Assessment of clinical outcomes after reduction of depressed calcaneal fractures using the push-out molding technique.

Introduction: As minimal invasive techniques for depressed calcaneal fracture treatment have become more common, great progress has been achieved with various surgical methods. While these techniques are still currently utilized, new methods have been developed. This study aimed to report the radiologic and clinical outcomes of depressed calcaneal fracture treatment with the "push-out molding" technique and to propose its clinical utility. Materials and methods: From March 2009 to October 2020, a retrospective study was conducted with 52 patients, who received the "push-out molding" technique to treat depressed intra-articular calcaneal fractures (Sanders type II, III, IV). Exclusion criteria were as follows: patients with bilateral calcaneal fractures, open fractures, and a follow-up period <12 months. Radiologic parameters were assessed at following periods: preoperative, postoperative, 3-month follow-up, and last follow-up. Limitation of range of motion (ROM), subjective satisfaction, and complications were assessed at the last follow-up period. Repeated measures ANOVA was used to analyze values at preoperative, postoperative, 3-month, and last follow-up periods. Results: Significant differences in the talo-calcaneal angle (p < 0.001), Böhler's angle (p=<0.001), Gissane's angle (p = 0.023), distance from the lower cortical border of calcaneus to the anterior (p=<0.001) and posterior (p=<0.001) points of posterior articular surface, calcaneal length (p = 0.019), and talo-calcaneal height (p=<0.001). Postoperatively, the posterior articular surface was well maintained, while 21.2% retained a ROM limitation by 20° or higher. Subjective satisfaction was as follows: excellent (42.3%), good (48.1%), fair (9.6%), and poor (0%). Conclusion: The "push-out molding" is a simple technique with the advantage of not requiring much force to treat depressed calcaneal fractures. It can be used as a beneficial surgical technique with minimal damage to the soft tissue, owing to the reduction from the depressed interior part and less severe ROM limitation.

Talus osteomyelitis by Candida krusei with multiple huge cystic lesions: a case report and review of literatures.

BACKGROUND: Osteomyelitis due to Candida krusei are extremely rare, given that only six cases have been reported, all of which are limited to the patients with immunocompromising risk factors. Here we report a case of C. krusei osteomyelitis in an immunocompetent patient, presenting with multiple huge cystic lesions of talus. CASE PRESENTATION: A 66-year-old female presented with one year history of painful swelling of right ankle and a draining sinus around lateral malleolus. Five months and three months ago, she had undergone arthroscopic synovectomy and bursectomy which revealed no causative organism. Open bursectomy with sinus tract excision was performed and intravenous antibiotic was administered. Two year after the surgery, the patient revisited the clinic for recurrent painful swelling with pus drainage at the same location. Multiple huge cystic lesions with osteolysis and sclerotic rim of talus were found and C. krusei was isolated from tissue culture. The patient received surgical debridement and prolonged antifungal treatment comprising caspofungin and voriconazole. CONCLUSIONS: In this case, C. krusei infection showed atypically aggressive osteolysis shown as multiple huge cystic abscess. High index of suspicion is critical for early diagnosis and treatment to prevent such devastating results even in an immunocompetent patient.

Subtalar distraction arthrodesis for calcaneal malunion - comparison of structural freeze-dried versus autologous iliac bone graft.

