A Novel Approach to Total Ankle Arthroplasty with Simultaneous Structural Tibial Cut Autograft for Anterior Tibial Bone Defects.

Severe bone defects pose a clinical challenge in total ankle arthroplasty (TAA) and are frequently considered contraindicated. We introduce an innovative approach that utilizes a structural tibial cut autograft to address anterior distal tibia bone defects during TAA. This technique is a viable alternative to employing revision TAA systems or resorting to excessively high tibial cuts. Furthermore, it facilitates achieving favorable sagittal alignment and ensures adequate fixation strength of the tibial component.

Robotic-assisted foot and ankle surgery: a review of the present status and the future.

The surgical application of robotics has increased significantly since its first application in 1985 for a brain biopsy acquisition. Robotic-assisted surgery has been one of the viable options in various surgical areas, and also in orthopaedic surgery. Robotic-assisted orthopaedic surgery has gained popularity as a mean of improving accuracy, reducing complications and achieving better patient satisfaction. Numerous clinical research studies have demonstrated advantages of robotic-assisted orthopaedic surgery, however, most of that researches were about the total knee arthroplasty, total hip arthroplasty and spine surgery. The application of robotic technology in foot and ankle surgery is in a very nascent stage. Furthermore, there has been little research on intraoperative use of robotics in foot and ankle surgery in literature. A review of previous preclinical studies in foot and ankle robotics and clinical research studies in various fields of robot-assisted orthopaedic surgery shows that its potential application and benefits over conventional techniques, such as total ankle arthroplasty, minimally invasive surgery for foot and ankle trauma or other corrective procedure, and intraoperative biomechanical testing. More studies on practical application of robotic technology to surgical procedure in the field of foot and ankle surgery are needed to confirm its clinical usefulness and cost effectiveness.

Medial Reduction in Sesamoid Position after Hallux Valgus Correction Surgery Showed Better Outcome in S.E.R.I. Osteotomy than DCMO.

BACKGROUND: The purpose of the present study was to compare the degree of sesamoid reduction after hallux valgus correction between distal chevron metatarsal osteotomy (DCMO) and S.E.R.I. (simple, effective, rapid, and inexpensive) osteotomy, and to analyze the effects on the recurrence of hallux valgus. METHODS: We retrospectively analyzed the foot radiographs of 60 feet (30 DCMO and 30 SERI) treated for hallux valgus from August 2013 to July 2017. Radiographic assessments were performed preoperatively, at early follow-up (at a mean of 3.1 months) and at the most recent follow-up (at a mean of 16.7 months). The location of the medial sesamoid was classified into seven stages, in accordance with the method described by Hardy and Clapham; stage IV or less was defined as the normal position for the medial sesamoid, and stage V or greater was defined as lateral displacement of the sesamoid. The pre- and post-operative hallux valgus angle, 1-2 intermetatarsal angle, and sesamoid position were compared between the two groups. RESULTS: The mean follow-up period was 18.4 (12-36) months in the DCMO group and 15.0 (12-36) months in the S.E.R.I. group (p = 0.108). The radiologic results showed that the hallux valgus angles were not significantly different between the two groups preoperatively and at the early follow-up: preoperatively, they were 28.8 ± 7.7 in the DCMO group and 32.6 ± 9.5 in the S.E.R.I. group (p = 0.101), and they were 10.4 ± 4.0 and 8.7 ± 5.0 (p = 0.148) at the early follow-up, respectively. However, at the most recent follow-up, the DCMO group (13.9 ± 5.6) showed significantly higher hallux valgus angles than the S.E.R.I. group (10.4 ± 6.4, p = 0.030), and there were no differences between the recurrence of hallux valgus in the DCMO group (13%)and that in the S.E.R.I. group (10%) (p = 0.553). There were no significant differences in the 1-2 intermetatarsal angles between the two groups at the early follow-up (6.1 ± 2.5 vs. 4.8 ± 3.1, p = 0.082) and at the most recent follow-up (7.3 ± 2.9 vs. 6.6 ± 3.5, p = 0.408). After hallux-valgus-correction surgery, the stage change of the tibia sesamoid position from the preoperative stage to the initial follow-up was significantly larger in the S.E.R.I. group (-4.4 ± 1.4) than in the DCMO group (-3.4 ± 1.1) (p = 0.003); the changes from the preoperative stage to the last follow-up were also significantly larger in the SERI group (-3.3 ± 1.7) than in the DCMO group (-2.4 ± 1.5) (p = 0.028); however, the changes from the initial follow-up to the last follow-up showed no significant differences between the two groups (+1.0 ± 1.1 in the DCMO group vs. +1.1 ± 1.2 in the S.E.R.I. group) (p = 0.822). The medial sesamoid was laterally subluxated in all the preoperative cases in the DCMO and S.E.R.I. groups. The lateral subluxation of the tibia sesamoid was more frequently observed in the DCMO group (four cases, 13%) than in the S.E.R.I. group (0 cases, 0%) (p = 0.038) at the early follow-up. CONCLUSION: In conclusion, our results demonstrated that the S.E.R.I. procedure is superior to DCMO in decreasing the hallux valgus angle and showed that the early post-operative reduction in the sesamoids can be a risk factor for the recurrence of hallux valgus.

