Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls.

BACKGROUND: While it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis. METHODS: A retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years). RESULTS: The valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031). CONCLUSION: Our findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.

PKR-Mediated Phosphorylation of eIF2a and CHK1 Is Associated with Doxorubicin-Mediated Apoptosis in HCC1143 Triple-Negative Breast Cancer Cells.

Triple-negative breast cancer is more aggressive than other types of breast cancer. Protein kinase R (PKR), which is activated by dsRNA, is known to play a role in doxorubicin-mediated apoptosis; however, its role in DNA damage-mediated apoptosis is not well understood. In this study, we investigated the roles of PKR and its downstream players in doxorubicin-treated HCC1143 triple-negative breast cancer cells. Doxorubicin treatment induces DNA damage and apoptosis. Interestingly, doxorubicin treatment induced the phosphorylation of eukaryotic initiation factor 2 alpha (eIF2α) via PKR, whereas the inhibition of PKR with inhibitor C16 reduced eIF2α phosphorylation. Under these conditions, doxorubicin-mediated DNA fragmentation, cell death, and poly(ADP ribose) polymerase and caspase 7 levels were recovered. In addition, phosphorylation of checkpoint kinase 1 (CHK1), which is known to be involved in doxorubicin-mediated DNA damage, was increased by doxorubicin treatment, but blocked by PKR inhibition. Protein translation was downregulated by doxorubicin treatment and upregulated by blocking PKR phosphorylation. These results suggest that PKR activation induces apoptosis by increasing the phosphorylation of eIF2α and CHK1 and decreasing the global protein translation in doxorubicin-treated HCC1143 triple-negative breast cancer cells.

Characteristics of medial gutter arthritis on weightbearing CT and plain radiograph.

OBJECTIVE: An ankle arthritis with medial gutter obliteration is known to have good results after joint preservation surgery. However, the diagnosis is often missed on radiographs. The aims of this study were to investigate sensitivity of radiographs in the identification of medial gutter arthritis, incidence and direction of the talar tilt on weightbearing CT (WBCT), and to assess radiographic alignment of the medial gutter arthritis. MATERIALS AND METHODS: Radiographic data was retrospectively evaluated in 102 ankles which were diagnosed medial gutter arthritis by using the WBCT at our clinic between January 2017 and June 2019. Among the 102 ankles, proportion of ankles which showed medial gutter arthritis on plain radiograph was obtained. The presence and direction of talar tilt were assessed on three coronal WBCT images at the anterior, middle, and posterior aspect of the ankle. Plain radiographic parameters were compared between the 102 ankles and control group. RESULTS: Plain radiograph showed medial gutter arthritis only in 63 ankles (62%) among the 102 ankles. Most of the ankles with medial gutter arthritis showed talar tilt on WBCT, and about half of all ankles showed valgus talar tilt at the anterior aspect of ankle on WBCT. In ankles with medial gutter arthritis, the mechanical axis of the lower extremity and the tibial plafond were varus angulated and the talus was medially translated compared to the control group. CONCLUSION: Radiographs were less sensitive than WBCT in demonstrating medial gutter arthritis. Anterior aspect of ankles with medial gutter arthritis often showed valgus direction of talar tilt. Varus mechanical axis deviation and varus tibial plafond are commonly associated with the medial gutter arthritis.

Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults.

BACKGROUND: A common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column. METHODS: We retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated. RESULTS: All radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon. CONCLUSION: DMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.

Eccentric ankle arthritis in the sagittal plane: a novel description of anterior and posterior ankle arthritis.

