Category Archives: ankle

Staged surgical intervention in the treatment of septic ankle arthritis with autologous circular pillar fibula augmentation: A case report

by Sham J. Persaud DPM, MS1*; Colin Zdenek DPM2; Alan R. Catanzariti DPM3

The Foot and Ankle Online Journal 10 (3): 6

Surgical management of chronic septic arthritis of the ankle joint is a challenging problem. Failure to initiate appropriate antibiotic therapy and perform incision and drainage within the first 24 to 48 hours of onset can result in subchondral bone loss and permanent joint dysfunction. Patients with chronic infection are not only at risk for loss of joint function, but also limb loss. This case report presents a staged procedure for limb salvage of patients with chronic septic arthritis of the ankle joint. Our technique includes use of both internal and external fixation, along with infection control and autologous pillar grafts. Though our case study is limited, the results are comparable to previous studies. This approach appears to be reasonable for limb salvage in end-stage degenerative joint disease following septic ankle arthritis.

Keywords: Septic arthritis, ankle, pillar graft, internal fixation, external fixation

ISSN 1941-6806
doi: 10.3827/faoj.2017.1003.0006

1 – West Penn Hospital, The Foot and Ankle Institute, Pittsburgh, PA 15224
2 – Silicon Valley Reconstruction Foot and Ankle Fellow, Palo Alta Medical Foundation, Mountain View, CA 94040
3 – Director of the Residency Training Program, West Penn Hospital, The Foot and Ankle Institute, Pittsburgh, PA 15224
* – Corresponding author: Sham Persaud, shamjoseph.persaud@ahn.org


Surgical management of chronic septic arthritis of the ankle joint is a challenging problem. Failure to initiate appropriate antibiotic therapy and perform incision and drainage within the first 24 to 48 hours of onset can result in subchondral bone loss and permanent joint dysfunction. Joint function after Staphylococcus aureus (S. aureus) septic arthritis is generally lost 25-50% of the time [1-4]. The mortality rate for septic arthritis has been reported as high as of 10-15% [1-2, 5-8].

Internal ankle arthrodesis techniques are reported to have between 88% to 100% primary fusion rates in patients with aseptic arthritis [9-12]. However the fusion rate for ankle arthrodesis in the setting of sepsis is roughly 71% to 93% [13-19].

Surgical management of septic arthritis requires debridement of all non-viable infected soft tissue and bone in order to eradicate infection [14-15, 20]. In addition to debridement, the use of local antibiotic delivery through polymethylmethacrylate (PMMA) has been shown to be an effective adjunct in treating infection [21-24]. Bactericidal levels of antibiotics from PMMA spacers are achieved through the process of elution where high concentrations of antibiotic are released locally, with minimal systemic effect, and limited risk to the patient. Peak antibiotic concentrations are mostly reached within the first week after placement; however, some studies have shown antibiotics may still be released at effective concentrations even after 4-6 weeks of implantation [25-30].

The use of long term intravenous (IV) or suppressive oral antibiotic therapy in conjunction with debridement is an important part of treatment. A 2-6 week course of IV antibiotic therapy is recommended depending on the severity of the infection and host immunity [14, 15, 20, 31].   

Fixation techniques for arthrodesis of the diseased ankle secondary to septic arthritis have been controversial. External fixation has been shown to provide adequate torsional stability, but is less effective in maintaining sagittal plane stability. On the other hand, internal fixation has been shown to provide excellent sagittal plane stability, but limited torsional stability. [19] Some authors believe a combination of both fixation techniques lead to optimal outcomes [12, 14, 15, 19, 20].

A concern with arthrodesis is following septic arthritis is loss of limb length. Cancellous bone graft has been shown to be effective in aiding with small defects [15, 20, 31]. Free vascularized bone graft has also been shown to be effective with large bony defects [14, 15, 20]. Use of allograft or synthetic bone grafts have rarely been mentioned in the literature [32]. One technique which has been described in aseptic ankle joint arthrodesis is the use of fibular pillar grafts as structural grafts to maintain length [33].

Patients with chronic infection are not only at risk for loss of joint function, but also limb loss. Cierny et al. related a 25% amputation rate for patients with arthrodesis of septic ankle joints [15]. This case report presents a staged procedure for limb salvage of patients with chronic septic arthritis of the ankle joint.

Case Report

A 54-year-old female with chronic right septic ankle arthritis for 6 months presented for evaluation. The patient had undergone arthrocentesis with corticosteroid, I&D with washout and long-term IV antibiotic therapy. She was offered a below knee amputation elsewhere but was reluctant to proceed and sought a second opinion. Her pre-operative radiographs can be seen in Figure 1 A-C and pre-operative MRI may be seen in Figure 2 A-B.  The patient chose to proceed with staged surgical approach for limb salvage.

Figure 1 Pre-operative radiographs; Mortise view, AP view, and Lateral view.

Figure 2 Pre-operative MRI; T1 Sagittal view, T2 Sagittal view.

The patient underwent needle biopsy of the tibia and talus with arthroscopic debridement. Arthroscopy was performed in standard fashion using a 2.7mm 30-degree arthroscope, utilizing a burr and shaver for ankle joint debridement.  Arthroscopic evaluation of the ankle joint revealed destruction of both tibial and talar articular surfaces.  Cartilage of both articular surfaces was degraded and granular in nature.  Cultures recovered S. aureus infection of the tibia.

Thirteen days later, open arthrotomy of the ankle joint with extensive debridement of the tibia and talus, as well as insertion of a Vancomycin cement spacer was performed.  The arthrotomy was performed using a lateral approach with a fibular osteotomy. The fibula was sent for pathology evaluation and culture, which were shown to be free of any bacterial infection.  Debridement was performed through osteotomies of both the tibia and talus which included the articular cartilage and subchondral plate (Figure 3). The joint was then pulse lavaged with 3L of normal saline-bacitracin mixture and a Vancomycin PMMA spacer was placed within the current ankle joint (Figure 4). This was then stabilized with a monolateral external fixator. The patient was placed on 6 weeks of antibiotic therapy by Infectious Disease including IV Cephazolin and PO Rifampin.

Figure 3 Intra-op radiograph status post fibula take down and wide excisional debridement of tibia and talus.

Figure 4 Intra-op radiographs and picture of Vancomycin PMMA spacer.

Ten weeks later, the patient underwent intramedullary (IM) nail tibiotalocalcaneal arthrodesis (TTC) (Figure 5). The original lateral incision was utilized to access the ankle joint.  The Vancomycin spacer was removed and soft-tissue specimens from the tibia and talus, which were sent for frozen section evaluation by pathology, were negative for infection. The bony surfaces were then prepared for arthrodesis in standard fashion using curettes, osteotomes, and drills. The subtalar joint was prepared in a similar fashion. The ankle was grafted with morselized femoral head combined with bone morphogenic proteins to provide osteoconduction and osteoinduction, as well as fibular pillar grafts to provide structural support and maintain length.  Fixation was accomplished with an IM nail. The patient remained non-weight bearing for 3 months.  She was then transitioned into a fracture boot for an additional month and then into a sneaker. No major or minor complications were noted throughout her recovery process. The patient has continued to improve throughout the post-operative course and is able to bear weight without assistance in standard foot gear. Serial radiographs have demonstrated complete union of all involved joints (Figure 6).

