Histopathological Confirmation of Axonal Sprouting in Regenerative Peripheral Nerve Interface.

Symptomatic neuroma represents a debilitating complication after major limb amputation. The regenerative peripheral nerve interface (RPNI) has emerged as a reproducible and practical surgery aimed at mitigating the formation of painful neuroma. Although previous animal studies revealed axonal sprouting, elongation, and synaptogenesis of proximal nerve stump within the muscle graft in RPNI, there is a lack of reports confirming these physiological reactions at the histopathological level in human samples. This report presents a case of below-knee amputation with RPNI due to foot gangrene resulting from polyarteritis nodosa. Subsequently, an above-knee amputation was necessitated due to the exacerbation of polyarteritis nodosa, providing the opportunity for histopathological examination of the RPNI site. The examination revealed sprouting, elongation, and existence of neuromuscular junction of the tibial nerve within the grafted muscle. To the best of our knowledge, this is the first report demonstrating axonal sprouting, elongation, and possibility of synaptogenesis of the nerve stump within the grafted muscle in a human sample.

Short-Term Risk Factors for Subtalar Arthrodesis After Primary Tibiotalar Arthrodesis.

While adjacent joint arthritis is a recognized long-term downside of primary tibiotalar arthrodesis (TTA), few studies have identified risk factors for early subtalar arthrodesis (STA) after TTA. This study aims to identify the risk factors for STA within the first few years following TTA. All patients older than 18 years undergoing TTA between 2008 and 2016 were identified retrospectively. Demographic data and comorbidities were collected alongside prior operative procedures, postoperative complications, and subsequent STA. Pre-and postoperative Kellgren-Lawrence osteoarthritis grade of the subtalar joint and postoperative radiographic alignment were obtained. A total of 240 patients who underwent primary TTA were included in this study with median follow up of 13.8 months. Twenty patients (8.3%) underwent STA after TTA due to symptomatic nonunion of TTA in 13 (65%), progression of symptomatic subtalar osteoarthritis (OA) in 4 (20%), and symptomatic nonunion of primary TTA combined progressively symptomatic subtalar OA in 2 (10%). Preoperative radiographic subtalar OA severity and postoperative radiographic alignment were not correlated with subsequent STA. Diabetes mellitus, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, and psychiatric disease were significantly associated with having a subsequent STA. The most common postoperative contributing factor for subsequent STA following primary TTA was the salvage of symptomatic ankle nonunion rather than subtalar joint disease. Patients considering an ankle fusion should be counseled of the risk of subsequent STA, especially if they have risk factors that include diabetes, Charcot arthropathy, neuropathy, alcohol use, substance use disorder, or psychiatric disease.

Runx2 and Runx3 differentially regulate articular chondrocytes during surgically induced osteoarthritis development.

The Runt-related transcription factor (Runx) family plays various roles in the homeostasis of cartilage. Here, we examined the role of Runx2 and Runx3 for osteoarthritis development in vivo and in vitro. Runx3-knockout mice exhibited accelerated osteoarthritis following surgical induction, accompanied by decreased expression of lubricin and aggrecan. Meanwhile, Runx2 conditional knockout mice showed biphasic phenotypes: heterozygous knockout inhibited osteoarthritis and decreased matrix metallopeptidase 13 (Mmp13) expression, while homozygous knockout of Runx2 accelerated osteoarthritis and reduced type II collagen (Col2a1) expression. Comprehensive transcriptional analyses revealed lubricin and aggrecan as transcriptional target genes of Runx3, and indicated that Runx2 sustained Col2a1 expression through an intron 6 enhancer when Sox9 was decreased. Intra-articular administration of Runx3 adenovirus ameliorated development of surgically induced osteoarthritis. Runx3 protects adult articular cartilage through extracellular matrix protein production under normal conditions, while Runx2 exerts both catabolic and anabolic effects under the inflammatory condition.

Effect of gait protocols and postoperative shoes on off-loading of forefoot in preoperative patients for forefoot disorders.

