Isolated Subtalar Repositional Arthrodesis Compared With Triple Arthrodesis for the Treatment of Progressive Collapsing Foot Deformity.

The optimal extent of arthrodesis for severe and rigid progressive collapsing foot deformity is controversial. Traditionally, triple arthrodesis has been recommended; however, good results have been reported using subtalar arthrodesis only. We compared the results of triple arthrodesis and isolated subtalar repositional arthrodesis. A total of 22 symptomatic feet were evaluated retrospectively. Isolated subtalar repositional arthrodesis was performed in 13 cases (the subtalar group) and double or triple arthrodesis in 9 cases (the triple group). Various radiographic variables for assessing flatfoot and osteoarthritic changes in ankle and tarsal joints were measured and compared between the 2 groups at 3 time points: preoperatively, 3 months postoperatively, and 4 y postoperatively. Additionally, we analyzed various factors that affect postoperative valgus talar tilt in the ankle joint, which has been associated with poor prognosis. There were no differences in preoperative demographic data and the severity of the disease between the 2 groups; both groups showed improvement in radiographic parameters postoperatively compared with preoperative results. With the numbers available, no significant differences could be detected in postoperative radiographic measurements between the 2 groups. Of all the variables analyzed, postoperative hindfoot alignment angle was associated with postoperative talar tilt development. Additionally, postoperative talar tilt was observed more in triple group than in subtalar group. In conclusion, isolated subtalar repositional arthrodesis is an effective procedure to correct advanced progressive collapsing foot deformity. In addition, Chorpart joint arthrodesis with improper position can cause valgus talar tilt in the ankle joint.

The Effects of Tibialis Anterior Tenotomy on Wound Complications and Functional Outcomes After Anterior Fusion Plating for Severe Ankle Arthritis.

Nonunion is known to be a relatively common complication following ankle arthrodesis. Various fixation techniques have been introduced to enhance the stability and to improve fusion rate. With the use of anterior plate supplementation, postoperative wound problems have been frequently reported despite better fusion rate. This study was performed to determine the effects of tibialis anterior (TA) tenotomy on wound complications and functional outcomes after anterior fusion plating for severe ankle arthritis. Forty-six patients who underwent ankle arthrodesis using anterior fusion plate were followed for more than 2 years. TA tenotomy was performed prior to wound closure in all patients. As a control group, 38 patients who underwent arthrodesis without TA tenotomy were analyzed. Functional outcomes were evaluated with Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure. Wound complication rate, time to fusion, fusion rate, time to pain relief were evaluated. Mean Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure scores significantly improved to 32.6 and 69.4 points at final follow-up, respectively. As compared to control group (33.8 and 67.7 points), there were no significant differences in functional outcomes. As postoperative wound complications, there were 1 case of wound dehiscence and 1 case of superficial wound infection. TA tenotomy group showed a significantly lower wound complication rate (4.3%) than control group (23.7%) (p < .001). While there were no significant differences in fusion rate, time to fusion, and time to pain relief between both groups, control group needed higher rate of implant removal. Ankle arthrodesis using anterior fusion plate in conjunction with TA tenotomy appears to be an effective surgical option for end-stage ankle arthritis, with excellent fusion rate and less wound complication rate. Although there were no specific functional deficits related to absence of TA tendon, further studies are needed to determine long-term effects of TA tenotomy in patients with a fused ankle.

Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients.

INTRODUCTION: Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population. METHODS: We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures. RESULTS: Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074). CONCLUSION: Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.

A quantitative evaluation of the individual components contributing to the functional ankle instability in patients with modified Broström procedure.

Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. A total of 46 patients (46 ankles) underwent the MBP for chronic ankle instability were eligible for this study and were followed for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a 6-meter hop test, and a cross 3-meter hop test. The error in joint-position sense significantly improved from a mean 4.3º to 2.8º (p < .001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm (p = .024). Balance retention time significantly improved from a mean 4.7 seconds to 6.4 seconds (p < .001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively (p = .031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense (p < .001), 86.9% in peroneal strength (p = .012), and 74.4% in postural control (p < .001) with significant side-to-side differences. Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively.

The Influence of Suture-Tape Augmentation on Biological Healing of the Anterior Talofibular Ligament in Chronic Ankle Instability: A Quantitative Analysis Using MRI.

While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL.

Lateral Collateral Ligament Reconstruction Using Suture-tape for Chronic Varus Metatarsophalangeal Instability of The Hallux.

