Medial sesamoid position in moderate to severe hallux valgus: Correlation between three radiographic measurements.

BACKGROUND: In hallux valgus surgery, it is essential to accurately assess the position of the sesamoids both pre- and postoperatively. Weight-bearing foot anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views are radiographic methods used to assess the medial sesamoid position. This study aimed to measure the medial sesamoid position and evaluate the correlation between these three radiographic methods. METHODS: This retrospective study comprised 59 feet from 49 patients who underwent hallux valgus surgery. The mean age of patients was 54.6 (range, 22-70) years. We took preoperative and postoperative measurements using the weight-bearing anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views to assess the medial sesamoid position. RESULTS: The mean grades of the medial sesamoid position preoperatively and 6 months postoperatively were 2.5 and 0.8, 1.6 and 0.4, and 1.3 and 0.3 points based on the anteroposterior, tangential sesamoid, and computed tomography axial views, respectively (P < 0.001). Preoperatively, there was a strong positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.645) and anteroposterior and computed tomography axial views (P < 0.001, r = 0.468). In contrast, the tangential sesamoid and anteroposterior views showed a weak positive correlation (P = 0.03, r = 0.283). Six months postoperatively, there was a positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.473), anteroposterior and computed tomography axial views (P < 0.001, r = 0.470), and tangential sesamoid and anteroposterior views (P < 0.001, r = 0.480). CONCLUSIONS: We observed that the anteroposterior view exhibited a higher degree of medial sesamoid position displacement than the computed tomography axial and tangential sesamoid views. For the preoperative evaluation of the medial sesamoid position, the correlation between the computed tomography axial and tangential sesamoid views was stronger than that between the tangential sesamoid and anteroposterior views. However, all three views showed strong correlations postoperatively.

Evaluation of clinico-radiological outcome of fibular valgization osteotomy with supra-malleolar osteotomy in patients with ankle osteoarthritis.

PURPOSE: There are controversies about combining distal tibia medial opening-wedge osteotomy (DTMO) with fibular valgization osteotomy (FVO) when performing supramalleolar osteotomy (SMO) for medial ankle osteoarthritis. This study aimed to assess the effect of FVO on the coronal translation of the mechanical axis by comparing the improvement of radiological indices after DTMO with and without FVO. METHODS: Forty-three ankles (mean follow-up: 42.0 months) were reviewed after SMO. Among them, 35/43 (81.4%) underwent DTMO with FVO, while 8/43 (18.6%) underwent DTMO only. To evaluate the effect of FVO radiologically, the medial gutter space (MGS) and talus centre migration (TCM) were measured. RESULTS: Post-operatively, MGS and TCM were not significantly different after DTMO only and DTMO with FVO. However, the improvement of MGS was significantly higher in the combined FVO group (0.8 mm (standard deviation [SD] 0.8 mm) vs. 1.5 mm (SD 0.8 mm); p = 0.015). More lateral translation of the talus was achieved in the FVO group (5.1 mm (SD 2.3 mm) vs. 7.5 mm (SD 3.0 mm); p = 0.033). However, the changes in the MGS and TCM were not significantly correlated with the clinical outcomes (p > 0.05). CONCLUSION: Our radiological evaluation confirmed a significant medial gutter space widening and lateral talar translation after the addition of FVO. The SMO with fibular osteotomy allows greater shifting of the talus and, therefore, the weight-bearing axis.

Comparative Analysis of Subtalar Ligaments Between Patients With Talocalcaneal Coalition and Control Subjects Using 3-Dimensional Magnetic Resonance Imaging.