OBJECTIVES: The purpose of this study was to clarify the effect of gait protocols and postoperative shoes on forefoot load in preoperative patients for forefoot disorders and compare footwear comfort between different types of postoperative shoes. METHODS: Fourteen subjects scheduled to undergo forefoot surgeries were recruited. The maximum force under the forefoot region was measured during 10 m straight walking in two gait patterns with six different shoe types. Visual analogue scale (VAS) scores for footwear comfort, subjective lower thigh pain, and electrical activities of lower thigh muscles were also evaluated. RESULTS: The body weight-normalized maximum force under the forefoot region significantly decreased in step-to gait compared to normal gait regardless of the shoe types used. Under the same gait condition, no significant difference was observed in the forefoot off-loading effect between the different shoe types used. Significantly worse VAS scores, significantly higher tibialis anterior muscle activities, and complaints of lower thigh pain were demonstrated in the gait with the reverse camber shoe. CONCLUSIONS: Gait protocol of step-to gait had more forefoot off-loading effect than postoperative shoes. The forefoot off-loading effect did not differ among the postoperative shoes, suggesting that postoperative shoes can be selected with an emphasis on footwear comfort.

Comparison between suture and staple fixations as internal fixation techniques for Akin osteotomy.

BACKGROUND: Suture and staple fixations are commonly used methods for Akin osteotomy; however, there has been a paucity of studies comparing these methods without bias. PATIENTS AND METHODS: We retrospectively compared the outcomes of 58 Akin osteotomies performed by a single surgeon using suture fixation and 39 Akin osteotomies performed by the same surgeon using staple fixation during the same period. RESULTS: Bone union at the osteotomy site was achieved in all cases with no cases of complications related to the materials used. Occurrence of breakage of the lateral cortex of the proximal phalanx showed no significant difference between the suture and staple groups. The lateral cortex breakage produced greater instability at the osteotomy site with the staple fixation compared to the suture fixation. CONCLUSIONS: Comparison of suture and staple fixations of Akin osteotomy demonstrated the superiority of suture fixation against staple fixation in terms of stability and cost-efficiency.

Clinical Outcomes After First Metatarsophalangeal Joint Arthrodesis by Flat Cut Joint Preparation With Individual Adjustment for Sagittal Alignment.

Sagittal misalignment is a major cause of patient dissatisfaction and re-operation after first metatarsophalangeal (MTP) joint arthrodesis. The stereotypical application of the fixed angle would be undesirable, especially in cases of flat or cavus foot. We retrospectively reviewed 31 cases (27 patients) in which first MTP joint arthrodesis was performed using the flat cut joint preparation technique with reference to the plantar clearance beneath the pulp of the toe while simulating weightbearing by pushing a board against the sole. The most common underlying cause of surgery was rheumatoid arthritis (22 cases [71%]). Clinical outcomes were evaluated by the Japanese of Surgery of the Foot (JSSF) hallux scale and the self-administered foot evaluation questionnaire (SAFE-Q). Twenty-three cases were also examined by pedobarography to evaluate postoperative walking plantar pressure. At the most recent follow-up of a mean 19.6 months, the toe-to-floor distance of the hallux in static standing posture was a mean of 2.5 mm (range, 0-10 mm). All but 1 foot (97%) achieved bone union. There were no complications or revisions due to misalignment of the fused MTP joint. JSSF hallux scales improved significantly from 47 preoperatively to 82 postoperatively. All subscale scores except general health and well-being in the SAFE-Q improved significantly at final follow-up versus preoperative period. Plantar pressure under the hallux was correlated with the toe-to-floor distance but not radiographic parameter. In conclusion, first MTP joint arthrodesis achieved good clinical outcomes when using toe-to-floor distance and Kirschner wire template for flat cut joint preparation.

Symptomatic Medial Bone Excrescence in the Distal Phalanx of the Hallux after the First Metatarsophalangeal Joint Arthrodesis: A Case Report and Radiographic Reviews.