Tau acetylation at K280 regulates tau phosphorylation.

PURPOSE/AIM OF THE STUDY: Accumulation of hyperphosphorylated tau is a key pathological finding of Alzheimer's disease. Recently, acetylation of tau is emerging as another key pathogenic modification, especially regarding the acetylation of tau at K280 of the hexapeptide 275VQIINK280, a critical sequence in driving tau aggregation. However, the relationship between these two key post-translational modifications is not well known. In this study, effect of acetylation of tau at K280 on tau phosphorylation profile was investigated. MATERIALS AND METHODS: The human neuroblastoma cell line, SH-SY5Y, was transfected with p300 acetyltransferase and tau to induce acetylation of tau. Phosphorylation profile after acetylation was evaluated on western blot. K280A-mutant tau was transfected to investigate the effect of acetylation of tau at K280 on tau phosphorylation profile. RESULTS: Overexpression of p300 acetyltransferase in tau-transfected SH-SY5Y human neuroblastoma cells increased acetylation of tau. Meanwhile, tau and its phosphorylation also increased at various sites such as S199/202, S202/T205, T231, and S422, but not at S396. However, blocking acetylation only at K280 with K280A-mutant tau reversed the increased phosphorylation of tau at S202/T205, T231, and S422, but not at S199/202 or S396. CONCLUSION: Here we identified tau phosphorylation profile in the context of p300-induced acetylation and K280A-mutant tau, demonstrating that tau acetylation affects phosphorylation differently by residues and that acetylation at K280 is a determinant of phosphorylation at some residues in the context of pathologic acetyltransferase activity. Yet, our results suggest there is a complex interplay yet to be explored between tau acetylation with tau phosphorylation.

Impact of Clinical and Lesion Features on Outcomes After Percutaneous Coronary Intervention in Bifurcation Lesions.

Background: Bifurcation percutaneous coronary intervention (PCI) is associated with higher risk of clinical events. Objectives: This study aimed to determine clinical and lesion features that predict adverse outcomes, and to evaluate the differential prognostic impact of these features in patients undergoing PCI for bifurcation lesions. Methods: We analyzed 5,537 patients from the BIFURCAT (comBined Insights From the Unified RAIN and COBIS bifurcAtion regisTries) registry. The primary outcome was major adverse cardiac events (MACE) at 2-year follow-up; secondary outcomes included hard endpoints (all-cause death, myocardial infarction) and lesion-oriented clinical outcomes (LOCO) (target-vessel myocardial infarction, target lesion revascularization). The least absolute shrinkage and selection operator (LASSO) model was used for feature selection. Results: During the 2-year follow-up period, MACE occurred in 492 patients (8.9%). The LASSO model identified 5 clinical features (old age, chronic renal disease, diabetes mellitus, current smoking, and left ventricular dysfunction) and 4 lesion features (left main disease, proximal main branch disease, side branch disease, and a small main branch diameter) as significant features that predict MACE. A combination of all 9 features improved the predictive value for MACE compared with clinical and lesion features (area under the receiver-operating characteristics curve: 0.657 vs 0.636 vs 0.581; P < 0.001). For secondary endpoints, the clinical features had a higher impact than lesion features on hard endpoints, whereas lesion features had a higher impact than clinical features on LOCO. Conclusions: In bifurcation PCI, 9 features were associated with MACE. Clinical features were predominant predictors for hard endpoints, and lesion features were predominant for predicting LOCO. Clinical and lesion features have distinct values, and both should be considered in bifurcation PCI.

Sodium Tetradecyl Sulphate Sclerotherapy for Lateral Malleolar Bursitis of the Ankle.