Figure 5 Intra-op radiographs (axial view, AP view, and lateral view) of IM nail with fibular pillar grafts.

Figure 6 Final radiographs showing consolidation (AP ankle, oblique ankle, lateral view) of IM nail with fibular pillar grafts.

Discussion

The fusion rate within the literature varies dramatically. Hawkins showed a variation between 71-94% depending on the control of infection within the joint [13]. Richter also reported a fusion rate of 86.6% for septic ankles [14]. Cierny et al reported results of 83% to 100%. Cierny believed this was secondary to the quality of the surrounding soft tissues. These cases used either external, or hybrid fixation techniques for their fusion [15].

Treatment of S. aureus septic ankle arthritis should include immediate lavage and debridement of the joint with culture and sensitivity driven antibiotic therapy [14, 15, 20].  However, this treatment alone leaves the patient predisposed to continued pain and discomfort secondary to sequela of septic arthritis. Therefore, ankle arthrodesis should be considered as a long-term option following resolution of the infection [4].

External fixation or a hybrid of external and internal fixation has been recommended for arthrodesis following septic ankle arthritis. We used a solitary IM nail for fixation in our cases. Klouche et al. discussed the use of internal fixation in a one-stage procedure using two cross screws through a lateral approach. There technique provided a cure rate of 85% and a consolidation rate of 89.5% at 4.8 months. Empiric antibiotics were administered to all patients and were modified based on culture and sensitivity results obtained at the time of surgery. No local antibiotics were used with their technique [34]. We used IV antibiotics before and after our definitive procedure, as well as, a Vancomycin loaded cement spacer following debridement of the infected bone.

Though our case study is limited, the results have been comparable to previous studies. This approach appears to be reasonable for limb salvage in end-stage degenerative joint disease following septic ankle arthritis. An evidence based study with increased numbers of patients and long term follow up would be beneficial in further accessing this technique for the treatment of septic arthritis of the ankle.

 

References

  1. Cooper C, Cawley MID. Bacterial arthritis in an English health district: a 10 year review. Ann Rheum Dis. 1986; 45:458-463.
  2. Peters RHJ, Rasker JJ, Jacobs JWG, Prevo RL, Karthaus RP. Bacterial arthritis in a district hospital. Clin Rheumatol. 1992; 11:351-355.
  3. Youssef PP, York JR. Septic arthritis: a second decade of experience. Aust N Z J Med. 1994; 24:307-311.
  4. Kaandorp CJE, Krunen P, Bernelot Moens HJ, Habbema JDF, Van Schaardenburg D. The outcome of bacterial arthritis: A prospective community-based study. Arthritis Rheum. 1997; 40(5):884-92.
  5. Meijers KAE, Dijkmans BAC, Hermans J, van den Broek PJ, Cats A. Non-gonococcal infectious arthritis: a retrospective study. J Infect. 1987; 14:13-20.
  6. Yu LP, Bradley JD, Hugenberg ST, Brandt KD. Predictors of mortality in non-postoperative patients with septic arthritis. Scand J Rheumatol. 1992; 21:142-144.
  7. Mathews C. J., Weston V. C., Jones A., Field M., Coakley G. Bacterial septic arthritis in adults. The Lancet.2010; 375(9717):846-855.
  8. Miller A, Abduljabbar F, Jarzem P. Polyarticular Septic Arthritis in an Immunocompetent Adult: A Case Report and Review of the Literature. Case Rep Orthop. 2015; 2015:602137.
  9. Scranton PE Jr. Use of internal compression in arthrodesis of the ankle. J Bone Joint Surg Am. 1985; 67:550–555.
  10. Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int. 1998; 19:3–9.
  11. Zwipp H, Grass R, Rammelt S, Dahlen C. Arthrodesis: non-union of the ankle—arthrodesis failed. Chirurg. 1999; 70:1216–1224.
  12. Kollig E, Esenwein SA, Muhr G, Kutscha-Lissberg F. Fusion of the septic ankle: experience with 15 cases using hybrid external fixation. J Trauma. 2003 Oct;55(4):685-91.
  13. Hawkins BJ, Langerman RJ, Anger DM, Calhoun JH. The Ilizarov technique in ankle fusion. Clin Orthop. 1994; 303:217–225.
  14. Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Ostermann PA. Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases. J Trauma. 1999; 47:1072–1078.
  15. Cierny G III, Cook WG, Mader JT. Ankle arthrodesis in the presence of ongoing sepsis: indications, methods, and results. Orthop Clin North Am. 1989;20:709–721.
  16. Johnson EE, Weltmer J, Lian GJ, Cracchiolo A III. Ilizarov ankle arthrodesis. Clin Orthop. 1992; 280:160–169.
  17. Lonner JH, Koval KJ, Golyakhovsky V, Frankel VH. Posttraumatic nonunion of the distal tibial metaphysis: treatment using the Ilizarov circular external fixator. Am J Orthop. 1995; suppl: 16–21.
  18. Stasikelis PJ, Calhoun JH, Ledbetter BR, Anger DM, Mader JT. Treatment of infected pilon nonunions with small pin fixators. Foot Ankle. 1993; 14:373–379.  
  19. Thordarson DB, Patzakis MJ, Holtom P, Sherman R. Salvage of the septic ankle with concomitant tibial osteomyelitis. Foot Ankle Int. 1997; 18:151–156.  
  20. Cierny G, Zorn EZ. Arthrodesis of the tibiotalar joint for sepsis. Foot Ankle Clin 1996; 1:177– 97.  
  21. Chen NT, Hong HZ, Hooper DC, May JW. The effect of systemic antibiotic and antibiotic impregnated polymethylmethacrylate beads on the bacterial clearance in wounds containing contaminated dead bone. Plastic Reconst Surg 1993; 97(2):1305–11.
  22. Donati D, Biscaglia R. The use of antibiotic impregnated cement in infected reconstructions after resection for bone tumours. J Bone Joint Surg Br 1998; 80(6):1045– 50.
  23. Popham GJ, Mangino P, Seligson D, et al. Antibiotic impregnated beads: Part II: factors in antibiotic selection. Orthop Rev 1991; 20:331–7.
  24. Ostermann PA, Henry SL, Seligson D. The role of local antibiotic therapy in the management of compound fractures. Corr 1993; 295:102– 11.
  25. Antrum RM, Solomkin JS. A review of antibiotic prophylaxis for open fractures. Orthop Rev 1987; 16:81–9.
  26. Eckman JB Jr, Henry SL, Manginio PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop 1988; 237:213–5.
  27. Lerner RK, Esterhai JL, Polomono RC, et al. Psychological, functional, and quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower extremity amputation. Arch Phys Rehab 1991; 72:122–6.
  28. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures.   J Bone Joint Surg Am 1974; 56:532– 41.
  29. Schentag JJ, Lasezkay G, Plant ME, et al. Comparative tissue accumulation of gentamycin and tobramycin in patients. J Antimicrob Chemother 1979; 4(SupplA):23–30.
  30. Seligson D, Popham GJ, Voos K, Henry SL, Faghri M. Antibiotic-leaching from polymethylmethacrylate beads. J Bone Joint Surg Am 1993; 75:714– 20.
  31. Stuart MJ, Morrey BF. Arthrodesis of the diabetic neuropathic ankle joint. Clin Orthop 1990; 253:209– 11.  
  32. Esterhai JL Jr, Sennett B, Gelb H, et al. Treatment of chronic osteomyelitis complicating nonunion and segmental defects of the tibia with open cancellous bone graft, posterolateral bone graft, and soft tissue transfer. Trauma 1990; 30:49–54.
  33. Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Ankle salvage surgery with autologous circular pillar fibula augmentation and intramedullary hindfoot nail. J Foot Ankle Surg. 2014 Sep-Oct; 53(5):601-5.
  34. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot Ankle Surg. 2011 Jan-Feb; 50(1):25-30.