BACKGROUND: To report radiographic characteristics of anterior and posterior ankle arthritis, which demonstrates the eccentric narrowing of either aspect of the tibiotalar joint in the sagittal plane. METHODS: Radiographic analysis of 19 ankles with anterior arthritis and 16 ankles with posterior arthritis was performed, which were defined as having both (1) eccentric narrowing of the anterior or posterior tibiotalar joint space on lateral radiographs and (2) talar tilt angle less than 4 degrees on anteroposterior radiographs. Measured radiographic parameters were: Talar tilt angle, medial distal tibial angle (MDTA), talar center migration (TCM), anterior distal tibial angle (ADTA), tibial axis-to-talus ratio (TT ratio), talo-first metatarsal (Meary) angle, hindfoot alignment angle (HAA), hindfoot moment arm, and mechanical axis deviation (MAD). An Intergroup comparison analysis, including a normal control group, was also performed. RESULTS: The TT ratio was significantly different between each group, indicating a distinct talus position in the sagittal plane. The anterior group had a significantly larger TCM than the control group and lower ADTA compared to other groups, indicating medial translation of the talus and anterior opening of the tibial plafond. The posterior group demonstrated a significantly higher Meary angle and lower HAA compared to other groups and lower MDTA compared to the control group, indicating lower medial longitudinal arch, valgus heel alignment, and varus tibial plafond. The MAD was significantly higher in both the anterior and posterior groups than the control group, indicating varus lower limb alignment. CONCLUSION: Anterior ankle arthritis demonstrated anteromedial translation of the talus and anterior opening of the tibial plafond. Posterior ankle arthritis was associated with the lower medial longitudinal arch and hindfoot valgus, indicating an association with flatfoot deformity. Both anterior and posterior ankle arthritis were associated with varus lower limb alignment.

Radiographic characteristics and outcomes of simple resection for naviculo-medial cuneiform coalition in adults.

BACKGROUND: This study aimed to report the outcomes of coalition resection in adults with naviculo-medial cuneiform (NC) coalition. METHODS: Seventeen adults (20 feet) who underwent NC coalition resection were identified. The location and morphology of coalitions and five angular parameters, including medial arch sag angle (MASA), were assessed on weightbearing radiographs. Pre- and postoperative visual analogue scale and foot function index were evaluated for clinical outcomes. RESULTS: Most feet (19 out of 20) had a coalition at the plantar-medial aspect, and there was no radiographic evidence of residual NC joint space compromise. There was no radiographic evidence of medial arch sag (MASA, p = 0.749) or recurrence at the final follow-up (21.7 months, range 12 to 48). Clinical scores improved significantly in all patients. CONCLUSIONS: Resection of NC coalition in adults can be successful and provides an option to arthrodesis when conservative treatments have failed.

Weight-bearing computed tomography findings in varus ankle osteoarthritis: abnormal internal rotation of the talus in the axial plane.

OBJECTIVES: To assess the incidence of abnormal internal rotation of the talus in the axial plane in patients with varus ankle osteoarthritis, and to determine whether this incidence differs from the severity of varus ankle osteoarthritis (moderate versus severe). MATERIALS AND METHODS: We retrospectively evaluated weight-bearing computed tomography (CT) and plain radiographs of 52 ankles with no abnormalities (control group) and 96 ankles with varus osteoarthritis (varus-OA group), which were further stratified into a moderate-OA subgroup (50 ankles) and a severe-OA subgroup (46 ankles). A new radiographic parameter on weight-bearing CT, the talus rotation ratio, was used to assess the rotation of the talus in the axial plane. The normal range of the talus rotation ratio was defined as the 95% prediction interval for talus rotation ratio values in the control group. Abnormal internal rotation of the talus was defined for talus rotation ratio values above the normal range. We determined the incidence of abnormal internal rotation of the talus in the varus-OA group, moderate-OA subgroup, and severe-OA subgroup. RESULTS: In the varus-OA group, the incidence of abnormal internal rotation of the talus was 45% (43 ankles), which corresponded to an incidence of 32% (16 ankles) in the moderate-OA subgroup and 59% (27 ankles) in the severe-OA subgroup (p = 0.013). CONCLUSION: Our study demonstrates that abnormal internal rotation of the talus occurs in patients with varus ankle osteoarthritis, and is more frequently noted in severe than in moderate varus ankle osteoarthritis.