Background: The aim of this study was to evaluate clinical outcomes of sodium tetradecyl sulphate (STS) sclerotherapy for conservative treatment of lateral malleolar bursitis of the ankle. Methods: We reviewed data from 20 consecutive patients (20 ankles) who underwent STS sclerotherapy between August 2018 and June 2019. After aspiration of fluid from the lateral malleolar bursal sac, 2 mL (20 mg) STS was injected into the sac. Clinical outcomes and side effects and complications were evaluated at 2 weeks, 3 months, 1 year, and 2 years after sclerotherapy. Responses to treatment were assessed according to degree of fluctuation, shrinkage of the bursal sac, and soft-tissue swelling. The 36-item short form survey (SF-36) was completed for each patient before and after therapy. Results: Complete response was observed in 17 patients (85%), and partial response was observed in 3 patients (15%) after STS sclerotherapy. SF-36 physical component scores improved from 62.2 (interquartile range, 5.2) before therapy to 70.0 (interquartile range, 7.9) at last follow-up (p < 0.05). One patient (5%) experienced transient hyperpigmentation at the injection site. No major complications occurred. Conclusions: STS sclerotherapy was an effective and safe treatment for patients with lateral malleolar bursitis of the ankle.

Long-Term Clinical Outcomes and Implant Survivorship of 151 Total Ankle Arthroplasties Using the HINTEGRA Prosthesis: A Minimum 10-Year Follow-up.

BACKGROUND: Few studies have investigated long-term clinical outcomes of a mobile-bearing total ankle arthroplasty (TAA) system. This study analyzed long-term outcomes of TAA using the HINTEGRA prosthesis at a single, non-developer center. METHODS: Primary TAAs were performed on 213 ankles in 194 patients, and 151 consecutive ankles [71%] in 136 patients with a minimum follow-up of 10 years after the primary TAA were included in this study. Clinical results were assessed using a visual analog scale (VAS) pain score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale score, the Ankle Osteoarthritis Scale (AOS) pain and disability subscores, and ankle range of motion. Prosthesis survivorship, reoperations, and risk factors were also evaluated. RESULTS: The mean follow-up was 135.5 months (range, 120.0 to 204.0 months). All clinical scores and ankle range of motion improved significantly from preoperatively to 2 years, 4 to 6 years, and ≥10 years after TAA (p < 0.001). A total of 43 ankles (28.5%) required revision procedures, with the most common reason being periprosthetic osteolysis (32 ankles [21.2%]). The overall implant survivorship was 93.5% in Kaplan-Meier survival analysis at the mean follow-up of 11.3 years after the TAA. CONCLUSIONS: TAA using the HINTEGRA prosthesis with careful follow-up observation and appropriate adjunct procedures for the treatment of end-stage ankle arthritis produced satisfactory clinical results, which were maintained at a follow-up of ≥10 years, and resulted in 93.5% of implant survivorship. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Real-World Treatment Selection Factors and 7-Year Clinical Outcomes between Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery in Left Main Disease.

BACKGROUND: The decision-making factors and long-term clinical outcomes between PCI and CABG in left main (LM) disease are still not well defined in the real world. METHODS: We evaluated consecutive patients (n = 230) with LM disease either treated by PCI (n = 118) or CABG (n = 112). The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiac death, spontaneous myocardial infarction (MI), stroke, and target vessel revascularization (TVR) for 7 years. RESULTS: In the multivariate-adjusted analysis, the presence of intermediate EuroSCORE II and high SYNTAX scores predisposed to CABG. Isolated LM disease was associated with receiving PCI. The PCI group had a similar rate of MACE (HRadj 0.97, 95% CI [0.48-1.94], p = 0.92) and a lower tendency of hard MACE (HRadj 0.49, 95% CI [0.22-1.07], p = 0.07) compared to the CABG group, mainly due to the balance between a higher rate of TVR (HRadj 9.71, p = 0.02) and a lower rate of stroke (HRadj 0.22, p = 0.09) with the PCI group than in the CABG group. CONCLUSIONS: The decision making of treatment strategy was made based on clinical and angiographic factors. The selected patients who received PCI showed similar MACE and trend of a lower rate of composite hard endpoints despite multivariate adjustment.

Outcomes of oblique supramalleolar osteotomy without fibular osteotomy for congruent- and incongruent-type medial ankle arthritis.