BACKGROUND: This study aims to analyze the outcomes of subtalar distraction arthrodesis (SDA) for calcaneal malunion using structural freeze-dried iliac allograft (FDIA) compared to using autologous iliac bone (AIB). METHODS: We retrospectively evaluated 57 consecutive cases (51 patients) of calcaneal malunion between March 2006 and December 2017. All patients were followed for an average of 22.8 months. All cases were treated by SDA using structural FDIA (17 cases, group 1), or AIB (40 cases, group 2). The outcome measures included the American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) scores, visual analog scale (VAS) pain scores, and radiographic measurements. RESULTS: The mean postoperative 3, 6, and 12 months of AOFAS scores and VAS pain score were significantly better in group 2 than those in group 1 (p < 0.05, for all). There were 3 cases (17.6%) of nonunion in the group 1, whereas the group 2 had 2 cases (5.0%), which did not shown significant difference between two groups (p = 0.492). Although the mean pre-, postoperative, and final follow-up radiologic parameters in both groups were similar, (p > 0.05, for all) the difference of talocalcaneal height, talocalcaneal angle, and talar declination angle from postoperative to final follow-up were significantly bigger in the group 1. (p < 0.05, for all). CONCLUSION: Although union rate was not significantly different between the two groups, we obtained more favorable clinical and radiologic outcomes in the autologous iliac bone group. Using FDIA without any orthobiological agent for SDA, there were significant more loss of radiological parameters due to inferior incorporation and biomechanical properties. When considering the SDA for calcaneal malunion, routine use of FDIA without any orthobiological agents as an interpositional graft for SDA is not recommended.

Clinical and radiographic outcomes of the Kramer osteotomy in the treatment of bunionette deformity.

BACKGROUND: Bunionette deformity is a painful bony prominence of the 5th metatarsal. We evaluated outcomes of using a Kramer osteotomy to treat this condition. METHODS: Retrospective study of patients treated with a Kramer osteotomy from 2003 and 2016. Outcome measures included Foot Functional Index (FFI) and radiographic measurements. RESULTS: 38 patients (43 feet) with an average follow-up of 55 months. Mean postoperative FFI1 was 19.4. Mean 4-5 IMA2 improved 3.9°, from 8.3° preoperatively to 4.4° on final postoperative films (p<0.01). Mean MTP-53 angle improved 13.2° from 13.6° preoperatively to 0.4° at final follow-up (p<0.01). There were 5 delayed unions (11.6%) and 1 non-union (2.3%). CONCLUSIONS: The Kramer osteotomy is an effective treatment option in patients with bunionette deformity, with significant correction of the 4-5 IM2 and MTP-53 angles and few complications.

Short-Term Results of a Ruptured Deltoid Ligament Repair During an Acute Ankle Fracture Fixation.

BACKGROUND: There is no consensus on the optimal treatment or preferred method of operation for the management of acute deltoid ligament injuries during an ankle fracture fixation. This study aimed to analyze the outcomes of repairing the deltoid ligament during the fixation of an ankle fracture compared to conservative management. METHODS: We retrospectively evaluated 78 consecutive cases of a ruptured deltoid ligament with an associated ankle fracture between 2001 and 2016. All of the ankle fractures were treated with a plate and screw fixation. Patients in the conservative treatment for ruptured deltoid ligament underwent management from 2001 to 2008 (37 fractures, group 1), while the operative treatment for ruptured deltoid ligament was included from 2009 to 2016 (41 fractures, group 2). The outcome measures included radiographic findings, the American Orthopaedic Foot & Ankle Society ankle-hindfoot scores, visual analog scale scores, and the Foot Function Index. All patients were followed for an average of 17 months. RESULTS: Radiologic findings in both groups were comparable, but the final follow-up of the medial clear space (MCS) was significantly smaller in the group 2 ( P < .01). Clinical outcomes were similar between the two groups ( P > .05). Comparing those who underwent syndesmotic fixation between both groups, group 2 showed a significantly smaller final follow-up MCS, and all clinical outcomes were better in group 2 ( P < .05). Linear regression analysis showed that the final follow-up MCS had a significant influence on clinical outcomes ( P < .05). CONCLUSION: Although the clinical outcomes were not significantly different between the 2 groups, we obtained a more favorable final follow-up MCS in the deltoid repair group. Particularly when accompanied by a syndesmotic injury, the final follow-up MCS and the clinical outcomes were better in the deltoid repair group. In the case of high-grade unstable fractures of the ankle with syndesmotic instability, a direct repair of the deltoid ligament was adequate for restoring medial stability. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

Debridement and Functional Rehabilitation for Achilles Tendon Infection Following Tendon Repair.