Long-Term Outcomes of Endoscopic Versus Surgical Resection of Superficial Submucosal Colorectal Cancer.

BACKGROUND: The long-term outcomes of endoscopic resection of superficial submucosal colorectal cancer (CRC) had not been adequately compared with those of surgical resection. AIMS: We aimed to compare the long-term clinical outcomes of endoscopic resection of superficial submucosal CRC to those of surgical resection. METHODS: Submucosal CRC patients with a tumor depth of sm1 or less than 1 mm from the muscularis mucosa were enrolled. Patients with unfavorable histology, such as poorly differentiated cancer or lymphovascular invasion, were excluded. Recurrence-free survival and overall survival were investigated in 87 patients who underwent endoscopic resection and in 171 patients who underwent surgical resection. RESULTS: The mean ages of the endoscopic and surgical resection groups were 59.7 and 59.8 years, respectively. Hospital stay was shorter in the endoscopic resection group (1.7 ± 1.6 vs. 8.6 ± 3.8 days; p < 0.001). The 3- and 5-year recurrence-free survival rates were 98.7 and 96.7 % in the endoscopic resection group and 98.7 and 97.5 % in the surgical resection group, respectively (p = 0.837). The 3- and 5-year overall survival rates were 100.0 and 95.2 % in the endoscopic resection group and 98.7 and 92.8 % in the surgical resection group, respectively (p = 0.928). Recurred cases showed an unfavorable histology that was overlooked at the time of initial resection. CONCLUSIONS: Long-term outcomes after endoscopic resection of superficial submucosal CRC are comparable to those after surgical resection. Thorough initial histopathological evaluations are needed to guarantee the correct indication for endoscopic resection of submucosal CRC.

Validity, reliability, and responsiveness of the Korean version of American Academy of Orthopedic Surgeons Foot and Ankle questionnaire.

The American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire (AFAQ) reflects patients' subjective disorder due to foot and ankle conditions. We evaluated the validity, reliability, and responsiveness of the Korean version of the AFAQ, after translation and transcultural adaptation of the original AFAQ into the Korean language. A total of 206 patients were enrolled, including 152 with chronic problems (experimental group) and 54 with acute problems (control group). We used the intraclass correlation coefficient to assess the test-retest reliability and Cronbach's α to assess internal reliability. Pearson's correlation coefficient was used to assess the criterion validity by correlating the Korean AFAQ scores with those from other validated scales (American Orthopaedic Foot and Ankle Society Hallux-Metatarsophalangeal-Interphalangeal scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale, and visual analog scale for pain). To analyze discriminant validity, we evaluated the difference between the experimental and control groups using the Student t test. Of the 152 patients in the experimental group, 29 revisited our clinic postoperatively and repeated the Korean AFAQ. To analyze responsiveness, we used paired t tests to evaluate postoperative changes. In terms of test-retest reliability, the intraclass correlation coefficient ranged from 0.979 to 0.999. In terms of internal reliability, Cronbach's α was 0.528 for the stiffness and swelling subscale and greater than 0.7 for all other subscales. In terms of criterion validity, Pearson's correlation coefficient ranged from 0.492 to 0.699. The probability of the null hypothesis for discriminant validity and responsiveness was statistically significant (p < .001 and p = .021, respectively). These results showed that the Korean version of the AFAQ had the same concept and intention as the original version and is reliable, valid, and responsive.

Peripancreatic tuberculous lymphadenopathy masquerading as pancreatic malignancy: a single-center experience.

