Preoperative increased pronation angle of the first metatarsus associated with correction loss after hallux valgus surgery: A semi-weight-bearing computed tomography study.

BACKGROUND: The effect of preoperative first metatarsal pronation on postoperative prognosis of hallux valgus (HV) surgery is under investigation. Utilizing semi-weight-bearing computed tomography, the preoperative pronation angle was assessed to quantify its impact on postoperative prognosis. METHODS: In a retrospective analysis of 31 feet, those with re-increased hallux valgus angle postoperatively were classified as the non-maintained group, and the remainder as the maintained group. Preoperative pronation angles were compared to establish a threshold. Subsequently, feet were re-classified into high or low-pronation categories. The relative risk of non-maintenance in high-pronation category was calculated. RESULTS: The non-maintained group exhibited a significantly higher preoperative pronation angle (p = 0.021), with a 28.4º threshold. The high-pronation category had a relative risk of 2.34 for non-maintenance. CONCLUSIONS: Increased preoperative first metatarsal pronation angle is associated with correction loss after HV surgery. Utilizing sWBCT to measure the pronation angle provides valuable insights into postoperative prognosis. LEVEL OF EVIDENCE: III.

Apoptosis Occurs in the Anterior Talofibular Ligament of Patients With Chronic Lateral Ankle Instability: An In Vitro Study.

BACKGROUND: Chronic lateral ankle instability is treated operatively, whereas most acute ankle sprains associated with acute anterior talofibular ligament injury are usually treated nonoperatively. This treatment strategy is widely accepted and has been validated using a variety of clinical or radiological methods. We suspected that there may be biological differences between chronic and acutely injured ligaments, particularly with respect to apoptosis. Apoptosis is known to cause ligament degeneration. If it could be demonstrated that apoptosis occurs more in the anterior talofibular ligament tissues of patients with chronic lateral ankle instability compared with patients with acute anterior talofibular ligament injury, biological evidence could be supported. QUESTIONS/PURPOSES: We sought to (1) elucidate the difference in the extent of apoptosis between patients with chronic lateral ankle instability and those with acute anterior talofibular ligament injury. In addition, we asked: (2) What is the expression level of apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c in each patient group? (3) Is there a correlation between apoptotic activities and the symptom duration period of chronic lateral ankle instability? METHODS: Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Anterior talofibular ligament tissues were harvested from patients who were divided into two groups: the chronic lateral ankle instability group and the acute anterior talofibular ligament injury group. Patients with insufficient remaining ligaments were excluded from the chronic lateral ankle instability group, and cases in which the tissue was severely damaged or the quality of collected tissue was insufficient because of severe impingement into the fracture site were excluded from the acute anterior talofibular ligament injury group. Tissues were collected from 21 patients (11 males and 10 females) in the chronic lateral ankle instability group with a mean age of 37 ± 14 years and from 17 patients (6 males and 11 females) in the acute anterior talofibular ligament injury group with a mean age of 49 ± 17 years. To investigate our first purpose, apoptotic cells were counted using a TUNEL assay. To answer our second question, Western blotting for apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c was performed to investigate apoptotic activity. Immunohistochemistry was also used to detect apoptotic enzymes. To answer our third question, the time elapsed after the first symptom related to chronic lateral ankle instability occurred and the expression level of each enzyme was investigated. RESULTS: More apoptotic cells were observed in the chronic lateral ankle instability group than in the acute anterior talofibular ligament injury group in the TUNEL assay. Western blotting revealed that the apoptotic activities of the chronic lateral ankle instability group were higher than those of the acute anterior talofibular ligament injury group: caspase 3 was 117 in the chronic lateral ankle instability group and 59 in the acute anterior talofibular ligament injury group (mean difference 58 [95% confidence interval (CI) 31 to 86]; p < 0.001), caspase 7 was 138 in the chronic lateral ankle instability group and 45 in the acute anterior talofibular ligament injury group (mean difference 93 [95% CI 58 to 128]; p < 0.001), caspase 8 was 126 in the chronic lateral ankle instability group and 68 in the acute anterior talofibular ligament injury group (mean difference 58 [95% CI 29 to 89]; p < 0.001), caspase 9 was 128 in the chronic lateral ankle instability group and 54 in the acute anterior talofibular ligament injury group (mean difference 74 [95% CI 44 to 104]; p < 0.001), and cytochrome c was 139 in the chronic lateral ankle instability group and 51 in the acute anterior talofibular ligament injury group (mean difference 88 [95% CI 46 to 129]; p < 0.001). Immunohistochemistry revealed higher expression of caspases 3, 7, 8, and 9 and cytochrome c in the chronic lateral ankle instability group compared with those in the acute anterior talofibular ligament injury group. Caspases 3, 7, and 9 showed no correlation with duration of chronic lateral ankle instability symptoms: the Pearson correlation coefficient was 0.22 [95% CI -0.25 to 0.69] for caspase 3 (p = 0.36), 0.29 [95% CI -0.16 to 0.74] for caspase 7 (p = 0.23), and 0.29 [95% CI -0.16 to 0.74] for caspase 9 (p = 0.23). CONCLUSION: In chronic lateral ankle instability, apoptotic activity in the anterior talofibular ligament was higher than in acute anterior talofibular ligament injury. CLINICAL RELEVANCE: Apoptosis occurs more in chronic injured ligaments than in acutely injured ligaments. Although urgent surgical repair is not required for acute anterior talofibular ligament injury, chronic lateral ankle instability may progress if the nonoperative treatment is not successful. Further research should focus not only on timing of apoptotic progression, but also on biological augmentation to reverse or prevent apoptosis within the anterior talofibular ligament.