Acknowledgements: None

Conflicts of Interest: None

Communications Author: Sham Persaud

Level of Evidence: Level IV Therapeutic Study

Application of the distally pedicled peroneus brevis: Technique, case study, and pearls

by Chad Seidenstricker DPM1, Megan L. Wilder DPM2, Byron L. Hutchinson DPM, FACFAS3pdflrg

Soft tissue defects of the distal leg and hindfoot are difficult to eradicate. Avascular structures become exposed through seemingly superficial wounds rather quickly. The present case describes a surgical technique for the peroneus brevis muscle flap for coverage of a postoperative lateral heel wound following a lateral extensile approach for ORIF of a calcaneal fracture. Nonoperative and operative wound care modalities failed over the course of several years, and a peroneus brevis rotational flap was attempted for wound coverage. Although several minor complications occurred, the wound had successful epithelialization at 3 months. The distally pedicled peroneus brevis muscle flap offers a good option at wound coverage in difficult to heal wounds of the distal leg and hindfoot.  

Key words: muscle flap, peroneus brevis, soft tissue defect, ankle, foot

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0003

1 – Podiatry Resident at Swedish Medical Center PGY-3, Seattle, WA
2 – The Everett Clinic, Marysville, WA
3 – Director, Franciscan Foot and Ankle Institute; Medical Director, Foot & Ankle Service, CHI Franciscan Health, Federal Way, WA.
* – Corresponding author: chaddpm14@gmail.com


Soft tissue defects of the foot and ankle present a significant challenge. There is little soft tissue coverage and exposed tendon and bone can easily occur following elective reconstruction or trauma, requiring surgery. Skin grafting is often not an option in this region as bone and tendon are not suitable as a recipient bed. Rotational muscle flap techniques for foot and ankle wound closure are gaining popularity and have proven effective. Muscle flaps offer pliability and can eradicate dead space, can overcome residual bacterial infection in bone, improve blood flow, and will provide a vascular recipient bed for split thickness skin grafting [1]. While negative pressure wound therapy devices are excellent at promoting expedited closure of deep wounds, they should not be placed directly over bone or tendon and especially not in the setting of residual infected tissue.

Indications for rotational muscle flap wound closure may include exposed bone with osteomyelitis, traumatic wounds, non-healing wounds over the lateral ankle and hindfoot after Achilles tendon procedures, surgical wound dehiscence recalcitrant to nonoperative therapies after calcaneal fractures, ankle fractures, and total ankle arthroplasty. In a systematic review, Yu et al, demonstrated a wound complication rate of 13.5% in calcaneal fractures after ORIF [2]. There has been a movement toward minimally invasive techniques, but the lateral extensile incision is still routinely utilized. Raikin et al demonstrated an 8.5% incidence of wound complications following TAR with anterior midline incisional approach that required at least one secondary visit for surgical wound debridement [3]. Wound dehiscence after TAR requires immediate definitive treatment to avoid catastrophic deep space infection.

The distally pedicled peroneus brevis muscle flap offers a relatively simple, reproducible and reliable option for wound closure with complication rate equal or reduced compared to other techniques. In general the muscle flap should not be used as a first line procedure, but is used in limb salvage situations and has very little downside. The peroneus brevis muscle flap also has the advantage of low donor site morbidity and heals with minimal scar.  Lower extremity surgeons can easily perform the peroneus brevis flap closure if it is acceptable in the foot and ankle specialist’s region to perform this type of procedure.

Rationale & Background

Attinger described the role of various intrinsic muscle flaps for small wound closure of the foot and reported a 96% success rate [4]. The abductor hallucis muscle flap has been reported to provide excellent outcomes in plantar heel defects [4,5]. While intrinsic flaps have proven efficacy for small wounds about the foot, they are not sufficient for larger wounds of the hindfoot, ankle and lower leg. Larger wounds in the distal third of the leg and hindfoot are amenable to the peroneus brevis flap. The peroneus brevis muscle is classified as a type IV muscle flap by Mathes and Nahai, which represents a muscle flap with segmental blood supply provided by branches of equal importance (Table 1) [6]. Ensat et al evaluated the blood supply of the peroneus brevis muscle flap identifying constant blood supply by segmental branches of the peroneal and tibial arteries and also supported Yang’s finding of the most distal pedicle being provided between 4-5 centimeters proximal to the tip of the fibula [7,8]. Ensat also recommended a pivot point at least 6-cm above the tip of the fibula to assure there is an intact vascular pedicle, however, this should always be evaluated intraoperatively [7]. The muscle length available for rotation is close to 20-cm, but due to distal flap necrosis, the most proximal 2-cm should always be removed, providing a muscle approximately 18-cm in length [9,10,11].

 

Table 1: Mathes & Nahai [6] classification of muscle and myocutaneous flaps
Type I: One vascular pedicle
Type II: Dominant pedicle(s) and minor pedicle(s)
Type III: Two dominant pedicles
Type IV: Segmental vascular pedicles (ie Peroneus Brevis)
Type V: One dominant pedicle and secondary segmental pedicles

The arc of rotation is determined by the most distal vascular pedicle, which should allow an average of 12-cm from the pivot point.

We present a case in which a chronic lateral heel wound following ORIF of calcaneus was treated successfully with a distally pedicled peroneus brevis flap. Our scenario is similar to Rodriguez who recently reported success of the peroneus brevis flap following wound dehiscence after ORIF of a lateral malleolar fracture with subsequent surgical wound dehiscence [12].