BACKGROUND AND AIM: Peripancreatic tuberculous lymphadenopathy is very rare and can be misdiagnosed with pancreatic or peripancreatic malignancies. The clinical characteristics and treatment outcome have not been well known. Herein, we investigated the accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), clinical features, and treatment outcomes. METHODS: We retrospectively analyzed 42 patients diagnosed with peripancreatic tuberculosis between December 2004 and January 2011 at the tertiary care hospital in Korea. RESULTS: Median age was 36 years (interquartile range, 30-55), and female was 66.7% (28/42). Nineteen patients (45.2%) had no symptoms, while the others had non-specific various symptoms. Thirteen (31.0%) had a previous history of tuberculosis. Initial impressions of the mass were pancreatic cancer in 14 (33.3%) and tuberculous lymphadenopathy in 13 patients (31.0%). EUS-FNA was performed in all 42 patients, with a diagnostic yield of pathologic examinations in 80.5%, polymerase chain reaction for tuberculosis in 42.9%, culture in 47.4%, and acid-fast bacilli staining in 10.0%. Tuberculosis is confirmed in 28 (66.7%), and probable tuberculosis in 14 (33.3%). All patients received anti-tuberculosis treatment, a 6-months regimen in 12 (28.6%) and a 9-months regimen in 28 (66.7%). Treatment response evaluated in 35 patients (83.3%) by computed tomography criteria showed complete response in 10 patients (28.6%), partial response in 23 (65.7%), stable disease in 1 (2.9%), and progressive disease in 1 (2.9%). CONCLUSIONS: Peripancreatic tuberculous lymphadenopathy is frequently mistaken for pancreatic malignancy. EUS-FNA can be helpful for an accurate diagnosis. Complete resolution of the lesion, however, was not common on following imaging study after treatment.

Portal hypertensive enteropathy diagnosed by capsule endoscopy in cirrhotic patients: a nationwide multicenter study.

BACKGROUND AND AIM: Due to the limited data on portal hypertensive enteropathy (PHE), the prevalence of and clinical factors related to PHE remain unclear. This study determined the prevalence of PHE using capsule endoscopy (CE) and PHE-related clinical factors. METHODS: This was a retrospective multicenter study using the Capsule Endoscopy Nationwide Database Registry. From 2,879 cases that underwent CE, 45 cirrhosis patients with portal hypertension (PH) were enrolled and divided into PHE (n = 18) and non-PHE (n = 27) groups. From computed tomography (CT) images, six secondary changes due to PH were scored to give a total CT score of 0-6. The main outcome variable was the prevalence of PHE and PHE-related clinical factors. RESULTS: The prevalence of PHE was 40 %. Comparing the PHE and non-PHE groups, the most common findings were angiodysplasias in 55.7 % (vs. 7.4 %, p = 0.001) and varices in 38.9 % (vs. 0 %, p = 0.001). Active bleeding was observed in 16.6 and 3.7 %, respectively, but this difference was not significant. In the univariate analysis, Child-Turcotte-Pugh class C (p = 0.002) and a high CT score (≥3 vs. <3, p = 0.004) were significantly associated with PHE. However, only a high CT score was significant in the multivariate analysis (odds ratio 11.19; 95 % confidence interval, 1.59-infinity; p = 0.040). CONCLUSIONS: The prevalence of PHE was 40 %, and it might be more prevalent in cirrhosis patients with PH who have a high CT score. CE is a useful diagnostic tool for evaluating PHE in cirrhosis patients with PH.

Rectal gastrointestinal stromal tumor: clinical features, endoscopic findings and prognosis.

BACKGROUND/AIMS: Rectal gastrointestinal stromal tumor (GIST) accounts for only a small portion of all GISTs, and reports regarding its clinical features and endoscopic findings are still lacking. METHODOLOGY: Thirty-two patients diagnosed as rectal GIST at Asan Medical Center, a tertiary university hospital in Korea between May 2003 and January 2011 were enrolled. RESULTS: The median age was 54 years (range, 31-79) with 18 males (56.2%). Common symptoms were hematochezia, anal pain, and defecation difficulty, although 11 patients were asymptomatic. The median size of tumor was 6.1 cm (range, 0.4-12.0 cm), and the median distance from the anal verge was 4 cm (range, 3 cm). The most common endoscopic finding was subepithelial tumor with normal overlying mucosa (63.1%), followed by subepithelial tumor with erosion, ulceration, or bleeding (31.6%). Preoperative imatinib was administered in eight patients (25.0%) that helped the downsizing the tumor and anal sphincter preserved. High-risk group by NIH risk classification and tumor size were associated with tumor recurrence, with the overall five-year recurrence-free survival of 67.2%. CONCLUSIONS: Common endoscopic feature of rectal GIST was subepithelial tumor with normal mucosa. Patients treated by definite resection with or without imatinib for rectal GIST seem to show a favorable clinical course.

