Prevalence and risk factors of wound complications after transtibial amputation in patients with diabetic foot.

BACKGROUND: Diabetic foot (DMF) complications are common and are increasing in incidence. Risk factors related to wound complications are yet to be established after trans-tibial amputation under the diagnosis of DMF infection. AIM: To analyze the prognosis and risk factors related to wound complications after transtibial amputation in patients with diabetes. METHODS: This retrospective cohort study included seventy-two patients with DMF complications who underwent transtibial amputation between April 2014 and March 2023. The groups were categorized based on the occurrence of wound complications, and we compared demographic data between the complication group and the non-complication group to analyze risk factors. Moreover, a multivariate logistic regression analysis was performed to identify risk factors. RESULTS: The average follow-up period was 36.2 months. Among the 72 cases, 31 (43.1%) had wound complications. Of these, 12 cases (16.7%) received further treatment, such as debridement, soft tissue stump revision, and re-amputation at the proximal level. In a group that required further management due to wound complications after transtibial amputation, the hemoglobin A1c (HbA1c) level was 9.32, while the other group that did not require any treatment had a 7.54 HbA1c level. The prevalence of a history of kidney transplantation with wound complications after transtibial amputation surgery in DMF patients was significantly greater than in cases without wound complications (P = 0.02). Other factors did not show significant differences. CONCLUSION: Approximately 43.1% of the patients with transtibial amputation surgery experienced wound complications, and 16.7% required additional surgical treatment. High HbA1c levels and kidney transplant history are risk factors for postoperative wound complications.

Closed reduction and internal fixation for tillaux fractures, based on pre-operative three-dimensional computed tomography.

OBJECTIVE: This study aimed to propose treatment protocol and identify patterns of tillaux fractures using three-dimensional (3D) computed tomography (CT) analysis and to describe an effective reduction technique. METHODS: Forty-two juvenile patients with tillaux fractures were evaluated with 3D-CT scan for fracture displacement pattern and received surgical treatment. Tillaux fragment was reduced by pushing the superomedial quadrant part of the fragment slightly downward towards the ankle joint from anterolateral to posteromedial through 5-mm skin incisions with mosquito forceps. A 4.0 cannulated screw was subsequently inserted from the anterolateral to the posteromedial side parallel to the ankle joint. We analysed the distance and direction of fracture displacement with 3D-CT before the surgery. Pre-operative and post-operative plain radiographs were evaluated. RESULTS: Pre-operative 3D-CT analysis revealed a common fracture pattern, varus tilt, and external rotation of fragment. We achieved satisfactory reduction with residual fracture gaps less than 2 mm in 42 cases. Two cases had a 13-mm anterior gap that was reduced by mini-open reduction because of periosteal impingement. No significant clinical complications were found. CONCLUSION: The closed reduction technique developed based on the fracture pattern identified by 3D-CT anatomical analysis is safe and effective in treating tillaux fractures.

Nail-preserving excision of glomus tumor in the second toe: Case report and literature review.

INTRODUCTION: This case report describes the diagnosis of a glomus tumor in the second toe of a 38-year-old female, followed by surgical treatment utilizing a transungual approach to preserve the nail. This study highlights the diagnostic challenges and surgical strategies to treat such tumors while preserving nail integrity. PATIENT CONCERNS: Pain occurred once a week, but over time, it increased, and just before seeking medical attention, she experienced pain more than 5 times a day. The pain worsened when cold water touched her toe. DIAGNOSIS: We observed a slight hump indicating nail plate deformity, and the patient exhibited severe pinpoint tenderness (positive Love test) in the affected area. Color duplex ultrasound was performed for further investigation, revealing a hypervascular hypoechoic nodule measuring 0.5 cm in size at the nail bed of the right second toe. INTERVENTION: The surgery was performed under digital nerve block anesthesia using a modified transungual nail-preserving approach for the excision of the glomus tumor. OUTCOMES: The pain that was reported prior to the surgery has improved postoperatively, and the recovery has been uneventful without any other complication. CONCLUSION: This paper provides a comprehensive examination of a rare glomus tumor in the second toe, elucidating both diagnostic intricacies and treatment modalities. It emphasizes the dual necessity of achieving total tumor excision while also considering aesthetic outcomes. The insights presented herein are intended to serve as valuable guidance for clinicians confronted with similar clinical scenarios, underlining the delicate interplay between effective tumor management and the preservation of cosmetic integrity.