BACKGROUND: An infected Achilles tendon after tendon repair is particularly difficult to treat because of the poor vascularity of the tendon as well as the thin surrounding soft tissue. For treatment of an infected Achilles tendon following tendon repair, we first focused on complete debridement and then promoted fibrous scar healing of the Achilles tendon using functional treatment. METHODS: We retrospectively reviewed all of the medical records of 15 tertiary referral patients with postoperative infection of the Achilles tendon occurring between 2007 and 2012. The mean follow-up time was 33 months (range, 22 to 97 months). The infected tissue and the necrotic tendon were debrided, and the ankle was placed in a short leg splint for 2 weeks. The splint was then replaced with an ankle brace for the next 4 weeks. Partial weight-bearing was allowed immediately, and full weight-bearing was allowed at 2 weeks postoperatively. We assessed and recorded the physical parameters such as the range of motion, calf circumference, ability to perform a single-limb heel rise, patient satisfaction, and Arner-Lindholm scale. Laboratory tests, postoperative ultrasonography, and isokinetic plantar flexion power tests were also performed. RESULTS: At a mean time of 17 days (range, 8 to 30 days) after debridement, infection signs such as discharge from the wound, redness, and local warmth resolved. The wound had healed and the stitches were removed at a mean of 17 days following the wound repair. At the time of the latest follow-up, there were no signs of active infection. Achilles tendon continuity recovered in all patients by fibrous scar healing. Compared with the contralateral side, there was no difference in the ankle range of motion in 8 patients. According to the Arner-Lindholm scale, 9 of the 15 results were excellent and 6 were good. Ten patients were able to perform a single-limb heel rise. Eleven of 15 patients returned to their pre-injury recreational activities. Diffuse homogeneous echotexture of the Achilles tendon with continuity was observed on the ultrasonographic examination. CONCLUSIONS: In this retrospective series, radical debridement, combined with antibiotic therapy and functional rehabilitation, was successful in eradicating infection and maintaining function in patients with postoperative infection following Achilles tendon repair. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mid-term follow up results of subtalar distraction arthrodesis using a double bone-block for calcaneal malunion.

PURPOSE: This study was designed to evaluate the mid-term results and efficacy of subtalar distraction double bone-block arthrodesis for calcaneal malunion. MATERIALS AND METHODS: From January 2004 to June 2007, we operated on 6 patients (10 cases). There were 5 males (9 cases) and 1 female (1 case), four of which presented with bilateral calcaneal malunion. Seven cases were operated on initially. The period between initial injury and arthrodesis was 23 months, and the average follow up period was 58 months. In operation, we applied an extensile lateral approach and arthrodesis was performed through a tricortical double bone-block and cannulated screws. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used for clinical evaluation. In radiologic analysis, plain X-ray and CT were examined to assess union and various parameters. RESULTS: The mean age of the patients was 41 years. All cases achieved radiologic union at the final follow-up. The mean AOFAS Ankle-Hindfoot scale (maximum of 94 points) increased from 43.3 points preoperatively to 85.4 points at the final follow-up. The radiologic analysis of the pre- and postoperative standing lateral radiographs showed improvements of 5.6 mm in talo-calcaneal height, 1.8° in talocalcaneal angle, 5.1° in talar declination angle and 5.3° in talo-first metatarsal angle. CONCLUSION: Subtalar distraction two bone-block arthrodesis provides overall good results not only in the short term but also the mid-term with significant improvement in clinical and radiologic outcomes. This procedure warrants consideration for managing calcaneal malunion with loss of height and subtalar arthritis.

Structure and function of papiliocin with antimicrobial and anti-inflammatory activities isolated from the swallowtail butterfly, Papilio xuthus.