Medial bone excrescence at the base of the distal phalanx of the hallux is a common manifestation which is rarely painful. In this case report, we described the first case of the excrescence becoming symptomatic one year after a metatarsophalangeal (MTP) joint arthrodesis of the great toe in a 74-year-old female. The medial bony excrescence which was obscure preoperatively became obvious postoperatively in the anteroposterior foot radiographs. The patient was successfully treated by an excision of the excrescence. In order to clarify the pathology of the excrescence, we reviewed the radiographs with respect to the excrescence before and after hallux surgeries including 97 metatarsal osteotomies and 33 MTP joint arthrodesis. The width of the excrescence measured in the anteroposterior foot radiographs displayed substantial increment one month after the hallux surgeries (osteotomy group: 0.9 ± 0.7 vs. 1.5 ± 0.7 mm, p < 0.01; arthrodesis group: 1.3 ± 0.8 vs. 1.8 ± 1.0 mm, p < 0.01). However, there was no significant difference in the width of the excrescence between one month after surgery and at the most recent follow-up of around 20 months in average after the surgery (osteotomy group: 1.5 ± 0.7 vs. 1.4 ± 0.7 mm, p = 0.62; arthrodesis group: 1.8 ± 1.0 vs. 1.8 ± 0.7 mm, p = 0.37). The present case and our radiographic review suggested that the postoperative medial bony excrescence was not the result of change of position of the preexisting excrescence. The correction of pronation deformity through hallux surgeries could emphasize the medial bony excrescence and cause symptomatic irritation upon shoe contact.

Outcomes of Scarf and Akin Osteotomy with Intra-Articular Stepwise Lateral Soft Tissue Release for Correcting Hallux Valgus Deformity in Rheumatoid Arthritis.

BACKGROUND: The effectiveness of scarf and Akin osteotomy with intra-articular lateral soft tissue release for the correction of hallux valgus (HV) in patients with rheumatoid arthritis (RA) has not been elucidated. METHODS: A total of 36 feet in 28 patients with RA who had scarf and Akin osteotomy with intra-articular stepwise lateral soft tissue release between 2015 and 2020 at a single institute were investigated retrospectively, with a mean follow-up period of 32.0 ± 16.9 months. Radiographic evaluations including the HV angle, intermetatarsal angle, and sesamoid position were performed preoperatively and postoperatively. Clinical outcomes were assessed using the Japanese Society of Surgery of the Foot (JSSF) hallux scale and self-administered foot evaluation questionnaire (SAFE-Q). RESULTS: The procedure resulted in significant HV correction, with a recurrence rate of 13.9%. The JSSF scale and all five SAFE-Q subscale scores significantly improved (p < 0.05), with no major complications. More than 90% of cases achieved adequate lateral soft tissue release without sacrificing the adductor tendon of the hallux. CONCLUSIONS: Intra-articular stepwise lateral soft tissue release in combination with scarf and Akin osteotomy provided satisfactory radiographic and patient-reported outcomes for the correction of HV in patients with RA with minimum lateral soft tissue release.

Juvenile Dysplasia Epiphysealis Hemimelica with Multiple Ankle Free Body.

Dysplasia epiphysealis hemimelica (DEH), also known as Trevor's disease, is a rare overgrowth of cartilage that commonly arises in the epiphyseal bone of children. We report a rare case of DEH originating from a talus accompanied by multiple intra-articular free bodies in a 7-year-old patient with ankle instability. After the primary surgery for free body removal and microfracture technique for the cartilage defects in the ankle joint, the free body recurred. Secondary surgery of arthroscopic free body removal with lateral ankle ligament repair succeeded in treating the patient, without further recurrence of the free body.

Diagnosis and Treatment of Chronic Lateral Ankle Instability: Review of Our Biomechanical Evidence.

Definitive diagnosis and optimal surgical treatment of chronic lateral ankle instability remains controversial. This review distills available biomechanical evidence as it pertains to the clinical assessment, imaging work up, and surgical treatment of lateral ankle instability. Current data suggest that accurate assessment of ligament integrity during physical examination requires the ankle to ideally be held in 16° of plantar flexion when performing the anterior drawer test and 18° of dorsiflexion when performing the talar tilt test, respectively. Stress radiographs are limited by their low sensitivity, and MRI is limited by its static nature. Surgically, both arthroscopic and open repair techniques appear biomechanically equivalent in their ability to restore ankle stability, although sufficient evidence is still lacking for any particular procedure to be considered a superior construct. When performing reconstruction, grafts should be tensioned at 10 N and use of nonabsorbable augmentations lacking viscoelastic creep must factor in the potential for overtensioning. Anatomic lateral ligament surgery provides sufficient biomechanical strength to safely enable immediate postoperative weight bearing if lateral ankle stress is neutralized with a boot. Further research and comparative clinical trials will be necessary to define which of these ever-increasing procedural options actually optimizes patient outcome for chronic lateral ankle instability.