PURPOSE: The purpose of this study was to find the differences in the subtalar ligaments between patients with talocalcaneal (TC) coalition and control subjects using 3-dimensional isotropic magnetic resonance imaging. METHODS: Magnetic resonance imaging of 27 ankles with TC coalition and 27 age- and sex-matched controls were retrospectively reviewed. Absence of cervical ligament, anterior capsular ligament (ACL), interosseous TC ligament (ITCL), and partial or complete absence of 3 roots of the inferior extensor retinaculum was analyzed. Thickness and width of ACL and ITCL were measured when possible. RESULTS: Absence of ACL and ITCL was significantly more frequent in TC coalition patients than in controls (59.2% vs 7.4%, P < 0.0001; 44.4% vs 7.4%, P = 0.004). Absence of cervical ligament and 3 roots of the inferior extensor retinaculum did not differ between the 2 groups. Thickness and width of ACL were significantly smaller in TC coalition patients than in control subjects (0.81 ± 0.23 vs 1.27 ± 0.41 mm, P < 0.0001; 5.26 ± 1.17 vs 7.07 ± 1.46 mm, P = 0.001). Thickness and width of ITCL did not differ between the 2 groups. In the TC coalition group, the absence of ACL and ITCL did not differ according to coalition type, patient demographics, and magnetic resonance imaging units. CONCLUSIONS: Anterior capsular ligament and ITCL are frequently absent in TC coalition patients. Even when present, the ACL is attenuated in TC coalition patients compared with controls.

Feasibility of MRI for the evaluation of interosseous ligament vertical segment via subtalar arthroscopy correlation: comparison of 2D and 3D MR images.

BACKGROUND: Interosseous ligament vertical segment (IOLV) and calcaneofibular ligament (CFL) have been reported to be important in stabilizing the subtalar joint. Unlike CFL, there is not much information regarding the comparison of MRI results with surgical evaluation of IOLV and the comparison between 2D and 3D MRI on IOLV evaluation. The feasibility of MRI in IOLV evaluation has yet to be reported. The purpose of this study was to evaluate the validity and reliability of MRI in IOLV tear detection via correlation with arthroscopic results. We also compared the diagnostic performance of 2D and 3D MR images. METHODS: In this retrospective study, 52 patients who underwent subtalar arthroscopy after ankle MRI were enrolled. Arthroscopic results confirmed IOLV tear in 25 cases and intact IOLV in 27 cases. Two radiologists independently evaluated the IOLV tears using only conventional 2D images, followed by isotropic 3D images, and comparison with arthroscopic results. RESULTS: Only the 2D sequences interpreted by two readers showed a sensitivity of 64.0-96.0%, a specificity of 29.6-44.4%, a positive predictive value of 51.6-56.4%, and a negative predictive value of 57.1-88.9%. Addition of isotropic 3D sequences changed the sensitivity to 60.0-80.0%, specificity to 63.0-77.8%, positive predictive value to 64.3-76.9%, and negative predictive value to 66.7-80.8%. The overall diagnostic performance of isotropic 3D sequences (AUC values: 0.679-0.816) was higher than that of 2D sequences (AUC values: 0.568-0.647). Inter-observer and intra-observer agreement between the two readers was moderate-to-good for both 2D and 3D sequences. The diagnostic accuracy in 19 patients with tarsal sinus fat obliteration tended to increase from 26.3-42.1% to 57.9-73.7% with isotropic 3D sequences compared with 2D sequences. CONCLUSIONS: Isotropic 3D MRI was feasible for the assessment of IOLV tear prior to subtalar arthroscopy. Additional 3D sequences showed higher diagnostic accuracy compared with conventional 2D sequences in IOLV evaluation. Isotropic 3D sequences may be more valuable in detecting IOLV tear in case of tarsal sinus fat obliteration.

A high rate of talocalcaneal interosseous ligament tears was found in chronic lateral ankle instability with sinus tarsi pain.

PURPOSE: To evaluate the arthroscopic findings of subtalar joints, including interosseous talocalcaneal ligament (ITCL) tear, in patients with chronic lateral ankle instability (CLAI) and sinus tarsi pain. METHODS: A total of 118 ankles (109 patients) having CLAI with sinus tarsi pain who had undergone subtalar arthroscopy and lateral ankle ligament surgery were evaluated. The medical records, radiologic images, and the arthroscopic images and videos were reviewed. ITCL tears were classified into 4 grades: grade 0 (no tear), grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The efficacy of magnetic resonance imaging (MRI) in diagnosing ITCL tears was also evaluated by comparing preoperative official readings of MRI to arthroscopic findings. The pre- and postoperative functional scores were also assessed. RESULTS: The overall tear rate of ITCL was 107/118 (90.7%). There were 29 ankles (23.6%) with grade 1, 42 ankles (35.6%) with grade 2, and 36 ankles (30.5%) with grade 3 tears. Isolated lateral ankle instability (LAI) was diagnosed in 43 ankles (36.4%), subtalar instability (STI) in 30 ankles (25.4%), and LAI with STI in 45 ankles (38.1%). There was a statistically significant relationship between the ITCL tear grade and the final diagnosis. ITCL tear was confirmed or suspected in 81 ankles (68.6%) on preoperative MRI. Pain Visual Analog Score and functional outcome scores including the American Orthopaedic Foot & Ankle Society and Karlsson-Peterson scores showed significant improvement after the surgery. CONCLUSION: A high rate (90.7%) of ITCL tears was noted in CLAI patients with sinus tarsi pain. ITCL damage may play an important role in subtalar instability in patients with CLAI and sinus tarsi pain. Subtalar arthroscopic evaluation for ITCL tear is important for correct diagnosis for CLAI with sinus tarsi pain. LEVEL OF EVIDENCE: IV.

