The Relationship Between Calcaneofibular Ligament Injury and Ankle Osteoarthritis Progression: A Comprehensive Analysis of Stress Distribution and Osteophyte Formation in the Subtalar Joint.

BACKGROUND: Ankle osteoarthritis (OA) mainly arises from trauma, particularly lateral ligament injuries. Among lateral ligament injuries, ankles with calcaneofibular ligament (CFL) injuries exhibit increased instability and can be a risk factor ankle OA progression. However, the relationship between CFL injury and OA progression remains unclear. Therefore, this study aims to assess the relationship between CFL injuries and ankle OA by investigating stress changes and osteophyte formation in subtalar joint. METHODS: We retrospectively reviewed the magnetic resonance imaging (MRI) and plain radiographic evaluations of 100 ankles of 91 patients presenting with chronic ankle instability (CAI), ankle OA, or other ankle conditions. The association between CFL injuries on the oblique view of MRI and the severity of ankle OA (based on Takakura-Tanaka classification) was statistically evaluated. Additionally, 71 ankles were further subjected to CT evaluation to determine the association between the CFL injuries and the Hounsfield unit (HU) ratios of the subtalar joint and medial gutter, and the correlation between the subtalar HU ratios and osteophyte severity were statistically evaluated. RESULTS: CFL injury was observed in 35.9% (14/39) of patients with stage 0, 42.9% (9/21) with stage 1, 50.0% (10/20) with stage 2, 100% (9/9) with stage 3a, and 90.9% (10/11) with stage 3b. CFL-injured ankles exhibited higher HU ratios in the medial gutter and lower ratios in the medial posterior subtalar joint compared to uninjured ankles. A negative correlation was observed between medial osteophyte severity and the medial subtalar joint HU ratio. CONCLUSION: Our findings suggest that CFL injuries are common in severe ankle OA impairing the compensatory function of the subtalar joint through abnormal stress distribution and osteophyte formation. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Effect of a compression staple on correction of varus deformity during arthroscopic ankle arthrodesis.

BACKGROUND: Arthroscopic ankle arthrodesis (AAA) has become popular because of its higher rate of bone union, lower invasiveness, and shorter hospital stays compared to those of open arthrodesis. However, postoperative malalignment is often observed for severe varus deformity, which can cause nonunion, pain, and adjacent joint arthrosis. A compression staple can provide a persistent, strong compressive force on the bone surface. This study aimed to clarify the difference in alignment correction in AAA by comparing a compression staple and screws fixation with screws-only fixation pre- and postoperatively. METHODS: Seventy ankles in 67 patients undergoing AAA were retrospectively reviewed. AAA with three screws through the distal tibia was performed in 53 ankles, and 17 ankles underwent AAA with a compression staple and two screws. After the preparation of the joint surface arthroscopically, patients in the S group had three canulated cancellous screws inserted through the medial tibia. Patients in the CS group had a compression staple placed at the lateral aspect of the tibiotalar joint and two screws inserted through the medial side. Clinical scores and pre-and postoperative alignment on plain radiographs were compared between the two procedures. RESULTS: There were no significant differences in the pre-and postoperative Japanese Society for Surgery of the Foot scale. One ankle in the S group exhibited nonunion. There were no significant differences in talar tilt and tibiotalar angles between the groups. The tibial plafond angle in the CS group was significantly lower than that in the S group (p < 0.05). Postoperatively, talar tilt and tibiotalar angles on the coronal image, and the lateral tibiotalar angle in the CS group were significantly lower than those in the S group (p < 0.05). CONCLUSION: AAA with a compression staple and two-screw fixations could obtain more optimal alignments than AAA with screw-only fixation, even in cases with severe varus deformity.

Comparison of Clinical Outcomes With Arthroscopic ATFL Repair With the CFL Repair and Open ATFL and CFL Repair in Chronic Lateral Ankle Instability.