Interrupted Incision Fasciotomy for Acute Compartment Syndrome After Extracorporeal Membrane Oxygenation: Surgical Technique with a Report of Two Cases.

BACKGROUND: After extracorporeal membrane oxygenation (ECMO), acute compartment syndrome (ACS) can develop because of limb ischemia or reperfusion. The standard treatment for ACS is emergency fasciotomy. We introduced an interrupted incision technique instead of a long double-incision to reduce blood loss and subsequent hypovolemia in ECMO patients. CASE PRESENTATION: Two patients were treated venoarterial ECMO with heparinization by inserting cannulas into their right femoral vessels: Case #1 after emergency pulmonary thrombectomy for massive pulmonary thrombi and Case #2 after percutaneous coronary intervention for ST-elevation myocardial infarction with ventricular fibrillation. Some of the '5 P' signs of ACS were detected on their right legs. We treated them with the interrupted incision fasciotomy: four or five skin incisions of 2-3 cm each on lateral side; one 6-7 cm proximal skin incision with one or two separate short distal skin incisions of 1-1.5 cm each on the posteromedial side. The subcutaneous layer was also incised through these interrupted incisions; interrupted multiple "soft tissue tunnels" can be formed above muscle layer between the incisions. Once the fascia was exposed, the connected fasciotomy was performed with the knife blade facing subcutaneous layer, rather than muscle. The two patients' foot pulse, skin color, and muscle tone were immediately restored, and delayed primary wound closures were possible. Both patients were satisfied with their limb salvage and could walk with a little help using an orthosis or a cane. CONCLUSIONS: We recommend the interrupted incision fasciotomy as an attractive and effective technique for ACS, particularly after ECMO.

One-Third Tubular Plate Remains a Clinically Good Option in Danis-Weber Type B Distal Fibular Fracture Fixation.