Frequency of rebleeding events in obscure gastrointestinal bleeding with negative capsule endoscopy.

BACKGROUND AND AIMS: Although capsule endoscopy (CE) is widely used as a first-line diagnostic modality for obscure gastrointestinal bleeding (OGIB), the rebleeding rate after negative CE varies according to different studies. We tried to elucidate the outcomes after negative CE for OGIB and to determine the risk factors associated with rebleeding. METHODS: We retrospectively reviewed data from 125 patients who had received CE for OGIB. RESULTS: PillCam SB capsules were used for 92 patients (73.6%) and SB2 capsules for the other 33 (26.4%). The complete visualization of the small bowel was achieved in 93 patients (74.4%). Of the 63 patients (50.4%) who showed negative CE results, 60 patients did not receive any further specific treatment for OGIB, and were analyzed for the rebleeding rate and risk factors for rebleeding. Of the 60 patients, rebleeding episodes were observed in 16 patients (26.7%), and the cumulative rebleeding rates after 6, 12, 24, and 36 months were 12.4%, 14.3%, 28.7%, and 35.9%, respectively. Substantial rebleeding events were observed with similar frequency both after negative CE without subsequent treatment (26.7%) and after positive CE without specific treatment (21.2%) (P = 0.496). CONCLUSIONS: Considerable rebleeding episodes were observed after negative CE result for OGIB. Further complementary diagnostic work-ups and close follow-up are needed to be considered for patients with OGIB and negative CE results.

Realignment Surgery for Failed Osteochondral Autologous Transplantation in Osteochondral Lesions of the Talus Associated With Malalignment.

BACKGROUND: While osteochondral autologous transplantation (OAT) offers favorable results in most patients with osteochondral lesions of the talus (OLT), some patients continue to experience persistent pain following the procedure. Information regarding the etiology of this pain and outcomes of revision surgery are limited. This study aimed to report results of revision surgery with realignment procedures in patients with failed OAT who demonstrated concomitant malalignment at the distal tibia or hindfoot. METHODS: Eight patients (8 ankles), who had been experiencing persistent pain for more than 1 year following OAT, underwent realignment procedures during revision surgery. All patients underwent primary OAT for the treatment of medial OLTs. Patients were divided into 2 groups based on the main location of deformity: the supramalleolar realignment group (SRG, 5 ankles) and the hindfoot realignment group (HRG, 3 ankles). No direct procedure was performed on the osteochondral lesion at the time of revision surgery. Ankle and hindfoot alignment were evaluated using 6 parameters in weightbearing radiographs. Computed tomography (CT) was used to assess for medial gutter narrowing, spur formation, and cyst volume around transplanted osteochondral plug preoperatively and postoperatively. Clinical outcomes were assessed using Foot Function Index and Visual Analogue Scale. RESULTS: All patients had medial gutter narrowing or spur formation, which are early signs of ankle arthritis. The SRG had varus distal tibial alignment with a median medial distal tibial angle of 85.7 degrees (interquartile range [IQR], 3.2). The HRG had valgus hindfoot alignment and a lower medial longitudinal arch with a median hindfoot moment arm of 8.4 mm (IQR, 6.1) and a median Meary's angle of 11.8 degrees (IQR, 1.4). Spontaneous restoration of the osteochondral lesion was observed after realignment surgery, with cyst volume decreasing from 0.2592 to 0.0873 cm3 (P < .05). Clinical scores improved in all patients. CONCLUSION: The current study demonstrates the effectiveness of realignment surgery in a selected patient group who experienced persistent pain and showed radiographic evidence of malalignment after primary OAT. Our study provides evidence supporting the use of realignment procedures in these cases, with results indicating improved patient-reported outcomes and spontaneous restoration of osteochondral lesions. LEVELS OF EVIDENCE: Level IV: Case series.