Papiliocin is a novel 37-residue cecropin-like peptide isolated recently from the swallowtail butterfly, Papilio xuthus. With the aim of identifying a potent antimicrobial peptide, we tested papiliocin in a variety of biological and biophysical assays, demonstrating that the peptide possesses very low cytotoxicity against mammalian cells and high bacterial cell selectivity, particularly against Gram-negative bacteria as well as high anti-inflammatory activity. Using LPS-stimulated macrophage RAW264.7 cells, we found that papiliocin exerted its anti-inflammatory activities by inhibiting nitric oxide (NO) production and secretion of tumor necrosis factor (TNF)-α and macrophage inflammatory protein (MIP)-2, producing effects comparable with those of the antimicrobial peptide LL-37. We also showed that the innate defense response mechanisms engaged by papiliocin involve Toll-like receptor pathways that culminate in the nuclear translocation of NF-κB. Fluorescent dye leakage experiments showed that papiliocin targets the bacterial cell membrane. To understand structure-activity relationships, we determined the three-dimensional structure of papiliocin in 300 mm dodecylphosphocholine micelles by NMR spectroscopy, showing that papiliocin has an α-helical structure from Lys(3) to Lys(21) and from Ala(25) to Val(36), linked by a hinge region. Interactions between the papiliocin and LPS studied using tryptophan blue-shift data, and saturation transfer difference-NMR experiments revealed that Trp(2) and Phe(5) at the N-terminal helix play an important role in attracting papiliocin to the cell membrane of Gram-negative bacteria. In conclusion, we have demonstrated that papiliocin is a potent peptide antibiotic with both anti-inflammatory and antibacterial activities, and we have laid the groundwork for future studies of its mechanism of action.

Identification of the most active interleukin-32 isoform.

Cytokines are crucial in host defence against pathogens such as bacteria, viruses, fungi and parasites. A newly described cytokine, interleukin-32 (IL-32), induces various proinflammatory cytokines (tumour necrosis factor-alpha, IL-1beta, IL-6) and chemokines in both human and mouse cells through the nuclear factor-kappaB and p38 mitogen-activated protein kinase inflammatory signal pathway. The IL-32 primarily acts on monocytic cells rather than T cells. In an attempt to isolate the IL-32 soluble receptor, we used an IL-32 ligand-affinity column to purify neutrophil proteinase 3, which is a serine proteinase involved in many inflammatory diseases. IL-32 has biological activity associated with Mycobacterium tuberculosis and chronic proinflammatory diseases such as rheumatoid arthritis. IL-32 is transcribed as six alternative splice variants and the biological activity of each individual isoform remains unknown. Here, we cloned the complementary DNA of the four IL-32 isoforms (alpha, beta, gamma and delta) that are the most representative IL-32 transcripts. To produce recombinant protein with a high yield, the amino acids of two cysteine residues were mutated to serine residues, because serine residues are not conserved among different species. The multi-step purified recombinant IL-32 isoform proteins were assessed for their biological activities with different cytokine assays. The gamma isoform of IL-32 was the most active, although all isoforms were biologically active. The present study will provide a specific target to neutralize endogenous IL-32, which may contribute to basic and clinical immunology.

Crossed screws versus dorsomedial locking plate with compression screw for first metatarsocuneiform arthrodesis: a cadaver study.

BACKGROUND: We hypothesized that a dorsomedial locking plate with adjunct screw compression would provide superior rigidity compared to crossed screws for first metatarsocuneiform (MTC) arthrodesis. MATERIALS AND METHODS: In ten matched lower extremity pairs, specimens in each pair were randomly assigned to receive screw fixation or plate with screw fixation. Bone mineral density (BMD) was measured. For the crossed-screw construct, two 4.0-mm cannulated screws were used. One screw was inserted dorsal to plantar beginning from the first metatarsal 10 to 15 mm distal to the joint, and the second was inserted from the cuneiform 8 to10 mm proximal to the joint, medial to the first screw, into the first metatarsal. For the plate construct, a 4.0-mm cannulated compression screw was inserted from the dorsal cortex of the first metatarsal to the plantar aspect of the medial cuneiform. A locking plate was inserted dorsomedially across the MTC joint. Specimens were loaded in four-point bend configuration (displacement rate, 5 mm/min) until failure of the fixation or 3-mm deformation. An extensometer was used to measure deformation. RESULTS: There was no difference in load to failure or stiffness between the two groups. BMD was positively correlated with load to failure in the screw (r = 0.893, p = 0.001) and the plate (r = 0.858, p = 0.001) construct. CONCLUSION: The plate construct with compression screw did not show different rigidity as compared with the screw construct with the numbers available. CLINICAL RELEVANCE: Further investigation of a dorsomedial plate with adjunct screw compression may be warranted for first MTC arthrodesis.