OBJECTIVE: To compare the clinical outcomes of locking plate (LP) and non-locking one-third tubular plate (TP) fixation, and to provide guidance on plate selection for Danis-Weber type B distal fibular fracture treatment. METHODS: In total, 83 patients who underwent plate fixation for Danis-Weber type B distal fibular fractures between March 2013 and July 2018 were retrospectively reviewed: 41 (49.0%) received LPs and 42 (51.0%) received TPs. Patients' demographic data, follow-up durations, the proportion of comminuted fractures, and ankle range of motion were investigated. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, Karlsson scale, Foot and Ankle Ability Measure (FAAM), and Lower Extremity Functional Scale (LEFS) scores were assessed. The radiographic union progression and implant removal time were evaluated, along with postoperative complications. Data from the LP and TP groups were compared statistically. RESULTS: The mean patient ages were 53.3 ± 17.5 years (range, 16-80 years) and 47.6 ± 17.0 years (range, 14-68 years) in the LP and TP groups, respectively (P > 0.05). The gender distribution did not differ significantly between groups (P > 0.05). Other demographic data also did not differ significantly between groups (P > 0.05). The mean follow-up durations were 16.8 ± 7.7 months (range, 13.0-19.0 months) in the LP group and 16.1 ± 6.2 months (range, 12.0-20.0 months) in the TP group (P > 0.05). Comminuted fractures were observed in 18 of 41 (43.9%) patients with LP and 10 of 42 (23.8%) patients with TP (P > 0.05). Forward bending ankle dorsiflexion was possible at the final follow-up in 82.9% and 85.7% of LP and TP patients, respectively (P > 0.05). The AOFAS ankle-hindfoot scale, Karlsson scale, FAAM, and LEFS scores did not differ significantly between groups at the final follow-up (P > 0.05). The pre-fracture and final postoperative scores on these four instruments did not differ significantly in the LP or TP group (P > 0.05). The mean times to radiographic union progression were 13.5 ± 7.1 weeks and 15.1 ± 10.2 weeks in the LP and TP groups, respectively (P > 0.05). The mean times to implant removal surgery reaffirming solid union were 15.6 ± 5.5 months and 14.8 ± 4.9 months in the LP and TP groups, respectively (P > 0.05). Hardware irritation was detected in five patients in the LP group (12.2%) and three in the TP group (7.1%) (P > 0.05). One patient in the LP group and two in the TP group developed superficial wound infections, which resolved without further surgical intervention. CONCLUSION: Conventional TP remains a good option for the fixation of Danis-Weber type B distal fibular fractures, regardless of the biomechanical properties.

Efficacy of a povidone-iodine foam dressing (Betafoam) on diabetic foot ulcer.

This study aimed to assess the efficacy of a new povidone-iodine (PVP-I) foam dressing (Betafoam) vs foam dressing (Medifoam) for the management of diabetic foot ulcers. This study was conducted between March 2016 and September 2017 at 10 sites in Korea. A total of 71 patients (aged ≥19 years) with type 1/2 diabetes and early-phase diabetic foot ulcers (Wagener classification grade 1/2) were randomised to treatment with PVP-I foam dressing or foam dressing for 8 weeks. Wound healing, wound infection, patient satisfaction, and adverse events (AEs) were assessed. The PVP-I foam and foam dressing groups were comparable in the proportion of patients with complete wound healing within 8 weeks (44.4% vs 42.3%, P = .9191), mean (±SD) number of days to complete healing (31.00 ± 15.07 vs 33.27 ± 12.60 days; P = .6541), and infection rates (11.1% vs 11.4%; P = 1.0000). Median satisfaction score (scored from 0 to 10) at the final visit was also comparable between groups (10 vs 9, P = .2889). There was no significant difference in AE incidence (27.8% vs 17.1%, P = .2836), and none of the reported AEs had a causal relationship with the dressings. The results of this study suggest that PVP-I foam dressing has wound-healing efficacy comparable with foam dressing, with no notable safety concerns. This study was funded by Mundipharma Korea Ltd and registered at ClinicalTrials.gov (identifier NCT02732886).

What should we be careful of ankle arthroscopy?

PURPOSE: Ankle arthroscopy has been used as a standard tool by foot and ankle surgeons. To overcome the narrowness of ankle joint, a noninvasive distraction technique is used for the successful visualization in ankle arthroscopy. The aim of this study was to investigate the incidence and type of complications associated with ankle arthroscopy using a noninvasive distraction technique and to report a troublesome complication. METHODS: We reviewed 514 patients' charts from 2003 to 2011. The same noninvasive distraction technique was used. Patients' demography, duration of follow-up, diagnoses, procedures, and complications related to ankle arthroscopy were analyzed. RESULTS: There were 388 male and 126 female; mean age was 37.2 years; mean follow-up duration was 33 months. The diagnoses were osteochondral lesion of talus, chronic ankle instability, anterolateral soft tissue impingement syndrome, and anterior bony impingement. We performed arthroscopic synovectomy, osteochondral procedure, bony spur excision, and loose body removal. The mean time of arthroscopic procedure was 47 min. There were neurologic complications (eight cases), skin necrosis of posterior thigh (three cases), instrument breakage (two cases), and superficial wound infection (one case). All complications were well resolved. The total duration of distraction plus tourniquet inflation exceeded 120 min in the three cases of skin necrosis. Skin necrosis was deemed to be resulted from the long tourniquet time. CONCLUSION: The noninvasive distraction technique is safe and effective for ankle arthroscopy. However, the distraction plus tourniquet requires attention because it can cause high pressure on posterior thigh resulting in soft tissue injury.