Case report

In this case report, a 63 year old male non-smoker sustained a closed intra-articular calcaneal fracture. The records from previous surgeons were not retrieved so the exact timeline is unknown but the following events occurred over the course of several years prior to his definitive operation and closure. The patient had an ORIF through a lateral extensile approach with dehiscence at the apex of the incision which never fully healed.  He had hardware removal and local wound care which failed. He then had a small rotational flap which failed, followed by an advancement flap which resulted in re-opening of the sinus tract and a chronically draining wound with exposed bone. He presented to a local plastic surgeon for consultation who felt a free flap was not a good option. He then presented to the author’s clinic for a preoperative evaluation.  On arrival to clinic the patient had a small wound at the apex with a sinus tract and suspected osteomyelitis of the lateral calcaneal wall, which was draining minor amounts of serous fluid (Figure 1). A distally pedicled peroneus brevis rotational flap was planned.

1

Figure 1 Chronic lateral hindfoot wound recalcitrant to several operative debridements, antibiotics, local wound care, and local skin flaps.

2

Figure 2 Lateral incision over the fibula, with the peroneus longus retracted inferiorly and the peroneus brevis muscle belly and tendon origin exposed.

Surgical technique

After skin preparation, and exsanguination of the limb, a pneumatic thigh tourniquet was inflated to 350mmHg. An incision was made overlying the lateral heel wound in a curvilinear fashion extending a few centimeters proximally and a few distal to the wound. The scar tissue was bluntly dissected through down to calcaneus, and the skin was elevated in a single layer as a flap. There was a loose portion of cement that was noted in the lateral wall of the calcaneus which had been left from a prior surgery and this was removed.

3

Figure 3 Peroneus longus in the right hand, and peroneus brevis muscle belly held in the left.

4

Figure 4 Peroneus brevis muscle belly being elevated off the fibula, moving proximally.

The calcaneus was debrided to good, healthy bleeding bone that appeared without signs of infection. Attention was then directed to the lateral leg where a standard incision was made as described by Eren [13]. The incision connected with the lateral heel wound incision. The crural fascia overlying the peroneals was incised (Figure 2). The peroneus brevis was followed up its muscle belly proximally until the origin was released (Figure 3,4,5). Segmental pedicles were ligated from proximal to distal until approximately 6-cm proximal to the lateral malleolus.

5

Figure 5 The free peroneus brevis flap, with distal vascular pedicles still in tact.

6

Figure 6 Intraoperative doppler to assure the pedicle is patent to provide blood supply to the brevis muscle.

7

Figure 7 The peroneus brevis muscle flap rotated down, showing adequate length to reach the lateral heel wound.

8

Figure 8 Closure of the harvest site, demonstrating easy closure of the harvest site.

Utilizing ultrasound, a vascular pedicle was identified at this level (Figure 6). Care was taken to not violate the pedicle. The peroneus brevis was folded from proximal to distal into the wound and overlying the exposed calcaneal wound (Figure 7). It was loosely secured in place overlying the lateral wall of the calcaneus. The wound was then closed in layers proximally, leaving the distal wound overlying the lateral wall of the calcaneus open with the muscle flap secured within the wound (Figures 8,9).

An Integra bilayer wound matrix was then placed and trimmed to the appropriate size overlying the muscle flap (Figure 10). It was secured in place around the rim of the wound utilizing staples with a single staple in the middle of the flap. The membrane was then fenestrated to allow drainage. The site was then dressed with negative pressure wound therapy (Figure 11). A monorail external fixator was applied to the medial calcaneus and medial tibia with half pins to establish stability while being able to access the wound for local wound assessment and care in the early wound healing phase (Figure 12). Proper alignment was confirmed under fluoroscopy. Sterile dressings were then applied. Tourniquet was deflated.

9

Figure 9 Closure of the incision along the lateral leg down to the original defect site. The original defect site should be left open, and ideally is covered with a biologic dressing.

10

Figure 10 Securing an Integra graft over the exposed peroneus brevis in the chronic wound site with staples.

11

Figure 11 Wound vac secured over the Integra graft after fenestrating the integra graft.

12

Figure 12 Unilateral External fixator applied to the medial tibia for stabilization of the muscle and the wound to allow for incorporation.

13

Figure 13 Application of STSG roughly 3 weeks after the Integra graft was placed. The silicone layer was removed and the wound was carefully debrided and cleansed prior to application. STSG secured with staples.

14

Figure 14 Healed lateral foot wound.

Follow up care

About 2 weeks later, he presented to the emergency department with fever and chills and was noted to have a pin tract infection, requiring removal of one of the pins in the ED. The following week he returned to the operating room for removal of the external fixator and debridement of a small portion of muscle flap necrosis.  Following debridement, the split-thickness skin graft (STSG) was secured with staples and negative pressure wound therapy was applied (Figure 13). The patient presented to clinic for follow-up seven days post-skin graft application and negative pressure wound therapy was removed. Four days later he returned to clinic and reported a visit to the ED for fever and previous talar pin site irritation and pain with two centimeter diameter of surrounding erythema. He was started on IV rocephin for a few days and then transitioned to a two week course of Keflex. He had resolution of infection. His donor site incision healed without incident. He was discharged with instructions to remain NWB to his surgical limb until complete incorporation of graft, about two months. At final three-month follow-up he had completely healed (Figure 14).

Discussion

There are several key points to discuss regarding this case report. First, there was partial flap necrosis, which required repeat debridement in the OR. For the case presented, the most proximal aspect of the peroneus brevis muscle belly was not debrided, which has been recommended by multiple authors [9,10,11]. Other potential ways to improve wound closure may include the use of bilayer membrane which, after it takes, will provide a superior surface for a STSG. Negative pressure wound therapy can be applied at 50-125mmHg [12]. It has been proposed that higher vacuum settings may be damaging to skin grafts, but this theory was not upheld [13].

Recently it was found that wound vac application at 75mmHg applied for seven days post-operatively significantly reduced partial flap necrosis and skin graft necrosis, and they concluded that prolonging the period of wound vac application may further reduce complications by eliminating shear force, improving neovascularization of the muscle, and reducing edema and venous congestion [14]. There is debate whether to perform the transfer of the brevis through a subcutaneous tunnel or whether to connect the harvesting incision to recipient site. It is not absolutely necessary to connect the incision with the recipient site, but there should not be excessive tension within the subcutaneous tunnel as this may obstruct venous outflow resulting in flap failure. If there is question, one should connect the recipient bed with the donor site incision.  

