‘Treat every patient as if it is your family’
Prof. dr. Dr. Gino Kerkhoffs has seen a variety of cases in his years working as an orthopedic surgeon. It goes too far to list everything. So on this page you will find a few gems that are both special and representative of Kerkhoffs’ vision and expertise.
A 17-year-old elite youth football player was referred to our Academic Center for Evidence based Sports medicine (www.acesamsterdam.nl). The patient was 1.89m in length and weighed 74 kilograms, left-footed and playing on the central midfield position. No specific history to the foot highly relevant to the current diagnosis was noted, apart from the patient presenting with a smaller right foot in length (-1.5 in European size) in comparison to the contralateral side. The patient had developed the current pain on the lateral side of the right foot without a clear traumatic onset and the pain eventually kept him from the pitch and also gave substantial pain on walking in daily life. Prior treatment had consisted of a conservative treatment protocol (immobilization period for 6 weeks) that did not resolve the symptoms.
On physical examination we saw a patient with a slight cavovarus foot. Adequate balance as well as adequate propriocepsis and strength of the musculature of the lower extremity was seen. Walking on his tiptoes was painful (recognizable) on the lateral side of the foot. There was no medial or lateral laxity of the ankle. There was a recognizable pain on palpation of the peroneus longus tendon over the cuboid. Resistance tests of the isolated peroneus longus was also positive for recognizable pain. The peroneus brevis was not painful. The pre-operative patient-reported outcome measures (PROMs) are listed in Table 1.
A peroneus longus tendinopathy was suspected. In order to evaluate both the tendinous component as well as the osseous components (os peroneum, shape of the cuboid, spurs, fragments) it was decided to obtain both an MRI scan (Figures 2, 3, and 4) and CT scan (Figure 5). The CT scan was made additional to the MRI scan due to the fact that the previous MRI scan having been made at a referring center showed a zone of bone marrow edema in the cuboid suggesting the presence of osseous pathology.
A 25 year old man presented to the emergency department of our hospital with persistent swelling and pain in his right heel. Two weeks before, while riding a wave in a professional competition off the coast in Portugal, he had suddenly felt a violent thump and pain in his right heel. The sharp pain and
profuse bleeding caused him to be thrown off the wave and return to shore. On arrival in the Portuguese emergency ward, initial evaluation revealed a foreign body sticking out of the right heel. The doctor removed the protruding part of the foreign body and bandaged the wound. Thereafter the patient was discharged from further care.
Two days later, on return to the Netherlands, the heel was still warm, swollen, and painful. Consultation with the patient’s general practitioner and sports medicine doctor resulted in prescription of rest and antibiotics (flucloxacillin 500 mg four times a day) for seven days. After the antibiotic course had been completed, the swelling and pain persisted although there was no fever. Three days later the patient presented to the emergency department. Initial evaluation showed a painful, inflamed, fluctuating swelling at both the medial and lateral side of the right heel. The lateral wound produced a small amount of pus. Body temperature was 37.1̊C.
The presence of a foreign body was noted on a standard lateral radiograph of the heel. This was seen as opacity at the cranial border of the posterior part of the calcaneus. This opacity was shaped as two dense parallel lines (fig 1). With the clinical characteristics and our anamnestic experience, a fish wound was suspected. The fish was found to be a needlefish, a member of the Belonid family (fig 2). The patient was operated on the same day.
The patient underwent surgical exploration of the lateral and medial side of the right heel with removal of the fish remnants and careful debridement (fig 3). Antibiotics were not prescribed, because all the foreign body had been removed. The wound was left to heal by secondary intention.
The wound was dressed with wet gauze and flushed twice daily. The patient was kept in hospital for two days, and immediate improvement was seen. There were no complica- tions. Four weeks after the accident, the patient had resumed his professional activities.
Thanks to a radical and revolutionary physiotherapeutic treatment, one of the most successful hockey players of all time recovered from a serious hamstring injury in record time. This case demonstrated that a classic and very expensive orthopedic intervention, with an extremely long rehabilitation period, is not always necessary.