BACKGROUND: Although high talar tilt and ankle mortise incongruence are risk factors for supramalleolar osteotomy (SMO), no study on lateral talofibular joint congruence exists. We aimed to evaluate the outcomes of oblique SMO without fibular osteotomy for medial ankle arthritis and compare them according to the lateral talofibular joint congruity. METHODS: Forty-eight ankles were retrospectively reviewed and divided according to preoperative talofibular joint congruity (congruent, 22 [45.8%] vs. incongruent, 26 [54.2%]). RESULTS: The mean VAS score, AOFAS score, and modified Takakura stage were significantly improved. No significant differences were noted in clinical outcomes, but the mean postoperative tibiotalar angle and difference between the upper and lower talofibular gaps were significantly different in both groups (p = 0.004 and p = 0.009, respectively). The mean Takakura stage at 1 and 2 years after surgery was higher in the incongruent group (p = 0.013, p = 0.012). CONCLUSION: This procedure was effective against early- to mid-stage medial ankle arthritis. Radiographic arthritic grade changed according to the talofibular joint congruity.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment.

BACKGROUND: Clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies regarding chronic syndesmosis injury remain unclear. PURPOSE: An international group of experts representing the fields of sports injuries in the foot and ankle area were invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injuries. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). STUDY DESIGN: Consensus statement. METHODS: From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 15 clinical questions and statements were related to the clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies for chronic syndesmosis injury and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. RESULTS: Of the 15 questions and statements, 5 reached unanimous support and 10 achieved strong consensus. CONCLUSION: This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with diagnosis, classification, and nonoperative treatment strategies for chronic syndesmosis injury.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 3: Fusion Techniques, Comorbidity Treatments, Postoperative Rehabilitation, and Return-to-Sport Indications.

BACKGROUND: Questions regarding surgical fusion techniques, postoperative treatment, and indications for return to sport after chronic syndesmosis injury or its comorbidities remain unanswered. PURPOSE: An international group of experts representing the field of injuries in the foot and ankle area was invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injury. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). STUDY DESIGN: Consensus statement. METHODS: From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 6 clinical questions and statements were related to surgical fusion techniques, comorbidity treatments, postoperative rehabilitation, and return-to-sports indications and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. RESULTS: Of the 6 questions and statements, 5 achieved unanimous support and 1 reached strong consensus. CONCLUSION: This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with surgical and postoperative treatment strategies for chronic syndesmosis injury.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 2: Indications for Surgical Treatment, Arthroscopic or Open Debridement, and Reconstruction Techniques of Suture Button and Screw Fixation.

BACKGROUND: The indications for surgical treatment of chronic syndesmosis injury are challenging for many orthopaedic clinicians, as there is no international consensus on the optimal management of these injuries. PURPOSE: An international group of experts representing the field of sports injuries in the foot and ankle area was invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injury. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). STUDY DESIGN: Consensus statement. METHODS: From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 9 items with 17 clinical questions and statements were related to indications for surgical treatment, arthroscopic versus open debridement, and suture button versus screw fixation reconstruction techniques and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. RESULTS: Of the 17 questions and statements, 4 achieved unanimous support, 11 reached strong consensus, and 2 reached consensus. CONCLUSION: This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with surgical indications and techniques for chronic syndesmosis injury.

Smoking may be more harmful to vasospastic angina patients who take antiplatelet agents due to the interaction: Results of Korean prospective multi-center cohort.

BACKGROUND: The interaction between smoking and the use of antiplatelet agents on the prognosis of vasospastic angina (VA) is rarely investigated. METHODS: VA-Korea is a nation-wide multi-center registry with prospective design (n = 1812). The primary endpoint was the composite occurrence of acute coronary syndrome (ACS), symptomatic arrhythmia, and cardiac death. Log-rank test and Cox proportional hazard model were for statistical analysis. Also, we conducted interaction analysis in both additive and multiplicative scales between smoking and antiplatelet agents among VA patients. For additive scale interaction, relative excess risk due to interaction (RERI) was calculated and for multiplicative scale interaction, the ratio of hazard ratio (HR) was calculated. All statistical analysis conducted by Stata Ver 16.1. RESULTS: Patients who were smoking and using antiplatelet agents had the highest incidence rate in the primary composite outcome. The incidence rate was 3.49 per 1,000 person-month (95% CI: 2.30-5.30, log-rank test for primary outcome p = 0.017) and HR of smoking and using antiplatelet agents was 1.66 (95%CI: 0.98-2.81). The adjusted RERI of smoking and using antiplatelet agents was 1.10 (p = 0.009), and the adjusted ratio of HR of smoking and using antiplatelet agents was 3.32 (p = 0.019). The current study observed the interaction between smoking and using antiplatelet agents in both additive and multiplicative scales. CONCLUSIONS: Smoking was associated with higher rates of unfavorable clinical outcomes among VA patients taking antiplatelet agents. This suggested that VA patients, especially those using antiplatelet agents should quit smoking.