The Effect of Gastrocnemius Recession and Tendo-Achilles Lengthening on Adult Acquired Flatfoot Deformity Surgery: A Systematic Review.

The purpose of this study was to evaluate the available clinical and radiographic evidence for incorporation of a gastrocnemius recession or tendo-Achilles lengthening into the surgical correction of adult acquired flatfoot deformity. A systematic review of the literature was performed using PubMed, Embase, Cochrane, CINAHL, and Google Scholar. Among the relevant articles, the level of evidence and quality was identified using the Methodological Index for Non-Randomized Studies tool. No study explicitly examined whether clinical or radiographic outcomes after adult acquired flatfoot deformity correction are improved when incorporating a gastrocnemius recession or tendo-Achilles lengthening compared with when no such procedure is performed, nor have they directly compared outcomes between 2 procedures. Studies demonstrated an overall improvement in postoperative range of motion and plantar flexion power after gastrocnemius recession, but such findings are hard to separate from the clinical contribution of concomitant corrective procedures to the foot itself. All studies that analyzed anteroposterior talo-calcaneal angle, anteroposterior lateral talo-first metatarsal angle and calcaneal inclination angle revealed improvement of each parameter postoperatively. There were no high-level evidence studies in the literature explicitly quantifying ankle range of motion, plantar flexion power, or radiographic impact of gastrocnemius recession or tendo-Achilles lengthening on adult acquired flatfoot deformity correction. Although gastrocnemius-soleus complex contractures have certainly been demonstrated to coexist with adult acquired flatfoot deformity, support for lengthening procedures is largely based on expert opinion or case series and is difficult to distinguish from the clinical contribution of associated corrective procedures.

Joint-Preserving Surgery for Hyperextension Deformity of the Hallux Interphalangeal Joint in a Patient with Rheumatoid Arthritis.

Interphalangeal hyperextension is one of the major hallux deformities in patients with rheumatoid arthritis; however, there is yet no established surgical method for this deformity. We here present the case of a 69-year-old female patient with rheumatoid arthritis who developed hallux interphalangeal hyperextension and painful callosity on the plantar hallux accompanied by limited dorsiflexion at the metatarsophalangeal joint. Lateral weight-bearing radiograph of the foot revealed misalignment of the medial column and hallux, including a collapsed medial arch, elevated first metatarsal, plantar flexion and deviation of the proximal phalanx, and hyperextension of the distal phalanx. The foot was successfully treated and became symptom-free with opening wedge osteotomy of the medial cuneiform, plantar and proximal translation of the metatarsal head, and tenotomy of the extensor hallucis longus. This case suggests that reconstruction of the sagittal alignment of the medial column and hallux through a combination of osteotomy and soft tissue intervention could be an optional treatment for interphalangeal hyperextension.

Alleviation of murine osteoarthritis by deletion of the focal adhesion mechanosensitive adapter, Hic-5.