A few other obstacles occurred which can be avoided. While pin tract infections are common when using external fixators, rarely catastrophic infection develops. Minor infections can be managed with local wound care and oral antibiotics oftentimes. As long as there is not failure at the bone-pin interface with loosening, fracture with nonunion or malunion, or chronic osteomyelitis,  it should not compromise your end result. Placing a unilateral fixator to stabilize the extremity offers several advantages. It offers stability to the extremity and the wound bed in the immediate postoperative phase while also permitting wound care and wound observation for the first few weeks after index surgery. The external fixator can be removed at the three week mark as this is when you can return to the operating room, remove the silicone layer from the bilayer membrane, and harvest and apply the STSG. Other options include applying a posterior splint for immobilization, but this doesn’t offer an easily accessible portal for wound evaluation and wound care and, makes continued care with a wound vac particularly difficult. If the recipient site is prone to shear forces, ie lateral malleolus, be sure to utilize a bulky soft dressing to protect the graft site. Although several publications [14,15] have advocated for single stage procedure, it is prudent to wait for application of the STSG until muscle flap viability is assured. This prevents unnecessary repeat skin grafting.

It has been demonstrated that the peroneus brevis muscle flap provides a reliable means for treating bone infections, providing blood supply, and a suitable recipient bed for skin grafting [1]. Preoperatively the patients should be evaluated for vascular insufficiency. As foot and ankle experts, sacrificing the primary evertor of the foot may seem uncouth, but these are limb salvage situations. One can perform a tenodesis of the the peroneus brevis to the longus to enhance eversion power if it is possible. However, it has been shown that eversion and plantarflexion are maintained following the procedure even without ancillary procedures and patients do not report lateral ankle instability [16]. The donor site is rarely problematic, and can be closed primarily without issue [10-12,16-18].

The peroneus brevis has a consistent blood flow [7,16,17]. The maximum number of vascular pedicles should be maintained as possible, but one can elect to ligate all pedicles leaving only the most distal intact approximately 6-cm proximal to the tip of the fibula. To ensure adequate blood supply will be provided by each successive pedicle, a vascular clip can be placed temporarily to ensure the next pedicle maintains adequate perfusion. Ensat et al demonstrated in a cadaveric model that there were an average of 5.1 segmental branches to the muscle. This included branches from both the peroneal and the anterior tibial artery, however, most branches were derived from the peroneal artery [7]. The most distal vascular branch was derived from the peroneal artery in 100% of cadavers at a distance about 4.3cm proximal to the tip of the lateral malleolus. There is also retrograde flow provided from the posterior tibial artery [7]. This is important in gaining a muscle flap with the most potential length. The pivot point should be at least 6-cm proximal to the lateral malleolus to ensure there is a vascular pedicle attached distally to supply the muscle when performing rotational flaps. The diameter of the pedicle must be at least 0.5mm, while the average size pedicle is 1.1mm this is rarely a problem [7]. The average length of the muscle is 19.8cm, but the most proximal 2-cm should be resected as this area of the graft is expected to undergo necrosis.

In conclusion, many studies have found reliability in this muscle flap. It offers great utility to cover defects in the distal leg and hindfoot. It can cover defects of the anterior ankle, lateral ankle and hindfoot. Despite some authors reporting an unfavorable success rate, the majority of reports found high rates of success and this should be considered in the reconstructive ladder for complex lower extremity wounds [10,11,18,19].

References

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  2. Yu X, Pang QJ, Chen L, Yang CC, Chen XJ. Postoperative complications after closed calcaneus fracture treated by open reduction and internal fixation: a review. Jour Int Med Research 2013; 42(1):17-25. PubMed
  3. Raikin SM, Kane J, Ciminiello ME. Risk factors for incision-healing complications following total ankle arthroplasty. J Bone Joint Surg 2010; 92 (12):2150-2155. (PubMed
  4. Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg  2002;110(4):1047-1054. PubMed
  5. Ortak T, Ozdemir R, Ulusoy MG, Tiftikcioglu YO, Karaaslan O, Kocer U, Sensoz O. Reconstruction of heel defects with a proximally based abductor halluces muscle flap. J Foot Ankle Surg 2005; 44(4): 265-270.  PubMed
  6. Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. New York: Churchill-Livingstone: 1997.
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Novel ankle cast designs with non-toxic material

by Hirsimäki J¹, Lindfors NC², Salo J³pdflrg

The Foot and Ankle Online Journal 7 (4): 5

Foot and ankle immobilization is usually based on circular support, either using casts or boot-like orthoses. Basic requirements for immobilization of the ankle region include reliable support and possibility of full weight bearing during healing. Woodcast® is a novel, freely 3D moldable cast material based on non-toxic components. The material is strong but light weight and can be used as a split or a cast. Our hypothesis was to test in a proof-of-concept type study, whether a new open cast design, leaving the calf area free can be clinically used in ankle immobilization. Thirty patients with an acute ankle fracture or a recently performed ankle arthrodesis were recruited.  Two different types of cast designs were used, one semi-rigid cast and one rigid cast. All fractures and arthrodesis healed well, with no major postoperative complications. Patient satisfaction was high in both groups and slightly higher in the semi-rigid group. This study shows that the ankle area can be immobilized using a novel type of a very light weight Woodcast® material.  By combining soft and hard wood composite materials, an optimal open cast design leaving the calf area free can be performed, allowing full weight bearing and reliable immobilizing of the ankle.

Key words: Ankle, fracture, immobilization, cast, orthosis, wood, orthopaedic equipment, orthopaedic fixation devices

ISSN 1941-6806
doi: 10.3827/faoj.2014.0704.0005

Address correspondence to: ¹Hirsimäki J, University of Eastern Finland, Yliopistonranta 1, 70211 Kuopio, Finland; Tel: +358 40 753 4415; E-mail: jhirsima@student.uef.fi

² Helsinki University Central Hospital, Department of Orthopaedic and Hand Surgery, Helsinki University, Helsinki, Finland
³ Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland


Immobilisation in fracture treatment has a long history. Fractures have been treated millennia with natural materials such as wood sticks, but it was only until 1852 that Plaster-of-Paris (POP) was first used in fracture treatment. Inorganic calcium based component had been traditionally used in building walls, but it required additional binding material to be used in limb immobilization. Cotton offered this possibility, and it was utilized almost simultaneously by two army doctors, Dutch Antonius Mathysen and Russian Nikolay Pirogov.

It took a long time to get the first commercially available POP on the market (Cellona, Germany 1932). Typically, POP offered sufficient rigidity with relatively thick and heavy layers, allowing at least partial weight bearing. But it was also brittle and did not tolerate water. As a first improvement to POP, fiberglass was introduced to fracture treatment in the 1950s. It is lightweight, rigid or semi-rigid, and tolerates both water and continuous mechanical loading during walking. It is partially moldable with a strong net like support structure as a limiting factor [1-3]. Modern orthopedic plaster casts are commonly based on synthetic plastic that contains up to 25% methylene diphenyl diisocyanate (MDI). Severe issues have been raised in occupational health sector related to use of isocyanates used in modern paints, moldable glues and orthopaedic casting materials like fiberglass and polyurethane [4].