It is important to eliminate instability related to chronic lateral ankle instability (CLAI) to prevent osteoarthritis progression. We performed arthroscopic anterior talofibular ligament (ATFL) repair and performed calcaneofibular ligament (CFL) repair if instability remained. This study aimed to assess the clinical outcomes of our arthroscopic procedure compared to that of open surgery. Forty ankles underwent arthroscopic surgery and 23 ankles underwent open surgery to repair the lateral ankle ligaments for CLAI. In the arthroscopic surgery, varus stress was applied under fluoroscopy after ATFL repair, and CFL repair was performed if instability remained. Open surgery was performed using the Broström procedure with ATFL and CFL repair. To assess clinical outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) and Karlsson-Peterson (KP) scores were collected preoperatively and at the final follow-up. The talar tilt angle (TTA) was measured preoperatively and 1 year postoperatively. The arthroscopic group showed significantly higher AOFAS and KP scores at the final follow-up compared to the open surgery group. There was no significant difference in TTA at 1 year between the groups. In open surgery, 2 patients required revision surgery. There were no major complications, but scar-related pain in 2 cases of open surgery was reported. Arthroscopic ATFL repair with the CFL repair gave satisfactory clinical outcomes compared to open surgery in CLAI because of low invasive to soft tissue including the joint capsule. It is important to minimize soft tissue dissection in repairing the lateral ankle ligament in patients with CLAI.

Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability.

PURPOSE: Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair. MATERIALS AND METHODS: Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed. RESULTS: The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05). CONCLUSIONS: Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability.

PURPOSE: Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI. MATERIALS AND METHODS: Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed. RESULTS: The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain. CONCLUSIONS: Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

Safe Insertion Angle of the Suture Button to Avoid Saphenous Structure in Syndesmosis Injury.

In placing the medial suture button for syndesmosis injury, the risk of great saphenous vein and saphenous nerve injury has been reported. This study aimed to determine the safe insertion angle of the guide pin to avoid saphenous structure injury during suture button fixation. The incidence of saphenous structure injury was investigated using 8 legs of cadavers. The greater saphenous vein was depicted on the skin using near-infrared light (VeinViewer® Flex) and the distance between the greater saphenous vein and the posterior edge of the tibia at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint was measured in the 60 legs of healthy participants. On computed tomography (CT) images, the angles between the greater saphenous vein and transmalleolar axis at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint were measured. The cadaveric study revealed that the percentages of contact with the saphenous nerve were 8.3% to 16.7%. Using near-infrared light, the vein and tibia distance was 32.9 ± 6.8 mm of 10 mm, 26.6 ± 6.4 mm of 20 mm, and 20.4 ± 6.4 mm of 30 mm. The angle between the vein and transmalleolar axis was 1.0° to 9.4°, and more proximal, the angle was smaller. The veins depicted by near-infrared light can be a landmark to identify great saphenous vein, and injury of the saphenous structure can be prevented using VeinViewer Flex or considering the insertion angle defined in this study when placing the suture button for syndesmosis injuries.Level of Evidence: Level IV.

Quantitative evaluation of calcaneofibular ligament injury on the oblique coronal view of magnetic resonance imaging in chronic lateral ankle instability.

BACKGROUND: In the treatment of chronic lateral ankle instability (CLAI), the repair of the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) is still being discussed, possibly due to the difficulty in assessing CFL injuries. In particular, it is challenging to evaluate the extent of CFL deficiency quantitively. We hypothesized that CFL tension change would alter morphology of the CFL on magnetic resonance imaging (MRI) and that measuring this morphological change allows assessing CFL injury quantitatively. Thus, this study aimed to analyze the feasibility of quantitatively assessing CFL injuries using MRI. METHODS: Sixty-four ankles with CLAI were included and divided into two groups: with (ATFL and CFL group, 31 ankles) or without CFL repair (ATFL group, 33 ankles) in addition to arthroscopic ATFL repair. The angle between the CFL and calcaneal axis (CFLCA) and the bending angles of the CFL was defined as the flexed CFL angle (FCA) were measured on the oblique CFL view of preoperative MRI. The diagnostic abilities of these angles for CFL injury and correlations between these angles and stress radiographs were analyzed. RESULTS: The sensitivity and specificity of CFLCA were 86.7 % and 88.7 %, and those of FCA were 63.3 % and 77.4 %, respectively. The combination of CFLCA and FCA improved the sensitivity to 93.3 %. The cutoff points of CFLCA and FCA were 3.8° and 121.2°, respectively. There were significant moderate and weak correlations between the talar tilting angle and CFLCA or FCA (rs = -0.533, and rs = -0.402, respectively). The CFLCA and FCA were significantly smaller in the ATFL and CFL group than those in the other groups. CONCLUSIONS: Measurement of CFLCA and FCA in oblique CFL view on MRI could be useful for the quantitative evaluation of CFL injury in patients with CLAI． LEVEL OF EVIDENCE: Level IV. case-control study.