Bone Marrow Stimulation for Osteochondral Lesions of the Talus: Are Clinical Outcomes Maintained 10 Years Later?

BACKGROUND: Arthroscopic bone marrow stimulation (BMS) is considered the first-line treatment for osteochondral lesions of the talus (OLTs). However, the long-term stability of the clinical success of BMS remains unclear. PURPOSE: To investigate the long-term clinical outcomes among patients who underwent BMS for OLT and to identify prognostic factors for the need for revision surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis was performed on 202 ankles (189 patients) that were treated with BMS for OLT and had a minimum follow-up of 10 years. The visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Outcome Score (FAOS) were assessed by repeated measures analysis of variance. Prognostic factors associated with revision surgery were evaluated with Cox proportional hazard regression models and log-rank tests. RESULTS: The mean lesion size was 105.32 mm2 (range, 19.75-322.79); 42 ankles (20.8%) had large lesions (≥150 mm2). The mean visual analog scale for pain improved from 7.11 ± 1.73 (mean ± SD) preoperatively to 1.44 ± 1.52, 1.46 ± 1.57, and 1.99 ± 1.67 at 1, 3 to 6, and ≥10 years, respectively, after BMS (P < .001). The mean ankle-hindfoot score also improved, from 58.22 ± 13.57 preoperatively to 86.88 ± 10.61, 86.17 ± 10.23, and 82.76 ± 11.65 at 1, 3 to 6, and ≥10 years after BMS (P < .001). The FAOS at the final follow-up was 82.97 ± 13.95 for pain, 81.81 ± 14.64 for symptoms, 83.49 ± 11.04 for activities of daily living, 79.34 ± 11.61 for sports, and 78.71 ± 12.42 for quality of life. Twelve ankles underwent revision surgery after a mean 53.5 months. Significant prognostic factors associated with revision surgery were the size of the lesion (preoperative magnetic resonance imaging measurement ≥150 mm2; P = .014) and obesity (body mass index ≥25; P = .009). CONCLUSION: BMS for OLT yields satisfactory clinical outcomes at a mean follow-up of 13.9 years. The success of the surgery may depend on the lesion size and body mass index of the patient.

Primary Autologous Osteochondral Transfer Shows Superior Long-Term Outcome and Survival Rate Compared With Bone Marrow Stimulation for Large Cystic Osteochondral Lesion of Talus.

PURPOSE: To compare the results of bone marrow stimulation (BMS) versus autologous osteochondral transfer (AOT) as primary surgical option for large cystic osteochondral lesion of talus (OLT) and to further distinguish factors associated with clinical failures and overall survival. METHODS: We retrospectively analyzed patients with symptomatic large cystic OLT (>300 mm3) who underwent either primary BMS or AOT between January 2001 and January 2016 with a minimum follow-up of 36 months. Lesion surface area and volume were measured on magnetic resonance imaging. Clinical outcomes were assessed using pain visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Survival outcomes and factors associated with clinical failures were evaluated using Kaplan-Meier analysis and Cox regression analyses, respectively. RESULTS: Fifty of the total 853 patients had large cystic OLTs. Thirty-two patients underwent primary BMS, and 18 patients underwent primary AOT. Mean follow-up period was 118 months, and average lesion surface area and volume were 152.8 mm2 and 850.7 mm3, respectively. The primary AOT group showed significantly superior improvements in clinical outcomes compared with the BMS group at last follow-up (P = .001). Fourteen patients in the primary BMS group and 2 patients in the primary AOT group experienced clinical failure. Kaplan-Meier analysis showed a superior survival rate of primary AOT (P = .042). Syndesmosis widening (hazard ratio 12.361; P = .004) and large lesion surface area (hazard ratio 1.011; P = .014) were significant relative risks of clinical failure in the primary BMS group. However, lesion volume showed no significant relationship with clinical failure. CONCLUSION: Long-term results of primary AOT showed superior clinical improvements and survival rate in treating large cystic OLT. Risk factors for failure in the primary BMS group were large lesion surface area and syndesmosis widening. STUDY DESIGN: Retrospective comparative study LEVEL OF EVIDENCE: III.

Intra-articular Injections of Hyaluronic Acid on Osteochondral Lesions of the Talus After Failed Arthroscopic Bone Marrow Stimulation.