Ligament stabilization improved clinical and radiographic outcomes for individuals with chronic ankle instability and medial ankle osteoarthritis.

PURPOSE: Chronic ankle instability with a long symptom duration is often accompanied by medial compartment ankle osteoarthritis (OA). However, the outcomes of individuals after ligament stabilization have rarely been reported. The radiographic and clinical outcomes after ligament stabilization in individuals with chronic ankle instability and medial compartment OA were investigated. METHODS: The study investigated 27 ankles with chronic ankle instability and medial compartment OA that underwent lateral ankle ligament reconstruction from 2007 to 2015 with a follow-up period of at least 1 year. Ligament stabilization was performed via either the modified Broström procedure (MBP) or lateral ankle reconstruction (LAR) using semitendinosus tendon allografts. RESULTS: The median instability duration was 60 (range 12-480) months, and the median follow-up period was 39 (range 12-108) months. The preoperative Takakura ankle OA stage was predominantly stage I (20 patients (74.1%)), followed by stage II (five patients (18.5%)). Ankle MRI (20 ankles) revealed medial cartilage denudation in three cases (15%), cartilage thinning in nine cases (45%), osteophyte formation in ten cases (50%), and loose body formation in six cases (30%). According to the arthroscopic results, the modified Outerbridge grade was two in nine cases and four in ten cases, so these grades were the most common (37.5% and 41.7%, respectively). The MBP was performed in 14 patients, and LAR was performed in 13 patients (52% and 48%, respectively); the bone marrow stimulation procedure was performed in 15 patients (55%). The visual analogue scale score decreased from 6.0 (SD 1.6) preoperatively to 1.8 (SD 1.6) postoperatively (p = 0.000). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score improved from 61.9 (SD 14.2) to 89.7 (SD 6.2), and the Karlsson-Peterson score improved from 54.7 (SD 13.9) to 88.3 (SD 9.0) (p = 0.000). There were no serious complications, and all patients were satisfied. CONCLUSIONS: Ligament stabilization with arthroscopic procedures for individuals with chronic ankle instability and medial ankle OA yielded significant functional outcomes with high patient satisfaction, even without radiographic improvement. LEVEL OF EVIDENCE: IV.

Differences Between Subtalar Instability and Lateral Ankle Instability Focusing on Subtalar Ligaments Based on Three Dimensional Isotropic Magnetic Resonance Imaging.

OBJECTIVE: The purpose of this study was to assess the differences between subtalar instability (STI) and lateral ankle instability (LAI) focusing on subtalar ligaments using 3-dimensional (3D) isotropic magnetic resonance imaging (MRI). METHODS: Preoperative MRIs of 10 patients with STI who failed nonoperative treatment and consequently underwent arthroscopic subtalar reconstruction were compared with preoperative MRIs of 23 patients with LAI who underwent ligament repair or reconstruction. Dimensions of anterior capsular ligament (ACL), interosseous talocalcaneal ligament (ITCL), calcaneofibular ligament (CFL), and anterior talofibular ligament (ATFL) were measured. Tears of ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed. RESULTS: Patients with subtalar instability had significantly lower ACL thickness and width than patients with LAI (thickness: 1.48 vs 2.12 mm, P = 0.045; width: 7.30 vs 8.64 mm, P = 0.029). An ACL thickness of 1.8 mm or less had sensitivity and specificity both at 75.0%, and an ACL width of 8 mm or less had sensitivity of 75.0% and specificity of 85.0% for discriminating STI from LAI. Absence or complete tear of ACL was more frequent in patients with STI than in patients with LAI (60.0% vs 13.0%, P = 0.010). The ATFL thickness was significantly greater in patients with LAI (P = 0.001). Complete tear of ATFL was more common in patients with LAI (P = 0.008). Complete tear of CFL was common in both the STI and LAI groups without significant difference (20.0% vs 21.7%). There was no significant difference in thickness and width of ITCL and in CFL thickness. Complete tear of ITCL, cervical ligament, and inferior extensor retinaculum were rare without significant difference. CONCLUSION: In patients with STI, the ACL is thin and narrow and more commonly absent or torn compared with patients with LAI. Complete tear of ATFL was more common in patients with LAI. Complete tear of CFL was commonly encountered in both the STI and LAI groups.