Development of osteophytes and joint space narrowing is associated with cartilage degeneration of the osteochondral fragment in the osteochondral lesion of the talus.

BACKGROUND: During surgery for osteochondral lesions of the talus (OLT), preservation or excision of the osteochondral fragment is chosen based on the cartilage condition which influences the indication and clinical outcomes of surgical treatments. However, it is difficult to predict arthroscopic and histological findings of the cartilage on osteochondral fragments by radiographic evaluation. We focused on osteoarthritis (OA) changes on plain radiographs to predict the cartilage condition of the OLT. This study aimed to evaluate whether OA changes, including osteophyte and joint space narrowing, could predict arthroscopic and histological findings of the cartilage in OLT. METHODS: Seventy ankles with OLT were included in this study. Osteophytes and joint space narrowing were scored on plain radiographs. Lesion sizes were measured on computed tomography images. The cartilage surfaces of fragments were arthroscopically assessed using the International Cartilage Repair Society (ICRS) grade. Biopsy specimens from 32 ankles were histologically analyzed using the Mankin score. The relationships between OA scores, lesion size, ICRS grades, and Mankin score were analyzed. RESULTS: OA changes were frequently observed with increasing ICRS grades, especially in the medial tibiotalar joint. OA scores in patients with ICRS grade 1 were significantly lower than those in ICRS grades 2,3, and 4. The lesion sizes in patients with ICRS grade 3 and 4 were significantly smaller than those in patients with ICRS grade 1 and 2. Histological analysis showed increasing Mankin scores as the ICRS grade worsened. A mild correlation existed between the OA and Mankin scores (rs = 0.494). CONCLUSIONS: OA changes, such as osteophyte formation and joint space narrowing, are associated with arthroscopic findings of the articular surface and cartilage degeneration in osteochondral fragment in OLT. Articular cartilage conditions can be predicted by OA changes on plain radiographs, which is useful for choosing the appropriate treatment for patients with OLT. LEVEL OF EVIDENCE: Level Ⅳ, case series.

Morphology and deformity of the distal phalanx in hallux valgus.

BACKGROUND: Studies have shown that the first metatarsal contributes to hallux valgus. The proximal phalanx, another factor that defines the hallux valgus angle, also contributes to the development of hallux valgus. There have been no reports on the use of computed tomography to evaluate bone morphology of the proximal phalanx. The purpose of this study was to analyze the morphology and deformity of the proximal phalanx and its relationship to hallux valgus using computed tomography, and to consider the indications for proximal phalanx surgery in hallux valgus. METHODS: Patients who consulted at our clinic for foot and ankle disorders and underwent both weight-bearing radiography and computed tomography between May 2019 and March 2022 were included in the study. The hallux valgus angle, sesamoid subluxation, first metatarsal length, proximal phalanx length, metatarsal-proximal phalanx ratio, proximal phalanx valgus angle, metatarsal-proximal phalanx angle, proximal phalanx rotation angle, and distal phalanx-proximal phalanx angle were measured. These parameters were compared between the hallux valgus and control groups. In the hallux valgus group, the hallux valgus and proximal phalanx valgus angles were measured and compared using weight-bearing radiographs. RESULTS: A total of 83 feet in 65 patients were diagnosed with hallux valgus (hallux valgus group; mean age of 68.0 ± 13.8 years) and 30 feet in 22 patients without hallux valgus (control group; mean age of 67.0 ± 25.8 years) were included in the study. The proximal phalanx length, metatarsal-proximal phalanx ratio and angle, and distal phalanx-proximal phalanx angle were significantly greater in the hallux valgus group than in the control group. However, the proximal phalanx valgus and rotation angles were not significantly different between the groups. CONCLUSION: Since there was no significant difference in the proximal phalanx morphology, except length, between the hallux valgus and control groups, the indications for osteotomy of the proximal phalanx should be carefully considered.

Achilles Tendon Reconstruction Using a Hamstring Tendon Autograft for Chronic Rupture of the Achilles Tendon in Patients Over 70 Years of Age: A Retrospective Case Series.