Ankle fractures can be treated in a conservative way when certain criteria are fulfilled. Some centers prefer cast immobilization also after plate fixation, others rely more on ORIF stability and accept functional orthosis or free mobilization. If cast is to be used, it is however of one basic design regardless of material used. The leg and calf area are covered with a circular cast having different additional layers for sufficient stability [5-9]. Different kind of pre-shaped orthosis have come to the market, initially for functional treatment of ankle sprains, and in some studies also for treatment of ankle fractures [10-14].

In 2010, an innovative wood-composite material was introduced for fracture treatment by Onbone Oy, Helsinki, Finland. The Woodcast® material is an ecologically friendly, biodegradable, wood-plastic composite material, with absolutely free three-dimensional (3D) molding properties. Because of its extreme strength and exceptional molding properties, we hypothesized that it could be possible to treat common ankle fractures and postoperative immobilization in ankle arthrodesis with a novel, open cast design. The goal for the cast was to leave the calf area free, and to allow cast removal and reinserting without tools. Absolute requirements were that the new cast design has to be stiff enough to allow full weight bearing.

This proof-of-concept type multicenter trial was conducted in accordance with the ethics principle originating in the latest version of the Declaration of Helsinki, applicable regulatory requirements, including the standards of the International Organization, and Finnish law and regulations. The study protocol was approved by the Ethics Committee of the Helsinki University Central Hospital (HUCH) and informed consent was obtained of the patients. The study was registered at www.clinicaltrials.gov.

Major hypothesis were that novel light weight cast designs could be successful in treatment of ankle fractures and as postoperative supporting device after ankle arthrodesis.

Methods

Casting materials

Woodcast® is a composite of thermoplastic polymer and a woody material approved for clinical use in limb immobilization (European approval in 2010). The material is hard in room and body temperature, but becomes moldable when heated up to +62 oC.  During cooling, it retains moldable down to 45 oC offering extended working time.  When ready, casting hardening can be enhanced with external cooling.  The material is non-toxic, does not release irritant aerosols, and can be handled without protective gloves. It is strongly self-adhesive and slightly adhesive toward padding and bandage materials, but does not attach to skin. It can be composted after use. The Woodcast® materials can be reheated repeatedly without affecting their mechanical properties, and they can be stretched and bent freely in 3D.

Patients

Thirty patients were enrolled in the study. The inclusion criteria were: Finnish or Swedish speaking patient, age between 0-90 years, a non-complicated ankle fracture or a performed elective foot arthrodesis normally requiring cast immobilization. The exclusion criteria were compromised co-operation for any reason, a complicated fracture, other simultaneous or earlier fractures, nerve, vessel or tendon injuries on the index extremity, malignancy and other severe diseases.

Postoperatively the patients were treated with other casting materials for two weeks. After two weeks the postoperative cast was changed either to a Woodcast® semi-rigid ankle cast model (Group 1) or a rigid model (Group 2). The cast technicians were educated for both models and the choice of design depended on the hospital they were working in.

Figure 1. A removable semi-rigid orthosis

Figure 1 A removable semi-rigid orthosis.

The semi-rigid model was made of 80 cm long Woodcast® 2 mm Soft, 40 cm long Woodcast® 4 mm and of a 15 cm peace of Woodcast® 2mm. The Woodcast® 4 mm offers mechanical stability and the Soft product is used to achieve flexibility. The cast material was applied on the anterior part of the extremity leaving the posterior side of the extremity free and then allowed to cool. The cast was then removed and finalized with soft tape around the edges (Figure 1). Padding and Velcro tape were used. During the immobilization period the patients were allowed to remove the cast temporarily.

The rigid cast was made of two 80 cm long Woodcast® 2mm pieces with paddings protecting the skin. A U-shaped casting material was applied from the lateral side, around the heel area and extending to medial side. The other 80 cm piece was cut oblique in two parts and applied anteriorly to stabilize the TC-joint and protect the plantar area during walking (Figure 2).

SONY DSC

Figure 2 A non-removable rigid cast.

Results

All patients completed the study. Thirteen (13/30) patients with ankle fractures were treated with the semi-rigid orthosis (Group 1). In 17/30 cases the rigid cast was used (Group 2) including 10 ankle arthrodesis patients and 7 trauma cases. In Group 1 the average age was 47.5 (the youngest patient being 24, and oldest 66 years old) and in group 2 the average age was 50.1 (the youngest patient being 24, and oldest 76 years old). Applying time was not depended on cast type rather skills of the technician. There were no major difference in immobilization time between Groups 1 and 2 (Table 1).

The orthopedic technicians reported that no primary complications occurred in Group 1, although in one case orthosis soft material broke from the metatarsus area during the last week of immobilization, but didn’t cause complications for the patient. Twelve (12/13) of the patients in Group 1 reported that they removed the orthosis themselves during the immobilization at least once.

Primary complications were reported by technicians in Group 2. Molding the cast was not easy in one case and in six of the cases there were issues applying the cast in correct position because of the multilayer composition. In two of the cases preheating the casting material didn’t occur fast enough.

table1

Table 1 Results of removable semi-rigid orthosis versus non-removable rigid cast.

Patient satisfaction was high in both groups yet superficial skin complications were seen in Group 2. Superficial maceration reported in 6/17 cases, focal compression in the cast 3/17 and 3/17 both simultaneously (Table 1). One rigid cast was changed to the semi-rigid orthosis because of the increased level of moisture in the cast with good results.  There were no skin complications in Group 1. There were no post-operative infections in either of the reported groups.

Discussion

Cast designs used in this study concentrate especially in immobilization of ankle joint and subtalar joint lines. Shortening the distal dimension in the cast gives more freedom to the toes, to the Lisfranc area, and finally to midtarsal Chopart joint line. This more targeted immobilization is possible with the specific material properties, but whether this has an effect on functional recovery remains to be seen in future studies. In acute ankle sprains (grades II & III), functional brace seems to give better outcome than total immobilization of the lower extremity [12,14]. It can be at least assumed that this kind of new material offers possibilities to design functional braces in the near future.

The anteromedial margin of tibia is the area where soft tissue layers are thinnest. This offers a good contact area for bone immobilization, but requires good fitting of cast material. Cast designs used in this study utilize this area as an anchor site for ankle immobilization. Although no direct force measures were included in this study, our emphasis is that this is far more stable than padded circular cast around the whole calf area with soft tissues on the posterior area. No patient had discomfort on this anteromedial area, even with the use of hard material only. The hard version of Woodcast®, 4 mm and 2 mm are extremely stiff and durable materials.  Hard material can be used as an internal support in elastic constructions, but if it is used as the only material attention must be paid on breathability and edges of cast design. Based on our experience in this relative small patient population, skin maceration and compression discomfort can occur in closed cast design. In Group 1, no patients with combined soft and hard material had cast related discomfort. This emphasizes the role of careful cast design, and use of appropriate padding.