Topical epidermal growth factor spray for the treatment of chronic diabetic foot ulcers: A phase III multicenter, double-blind, randomized, placebo-controlled trial.

AIMS: This study was conducted to evaluate the efficacy and safety of a novel spray-applied growth factor therapy containing recombinant human epidermal growth factor (rhEGF) for the treatment of chronic diabetic foot ulcers (DFU). METHODS: This study was a phase III double-blind, randomized, placebo-controlled trial. 167 adult patients at six medical centers were randomized to receive routine wound care plus either topical spray treatment with 0.005% rhEGF (n = 82) or an equivalent volume of saline spray (n = 85) twice a day until ulcer healing or for up to 12 weeks. RESULTS: Demographics, medical status, and wound characteristics were comparable between rhEGF and placebo groups. More patients in the rhEGF group significantly had complete wound healing compared to placebo (73.2% versus 50.6%, respectively; P = .001). Wound healing velocity was faster in the rhEGF group (P = .029) regardless of HbA1c levels. The rhEGF group had a shorter median time to 50% ulcer size reduction (21 versus 35 days; hazard ratio = 3.13, P < .001) and shorter time to complete ulcer healing (56 versus 84 days; hazard ratio = 2.13, P < .001). CONCLUSIONS: This study confirms that application of spray-applied rhEGF in DFU patients results in faster healing velocity and higher complete healing rate regardless of HbA1c levels.

Origin of Satellite Ganglion Cysts with Effusion in the Flexor Hallucis Longus Tendon Sheath around the Hallux.

BACKGROUND: To describe the clinical and magnetic resonance imaging findings of ganglion cysts with effusion in the flexor hallucis longus tendon sheath around the hallux to evaluate their origin. METHODS: Patients with recurrent or painful ganglion cysts around the hallux with effusion in the flexor hallucis longus tendon sheath who underwent surgical treatment at St. Vincent's Hospital from February 2007 to August 2016 were investigated. Surgical indication was a painful or recurrent mass caused by the cystic lesions. Those without effusion of the flexor hallucis longus tendon sheath were excluded. We assessed the clinical and magnetic resonance imaging findings. RESULTS: Magnetic resonance imaging findings in all patients showed several ganglion cysts around the hallux and large fluid accumulations within the flexor hallucis longus tendon sheath. Regarding the location, six ganglion cysts were on the dorsomedial aspect, one on the plantar medial aspect, seven on the plantar lateral aspect, and one in the toe pulp. Ten patients showed joint effusions in both the metatarsophalangeal and interphalangeal joints, two in the metatarsophalangeal joints, and three in the interphalangeal joints. There were communication stalks with a tail shape or abutment between ganglion cysts with surrounding joint effusions. Intraoperatively, connections between ganglion cysts, the synovial cyst of the flexor hallucis longus tendon sheath, and surrounding joints were seen. CONCLUSIONS: Synovial fluid accumulation in the metatarsophalangeal or interphalangeal joint supplies the synovial cyst of the flexor hallucis longus tendon sheath and subsequently ganglion cysts in the hallux. In clinical practice, the surgeon should carefully check surrounding joints with tendon sheaths to prevent recurrence of the ganglion cysts around the hallux.

Gait Analysis of Symptomatic Flatfoot in Children: An Observational Study.