Reconstruction techniques using autologous hamstring tendons were generally applied for chronic Achilles tendon rupture with a large defect size. Previous studies have reported good clinical results of this technique for young or middle-aged patients, however, the clinical outcomes in older patients have been unclear. This retrospective case series reviewed four male patients aged >70 years (mean age, 78.5 years) who underwent Achilles tendon reconstruction using the hamstring tendon autograft for chronic rupture of the Achilles tendon with a large tendon defect. The proximal-distal length between the healthy tendon stumps was measured using sagittal T2-weighted magnetic resonance imaging (MRI). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and postoperative complications were evaluated. The duration from the traumatic event or appearance of symptoms to surgery was 3.8 (range, 2-6) months. The mean measured gap between the healthy tendon stumps was 67.5 mm on MRI. The AOFAS ankle-hindfoot score improved from 67.3 to 99.5 at the mean follow-up period of 40.3 (range, 23-75) months. No donor site morbidity was observed in all patients. Re-rupture was detected at the five-month follow-up in one patient who had removed a hinged ankle-foot orthosis with adjustable heel wedges without permission. Achilles tendon reconstruction using a hamstring tendon is a viable option for treating selected patients with chronic rupture of the Achilles tendon with a large tendon defect even in older patients. To improve clinical outcomes, a better understanding should be provided to family members as well as older patients regarding the postoperative rehabilitation program.

Plantar Plate Repair using Suture Anchors for Chronic Plantar Plate Rupture of the first Interphalangeal Joint in a Pediatric Patient: A Case Report.

Introduction: Injuries of the great toe are common sports-related injuries; however, isolated traumatic plantar plate tears at the interphalangeal (IP) joint are relatively rare. Here, we present a pediatric case of a chronic plantar plate tear of the IP joint of the great toe that was difficult to diagnose definitively, which delayed surgical treatment. Case Report: An 11-year-old girl was injured when she collided with her right great toe while using a jump box during gymnastics. She felt pain in her great toe that progressively worsened despite conservative treatment at an initial clinic, and she experienced hyperextension of the IP joint. She was referred to our outpatient clinic because of diagnostic difficulty and increased symptoms, such as pain and swelling of the plantar side of her right great toe. Physical examination revealed swelling and tenderness on the plantar aspect of the IP joint and the impossibility of active flexion of the IP joint. The passive range of motion was 35° during extension. Ultrasonography revealed a low-echoic area on the plantar plate on the phalangeal side. Thus, we diagnosed the patient with a chronic plantar plate tear of the IP joint of the right great toe and performed surgical treatment 8 months after its onset. The plantar plate ruptured at the insertion of the proximal phalanx; however, the insertion of the distal phalanx remained intact. The plantar plate was repaired using suture anchors, and excellent short-term postoperative results were obtained at the 1-year follow-up. Conclusion: Isolated plantar plate rupture is difficult to diagnose definitively in the acute phase because of the lack of specific findings on physical and radiographic examinations. Plantar plate rupture should be suspected as a differential diagnosis in patients with great toe injuries due to axial load and hyperextension forces. Plantar plate repair using suture anchors may be a useful option for treating plantar plate tears of the IP joint of the great toe when its insertion into the distal phalanx is preserved, even during the chronic phase.

Talonavicular Arthrodesis Using a Screw and Compression Staple in a Patient With Bipartite Navicular Bone: A Case Report.

The bipartite navicular bone is a relatively rare pathological condition in which the navicular bone is segmented. As a high nonunion rate in talonavicular arthrodesis of the foot has been reported, an effective fixation method is required to achieve bone union. A compression staple can provide a persistent strong compressive force on the bone surface, which is advantageous for arthrodesis, especially for the joints with a high incidence of nonunion. A 13-year-old boy presenting with left foot pain was diagnosed with bipartite navicular. Imaging of the left foot showed that the navicular bone was divided into two parts and flatfoot deformity. After the failure of conservative treatment, talonavicular arthrodesis was performed. The lateral fragment was removed, and the talar and medial fragments were fixed using a cannulated cancellous screw (CCS) (Ace Medical, El Segundo, CA, USA) and compression staple (DynaNite, 15 mm × 12 mm, Arthrex, Inc., Naples, USA) to correct the flatfoot. Bone union was achieved, and flatfoot improved. Thirteen months postoperatively, his symptoms disappeared, and all categories of the Self-Administered Foot Evaluation Questionnaire scored 100 points. Although the bipartite navicular bone has no established treatment due to its rareness, talonavicular arthrodesis using a combination of CCS and compression staple yields good short-term clinical outcomes including good alignment.

Comparisons of the effects of silk elastin and collagen sponges on wound healing in murine models.