Excessive mechanical stress is a major cause of knee osteoarthritis. However, the mechanism by which the mechanical stress begets osteoarthritis development remains elusive. Hydrogen peroxide-inducible clone-5 (Hic-5; TGFß1i1), a TGF-ß inducible focal adhesion adaptor, has previously been reported as a mediator of mechanotransduction. In this study, we analyzed the in vivo function of Hic-5 in development of osteoarthritis, and found that mice lacking Hic-5 showed a significant reduction in development of osteoarthritis in the knee. Furthermore, we found reduced expression of catabolic genes, such as metalloproteinase-13 and a disintegrin and metalloproteinase with thrombospondin type 1 motif 5 in osteoarthritic lesions in mice lacking Hic-5. During osteoarthritis development, Hic-5 is detected in chondrocytes of articular cartilage. To investigate the role of Hic-5 in chondrocytes, we isolated chondrocytes from articular cartilage of wild type and Hic-5-deficient mice. In these primary cultured chondrocytes, Hic-5 deficiency resulted in suppression of catabolic gene expression induced by osteoarthritis-related cytokines such as tumor necrosis factor α and interleukin 1ß. Furthermore, Hic-5 deficiency in chondrocytes suppressed catabolic gene expression induced by mechanical stress. Revealing the regulation of chondrocyte catabolism by Hic-5 contributes to understanding the pathophysiology of osteoarthritis induced by mechanical stress.

Development of intraoperative plantar pressure measuring system considering weight bearing axis.

PURPOSE: Surgical reconstructions in three dimensions are needed for treatment of foot and ankle deformities. However, surgical results might be influenced by the skill and experience of doctors which complement the limited information for reconstructions in three dimensions. To solve these, studies were carried out to measure plantar pressure distribution during surgery. Though, it was impossible to accurately measure plantar pressure distribution accurately during operation. Therefore, we proposed an intraoperative plantar pressure measurement (IPPM) device that enables proper navigation in the push direction. METHODS: For this purpose, first, we investigated how the physiological load axis passes through the human body to identify the pushing direction of the pressure sensor of the device toward the patient's foot. In particular, we hypothesized that the physiological load axis passes through the femoral head center and we evaluated this in a measurement experiment with nine healthy subjects. Second, based on these results, we developed the IPPM device that has two force sensors to identify the pushing direction toward the femoral head center and a conductive ink sensor to measure plantar pressure distribution. Finally, we conducted the experiments with nine healthy subjects and two users. RESULTS: From the first experimental results, the physiological load axis was found to pass through the femoral head center in normal standing posture. From the evaluation experiment, there are no significant differences statistically in plantar pressure distributions between the conditions of using IPPM device and without using it for both a medical student and a surgeon. However, in some cases the plantar pressure distribution can be reproduced similarly to that of the standing posture, and also from the evaluation experiment concerning the relation between CoP position and NCC, the NCC tends to increase when the position of the CoP is closer to that at the standing posture. CONCLUSION: The IPPM device has possibility to reproduce the plantar pressure distribution during surgery and prevent the recurrence of surgical complications.

Guideposts for Inserting Intercuneiform Joint Arthrodesis Screws: Analysis Using Multiplanar Reconstructed Computed Tomography.

Intercuneiform arthrodesis is often required for various midfoot pathologies; however, intercuneiform screw insertion is not easy due to the complicated anatomical structure of cuneiforms. This study aimed to determine the advisable screw entry point and direction using intraoperatively detectable landmarks. The computed tomography (CT) scan data of feet were reformatted using OsiriX software multiplanar reconstruction. First, based on the data of 10 CT scans of normal feet, we determined the advisable screw entry point at the upper one-third in the dorsoplantar direction and center in the anteroposterior direction on the medial aspect of the medial cuneiform and insertion direction toward the outermost point of the base of the fifth metatarsal in the axial plane and parallel to the plantar surface in the coronal plane. Second, we examined the accuracy of these newly designed guideposts in the simulation using other CT scan data of the other 27 normal feet and 12 flat feet. The simulated screw trajectory penetrated the mid three-fifths of all three cuneiforms in 97% of the normal feet and 92% of the flat feet with no cases of cortical wall violation. Levels of Evidence: Level V: Expert opinion.

Orthotropic live transplantation for cirrhosis from hepatitis C virus leads to correction of factor IX deficiency allowing for ankle arthroplasty without factor replacement in a patient with moderate haemophilia B.