CT arthrography visualizes tissue growth of osteochondral defects of the talus after microfracture.

PURPOSE: Little is known about the arthroscopic or radiographic outcomes after arthroscopic microfracture of osteochondral lesions of the talus (OLTs). The purpose of this study was to investigate tissue growth after arthroscopic microfracture of OLTs using computed tomography arthrography (CTA) and to identify the relationship between CTA findings and clinical outcomes. We hypothesized that the morphology of the repaired tissue would be similar to that of normal anatomy and correlate with the clinical outcomes. METHODS: Forty-two ankles treated using arthroscopic microfracture of OLTs between 2009 and 2014 were monitored. CTA was performed post-operatively at 6 months and at 1 and 2 years after surgery. The post-operative thickness of the repaired tissue associated with OLT (grade) and the volume of the subchondral cystic lesions were evaluated using CTA. Clinical outcomes, including the pain visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle functional scores, were evaluated and correlated with CTA. RESULTS: The proportion of fully grown tissue (grade 3) increased over time; specifically, the rates were 12/40 (33.3%) at 6 months, 11/18 (61.1%) at 1 year, and 8/10 (80%) at 2 years after surgery (p = 0.005). The VAS pain (p < 0.001) and AOFAS scores (p < 0.001) were also improved at the final follow-up; however, they were not associated with repaired tissue thickness as shown by CTA (n.s.). CONCLUSIONS: After microfracture of OLTs, tissue growth in the osteochondral defects was well visualized using CT arthrography and was observed in most cases. However, the CTA findings were not related to the clinical outcomes. LEVEL OF EVIDENCE: IV.

The effect of smoking on the outcomes of lateral ankle ligament reconstruction.

BACKGROUND: Although smoking is known to be harmful to the musculoskeletal system, no studies have investigated its effects on the outcomes of ankle ligament surgery. We determined the effects of smoking on the clinical and radiological outcomes of lateral ankle ligament reconstruction using tendon allografts according to smoking status. METHODS: From among 105 patients with chronic ankle instability who were treated with anatomical reconstruction of the anterior talofibular ligament and the calcaneofibular ligament using semitendinosus tendon allografts and bio-tenodesis screws, 70 ankles, from 23 smokers and 47 non-smokers, were analyzed. Visual analog scale (VAS) pain scores, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, Karlsson scores and complications were routinely determined at each follow-up visit. Anterior translation and the talar tilt angle on radiographic stress views were also assessed. RESULTS: The mean follow-up period was 21.8 months (12-68 months). No significant differences were observed between the two groups with respect to age, gender, body mass index, or the duration of preoperative symptoms. The mean preoperative pain VAS scores were 5.8 and 5.3 among non-smokers and smokers, respectively. Postoperatively, the mean pain VAS score improved to 1.4 in both groups (p < 0.001). Clinical and radiographic measures did not show significant changes according to the presence of smoking after surgery. However, two wound complications, 1 delayed healing and 1 superficial necrosis, occurred in non-smokers, whereas five, 2 delayed healing, 2 superficial infections and 1 superficial necrosis in smokers (p = 0.035). CONCLUSION: The radiographic outcomes of smokers were comparable to those of non-smokers in the short term, whereas wound complications were more common in the smoker group.

Subtalar instability: imaging features of subtalar ligaments on 3D isotropic ankle MRI.