Chronic varus instability or recurrent subluxation following isolated metatarsophalangeal dislocation of the hallux is a rare injury. A young Judo athlete with a history of repetitive sport injuries complained of recurrent medial dislocation of the hallux for 3 years. For prior injuries, he underwent manual reduction under local anesthesia and recovered with splint immobilization. Physical examination and fluoroscopic radiograph demonstrated the reducible but unstable first metatarsophalangeal joint to slight varus stress, and magnetic resonance imaging revealed an insufficient remnant of the lateral collateral ligament. For patients with the failed conservative treatment, no consensus has been reached regarding the best joint-salvage procedure to achieve a restoration of metatarsophalangeal stability and a fast return to sport activity. We report a case who achieved satisfactory clinical outcome through the collateral ligament reconstruction using a suture-tape.

Realignment Calcaneal Osteotomy for Bilateral Complete Talocalcaneal Synostosis: A Case Report.

Talocalcaneal synostosis is a congenital failure of the segmentation between tarsal bones. It may be very difficult to differentiate from talocalcaneal coalition, known as the most common tarsal coalition, especially in cases with a large bone bridge. Complete talocalcaneal synostosis is very rare, and there are few references in the literature about the clinical outcomes and operative methods for symptomatic synostosis. We report a case of a 15-year-old female with bilateral complete talocalcaneal synostosis and heel varus deformity who has experienced good clinical results after lateral sliding calcaneal osteotomy for hindfoot realignment.

Prognostic factors for intermediate-term clinical outcomes following Bosworth fractures of the ankle joint.

BACKGROUND: This retrospective comparative study was performed to evaluate the clinical outcomes after surgical treatment for Bosworth fracture-dislocation, and to analyse the prognostic factors related to postoperative outcomes. METHODS: Fifteen patients were followed for ≥2 years after Bosworth fracture-dislocation. Twenty-five ankle fracture-dislocations as control group were enrolled to compare clinical outcomes. Clinical evaluation consisted of the AOFAS and Olerud-Molander scores. Patient and injury factors were analysed to identify the outcome predictors. RESULTS: There were no significant differences in either clinical evaluation score as compared to control group (P=0.245, .302, respectively). The time interval to operation and number of manual reduction attempts were found to be predictive factors for poor outcomes (P=0.004, .038, respectively). CONCLUSION: As compared to more common patterns of ankle fracture-dislocations, intermediate-term clinical outcomes after Bosworth fracture-dislocations were statistically comparable. Delayed surgical reduction and repeated attempts at closed reduction appear to be negative outcome predictors.

The peroneal strength deficits in patients with chronic ankle instability compared to ankle sprain copers and normal individuals.

BACKGROUND: Despite a consensus regarding the correlation of peroneal strength deficit with chronic ankle instability (CAI), there are conflicting reports in regards to peroneal strength as assessed by isokinetic dynamometer in patients with CAI. The purpose of this study was to evaluate the changes of isokinetic strength in patients with CAI compared to ankle sprain copers and normal individuals. METHODS: Forty-two patients (CAI group) with chronic ankle instability who were scheduled for the modified Broström procedure met inclusion criteria. Thirty-one ankle sprain copers (ASC group) who were eligible at 6 months after acute injury and 30 controls were recruited. The muscle strength associated with four motions of the ankle were evaluated using isokinetic dynamometer. RESULTS: Peak torque for inversion and eversion at 60°/s angular velocity were significantly lower in the CAI group compared to the ASC and control group (P=.004, P<.001, respectively). Deficit ratio of peak torque for eversion at 60°/s and 120°/s in the CAI group were 33.8% and 19.8%, respectively, which indicated significant side to side differences (both P<.001). The evertor/invertor strength ratio (0.59) for eversion at 60°/s was significantly lower in the CAI group (P<.001). CONCLUSION: As compared to the ankle sprain copers and normal individuals, patients with chronic ankle instability who were scheduled for modified Broström procedure demonstrated a significant weakness of isokinetic peroneal strength. Isokinetic muscular assessment can provide the useful preoperative informations regarding functional ankle instability focusing on peroneal weakness.

A randomized comparison between lateral ligaments augmentation using suture-tape and modified Broström repair in young female patients with chronic ankle instability.

BACKGROUND: Although various minimally invasive procedures for chronic ankle instability are increasingly being used, a question regarding whether these procedures can be a viable alternative of the modified Broström procedure remains controversial. This study was conducted to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients. METHODS: Sixty female patients with chronic lateral ankle instability were randomly assigned and underwent surgical treatments by one surgeon. Twenty-eight patients with suture-tape augmentation and 27 modified Broström procedures were followed ≥2 years and analysed in this comparative study. The clinical evaluation included the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and stress radiographs. Medical expense related with operation was analysed to evaluate the cost-effectiveness. RESULTS: There were no statistically significant differences in the clinical outcomes between two procedures based on FAOS, FAAM, recurrence rate of instability, and stress radiographs. Total medical expense was approximately 1.3 times more in the suture-tape group (P<0.001), despite shorter operation time. CONCLUSIONS: Lateral ankle ligaments augmentation using suture-tape showed the similar clinical outcomes but low cost-effectiveness, as compared to modified Broström repair for young female patients with chronic ankle instability.