Introductions: Silk elastin, a recombinant protein with repeats of elastin and silk fibroin, possesses a self-gelling ability and is a potential wound dressing material. The aim of this study is to elucidate the mechanism of the wound healing-promoting effect of silk elastin by comparing its in vivo behavior in a mouse wound model with that of a collagen sponge. Methods: Skin defects (8 mm in diameter) were created on the backs of C57BL/6J and BKS.Cg- + Lepr/+Lepr db male mice. Silk elastin sponges of 2.5 or 5.0 mm thickness, as well as collagen sponges, were placed on the wounds and secured with a polyurethane film. In the control group, only the polyurethane film was applied. The remaining wound area was grossly evaluated, and tissue samples were collected after 7, 14, and 21 days for histological evaluation, including neoepithelialization, wound contraction, granulation tissue formation, newly formed capillaries, and macrophages. Genetic analysis was conducted using real-time polymerase chain reaction. Results: In the study with C57BL/6J, there were no significant differences between the silk elastin and collagen sponge groups. Similarly, in the study using BKS.Cg- + Lepr/+Lepr db, no significant differences were found in the remaining wound area and granulation tissue formation between the silk elastin and collagen sponge groups. However, on day 14, the 5.0-mm-thick silk elastin sponge group showed increased macrophages, longer neoepithelialization, and more frequent angiogenesis compared to other groups. Gene expression of inducible nitric oxide synthase and arginase-1 was also higher in the 5.0 mm thick silk elastin sponge group. Conclusions: Silk elastin sponges demonstrated superior neoepithelialization and angiogenesis compared to collagen sponges. The results suggest that silk elastin and collagen sponges promote wound healing through different mechanisms, with silk elastin possibly enhancing wound healing by facilitating increased macrophage migration. Further studies are needed, but silk elastin shows great potential as a versatile wound dressing material.

Augmentation of the medial collateral ligament using suture tape reduces the recurrence after corrective surgery for severe hallux valgus.

BACKGROUND: The severity of hallux valgus (HV) deformity is associated with recurrence after corrective surgery because of the degenerative change of the medial capsule including the medial collateral ligament (MCL) at the metatarsophalangeal joint. This study aimed to assess the effectiveness of the MCL augmentation using a suture tape anchor of the recurrence of HV and to evaluate the histological changes of the medial joint capsule in HV patients. METHODS: Thirty-four feet with severe hallux valgus were included and divided into 2 groups. Seventeen feet had the MCL reconstruction using suture tape anchor with a combination of the corrective osteotomy as the suture tape group (mean age, 64.0 years), and other seventeen feet had the corrective osteotomy without MCL reconstruction as the control group (mean age, 62.0 years). HV angle (HVA) and intermetatarsal angle (IMA) on the weight-bearing radiograms and the Japanese Society for Surgery of the Foot (JSSF) score in both groups were compared at the final follow-up. The medial capsule was harvested from other 20 feet with HV and the relationship between the severity of HV and the histological findings was analyzed. RESULTS: HVA, IMA, and JSSF scores in both groups were significantly improved from preoperatively to the final follow-up (P < 0.01). At the final follow-up, HVA in the suture tape group (9.2°) was significantly smaller than that in the control (15.4°) (P < 0.01). There were no significant differences in the IMA and the JSSF score at the final follow-up between both groups. Histological scores in HV with ≥40° HVA was significantly worse than those in <40°. CONCLUSION: The medial joint capsule in severe HV deformity showed the degenerative change and the MCL reconstruction using suture tape combined with osteotomy provides a strong medial constraint to prevent the recurrence of the deformity in severe hallux valgus. LEVEL OF CLINICAL EVIDENCE: 3.

Correction effects of peroneus longus contraction on hallux valgus radiographic parameters.