BACKGROUND: MRI analysis of subtalar ligaments in the tarsal sinus has not been well performed. We retrospectively investigated the appearance of subtalar ligaments using 3D isotropic MRI and compared imaging findings of subtalar ligaments between patients with subtalar instability (STI) and controls. METHODS: Preoperative MRIs of 23 STI patients treated with arthroscopic subtalar reconstruction were compared to MRIs of 23 age- and sex-matched control subjects without STI. Thickness and width of anterior capsular ligament (ACL) and interosseous talocalcaneal ligament (ITCL) as well as thickness of calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) were measured. Abnormalities in ACL, ITCL, CFL, ATFL, cervical ligament, and inferior extensor retinaculum were analyzed. RESULTS: STI patients had significantly smaller ACL thickness and ACL width than controls (ACL thickness: 1.73 mm vs. 2.22 mm, p = 0.007; ACL width: 7.21 mm vs. 8.80 mm, p = 0.004). ACL thickness of ≤2.1 mm had a sensitivity of 66.7% and a specificity of 66.7% for diagnosis of STI. ACL width of ≤7.9 mm had a sensitivity of 80.0% and a specificity of 76.2% for the diagnosis of STI. However, thickness and width of ITCL, thickness of CFL, or thickness of ATFL was not significantly different between the two groups. Absence or complete tear of ACL was significantly more frequent in STI patients than that in controls (34.8% vs. 8.7%, p = 0.035). Complete tear of CFL and ATFL was more common in STI patients than that in controls, although the difference between the two groups was not statistically significant. Abnormalities of ITCL, cervical ligament, or inferior extensor retinaculum were not significantly different between the two groups. CONCLUSIONS: MRI features of thin or narrow ACLs may suggest STI. Absence or complete tear of ACL was significantly more common in STI patients than that in controls.

Clinical and radiological outcomes of midfoot derotational osteotomy for midfoot-forefoot varus deformity.

BACKGROUND: Moderate to severe midfoot-forefoot varus deformities are commonly found in several conditions. However, few techniques are available to correct these deformities. So, we evaluated the clinical and radiological outcomes of patients who underwent midfoot derotational osteotomy to achieve plantigrade foot. METHODS: From 2006 to 2014, 6 patients (7 feet) underwent midfoot derotational osteotomy. A visual analog scale (VAS) pain and the American Orthopedic Foot & Ankle Society (AOFAS) functional score were evaluated. Radiographic parameters, including tibiocalcaneal angle (TCA) and navicular height (NH), were assessed. RESULTS: The mean patient age at surgery was 48.0 years (37-58). From before the operation to the final follow-up, the mean VAS score decreased from 6.5 (2-9) to 1.3 (0-4) and the mean AOFAS score improved from 42.7 (34-58) to 77 (68-87). All patients were satisfied with outcomes. The mean TCA significantly improved from 33.8° (9.9-66.7) to 12.7 (5.1-27.6) (p = 0.018)and the mean NH decreased from 46.7 mm (32.8-67) to42.6 (30.1-60.8) (p = 0.018). CONCLUSION: Severe midfoot-forefoot varus deformities can be efficiently corrected by midfoot derotational osteotomy resulting in favorable clinical and radiological outcomes and high patient satisfaction. LEVEL OF EVIDENCE: IV, case series.

Outcome of subtalar instability reconstruction using the semitendinosus allograft tendon and biotenodesis screws.

PURPOSE: Subtalar instability (STI) has often been obscured by lateral ankle instability. Moreover, although there have been several reports of techniques for reconstructing STI, no clinical outcome results are known to have been published. The authors report the clinical and radiographic outcomes of the ligament reconstruction of STI with a recently reported novel technique utilising a semitendinosus tendon allograft and interference screws. METHODS: This study is based on 20 ankles that underwent ligament reconstruction for STI between 2009 and 2013. The average follow-up period was 15.0 ± 5 months, and the average age at surgery was 28.1 ± 10.8 years old. Visual analogue (VAS) pain scores, American Orthopedic Foot and Ankle Society (AOFAS) and Karlsson-Peterson ankle scores as well as patient satisfaction were evaluated. Radiographic evaluation of medial translations of calcaneus and subtalar tilt angles was preformed with ankle and Broden's stress radiographs. RESULTS: The VAS pain score decreased from 6.1 ± 1.1 preoperatively to 1.8 ± 1.2 post-operatively (p < 0.05). The AOFAS score improved from 66.0 ± 12.2 preoperatively to 89.6 ± 6.7 post-operatively, and the Karlsson-Peterson score improved from 57.0 ± 13.5 to 91.1 ± 6.8 (p < 0.05). There were no complications such as recurred STI or subtalar joint stiffness. All of the patients were satisfied with the surgery. Subtalar tilt angle decreased from 11.5° preoperatively to 3.0° post-operatively, and the calcaneal medial translations decreased from 7.4 to 3.9 mm. CONCLUSION: This is the first report on the comprehensive clinical and radiographic outcomes of STI reconstruction using a semitendinosus tendon allograft and interference screws. The novel technique of STI reconstruction was found to show encouraging clinical outcomes with high patient satisfaction. LEVELS OF EVIDENCE: IV.