Dome Supramalleolar Osteotomies for the Treatment of Ankle Pain with Opposing Coronal Plane Deformities Between Ankle and the Lower Limb.

BACKGROUND: The dome-type osteotomy is a powerful technique for deformity correction of the limb. However, there is limited information about the utility of dome supramalleolar osteotomy (SMO) in ankle joint preservation surgery. This study aimed to describe the technique and indications for dome SMO in distal tibial malalignment. METHODS: Twenty-three patients (23 ankles) who underwent dome SMO with a 2-year follow-up were reviewed. Dome SMO was indicated when there were opposing deformities in the ankle and lower limb mechanical axis (ie, varus ankle deformity with valgus lower limb alignment and vice versa) where inherent translation following conventional wedge-type osteotomies could worsen the deformity of the entire lower limb. Patients were divided into 2 groups based on preoperative ankle alignment: the varus ankle group (n = 11) and the valgus ankle group (n = 12). The radiographic correction was assessed using 6 parameters from weightbearing ankle and hindfoot alignment views. In addition, the lower limb mechanical axis was assessed with ankle center deviation (ACD) from the hip-knee (HK) line on the whole limb radiograph, and the weightbearing line (WBL) point was measured to identify changes in the weightbearing load within the ankle joint. RESULTS: Preoperatively, the varus ankle group had varus ankle deformity (tibiotalar angle [TTA], 76.5 ± 5.8 degrees) with valgus lower limb mechanical axis, whereas the valgus ankle group had valgus ankle deformity (TTA, 99.1 ± 4.5 degrees) with varus lower limb mechanical axis alignment. Postoperatively, a significant improvement in the ankle alignment and the lower limb mechanical axis was observed in both groups. The ACD significantly changed toward the HK line, suggesting an improved lower limb mechanical axis, and the WBL point showed a significant shift of the weightbearing axis toward the uninvolved area within the ankle joint. CONCLUSION: Dome SMO demonstrated a successful correction of local deformity while simultaneously realigning the hip-knee-ankle axis toward neutral. Additionally, an effective load shifting toward an uninvolved area within the ankle joint was observed. LEVEL OF EVIDENCE: Level IV, case series.

Repositional Subtalar Arthrodesis Combined With Supramalleolar Osteotomy for Late-Stage Varus Ankle Arthritis With Hindfoot Valgus.

BACKGROUND: Late-stage varus ankle arthritis is thought to be associated with varus of the tibial plafond and hindfoot. However, some late-stage varus arthritis show hindfoot valgus, which can be explained by subtalar subluxation with opposite directional motion between the talus and calcaneus. We hypothesized that late-stage varus ankle arthritis with hindfoot valgus could improve with repositional subtalar arthrodesis and supramalleolar osteotomy (SMO). The purpose of this study was to investigate the clinical and radiographic results of the repositional subtalar arthrodesis combined with SMO for late-stage varus ankle arthritis with hindfoot valgus. METHODS: This study includes 16 consecutive patients (16 ankles) with late-stage varus ankle arthritis of Takakura stage 3-b and hindfoot valgus who were treated using repositional subtalar arthrodesis combined with SMO and followed for a minimum of 2 years. Clinical results were assessed with the visual analog scale (VAS) and the Foot Function Index (FFI). Radiographic results were assessed with standard parameters measured on weightbearing foot and ankle radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up. RESULTS: VAS and FFI significantly improved after surgery. Mean talar tilt angle improved from 12.8 ± 2.8 degrees to 3.9 ± 3.1 degrees (P < .001). Talus center migration and Meary angle significantly improved after surgery. Medial distal tibial angle, lateral talocalcaneal angle, hindfoot moment arm, and talonavicular coverage angle significantly changed after surgery. Radiographic stage improved in 15 ankles (93.8%) after surgery. CONCLUSION: In this series with minimum 2-year follow-up, we found that late-stage (Takakura stage 3-b) varus ankle arthritis with hindfoot valgus clinically and radiographically improved with repositional subtalar arthrodesis combined with SMO. LEVEL OF EVIDENCE: Level IV, prognostic.

