment is performed via hip arthroscopy and essentially consists of removing the damaged tissue with a shaver and/or with an electrocautery device. I perform this technique rarely, as preservation of this tissue when possible is beneficial.
2. Repair: This treatment also is performed via hip arthroscopy and consists of placing suture anchors in the bone and reattaching the labral tissue after it has been prepared. There is increasing evidence that this technique of repair is superior to debridement when possible.
3. Reconstruction: Also performed via hip arthroscopy, this technique may be performed when the labral tissue is too damaged or too small to be repaired. The technique consists of replacing the labrum with new tissue, and may be performed with autograft or allograft tissue.
4. Joint replacement: When the labral damage is associated with significant hip arthritis, the best treatment option is a hip replacement.

Thursday, July 8, 2010

All arthroscopic allograft reconstruction of hip labral tear and deficiency

A young active patient who had previously undergone hip arthroscopy and labral debridement was reconstructed with allograft tissue. This was featured in a Channel 10 news story

Sunday, June 13, 2010

Instrumentation for hip arthroscopy and hip labral (labrum) tears

How is it possible to reconstruct the hip if it is a deep, ball and socket joint? The answer in part lies in the instrumentation, which includes a number of curved, flexible, and long instruments to do the work. Progress in the area of hip arthroscopy has paralleled progress in instrumentation, which allows for improved access, manipulation, preparation, and refixation of the tissues.

Saturday, April 17, 2010

Ankle fracture

Which ankle fractures are treated surgically? When do you treat them? The simple answer is that unstable ankle fractures are treated surgically. If both the medial and lateral sides of the ankle are fractured (called a bimalleolar ankle fracture) or if three sides are fractured (including the posterior malleolus, that is a trimalleolar ankle fracture), then surgical open reduction and internal fixation is recommendable. Fractures of the lateral malleolus alone, when displaced and in combination with a severe injury to the medial, or deltoid ligament, may also be unstable and benefit from surgical fixation. The timing for surgery is dependent on the skin and soft tissues, and is typically done around a week after the injury, to allow the swelling to minimize and thereby decrease risk for wound problems. The ankle fracture may also be treated within a few hours of the injury, before much swelling has developed.

Tuesday, April 6, 2010

Arthroscopy for ankle fractures?

When is ankle arthroscopy recommendable for ankle fractures? There are two randomized studies published on the use of arthroscopy in ankle fractures. One study demonstrated better results in patients who underwent arthroscopy at the time of open reduction internal fixation and the second study demonstrated equivalent results. Based on this data, I do not perform an ankle arthroscopy on all patients who have had an ankle fracture. With patient specific factors also considered, I tend to perform the arthroscopy on higher energy injuries, such as ankle subluxations or dislocations or syndesmosis injuries. At the time of arthroscopy, Ferkel reported a high rate of damage to the articular surfaces following ankle fractures, and my experience supports this fact. At the time of arthroscopy, loose bodies of cartilage alone or a combination of cartilage and bone can be treated, and the joint is looked at thoroughly to identify and treat any other associated injuries. This damage to the inside of the joint can be a cause of chronic pain if left untreated.