Unique expression of a small IL-32 protein in the Jurkat leukemic T cell line.

Interleukin (IL)-32 was recently identified as a new cytokine which induces various proinflammatory cytokines in human monocytes and macrophages. Therefore, IL-32 has been primarily studied in inflammatory models such as rheumatoid arthritis and inflammatory bowel diseases. The regulation of endogenous IL-32 in other immune cells remains unknown. In the present study, we stimulated Jurkat T cells with phytohaemagglutinin (PHA) and phorbol myristate acetate (PMA) and examined IL-32 expression at both the mRNA and protein levels. All mRNAs of the four IL-32 isoforms and the 12-15 kDa IL-32 protein were independent of PHA and PMA stimulation, however a 9 kDa molecular weight IL-32 protein in the cell culture supernatant was induced by PHA and PMA after 16 h of stimulation. Compared to other human cell lines, the Jurkat cell line constitutively expressed a 12-15 kDa molecule of IL-32, which is smaller than the known IL-32 isoforms. We used IL-32 shRNA to examine the specificity of the 12-15 kDa molecule. Upon IL-32 shRNA transfection, the 12-15 kDa band was decreased specifically as compared to the control scrambled clone. Thus, the constitutive expression of IL-32 mRNA as well as the predominant production of a smaller sized IL-32 isoform in Jurkat cells may implicate a role for IL-32 in human T cell leukemia.

Interleukin-32 induces the differentiation of monocytes into macrophage-like cells.

After emigration from the bone marrow to the peripheral blood, monocytes enter tissues and differentiate into macrophages, the prototype scavenger of the immune system. By ingesting and killing microorganisms and removing cellular debris, macrophages also process antigens as a first step in mounting a specific immune response. IL-32 is a cytokine inducing proinflammatory cytokines and chemokines via p38-MAPK and NF-kappaB. In the present study, we demonstrate that IL-32 induces differentiation of human blood monocytes as well as THP-1 leukemic cells into macrophage-like cells with functional phagocytic activity for live bacteria. Muramyl dipepide (MDP), the ligand for the intracellular nuclear oligomerization domain (NOD) 2 receptor, has no effect on differentiation alone but augments the monocyte-to-macrophage differentiation by IL-32. Unexpectedly, IL-32 reversed GM-CSF/IL-4-induced dendritic cell differentiation to macrophage-like cells. Whereas the induction of TNFalpha, IL-1beta, and IL-6 by IL-32 is mediated by p38-MAPK, IL-32-induced monocyte-to-macrophage differentiation is mediated through nonapoptotic, caspase-3-dependent mechanisms. Thus, IL-32 not only contributes to host responses through the induction of proinflammatory cytokines but also directly affects specific immunity by differentiating monocytes into macrophage-like cells.

Treatment of open tibial shaft fractures using tightly fitted interlocking nailing.

Between 2000 and 2003 we treated 23 patients who sustained open tibial shaft fractures with tightly fitted interlocking intramedullary nailing. There were three grade I, eight grade II, nine grade IIIa, and three grade IIIb open fractures. Nail diameters were decided on using preoperative and intraoperative radiographs. Nails were introduced after gentle passage with a 7- to 8-mm hand reamer. Union was obtained in all cases. Nine (37.5%) fractures, however, required additional procedures before union. Three of them gained union through exchange nailing, bone graft, and bone transport, respectively. The remaining six underwent dynamisation. Two of them required an additional exchange nailing for non-union; thereafter one healed and the other gained union through an additional bone graft. Deep infection occurred in one case. Screw breakage occurred in one case only. Tightly fitted nailing produced a significantly lower incidence of locking screw breakage. However, even with this advantage, this technical modification has failed to show clinical advantage in terms of higher healing rate or lower rate of secondary procedures.