The immobilization or the cast itself can cause several complications. Pressure sores are common complications if improper techniques are used. The risk receiving pressure sores increases in patients who suffer from peripheral nerve or vessel disorders. Compartment syndrome may develop due to a too tight cast [15]. Immobilization may also lead to problems such as joint stiffness, muscle atrophy, cartilage degradation, ligament weakening and osteoporosis [9]. Deep venous thrombosis (DVT) is perhaps the most common complication in lower extremity immobilization, with an incidence of 1.1% to 20% in various type of lower limb injuries treated with a circular cast [16]. In this study, no DVT occurred although no prophylactic agents were used. The number of patients in this proof-of-concept study is too low to draw any solid conclusions on this, but it can be assumed that this type of novel cast design leaving the calf muscle area free could even decrease the risk of DVT. If a DVT is suspected, a circular cast has to be removed, but this open design allows ultrasound diagnostics directly with cast on.

Achilles tendon ruptures are prone to wound complications [18]. Although these ruptures were not in the scope of this study, it is evident that this kind of easily removable cast will fit well in treatment of these injuries. One advantage would be to monitor and treat wound complications even with the cast on. It also gives a direct access to healing tendon, either to monitor tendon healing with ultrasound, or possibly to stimulate tendon healing with external pulsating equipment.

Conclusions

This study challenges the long-time circular cast design in ankle immobilization. It seems that even a semi-rigid open wood composite cast is safe and strong enough to stabilize common ankle fractures, and to successfully protect postoperative period after ankle arthrodesis.  Taken together current data is very promising for an open type cast technology, further and larger studies are highly warranted.

References

  1. Colditz J. Plaster of Paris: The Forgotten Hand Splinting Material. J Hand Ther 2002 Apr-Jun;15(2):144-57.(Pubmed)
  2. Lindfors NC, Salo J. A Novel Nontoxic Wood-Plastic Composite Cast. Open Med Dev J 2012; 4:1-5. (Link)
  3. Runumi G, Utpal KN. Study of Effect of NCO/OH Molar Ratio and Molecular Weight of Polyol on the Physico-Mechanical Properties of Polyurethane Plaster Cast. World Appl Sci J 2013; 21(2):276-283. (Link)
  4. Suojalehto H, Linström I, Henriks-Eckerman M-L, Jungwelter S, Suuronen K. Occupational asthma related to low levels of airborne methylene diphenyl diisocyanate (MDI) in orthopedic casting work. Am J Ind Med 2011 Dec;54(12):906-10. (Pubmed)
  5. Lee YS, Chen SW. Lateral fixation of open AO type-B2 ankle fractures: the Knowles pin versus plate. Int Orthop 2009 Aug;33(4):1135–1139. (Pubmed)
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  8. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. J Bone Joint Surg 2000 Mar;82(2):246-9. (Pubmed)
  9. Halanski M., Noonan KJ. Cast and Splint Immobilization: Complications. J Am Acad Orthop Surg 2008 Jan;16(1):30-40. (Pubmed)
  10. Dietrich A, Lill H, Engel T, SchönfelderM, Josten C. Conservative functional treatment of ankle fractures. Orthop Trauma Surg 2002 Apr;122(3):165-168. (Pubmed)
  11. Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, Szczepura A, Wilson S, Lamb SE. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. Health Technol Assess 2009 Feb;13(13). (Pubmed)
  12. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, Best R. Treatment of acute ankle ligament injuries: a systematic review. Orthop Trauma Surg 2013 Aug;133(8):1129–1141. (Pubmed) FORUM
  13. Wykes PR, Eccles B, Thennavan B; Barries JL. Improvement in the treatment of stable ankle fractures: an audit based approach. Injury 2004 Aug;35(8):799-804. (Pubmed)
  14. Polzer H, Kanz KG, Prall WC. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev 2012 Jan;4(2):22-32. (Pubmed)
  15. Pifer G. Casting and splinting: Prevention of complications. Top Emerg Med 2000;22:48-54. (Link)
  16. Patil S, Gandhi J, Curzon I, Hui ACW. Incidence of deep-vein thrombosis in patients with fractures of the ankle treated in a plaster cast. J Bone Joint Surg 2007; 89:1340-3. (Link)
  17. Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011 Apr;2:59–69. (Pubmed)
  18. Roderik Metz R, Kerkhoffs G, Verleisdonk EJ, Van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskeletal Disorders 2007 Nov;8:108. (Link)

Tuberculous Tenosynovitis of Ankle with Rice Bodies

By K P Raju, Dr J Mohan Kumar, Dr Roshan Shettypdflrg

The Foot and Ankle Online Journal 6 (10): 1

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the ankle at presentation is extremely rare, and the diagnosis is often missed. Tuberculosis can involve pulmonary as well as extrapulmonary sites. The musculoskeletal system is involved in 1–3% of patients with TB. Although musculoskeletal TB has become uncommon in the Western world, it remains a huge problem in India . Isolated soft tissue TB is extremely rare. Early diagnosis and prompt treatment are mandatory to prevent serious destruction of joints. Due to the nonspecific and often indolent clinical presentation, the diagnosis may be delayed. Radiological assessment is often the first step in the diagnostic workup of patients with musculoskeletal TB and further investigations are decided by the findings on radiography. Both the radiologist and the clinician should be aware of the possibility of this diagnosis. The authors encountered a rare case of tubercular tenosynovitis of ankle with rice bodies.

Key words: Tuberculosis, tenosynovitis, ankle, rice bodies, fibrin.

Accepted: September, 2013
Published: October, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0610.001

Address correspondence to: Dr K P Raju, Dr J Mohan Kumar, Dr Roshan Shetty, BGS Global Hospital & BGS GIMS, Bengaluru,India.
Email: drjmohankumar@yahoo.co.in


Tuberculous tenosynovitis was first described by Acrel in 1777. Particles are named “rice body”, due to their resemblance to shiny rice grains, was first described by Reise in1895.[1] Rice body formation may occur with a systemic inflammatory disease or alone in localized form. While it is mostly seen in patients with rheumatoid arthritis,[2] it may also be accompanied by juvenile rheumatoid arthritis,[3,4] tuberculous arthritis, tuberculous tenosynovitis and tuberculous bursitis,[5] atypical mycobacterial tenosynovitis,[7,8] osteoarthritis,[9] in addition to nonspecific arthritis, tenosynovitis, and bursitis.[10]

Rice body formation may occur in intra-articular structures, at tendon insertions and synovial structures like periarticular bursa of the shoulder, knee, wrist and ankles, which are the most common sites of involvement.[2,5] Both primary tuberculous bursitis and tenosynovitis are rare conditions.[6] Diagnosis with classical radiography is challenging. Arthrography, bursography, ultrasonography (USG) and magnetic resonance imaging (MRI) are useful techniques in preoperative diagnosis. The histological structure usually comprises an amorphous core of necrotic cells in the center, surrounded by a layer of fibrin and collagen.[11]

ricebodies1a ricebodies1b

Figure 1A and 1B T1-weighted sagittal image showing hypointense mass with slightly hyperintense septaes. (A) T2-weighted image showing hyperintense liquid with nodular, diffuse hypointense structures lined in a thick capsular mass.(B)

We present a case of rice body formation in tubercular tenosynovitis of ankle, without any systemic disease.