BACKGROUND: Hypermobility of the first tarsometatarsal joint plays an important role in hallux valgus pathogenesis. The peroneus longus is recognized as a dynamic stabilizer of the first tarsometatarsal joint. However, the association between the peroneus longus function and the hallux valgus deformity remains unknown. This study aimed to determine the effect of peroneus longus contraction induced by electrical muscle stimulation on the correction of hallux valgus radiographic parameters in patients with hallux valgus. METHODS: Thirty-five patients with hallux valgus (47 feet; 2 men, 33 women; mean age 64.9 years) were included. Non-weight-bearing dorsoplantar radiographs of the foot were obtained with and without electrical muscle stimulation of the peroneus longus. Radiographic parameters of hallux valgus deformities, including the hallux valgus angle, intermetatarsal angle, first metatarsal protrusion distance, and distance between the first and second metatarsal bases, were measured and compared between the two conditions. RESULTS: All hallux valgus radiographic parameters were significantly improved by contraction of the peroneus longus. The median hallux valgus angle decreased by 13.2°. Fewer changes in the hallux valgus angle were identified in patients with severe deformity and geriatric patients. CONCLUSIONS: Although the peroneus longus muscle has received little attention in the management of hallux valgus, our findings suggest that it has the potential to be a novel conservative approach for treating mild-to-moderate hallux valgus.

Hounsfield Unit values on the subchondral bone are related to clinical outcomes in bone marrow stimulation for osteochondral lesions of the talus.

BACKGROUND: Poor clinical outcomes in bone marrow stimulation (BMS) for the osteochondral lesion of the talus (OLT) are caused by subchondral bone deterioration. It is reported that microfracture induces endochondral ossification in the subchondral bone, which may affect the subchondral bone condition after BMS. This study analyzed osteosclerotic patterns of the bed in OLTs on computed tomography (CT) images and the relationship between the subchondral bone condition and clinical outcomes of BMS. METHODS: Sixty-nine ankles in 61 patients with OLT were included. Hounsfield unit (HU) on the bed of OLTs was measured on CT images and the pattern of osteosclerosis or absorption in the bed was analyzed. In these patients, 25 ankles in 24 patients underwent BMS. They were divided into 2 groups according to the presence of bone marrow edema (BME) one year after surgery, and clinical outcomes were compared. RESULTS: HUs in the anterior region were significantly higher than those of other areas. In patients with BMS, the JSSF scale for BME positive group (88.0 ± 7.7 points) was significantly lower than that for BME negative group (95.0 ± 6.1 points) (p < 0.05) at the final follow-up. On preoperative CT images, HU values of the central region in the BME-positive group were significantly lower than those in the BME-negative group (p < 0.05). CONCLUSION: Osteosclerotic changes in the anterior part of the bed were frequently observed, and BMS for the area with low HU values decreased clinical outcomes. BMS should be performed with attention to subchondral bone condition to obtain good clinical outcomes. LEVEL OF EVIDENCE: 4, case series.

Risk Factors for the Recurrence of Instability After Lateral Ankle Ligament Repair.

BACKGROUND: Arthroscopic anterior talofibular ligament (ATFL) repair is widely performed for chronic lateral ankle instability (CLAI). Although many studies have reported excellent outcomes with this procedure, the recurrence of instability remains a common concern. Therefore, this study aimed to analyze the risk factors for the recurrence of instability after arthroscopic repair for CLAI. METHODS: Fifty-six ankles of 53 patients with a mean age of 31.8 ± 14.7 years were retrospectively reviewed. All patients underwent arthroscopic ATFL repair. If instability remained immediately after ATFL repair, calcaneofibular ligament (CFL) repair was performed. The Ankle Activity Score (AAS) was assessed preoperatively, and clinical outcomes including the Japanese Society for Surgery of the Foot scale, Karlsson-Peterson scores, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were evaluated preoperatively and at the final follow-up. Talar tilt angle (TTA) was assessed preoperatively and 1 year postoperatively. Ankles were divided into 2 groups-nonrecurrence (postoperative TTA, <6 degrees) and recurrence (postoperative TTA, ≥6 degrees)-and clinical outcomes were compared. RESULTS: Sixteen ankles showed recurrent instability, whereas 40 did not. AAS, TTA, and social functioning in the SAFE-Q were significantly higher in the recurrence group than those in the nonrecurrence group preoperatively. In addition, the rate of poor ATFL remnant quality and the number of CFLs not repaired despite the preoperative injury diagnosis were significantly higher in the recurrence group than in the nonrecurrence group. CONCLUSION: Arthroscopic repair for ATFL and CFL deficiencies with preoperative high activity, poor remnant quality, and neglected CFL injury can result in the recurrence of instability. Appropriate surgical procedures to prevent the recurrence of instability should be selected for these ankles. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Distraction arthroplasty combined with autologous bone grafting for diffuse-type tenosynovial giant cell tumour with articular cartilage defect and subchondral bone cysts: A case report.