BACKGROUND: The purpose of the study was to compare clinical and functional outcomes before and after hyaluronic acid (HA) injections in patients with osteochondral lesions of the talus who experienced a failure of their primary treatment with arthroscopic microfracture surgery. METHODS: A total of 40 patients were included in the final study. These patients had received microfracture surgery but continued to experience postoperative pain over an average of 13.0 months (range, 0-81 months) and were available for investigation with a mean follow-up for 29.1 months (SD 14.7; range 2.6-79.6 months). All patients received intra-articular injections of HA once per week for 3 weeks. We assessed clinical and functional outcomes before and after injection using the American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), Short Form Health Survey (SF-36), the visual analog scale (VAS) for pain, and the Alexander subjective scale. RESULTS: The AOFAS score significantly increased from 50.7 ± 13.8 to 79.9 ± 13.8 and the FAOS scores for symptom, pain, daily living, and sports were significantly higher postinjection compared to preinjection (all P < .001). Similarly, the mean VAS for pain was significantly decreased after 6 weeks following injection and continued to decrease over the follow-up period; the mean VAS was significantly lower postinjection compared to preinjection at 12 months (P < .001). CONCLUSION: Intra-articular HA injections on average significantly improved clinical and functional scores after failed primary operative treatment. HA injections may provide an alternative to secondary operative treatment and provide better clinical outcomes than other conservative treatments. LEVEL OF EVIDENCE: Level II, prospective observational cohort study.

Diagnosis and Operation Results for Chronic Lateral Ankle Instability with Subtle Cavovarus Deformity and a Peek-A-Boo Heel Sign.

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly (p=0.001), and instability did not recur. Radiographically, all stress parameters improved significantly (p=0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287).

Enhancement of Mesenchymal Stem Cell-Driven Bone Regeneration by Resveratrol-Mediated SOX2 Regulation.

Mesenchymal stem cells (MSCs) are an attractive cell source for regenerative medicine. However, MSCs age rapidly during long-term ex vivo culture and lose their therapeutic potential before they reach effective cell doses (ECD) for cell therapy. Thus, a prerequisite for effective MSC therapy is the development of cell culture methods to preserve the therapeutic potential during long-term ex vivo cultivation. Resveratrol (RSV) has been highlighted as a therapeutic candidate for bone disease. Although RSV treatment has beneficial effects on bone-forming cells, in vivo studies are lacking. The current study showed that long-term (6 weeks from primary culture date)-cultured MSCs with RSV induction retained their proliferative and differentiation potential despite reaching ECD. The mechanism of RSV action depends entirely on the SIRT1-SOX2 axis in MSC culture. In a rat calvarial defect model, RSV induction significantly improved bone regeneration after MSC transplantation. This study demonstrated an example of efficient MSC therapy for treating bone defects by providing a new strategy using the plant polyphenol RSV.

Assessment of Korea's Orthopedic Research Activities in the Top 15 Orthopedic Journals, 2008-2017.

BACKGROUND: Bibliometrics is increasingly used to assess the quantity and quality of scientific research output in many research fields worldwide. This study aims to update Korea's worldwide research productivity in the field of orthopedics using bibliometric methods and to provide Korean surgeons and researchers with insights into such research. METHODS: Articles published in the top 15 orthopedic journals between 2008 and 2017 were retrieved using the Web of Science. The number of articles, citations and h-index (Hirsch index), funding sources, institutions, and journal patterns were analyzed. RESULTS: Of the total 39,494 articles, Korea's contribution accounted for 5.6% (2,161 articles), ranking fifth in the world in the number of publications. Korea ranked sixth (with 29,456) for total citations worldwide but ranked 17th (13.64) in terms of average citation per item and 14th (55) in terms of h-index. Korea showed the most prolific productivity in the field of sports medicine and arthroscopy. The institution that produced the highest number of publications was Seoul National University (n = 386, 17.9%). CONCLUSIONS: Orthopedic research in South Korea demonstrated high productivity in terms of the number of publications in high-quality journals between 2008 and 2017. However, total citations and average citations per article were still relatively low. Efforts should be made to increase citation rates for further improvement in research productivity in the field of orthopedics.

Primary Versus Secondary Osteochondral Autograft Transplantation for the Treatment of Large Osteochondral Lesions of the Talus.

BACKGROUND: Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT. PURPOSE: To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: From 2005 to 2014, 46 patients with large OLT (≥150 mm2) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis. RESULTS: Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm2 (range, 151.7-296.3 mm2). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm2 on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947). CONCLUSION: Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.