Analgesic effectiveness of continuous versus single-injection adductor canal block in addition to continuous popliteal sciatic nerve block for bimalleolar and trimalleolar ankle fracture surgery: Prospective randomized controlled trial.

BACKGROUND: The adductor canal block is a well-known procedure for controlling postoperative pain after medial malleolus fracture surgery. Continuous nerve block is a viable option for blocking pain for a longer period although the literature on this subject is scarce. Therefore, this study aimed to compare continuous adductor canal block (cACB) group to single-injection adductor canal block (sACB) group in those with bimalleolar or trimalleolar ankle fractures. The procedure was performed in addition to a continuous sciatic nerve block for postoperative pain relief and patient satisfaction. METHODS: The study included 57 patients who had bimalleolar or trimalleolar ankle fractures and underwent open reduction and internal fixation between August 2016 and June 2018. Each patient received a continuous sciatic nerve block and was divided into two groups: those who received cACB and those who received sACB. Each postoperative pain was scored at 4, 8, 12, 24, 48, and 72 h after surgery. Additionally, the consumption of rescue medications and patient satisfaction were evaluated. RESULTS: The two groups displayed no disparity in medial side ankle pain at 4 h and 8 h after surgery, but significantly higher pain in the sACB group at 12, 24, 48, and 72 h after surgery. However, there was no difference in the pain at the lateral side of ankle and consumption of rescue medication. In addition, the cACB group showed more satisfaction than the sACB group did. CONCLUSION: CACB is better than sACB in terms of postoperative pain control and patient satisfaction. cACB can be used for postoperative pain control in ankle fractures involving the medial malleolus. LEVEL OF EVIDENCE: Prospective Randomized Controlled Trial, Level 2.

Intraoperative assessment of hindfoot alignment using C-arm fluoroscopy.

BACKGROUND: Hindfoot malalignment can cause various foot and ankle problems. For better surgical performance and correction of hindfoot malalignments, reliable intraoperative determination of hindfoot alignment is essential. However, there is no standard method for the intraoperative assessment of hindfoot alignment. We devised an intraoperative modified Méary posteroanterior (IOPPA) view to assess intraoperative hindfoot alignment. This study aimed to compare this intraoperative method with other radiographic hindfoot alignment measurements. METHODS: Thirty-seven patients (47 feet) with various foot and ankle conditions scheduled to undergo surgery were prospectively recruited. Before surgery, the Saltzman, long axial, and modified Méary views were taken in a controlled and standardized fashion. IOPPA views were obtained under simulated weight bearing conditions using C-arm fluoroscopy in the operating room before surgery. The relationship between the IOPPA view and the three radiographic hindfoot alignments was evaluated using Pearson's correlation. RESULTS: The mean hindfoot alignment angle was varus 3.50° (CI, varus 1.91 to 5.08) on the Saltzman view, varus 2.00° (CI, varus 0.60 to 3.39) on the long axial view, varus 0.13° (CI, valgus 1.41 to varus 1.67) on the modified Méary view, and varus 1.32° (CI, valgus 0.02 to varus 2.65) on IOPPA view. The IOPPA view and the three other hindfoot alignment views were found to be significantly correlated (r = 0.60 for the Saltzman view, r = 0.50 for the long axial view, r = 0.71 for the modified Méary view, P < .05). The intraobserver ICC (Intraclass Correlation Coefficient) value was 0.974 and interobserver ICC (Intraclass Correlation Coefficient) value was 0.988 for the IOPPA view (P < .001). CONCLUSION: There was a statistically significant correlation between the IOPPA view and the other three hindfoot alignment views. We also found that interobserver and intraobserver ICC values were excellent. This study proposes that the IOPPA view can be used as a reliable intraoperative assessment tool for hindfoot alignment. LEVEL OF EVIDENCE: Prospective study.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note.

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures.