Is generalized ligamentous laxity a prognostic factor for recurred hallux valgus deformity?

BACKGROUND: This study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity. METHODS: There were 23 cases in laxity group (Beighton score ≥5 points) and 175 in non-laxity group with a mean followup of 46.3 months. Clinical evaluation consisted of the AOFAS score, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis. RESULTS: Recurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (P=.218). There were no significant differences in clinical and radiographic measurements at final followup between the 2 groups. Preoperative HVA and IMA were found to be predictive factors of recurrence (OR=6.3, 4.2; P=.001, .018, respectively). CONCLUSION: There were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity.

Revision with suture-tape augmentation after failed collateral ligament reconstruction for chronic interphalangeal instability of the hallux.

Chronic varus instability or recurrent subluxation following isolated interphalangeal dislocation of the hallux is a rare injury. No consensus has been reached regarding the best joint-salvage procedure for patients with the failed collateral ligament reconstruction using tendon graft. We report a case who achieved satisfactory clinical outcome through a modified surgical procedure (revision collateral ligament reconstruction augmented with suture-tape).

A new screening method for multidirectional shoulder instability on magnetic resonance arthrography: labro-capsular distance.

OBJECTIVE: To compare the capsular dimension as measured on magnetic resonance arthrography (MRA) between patients with multidirectional instability (MDI) of the shoulder and control subjects without instability. Ultimately, we aimed to develop an easy and reliable new screening method to assess MDI of the shoulder using MRA. MATERIALS AND METHODS: MRA images of patients with MDI of the shoulder (n = 25) during a 6-year period (February 2010 to May 2015) were retrospectively reviewed. A control group (n = 26) without instability was also identified. The capsular area was measured using a new screening method we termed labro-capsular (LC) distance. MRA images of the two groups were randomly mixed, and two orthopedic surgeon reviewers recorded anterior, posterior, and inferior LC distance measurements on axial and coronal images using a mid-glenoid cut. RESULTS: The inferior LC distance increased significantly in the patient group versus control group (P < 0.001), but there were no statistically significant differences in the anterior (P = 0.1165) and posterior (P = 0.5229) LC distances. An inferior LC distance >16.88 mm is most suggestive of MDI of the shoulder because of its high sensitivity (76 %) and specificity (96 %). CONCLUSION: The inferior LC distance can be easily and quickly measured and used as an effective clinical screening method for atraumatic MDI of the shoulder.

Percutaneous Deltoid Ligament Augmentation Using Suture Tape for Medial Ankle Instability.

Compared with lateral ankle instability, medial ankle instability has many fewer treatment strategies and fewer reconstructive options available. The best method for deltoid ligament reconstruction remains unclear. Percutaneous deltoid ligament augmentation using suture tape represents a novel alternative technique for chronic medial ankle instability.

A ligament reattachment technique for high-demand athletes with chronic ankle instability.

The present prospective study was conducted to evaluate the clinical outcomes of the new ligament reattachment procedure for chronic lateral ankle instability in high-demand athletes. A total of 24 athletes <30 years old were followed for >2 years after undergoing the modified Brostrom procedure using the suture bridge technique. The clinical evaluation included the Karlsson score, the Sefton grading system, and the period to return to exercise. As an evaluation of mechanical stability, the talar tilt angle and anterior talar translation were measured on stress radiographs. The Karlsson score had improved significantly from a preoperative average of 43.5 points to 92.2 points. Using the Sefton grading system, 22 (91.7%) patients achieved satisfactory results. The period to return to exercise was as follows: a mean of 8.4 weeks for jogging, 12.5 weeks for spurt running, 10.5 weeks for jumping, 9.2 weeks for 1 leg standing for >1 minute, 10.6 weeks for walking on uneven ground, and 11.2 weeks for going downstairs. The talar tilt angle and anterior talar translation had improved significantly from the preoperative average of 15.4° and 13.3 mm to 3.8° and 4.2 mm at 2 months postoperatively and 4.9° and 4.8 mm at the final follow-up visit, respectively. The modified Brostrom procedure using the suture bridge technique resulted in satisfactory clinical outcomes comparable to those with conventional ligament reattachment techniques. The suture bridge technique appears to be an effective treatment option for chronic ankle instability in high-demand athletes.