Clinical and Radiographic Results of Ankle Joint Preservation Surgery in Posterior Ankle Arthritis.

BACKGROUND: Little information is available about how to manage ankles with eccentric arthritis in the sagittal plane. This study aimed to report clinical and radiographic outcomes following joint preservation surgery for ankles with eccentric arthritis at the posterior tibiotalar joint and a plantarflexed talus in the sagittal plane, which we named posterior ankle arthritis. METHODS: Ten ankles with posterior ankle arthritis were treated with realignment surgery between 2017 and 2018. Posterior ankle arthritis was defined as having both (1) eccentric narrowing of the joint space at the posterior aspect of the tibiotalar joint on weightbearing lateral radiographs and (2) coronal talar tilt angle less than 4 degrees on weightbearing anteroposterior radiographs. Flatfoot reconstruction with a hindfoot arthrodesis procedure was performed in all patients (subtalar arthrodesis, n = 9; triple arthrodesis, n = 1), and a supramalleolar osteotomy was added in patients with varus distal tibial alignment (n = 6). Pain, functional outcome (foot function index [FFI]), radiographic arthritis stage (stage I to IV), and 9 radiographic parameters, including lateral talar center migration (LTCM), were evaluated on pre- and postoperative weightbearing radiographs. All patients completed a minimum 2-year follow-up. RESULTS: Preoperative radiographic evaluation demonstrated that ankles with posterior arthritis had a lower medial longitudinal arch, forefoot abduction, and valgus hindfoot alignment. Postoperatively, sagittal tibiotalar alignment was restored, as evidenced by an improved median LTCM from -3.3 to -0.3 mm (P < .001). The radiographic arthritis stage improved in 7 (70%) patients, whereas 3 (30%) remain unchanged in the same stage. The median score for pain (visual analog scale) decreased significantly from 8 to 2, and the median FFI improved significantly from 67.8 to 23.4 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up. CONCLUSION: The study results suggest a possible relationship between posterior ankle arthritis and the plantarflexion of the talus, which can be seen in the setting of a flatfoot deformity. Reconstruction of the flatfoot deformity using subtalar arthrodesis restored the tibiotalar relationship in the sagittal plane and resulted in clinical improvements at an average 2.3-year follow-up in this 10-ankle case series. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Joint Preservation Surgery in Valgus Ankle Arthritis Without Deltoid Ligament Insufficiency.

BACKGROUND: To date, information about the role of proximal alignment correction in treating nontraumatic valgus ankle arthritis is limited. This study aimed to report outcomes of realignment surgery, including supramalleolar correction in valgus arthritic ankles without evidence of deltoid ligament insufficiency. METHODS: Thirteen patients (13 ankles) who underwent joint preservation surgery for valgus ankle arthritis without evidence of deltoid ligament insufficiency were reviewed. Medial opening wedge supramalleolar osteotomy (n = 11) and varization supramalleolar dome osteotomy (n = 2) were performed to realign the hip-knee-ankle-hindfoot axis. Concomitant hindfoot correction was accompanied with either medial displacement calcaneal osteotomy (n = 8) or subtalar arthrodesis (n = 5). Pain, functional outcome (Foot Function Index [FFI]), radiographic arthritis grade (grades 0-4), 9 plain radiographic parameters, and 2 weightbearing computed tomography parameters were evaluated pre- and postoperatively. All patients completed a minimum 2-year follow-up. RESULTS: Preoperatively, 10 ankles (77%) demonstrated a varus tibial plafond, and 3 ankles (23%) demonstrated a valgus or neutral tibial plafond. Postoperatively, radiographic arthritis grade improved in all except 1 patient, and the mean talar tilt angle improved from 5.5 to 1.7 degrees. The mean pain score (visual analog scale) decreased significantly from 7.3 to 2.5 (P < .05), and the mean FFI improved significantly from 57.7 to 18.6 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up. CONCLUSION: This study demonstrated a possible relationship between lower limb malalignment and valgus ankle arthritis. Realignment surgery, including supramalleolar osteotomies, which straightens the mechanical axis and decreases the slope of the tibial plafond, may be a reasonable approach in joint preservation of valgus ankle arthritis without deltoid ligament insufficiency. LEVEL OF EVIDENCE: Level IV, case series.