BACKGROUND: Flatfoot deformity is a lever arm disease that incurs kinetic inefficiency during gait. The purpose of this study was to measure the degree of kinetic inefficiency by comparing the gait analysis data of a flatfoot group with a normal control group. METHODS: The patient group consisted of 26 children (21 males and 5 females) with symptomatic flatfoot. They were examined with gait analysis between May 2005 and February 2014. Exclusion criteria were patients with secondary flatfoot caused by neuromuscular disorders, tarsal coalition, vertical talus, or others. Patients' mean age was 9.5 years (range, 7 to 13 years). The gait analysis data of the study group and the normal control group were compared. RESULTS: The mean vertical ground reaction force (GRF) in the push-off phase was 0.99 for the patient group and 1.15 for the control group (p < 0.05). The mean ankle moment in the sagittal plane during the push-off phase was 0.89 for the patient group and 1.27 for the control group (p < 0.05). The mean ankle power in the sagittal plane during the push-off phase was 1.38 for the patient group and 2.52 for the control group (p < 0.05). The aforementioned results show that patients with pes planovalgus had a reduction of moment, power, and GRF in the push-off phase during gait. CONCLUSIONS: Symptomatic flatfeet had a moment inefficiency of 30% and power inefficiency of 45% during gait compared to feet with preserved medial longitudinal arches.

Cryptococcal Osteomyelitis of the First Metatarsal Head in an Immunocompetent Patient.

Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.

Ultrasonographic examination of plantar fasciitis: a comparison of patient positions during examination.

BACKGROUND: Musculoskeletal ultrasound is a non-invasive and low-cost modality for real-time visualisation of the plantar fascia. Ultrasound examination for plantar fasciitis is generally performed with the patient in a prone position, although the rational for using a prone position has not been validated. The aim of the study was to investigate if ultrasound examination in a supine position, which is more comfortable than the prone position, is valid. METHODS: We conducted a prospective study of 30 participants with plantar fasciitis, 8 men (27 %) and 22 women (73 %), with a mean age of 53.9 ± 12.6 (range, 32 to 77) years, and an equal distribution of left and right feet. The plantar heel was divided into three portions for ultrasound examination: medial, central and lateral. Two measurements of plantar fascia thickness were obtained for each portion, with participants in 2 positions (supine and prone) and for 2 ankle postures (neutral and 15° of plantarflexion). Mean measurements of plantar fascia thickness were compared between the two positions (Wilcoxon signed rank tests for non-normally distributed data and paired t-tests for normally distributed data). Participants were asked to report their preferred position for examination, supine or prone. RESULTS: The measured thickness was comparable for both supine and prone positions, for both ankle postures, neutral and 15° of plantarflexion (p > 0.05). A specific self-reported preferred position was not identified. CONCLUSIONS: Ultrasound examination of plantar fasciitis can be performed in the supine position without any significant difference in measurement compared to examination in the conventional prone position. TRIAL REGISTRATION: The Catholic Medical Center Office of Human Research Protection Program (CMC-OHRP)/Institutional Review Board approved the current study (Approval No. KC12DISI0338), and all participants provided their written informed consent for participation and publication.

Standard addition/absorption detection microfluidic system for salt error-free nitrite determination.

A continuous-flow microfluidic chip-based standard addition/absorption detection system has been developed for accurate determination of nitrite in water of varying salinity. The absorption detection of nitrite is made via color development using the Griess reaction. We have found the yield of the reaction is significantly affected by salinity (e.g., -12% error for 30‰ NaCl, 50.0 µg L(-1)N-NO2(-) solution). The microchip has been designed to perform standard addition, color development, and absorbance detection in sequence. To effectively block stray light, the microchip made from black poly(dimethylsiloxane) is placed on the top of a compact housing that accommodates a light-emitting diode, a photomultiplier tube, and an interference filter, where the light source and the detector are optically isolated. An 80-mm liquid-core waveguide mounted on the chip externally has been employed as the absorption detection flow cell. These designs for optics secure a wide linear response range (up to 500 µg L(-1)N-NO2(-)) and a low detection limit (0.12 µg L(-1)N-NO2(-) = 8.6 nM N-NO2(-), S/N = 3). From determination of nitrite in standard samples and real samples collected from an estuary, it has been demonstrated that our microfluidic system is highly accurate (<1% RSD, n = 3) and precise (<1% RSD, n = 3).

Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach.