Reconstruction of compound loss of lateral malleolus and lateral ankle ligaments with double-bundle Achilles tendon-bone allograft.

Open ankle fracture, including compound loss of the lateral malleolus, lateral ankle ligaments, and overlying skin, is a severe injury and can result in ankle instability and permanent disability. Treatment of this injury is challenging and requires bone grafting and soft tissue reconstruction. In the present report, we describe a unique reconstruction technique for compound loss of the lateral malleolus, lateral ankle ligaments, and the overlying skin using a double-bundle Achilles tendon-bone allograft combined with a reverse sural fasciocutaneous flap. The patient obtained a stable ankle with nearly full range of motion and displayed satisfactory function during the follow-up period.

Improvement of Valgus Deviation of the Lesser Toes of Moderate to Severe Hallux Valgus After Proximal Chevron Metatarsal Osteotomy and Akin Osteotomy.

BACKGROUND: This study examines the correction of lesser toe valgus deviation following proximal chevron metatarsal osteotomy (PCMO) and Akin osteotomy in moderate to severe hallux valgus patients, while identifying influencing factors. METHOD: Among 89 patients (116 feet), those with moderate to severe hallux valgus underwent PCMO and Akin osteotomy. Radiologic assessments included preoperative metatarsus adductus angle (MAA), hallux valgus angle (HVA), intermetatarsal angle (IMA), valgus angles of the second to fourth metatarsophalangeal joints, and hallux valgus recurrence. Assessments included visual analog scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, and patient satisfaction over an average follow-up of 30.6 ± 21.2 (range, 12-99) months. RESULTS: The mean preoperative HVA of 34.4 degrees decreased to 8.7 degrees at final follow-up. The valgus angles of the second, third, and fourth toes improved by 37.1%, 27%, and 44.5%, respectively. In metatarsus adductus patients, lesser toe valgus angles were significantly higher both preoperatively and at final follow-up. Hallux valgus recurrence patients had higher preoperative and final follow-up IMA and valgus angles in the second and third toes. Nonrecurrence patients showed greater decreases in these angles. A larger HVA correction corresponded to a greater decrease in lesser toe valgus deviation. VAS and AOFAS scores improved significantly at the last follow-up. CONCLUSION: The study found a significant reduction in the valgus angle of the second, third, and fourth toes after PCMO and Akin osteotomy in moderate to severe hallux valgus cases, without additional surgeries on lesser toes. The lesser toe angular reductions were less pronounced in patients with metatarsus adductus or with hallux valgus recurrence. LEVEL OF EVIDENCE: Level IV, case series.

Clinical outcomes of endovascular treatments for critical limb ischemia with chronic total occlusive lesions limited to below-the-knee arteries.