Joint Preservation Surgery for Varus Ankle Arthritis with Large Talar Tilt.

BACKGROUND: Varus ankle arthritis with large talar tilt (TT) is a challenging condition when considering joint preservation surgery. Three-dimensional deformity of the talus has been demonstrated with weightbearing computed tomography in varus ankle arthritis with large TT. The aim of this study was to investigate the clinical and radiographic results of posterior tibial tendon (PTT) transfer generally combined with bony realignment for varus ankle arthritis with large TT in nonparalytic ankle arthritis and to determine the indications for PTT transfer. METHODS: This study includes 23 ankles with varus arthritis and TT larger than 7.5 degrees. Patients were categorized into improved (19 ankles) and unimproved (4 ankles) groups according to the postoperative clinical results at the last follow-up. Clinical and radiographic results were compared between the groups. A cut-off point for preoperative TT that indicated a borderline between improved and unimproved groups was determined to suggest the appropriate indication for joint preservation surgery. RESULTS: In the improved group, TT, radiographic stage, Meary angle, and hindfoot alignment significantly improved at 6 months after surgery and were maintained at the last follow-up. In the unimproved group, the radiographic parameters mentioned above did not improve at 6 months after surgery, and TT decreased to 0.8 degrees as radiographic stage had progressed to end-stage arthritis at the last follow-up. In this small series, the cut-off point for predicting failure of surgery was 14.3 degrees of preoperative TT. CONCLUSION: PTT transfer often combined with bony realignment procedures may be a reasonable option for treating painful varus ankle arthritis with TT less than 14 degrees and hindfoot varus. LEVEL OF EVIDENCE: Level IV, case series.

G-Protein-Coupled Receptor 120 Mediates DHA-Induced Apoptosis by Regulating IP3R, ROS and, ER Stress Levels in Cisplatin-Resistant Cancer Cells.

The omega-3 fatty acid docosahexaenoic acid (DHA) is known to induce apoptosis and cell cycle arrest via the induction of reactive oxygen species (ROS) production and endoplasmic reticulum (ER) stress in many types of cancers. However, the roles of DHA in drug-resistant cancer cells have not been elucidated. In this study, we investigated the effects of DHA in cisplatin-resistant gastric cancer SNU-601/cis2 cells. DHA was found to induce ROS-dependent apoptosis in these cells. The inositol 1,4,5-triphosphate receptor (IP3R) blocker 2-aminoethyl diphenylboninate (2-APB) reduced DHA-induced ROS production, consequently reducing apoptosis. We also found that G-protein-coupled receptor 120 (GPR120), a receptor of long-chain fatty acids, is expressed in SNU-601/cis2 cells, and the knockdown of GPR120 using specific shRNAs alleviated DHA-mediated ROS production and apoptosis. GPR120 knockdown reduced the expression of ER stress response genes, similar to the case for the pre-treatment of the cells with N-acetyl-L-cysteine (NAC), an ROS scavenger, or 2-APB. Indeed, the knockdown of C/EBP homologous protein (CHOP), a transcription factor that functions under ER stress conditions, markedly reduced DHA-mediated apoptosis, indicating that CHOP plays an essential role in the anti-cancer activity of DHA. These results suggest that GPR120 mediates DHA-induced apoptosis by regulating IP3R, ROS, and ER stress levels in cisplatin-resistant cancer cells, and that GPR120 is an effective chemotherapeutic target for cisplatin resistance.