: Liver transplantation is one of the treatments for haemophilic patients having severe liver cirrhosis who are infected with the hepatitis C virus. Patients with haemophilia can develop arthroplasty requiring surgical intervention, and the surgical outcomes of patients undergoing such procedures after liver transplant has not been reported. Treatment for arthropathy is important for improving the quality of life for patients who survive after liver transplantation. We report the first case of ankle arthroscopic arthrodesis in a patient with haemophilia B after undergoing living donor liver transplantation. We carefully monitored the patient's factor IX (FIX) plasma levels during his perioperative period, and we successfully performed his arthroscopic ankle arthrodesis without administration of any additional FIX concentrates. Our case has demonstrated the feasibility of joint surgery after liver transplantation without administration of additional clotting factors while monitoring FIX activity.

A Mouse Intervertebral Disc Degeneration Model by Surgically Induced Instability.

STUDY DESIGN: An experimental study to develop a mouse model of lumbar intervertebral disc degeneration (IDD). OBJECTIVE: The aim of this study was to develop a mouse lumbar IDD model using surgically induced instability and to compare the findings of this model to those in human IDD. SUMMARY OF BACKGROUND DATA: Previously, various kinds of inducers have been used to reproduce IDD in experimental animals; however, there is yet no standard mouse lumbar IDD model without direct injury to intervertebral disc. METHODS: A total number of 59 C57BL/6J male mice at 8 weeks old were used. Instability of lumbar spine was induced by surgical resection of posterior elements, including facet joints, supra- and interspinous ligaments. We then analyzed time course changes in radiographical (n = 17) and histological analyses (n = 42), and compared these findings with those in human IDD. RESULTS: Radiographical analyses showed that the disc height began to decrease in the first 2 weeks after the surgery, and the decrease continued throughout 12 weeks. Bone spurs at the vertebral rims were observed in the late stage of 8 and 12 weeks after the surgery. Histological analyses showed that the disorder of the anterior anulus fibrosus (AF) was initially obvious, followed by posterior shift and degeneration of the nucleus pulposus (NP). Proteoglycan detected in inner layer of AF and periphery of NP was decreased after 8 weeks. Immunohistochemistry displayed the increase of type I and X collagen, and matrix metalloproteinase 13 in the anterior AF. CONCLUSION: Surgical resection of posterior elements of mouse lumbar spine resulted in reproducible IDD. Because the present procedure does not employ direct injury to intervertebral disc and the radiological and histological findings are compatible with those in human IDD, it may contribute to further understanding of the native pathophysiology of IDD in future. LEVEL OF EVIDENCE: N/A.

Anterior Impingement Syndrome of the Ankle Caused by Osteoid Osteoma in the Talar Neck Treated with Arthroscopy and 3D C-Arm-Based Imaging.

Osteoid osteoma in periarticular lesions tends to have an unusual presentation that likely leads to a delayed or missed diagnosis compared with a typical osteoid osteoma in the metaphysis or diaphysis of the long bone. In cases that are unresponsive to conservative treatment, surgical interventions including en bloc resection, computed tomography-guided percutaneous treatment, and arthroscopic resection have been performed; however, these methods frequently result in inadequate tumor resection and recurrence. Here we present a case of a 16-year-old girl with osteoid osteoma in the talar neck presenting as anterior impingement syndrome due to marked synovitis in the ankle joint which was successfully treated without complications by arthroscopic synovectomy and tumor resection followed by intraoperative 3D C-arm-based imaging confirming complete tumor lesion removal. Her pain was relieved immediately after the surgery, and there was no recurrence at 12 months of follow-up. This is the first case report of the surgical treatment of the osteoid osteoma in the talar neck with the combination methods of arthroscopy and 3D C-arm-based imaging.

Interdigital Neuroma in the Second Intermetatarsal Space Associated with Metatarsophalangeal Joint Instability.

The entrapment theory is the most commonly accepted theory concerning the development of interdigital neuroma; it incriminates the deep transverse metatarsal ligament as the major causative factor of the condition. This report presents a patient with interdigital neuroma in the second intermetatarsal space, which was strongly suspected to be caused by the metatarsophalangeal joint instability due to plantar plate injury. Surgical intervention revealed that the neuroma was located more distally and dorsally than the deep transverse metatarsal ligament and was pinched between the adjacent metatarsal heads, suggesting the involvement of the metatarsophalangeal joint instability and chronic trauma as etiologies in this case.