Haglund syndrome is characterized by chronic posterior heel pain associated with a posterosuperior calcaneal prominence. We assessed the clinical and radiologic outcomes after operative treatment of Haglund syndrome using the central tendon-splitting approach. Fifteen feet in 15 patients were investigated retrospectively after surgery. Of the 15 patients, 14 were males (93.3%) and 1 was female (6.7%). Their mean age was 33.1 ± 8.2 (range 20 to 50) years. The mean follow-up duration was 3.5 ± 1.5 years (range 24 to 90 months). The American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale and Victorian Institute of Sport Assessment-Achilles scores were investigated to assess the clinical outcomes. Patient satisfaction was assessed at the latest follow-up visit. The lateral talo-first metatarsal angle, calcaneal pitch angle, Fowler-Philip angle, and parallel pitch line were measured to assess the foot shape and radiographic outcomes. Clinically, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 62.1 ± 7.5 preoperatively to 92.5 ± 3.5 at the latest follow-up visit. The mean Victorian Institute of Sport Assessment-Achilles score increased from 53.2 ± 7.4 to 89.6 ± 3.4. All patients were satisfied with the operative results. Radiographically, all patients had cavus feet with an increased lateral talo-first metatarsal angle (mean +5.9° ± 5.0°) and calcaneal pitch angle (mean 26.0° ± 3.8°). The mean Fowler-Philip angle decreased from 58.9° ± 15.0° to 32.5° ± 7.2° postoperatively, and the positive parallel pitch line had changed to a negative value in all cases. Operative treatment with the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome.

Infectious Achilles Tendinitis After Local Injection of Human Placental Extracts: A Case Report.

Local injections of corticosteroids or human placental extracts are sometimes used for the treatment of resistant tendinitis or fasciitis. We report a case of infectious Achilles tendinitis complicated by calcaneal osteomyelitis after injection of human placental extracts for the Achilles tendinitis. She was treated with excision of the infected bone and tendon, followed by V-Y lengthening of the proximal portion of the Achilles tendon in a single stage. At 2 years postoperative, she remained symptom free without any signs of recurrence, and the follow-up magnetic resonance imaging scan demonstrated a well-maintained Achilles tendon with normal signal intensity.

Arthroscopic versus posterior endoscopic excision of a symptomatic os trigonum: a retrospective cohort study.

BACKGROUND: Both subtalar arthroscopic and posterior endoscopic techniques are used to treat posterior ankle impingement syndrome (PAIS). However, there have been no studies comparing the 2 procedures. HYPOTHESIS: Both arthroscopic and endoscopic excisions of the os trigonum are safe and effective in treating PAIS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty-eight patients were treated with excision of the os trigonum either by an arthroscopic (16 patients) or endoscopic (12 patients) technique. The mean patient age was 29.8 years (range, 17-55 years), and the mean follow-up period was 30 months (range, 18-58 months). Preoperative and postoperative visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Maryland Foot Score (MFS) were used to analyze the functional results. Duration of surgery, time to return to sports (RTS), and patient satisfaction were evaluated as well. The size of the os trigonum was measured using T1-weighted sagittal magnetic resonance imaging (MRI). The clinical and MRI results were compared between the 2 groups. RESULTS: The VAS score, AOFAS score, and MFS for both the arthroscopic group (preoperative: 6.3, 63.8, and 61.5, respectively; postoperative: 1.2, 89.9, and 89.6, respectively) and endoscopic group (preoperative: 6.7, 64.8, and 62.5, respectively; postoperative: 1.2, 89.9, and 88.4, respectively) improved significantly (P < .01). The mean surgery and RTS times were 39.4 minutes and 7.5 weeks in the arthroscopic group and 34.8 minutes and 8.0 weeks in the endoscopic group, respectively (P > .05). All patients were satisfied with the results. There were no significant differences between the 2 groups in the preoperative and postoperative VAS score, AOFAS score, or MFS (P > .05). The mean size of the os trigonum was 11.1 × 8.8 mm(2) in the arthroscopic group and 12.6 × 10.4 mm(2) in the endoscopic group, and the difference was significant (P < .05). Two patients underwent both arthroscopic and endoscopic procedures because of technical difficulty in removing the large os trigonum arthroscopically. CONCLUSION: Both arthroscopic and posterior endoscopic excisions of the os trigonum were safe and effective in treating PAIS. The arthroscopic procedure was more demanding, especially in cases of a large os trigonum. The posterior endoscopic approach had the advantage of addressing problems in the posterior ankle joint and allowed a more extensive release of the flexor hallucis longus.