BACKGROUND: Diabetes mellitus tends to have the greatest impact on the smaller vessels and contributes significantly to occlusive disease from the popliteal artery distally. PURPOSE: To evaluate the clinical outcomes after a balloon angioplasty with or without stent placement in diabetic patients with critical limb ischemia (CLI) by chronic total occlusion (CTO) limited to below-the-knee (BTK) arteries. MATERIAL AND METHODS: From August 2005, patients who presented CLI and CTO limited to the BTK arteries, and who underwent endovascular treatment, were included in this study. The primary endpoints evaluated were technical success, limb salvage, and primary patency. The secondary endpoints evaluated were 30-day access site, intervention site, and systemic complications. Patency and limb salvage were evaluated using the Kaplan-Meier method and compared using Fisher's exact test. RESULTS: The BTK endovascular treatment (EVT) was performed on 64 limbs. Technical success rate was 93.8% and limb salvage rate was 90.6%. Three of four limbs with technical failure and three of 60 limbs with technical success underwent BTK amputation and the comparison of these rates were significantly different (75% vs. 5%, P = 0.002). Primary patency rates for the limbs were 75% and 59.1% at 6-month and 12-month follow-up, respectively. Minor complications disappeared through the follow-up periods and there was no 30-day complication or systemic adverse events for the treated vessel. CONCLUSION: Even though EVT for CLI in patients with diabetes and CTO in isolated BTK arteries does not have comparable primary patency, it can lead to a very high rate of limb salvage. This result can accentuate the importance of more blood flow to the foot by means of successful revascularization using EVT rather than long-term patency in CTO of isolated BTK arteries.

Total ankle arthroplasty with combined calcaneal and metatarsal osteotomies for treatment of ankle osteoarthritis with accompanying cavovarus deformities: early results.

BACKGROUND: Our study evaluated the short-term clinical and radiographic results of total ankle arthroplasty (TAA) with combined bony reconstructions for treatment of end-stage ankle osteoarthritis with accompanying cavovarus/hindfoot varus deformities. METHODS: This study included 8 patients (10 ankles) with ankle osteoarthritis (OA) who were treated by TAA with combined calcaneal and metatarsal osteotomies between September 2004 and June 2010 and were followed an average of 17.9 months (12-43 months). Visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographic measurements, and patient satisfaction were evaluated. RESULTS: The average patient age was 66.2 years (range, 55-76 years). Eighteen bony reconstruction procedures such as lateral sliding calcaneal osteotomy (n = 9) and first metatarsal dorsiflexion osteotomy (n = 4) were performed in addition to TAA. VAS pain score improved from an average of 8.8 (range, 6-10) preoperatively to an average of 2.4 (range, 0-7) (P < .05), and the AOFAS score improved from 36.9 (range, 14-71) preoperatively to 89.3 (range, 68-100) (P < .05). Ninety percent of the patients were satisfied with the results. Radiographically, the tibiocalcaneal angle (TCA) improved from a preoperative average of 19.0 degrees (range, 13-23 degrees) to 0.2 degrees (range, -5.4 to 2.8 degrees), the tibial axis-talar dome angle (TA-TDA) improved from a preoperative average of 15.6 degrees (range, 11.1-18.0 degrees) to 3.3 degrees (range, 1.7-5.6 degrees), and the talar dome-ground surface angle (TD-GSA) improved from a preoperative average of 21.2 degrees (range, 15.4-27.5 degrees) to 5.1 degrees (range, 1.8-10.2 degrees) (P < .05). CONCLUSION: We found that it was occasionally necessary to perform combined calcaneal and metatarsal osteotomies with TAA in order to successfully treat ankle OA with an accompanying cavovarus/varus deformity. The TD-GSA and TCA were also found to be important radiographic parameters in assessing varus ankles. LEVEL OF EVIDENCE: IV, retrospective case series.

Fluid-Attenuated Inversion Recovery Sequence with Fat Suppression for Assessment of Ankle Synovitis without Contrast Enhancement: Comparison with Contrast-Enhanced MRI.

The purpose of this study was to investigate the feasibility of the fluid-attenuated inversion recovery sequence with fat suppression (FLAIR-FS) for the assessment of ankle synovitis without contrast enhancement. FLAIR-FS and contrast-enhanced, T1-weighted sequences (CE-T1) of 94 ankles were retrospectively reviewed by two radiologists. Grading of synovial visibility (four-point scale) and semi-quantitative scoring of synovial thickness (three-point scale) were performed in four compartments of the ankle in both sequences. Synovial visibility and thickness in FLAIR-FS and CE-T1 images were compared, and agreement between both sequences was assessed. Synovial visibility grades and synovial thickness scores for FLAIR-FS images were lower than those for CE-T1 images (reader 1, p = 0.016, p < 0.001; reader 2, p = 0.009, p < 0.001). Dichotomized synovial visibility grades (partial vs. full visibility) were not significantly different between both sequences. The agreement in synovial thickness scores between the FLAIR-FS and CE-T1 images was moderate to substantial (κ = 0.41-0.65). The interobserver agreement between the two readers was fair for synovial visibility (κ = 0.27-0.32) and moderate to substantial for synovial thickness (κ = 0.54-0.74). In conclusion, FLAIR-FS is a feasible MRI sequence for the evaluation of ankle synovitis without contrast enhancement.