Dynamic positional deformity of the hallux.

The present study reports a case with concomitant tethering of the flexor tendon and extensor tendon of the hallux after closed tibiofibular shaft fractures. We have obtained good clinical results using tenotomy of the flexor hallucis longus tendon and Z-plasty lengthening of the extensor hallucis longus tendon. Because few studies have described the clinical results and operative methods for this type of combined deformity, we report a case with dynamic positional deformity of the hallux.

Outcomes of the modified Brostrom procedure using suture anchors for chronic lateral ankle instability--a prospective, randomized comparison between single and double suture anchors.

The present prospective, randomized study was conducted to compare the clinical outcomes of the modified Brostrom procedure using single and double suture anchors for chronic lateral ankle instability. A total of 50 patients were followed up for more than 2 years after undergoing the modified Brostrom procedure. Of the 50 procedures, 25 each were performed using single and double suture anchors by 1 surgeon. The Karlsson scale had improved significantly to 89.8 points and 90.6 points in the single and double anchor groups, respectively. Using the Sefton grading system, 23 cases (92%) in the single anchor group and 22 (88%) in the double anchor group achieved satisfactory results. The talar tilt angle and anterior talar translation on stress radiographs using the Telos device had improved significantly to an average of 5.7° and 4.6 mm in the single anchor group and 4.5° and 4.3 mm in the double anchor group, respectively. The double anchor technique was superior with respect to the postoperative talar tilt. The single and double suture anchor techniques produced similar clinical and functional outcomes, with the exception of talar tilt as a reference of mechanical stability. The modified Brostrom procedure using both single and double suture anchors appears to be an effective treatment method for chronic lateral ankle instability.

Comparison of Intermediate-Term Clinical Outcomes Between Medial and Lateral Osteochondral Lesions of the Talus Treated With Autologous Osteochondral Transplantation.

BACKGROUND: The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure. METHODS: Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt. RESULTS: The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups. CONCLUSION: A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy. LEVEL OF EVIDENCE: Level IV, retrospective comparative study.

Point-of-Care Testing of the MTF1 Osteoarthritis Biomarker Using Phenolphthalein-Soaked Swabs.

Osteoarthritis (OA) is the most common joint disease, which accompanies pain and inconvenience in daily life owing to degradation of cartilage and adjacent tissues. In this study, we propose a simple point-of-care testing (POCT) kit for the detection of the MTF1 OA biomarker to achieve on-site clinical diagnosis of OA. The kit contains an FTA card for patient sample treatments, a sample tube for loop-mediated isothermal amplification (LAMP), and a phenolphthalein-soaked swab for naked eye detection. The MTF1 gene was isolated from synovial fluids using an FTA card and amplified using the LAMP method at 65 °C for 35 min. A test part of the phenolphthalein-soaked swab was decolorized in the presence of the MTF1 gene due to the pH change after the LAMP, but the color remained pink in the absence of the MTF1 gene. The control part of the swab served as a reference color in relation to the test part. When real-time LAMP (RT-LAMP), gel electrophoresis, and colorimetric detection of the MTF1 gene were performed, the limit of detection (LOD) was confirmed at 10 fg/µL, and the overall processes were completed in 1 h. The detection of an OA biomarker in the form of POCT was reported for the first time in this study. The introduced method is expected to serve as a POCT platform directly applicable by clinicians for easy and rapid identification of OA.

Comparison between suture anchor and transosseous suture for the modified-Broström procedure.

BACKGROUND: This prospective, randomized study was conducted to compare clinical outcomes of the modified Broström procedure using suture anchor or transosseous suture technique for chronic ankle instability. METHODS: Forty patients were followed for more than 2 years after modified Broström procedure. Twenty procedures using a suture anchor and 20 procedures using a transosseous suture were performed by one surgeon. The clinical evaluation consisted of the Karlsson scale and the Sefton grading system. Talar tilt and anterior talar translation were measured on anterior and varus stress radiographs. RESULTS: The Karlsson scale had improved significantly to 90.8 points in the suture anchor group, and to 89.2 points in the transosseous suture group. According to Sefton grading system, 18 patients (90%) in suture anchor group and 17 patients (85%) in transosseous suture group achieved satisfactory results. The talar tilt angle and anterior talar translation improved significantly to 5.9 degrees and 4.2 mm in suture anchor group, and to 5.4 degrees and 4.1 mm in transosseous suture group, respectively. CONCLUSION: No significant differences existed in clinical and functional outcomes between the two techniques for ligament reattachment. Both modified Broström procedures using the suture anchor and transosseous suture seem to be effective treatment methods for chronic lateral ankle instability.