Osteochondroma of the distal tibia complicated by a tibialis posterior tendon tear.

Osteochondroma of the bone can irritate the overlying soft tissue, resulting in pain and discomfort. Rarely, a tendon tear can occur by an impinging bony mass. We report a case of osteochondroma of the distal tibia in a 23-year-old female patient that was complicated by a partial tear of the tibialis posterior tendon. She was treated with excision of the bony mass combined with tendon debridement and repair. The follow-up examination at 5 years postoperatively showed successful results.

Arthroscopy of the first metatarsophalangeal joint in 59 consecutive cases.

The authors analyzed the results of 59 consecutive cases of the first metatarsophalangeal (MTP-I) joint arthroscopy to verify the efficacy and safety of the procedure. Fifty-nine patients were followed for >18 months after MTP-I joint arthroscopic procedures. The mean duration of follow-up was 25 months. Clinically, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the satisfaction of the patients were evaluated. Hallux valgus angle, the first intermetatarsal angle, and medial sesamoid position were analyzed in cases of hallux valgus. The American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal scale score was increased from 69 points preoperatively to 92 points postoperatively (p < .05). Radiologically, the mean hallux valgus angle was decreased from 29.2° preoperatively to 9.7° postoperatively (p < .05). The mean first intermetatarsal angle was decreased from 14.8° preoperatively to 7.7° postoperatively (p < .05). The medial sesamoid position was improved from 4.8 preoperatively to 2.0 postoperatively (p < .05). Ninety-five percent of the patients were satisfied with the procedures. There was 1 case of a wound problem and 1 case of temporary digital nerve injury as complications. Based on our experience, arthroscopy of MTP-I joint appears to be a safe and reproducible procedure for selected cases of MTP-I joint disorders.

Nodular excision for painful localized Achilles tendon xanthomas in type II hyperlipoproteinemia: a case report.

Achilles tendon xanthomas are often associated with type II hyperlipoproteinemia, in which low-density lipoprotein derived from the circulation accumulates in the tendons. Sometimes coronary artery disease can jeopardize the life of the patient if the condition is neglected. We describe the case of bilateral painful Achilles tendon xanthomas in a heterozygous type II hyperlipoproteinemia family. Her symptoms were not alleviated despite anti-inflammatory medication and eccentric exercise for 6 months. She was treated with nodular excision of the xanthomas bilaterally and then with postoperative statins to avoid recurrence.

Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe.

BACKGROUND: The treatment of lateral ankle instability is challenging when the remaining ligamentous tissue is insufficient. Anatomic reconstruction with a tendon graft is a good option that can produce a stable ankle and avoid the complications of a nonanatomic tenodesis procedure. HYPOTHESIS: A new technique for anatomically reconstructing the lateral ligaments of the ankle using an extensor digitorum longus tendon graft of the fourth toe will be effective for treating lateral ankle instability with chronic ligamentous insufficiency. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-four patients were treated with anatomic reconstruction of the ligaments using the long extensor tendon of the fourth toe. The mean age was 35.7 years (range, 16-53 years). The minimum follow-up was 24 months (range, 24-57 months; mean, 37 months). There were 17 cases of chronic ligamentous insufficiency, 3 failed Brostrom operations, and 4 others. Preoperative and postoperative Karlsson scales were used to analyze the functional results. The anterior displacement and the talar tilt angle on standard stress radiography of the talocrural joint were measured preoperatively and at the time of last follow-up for comparison. RESULTS: The results on the Karlsson scale increased from 48.0 ± 4.2 points preoperatively to 92.2 ± 3.8 points at the latest follow-up (P < .01). Radiographically, the mean anterior displacement was 6.7 ± 1.2 mm before operation and 3.4 ± 0.6 mm at the latest follow-up (P < .01). The mean talar tilt angle was 12.3° ± 1.1° before the operation and 4.3° ± 0.8° at the latest follow-up (P < .01). CONCLUSION: Anatomic reconstruction of the lateral ankle ligaments using the long extensor tendon of the fourth toe appears to be an effective surgical option for chronic insufficiency of the lateral ankle ligament.