Tenosynovial giant cell tumour (TGCT) encompasses a group of lesions that present with synovial differentiation and most commonly occur in the joint synovium, bursae, and tendon sheaths. Diffuse-type TGCT (Dt-TGCT), previously known as pigmented villonodular synovitis, is one of the most common benign soft-tissue tumours of the foot and ankle and usually affects young adults. The differential diagnosis of Dt-TGCTs remains a clinical problem because their clinical symptoms are similar to those of inflammatory arthritis, including rheumatoid arthritis. Moreover, persistent Dt-TGCTs can lead to articular deterioration, including osseous erosions and subchondral bone cysts. Joint-preserving procedures are considered optimal for treating younger patients with ankle osteoarthritis because the indication of ankle arthrodesis and total ankle arthroplasty is limited. Thus, ankle distraction arthroplasty could be an alternative for treating Dt-TGCT with articular deterioration in young patients. Here, we report about a woman in her early 30s who presented with ankle pain owing to a Dt-TGCT with an articular cartilage defect and subchondral bone cysts. We performed ankle distraction arthroplasty combined with an autologous bone graft. A follow-up examination at 2 years revealed preservation of physical function and pain alleviation. These findings suggest that distraction arthroplasty is a viable treatment option for remedying the destruction of the articular cartilage and subchondral bone owing to Dt-TGCTs in young adults.

The role of the oblique medial osteotomy angle during osteochondral fragment fixation in patients with a posteromedial osteochondral lesion of the talus.

BACKGROUND: Medial malleolar osteotomy has been widely performed for posteromedial osteochondral lesions of the talus (OLT) to expose the lesion. In osteochondral fragment fixation, bioabsorbable pins should be inserted as perpendicular as possible to obtain the rigid fixation. However, the exposure of the lesion may depend on the osteotomy angle, which affects the pin insertion angles. This study aimed to analyze the relationship between pin insertion and osteotomy angles in the medial malleolar osteotomy. METHODS: Twenty-four ankles of 23 patients were included. The malleolar bisector angle which was calculated from radiographs and actual osteotomy angles were measured on radiographs, and the pin insertion and osteotomy angles were measured using MRI. The intersection angle was defined by the tangential line of the tibial plafond and medial malleolar articular facet, and the bisector of this angle was defined as the malleolar bisector angle. The relationship between pin insertion and osteotomy angles was analyzed. RESULTS: There was no significant difference between the actual osteotomy (55.7° ± 6.6°) and malleolar bisector angles (57.4° ± 4.3°) on the radiograph. There was a significant correlation between pin insertion and osteotomy angles (rs = 0.601). The pin insertion angle (54.3° ± 5.9°) in the lower actual osteotomy angle than the malleolar bisector angle was smaller than those in the higher actual osteotomy angle (63.4° ± 8.2°). CONCLUSIONS: This study showed the osteotomy angle affected pin insertion angle. The osteotomy angle should not be smaller than the malleolar bisector angle at medial malleolar osteotomy to insert pins as perpendicular as possible for fixation of posteromedial OLTs.

Development of a Novel Material to Promote Wound Healing at Bronchial Defects.

BACKGROUND: Bronchopleural fistula (BPF) is a critical complication that may progress to pneumonia and empyema, but optimal treatment remains uncertain. Our purpose was to develop a novel material for bronchial occlusion that can be used to treat BPF by blocking airflow and promoting wound healing. METHODS: Sponges were prepared in concentrations of 25, 40, and 50 mg/dL of silk-elastin by hydrophobic processing. Five adult Beagle dogs underwent right anterior lobectomy, and 5 underwent left posterior lobectomy. Silk-elastin sponges were placed at bronchial stumps of 8 dogs, and silicone plugs were placed at the stumps of 2 dogs as a control. RESULTS: Postoperative complications were not observed, except in 1 dog in which the silicone plug had been placed and which had massive subcutaneous emphysema at 4 weeks after operation. Histologic examination revealed that stumps were covered with connective tissue and that there was more regeneration of airway epithelium in the silk-elastin sponge group than in the silicone plug group. There were increased numbers of myofibroblasts around the bronchial stump occluded by silk-elastin sponges at 2 weeks after placement, which completely disappeared after 2 months, during which abundant neovascularization occurred. CONCLUSIONS: We showed that silk-elastin sponges can manage and promote regeneration of bronchial epithelium. Our results demonstrate that bronchial occlusion with a silk-elastin sponge is a promising option for treatment of BPF.