Anatomic reconstruction of the anterior talofibular and calcaneofibular ligaments using a semitendinosus tendon allograft and interference screws.

PURPOSE: The purpose of this study was to evaluate the functional and radiographic outcomes of a novel surgical technique devised to treat chronic lateral ankle instability. The technique involves direct repair of the anterior talofibular ligament and anatomic reconstructions of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) using a free semitendinosus tendon allograft and interference screws. METHODS: This retrospective study involved a review of the records of 27 patients (28 ankles) with chronic lateral ankle instability treated from 2007 to 2009. VAS pain scores, AOFAS scores, Karlsson-Peterson ankle scores (24 ankles), and patient satisfaction were evaluated at median of 19 (12-26) months postoperatively. Radiographically, talar tilt angles and anterior talar translation were assessed in pre- and postoperative ankle stress views. RESULTS: Median patient age at surgery was 36.5 (16-57) years. Median VAS pain score decreased from 6 (3-9) to 2 (0-4) (P < 0.05), and median AOFAS score improved from 63 (41-84) to 91 (81-100) preoperatively to final follow-up (P < 0.05). Median Karlsson-Peterson score also significantly improved from 55 (32-77) to 80 (59-100) (P < 0.05), whereas talar tilt decreased from 17.8° (10.0°-25.5°) to 6.7° (0.3°-13.0°) and the mean anterior drawer test decreased from 10.0 mm (0.6-19.4) to 4.5 mm (0.2-8.7) (P < 0.05). Eighty-eight percent (21/24) were satisfied with surgery. No complication, such as subtalar stiffness or recurrent instability, was encountered. CONCLUSIONS: The described technique, which involves anatomic reconstruction of the ATFL and CFL using the semitendinosus tendon and interference screws with direct repair of the capsule, is a viable option for treating lateral ankle instability with stable tendon fixation and provides satisfactory clinical outcomes. LEVEL OF EVIDENCE: Case-series, Level IV.

Analysis of repeated lesions after diabetic forefoot amputation.

AIM: This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation. METHODS: The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined. RESULTS: Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer. CONCLUSIONS: Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.

Role of arthroscopic microfracture for cystic type osteochondral lesions of the talus with radiographic enhanced MRI support.

PURPOSE: Comparatively little literature is available on treatment evaluations of individual osteochondral lesions of the talus (OLT), such as cystic type OLT. It is also noteworthy that controversy still exists regarding the best primary treatment option for cystic type OLT. The purpose of this study was to evaluate the clinical outcomes of arthroscopic microfracture of symptomatic cystic type OLT, irrespective of lesion size, and to verify the efficacy of enhanced ankle MRI for predicting the nature of cystic osteochondral lesions. METHODS: In this study, the authors assessed 22 patients with cystic type OLTs, who all underwent arthroscopic debridement and microfracture with a minimum of 18-month follow-up. There were 16 men and 6 women. Median patient age was 40 (20-64) years. Preoperative and postoperative VAS and AOFAS scores were evaluated. RESULTS: At a median follow-up of 32 months (18-63), AOFAS scores improved from a median of 69 preoperative (29-88) to 90 postoperative (75-100) (P < 0.05); and VAS scores improved from a mean of 7.0 ± 1.8 to a mean of 1.7 ± 1.9, respectively (P < 0.05). The overall patient satisfaction rate was 86%. Gadolinium-enhanced MRI scans performed on 21 feet all showed enhancement of varying intensities (from low to high) for the cystic OLTs, implying a vasculogenic potential. CONCLUSIONS: The study shows that arthroscopic microfracture is a desirable first-line treatment for addressing symptomatic cystic type OLT irrespective of lesion size. Enhanced ankle MRI was also found to be a useful and important for predicting the natures of cystic osteochondral lesions. LEVEL OF EVIDENCE: Case-series, Level IV.