Case report

A 25-year-old woman presented with a mass in her right ankle, which had been present for 2 years. She experienced a mild pain during long walks and going up and down the stairs. She had no history of trauma, tuberculosis or systemic inflammatory disease. On physical examination there was an immobile soft tissue mass of 7×3×2 cm in her right ankle. The mass was tender on palpation and there was no redness or increase in warmth of the skin. There was no limitation in the motion of the ankle joint despite the pain. The laboratory tests were within normal limits and chest radiograph did not reveal any abnormality. Ankle radiograph showed a soft tissue shadow. On MRI images there was a lobulated mass with peripheral contrast enhancement around the lateral aspect of ankle. The mass had neat contours, consisted of numerous, small nodular regions and had no connection with the tibiotalar joint. There was no effusion or a space occupying lesion within the joint. T1-weighted sagittal image showed a hypointense mass with slightly hyperintense septaes, and T2-weighted image a hyperintense liquid with nodular, diffuse hypointense structures with a thick capsule. (Fig. 1A and 1B)

Surgical treatment was advised for chronic, nonspecific bursitis. Numerous, shiny and grainy particles were removed following the incision of the tenosynovium around the peroneal tendon. (Fig. 2A and 2B)

Pathological examination of the excised particles revealed synovial necrosis and fibrin deposition in the center, surrounded by scores of granulomatous structures with giant cells, in addition to apparent inflammatory infiltration of lymphocytes, plasma cells and macrophages. (Fig 3A and 3B)

ricebodies2a ricebodies2b

Figure 2A and 2B Surgical exploration reveals a large, nodular mass along the course of the peroneal tendon. (A) Inside the mass were numerous, grainy particles or rice bodies rich in fibrin and collagen. (B)

The case was diagnosed as rice body formation secondary to tubercular tenosynovitis of peroneal tendon, based on the MRI findings, intraoperative appearance, and histopathological report. Antituberculous treatment was started as soon as the identification of M. tuberculosis was confirmed. After one year of treatment the patient had full range of motion without pain. Recurrence was not observed during the two year follow-up period.

ricebodies3a ricebodies3b

Figure 3A and 3B Microscopic evaluation reveal synovial necrosis and fibrin deposition (center) surrounded by scores of granulomatous structures with giant cells, in addition to apparent inflammatory infiltration of lymphocytes, plasma cells and macrophages. (A) Numerous rice bodies isolated from the mass. (B)

Discussion

Rice bodies are free particles that have a cartilage-like shiny appearance, can reach high numbers, and are of synovial origin.[12] There is no consensus on the etiology. The condition is believed to develop as a nonspecific response to synovial inflammation.[3] Synovial ischemia and necrosis due to hypoxia, caused by the disruption of microcirculation, are thought to be the triggering factors. Rice bodies are formed by the necrotized particles which break away from the synovium and adhere to the fibrin in the joint space, tendon sheath or inside the bursa. After phagocytosis by the macrophages they are denatured in phagolysosomes and by acting like collagen antigens they lead to an auto-immune response.[11] Another hypothesis suggests that collagen, newly synthesized by synovial cells, can lead to formation of rice bodies. It should be, however, kept in mind that the condition might be misinterpreted as synovial chondromatosis. In the literature, it is emphasized that pathological misdiagnosis is possible and there is no evidence of cartilage tissue presence in rice bodies. Histopathological examination of our case, likewise, presented no sign of cartilage tissue in the bodies.

Some authors have advocated that the emergence of rice bodies is due to a new formation caused by the progressive growth of fibronectin and fibrin aggregates in the synovial fluid, independent from the synovial elements.[11,13] While 47% of the synovial protein is composed of collagen in rheumatic diseases, in rice body proteins this percentage is only 10%. Rice bodies are richer in fibrin.

However, Popert, et al., have shown the particles are not homogenous.[13] While some rice bodies are mostly formed of fibrin, some are composed of synovial membrane. Some others are formed of synovial core surrounded by fibrin.[11,12] Muirhead et al., in their ultrastructural study, reported that rice bodies can be of multiple origins based on their localizations.[10]

In our study, pathological examination of the excised bodies presented a structure with synovial necrosis and fibrin deposition in the center.

Chen et al., [14] in their case study, discussed the probability of correct preoperative diagnosis and emphasized the importance of T2-weighted MRI.They reported that rice bodies were seen in the hyperintense bursal fluid as numerous hypointense areas. This view is slightly hyperintense compared to skeletal muscle.[14] Likewise, in our case, preoperative T2-weighted MRI images with sagittal sections showed hyperintense synovial fluid with nodular and diffuse hypointense structures that had a thick capsule, surrounding the peroneal tendon. In addition, two entities stand out in differential diagnosis: pigmented villonodular synovitis and synovial osteochondromatosis. Rice bodies differ from villonodular synovitis with the absence of hemosiderin deposits, and from osteochondromatosis with the absence of radiographic evidence of ossification in the soft tissues. Synovial chondromatosis was a differential diagnosis in this case. This rarely involves a synovium lined bursa[15] and has an unmineralised metaplastic cartilage.[16] In unossified synovial chondromatosis, MRI will be helpful in the differential diagnosis. As rice bodies are rich of fibrous structures, they appear darker (hypointense) in T2-weighted images, close to the intensity of muscles. In contrast, synovial chondromatoses are rich in cartilage and appear more hyperintense, compared to rice bodies.[3,17]

Looking at the MR images of our case and other patients, we believe the T2-weighted images can be an important criterion in diagnosis and differential diagnosis. Although symptomatic improvements with long-acting steroids, aspiration and lavage have been reported, basic approach in the treatment is surgical excision.[13,18] No recurrence was observed in the follow-up period of two years, following the excision of rice bodies in our case. It should be kept in mind that rice bodies can be seen in an extra-articular localization and with no association with a systemic inflammatory disease. Clinical examination and MRI are of great importance in diagnosis and surgical excision will provide a safe and definitive treatment.

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3. Chung C, Coley BD, Martin LC. Rice bodies in juvenile rheumatoid arthritis. AJR Am J Roentgenol 1998 170:698-700.[PubMed]
4. Cuomo A, Pirpiris M, Otsuka NY. Case report: biceps tenosynovial rice bodies. J Pediatr Orthop B 2006 15: 423-425.
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