PURPOSE: We describe a novel technique that uses an aiming drill guide and ankle arthroscopy for direct visualization and reduction of the depressed articular surface located between the posterior tibia and the fractured posterior malleolus. This technique requires less soft tissue dissection to visualize and reduce the depressed articular surface. METHODS: Between June 2014 and May 2019, 126 patients were surgically treated for trimalleolar fractures. Among them, 11 had depressed articular fragment between the posterior tibia and the fractured posterior malleolus reduced using our novel technique. The study included six men and five women, with a mean age of 46.5 (range: 23-62) years. RESULTS: In eight (73%) cases, the articular surface was reduced, with the articular surface step-off being less than 2 mm, as noted on postoperative computed tomography (CT). Syndesmosis congruity within an anterior-to-posterior difference of less than 2 mm was confirmed in nine (82%) cases via postoperative CT. The mean 100-mm visual analog scale (VAS) and the mean Olerud-Molander ankle score at the final follow-up were 16.6 ± 14.5 and 87.7 ± 7.5, respectively. CONCLUSIONS: The depressed articular fragment located between the posterior tibia and the fractured posterior malleolus can be treated using an aiming drill guide and ankle arthroscopy. Ankle arthroscopy is used for direct visualization of the depressed articular surface, and the aiming drill guide can guide the bone plunger precisely to the depressed articular surface for reduction. This technique requires less soft tissue dissection than conventional techniques to visualize and reduce the depressed articular surface.

Screw stripping and its prevention in the hexagonal socket of 3.5-mm titanium locking screws.

There have been several reports about the difficulties in removing 3.5-mm titanium locking screws from plates due to the stripping or rounding of the hexagonal screw socket. We investigated whether stripping the locking screw sockets can be prevented by using different screwdrivers or interposing materials into the socket during removal. We overtightened 120 3.5-mm titanium locking screws (Depuy Synthes, Paoli, PA) equally into locking plates on sawbone tibia models, applying a uniform torque of 4.5 Nm, exceeding the recommended torque of 1.5 Nm. Twenty screws each were removed using a straight-handle 2.5-mm screwdriver, T-handle screwdriver, hex key wrench, and straight-handle screwdriver with a non-dominant hand. In addition, 20 screws were removed using foil from a suture packet inserted into the screw socket or using parts of a latex glove inserted into the screw socket. The incidence rates of screw stripping using the straight-handle screwdriver, T-handle screwdriver, hex key wrench, non-dominant hand, foil interposition, and latex glove interposition were 75%, 40%, 35%, 90%, 60%, and 70%, respectively. When a T-handle screwdriver or hex key wrench was used, the probability of screw stripping was 4.50 times (odds ratio = 4.50, 95% confidence interval = 1.17 to 17.37, p = 0.03) and 5.57 times (odds ratio = 5.57, 95% confidence interval = 1.42 to 21.56, p = 0.01) lower than that with the straight-handle screwdriver, respectively. Foil or latex glove interpositions did not prevent screw stripping. Thus, in the current experimental study, T-handle screwdriver or hex key wrench usage decreased the incidence rate of screw stripping during removal compared to straight-handle screwdriver use.

Use of a Locking Plate and Drill Sleeves to Guide Dome-Shaped Supramalleolar Osteotomy: Technique Tip.

Level of Evidence: Level V, expert opinion.

Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures.

BACKGROUND: Nonunion is a rare complication for distal fibular fractures. However, when there is a high degree of comminution, nonunion may occur. In this article, we describe a novel technique that uses the oblong hole of a locking plate to lengthen the fibula for fracture reduction. This technique is straightforward and allows for easy control of the comminuted fracture to restore length and rotation at the time of plate application without opening the fracture site. METHODS: Thirty-five consecutive patients, who were treated with the minimally invasive plate osteosynthesis (MIPO) technique for comminuted distal fibular fractures were retrospectively studied. The study included 19 men and 16 women, with a mean age of 47.0 years (range, 20 to 72). There were 3 lateral malleolar fractures with deltoid injury, 11 bimalleolar fractures, 7 trimalleolar fractures, and 14 distal tibiofibular fractures. The quality of fracture reduction was assessed by comparing the radiologic parameters (fibular length, talocrural angle, and medial clear space) between the affected ankle and the contralateral uninjured ankle. RESULTS: Two patients were not reachable and 5 declined to visit the clinic. For these 7 patients, the latest outcomes that were measured prospectively were used. Postoperative radiographs showed well-aligned ankle mortise, with fibular length restoration. The mean Olerud-Molander ankle score was 82.1 ± 10.7 at a mean of 27.2 months (range, 12 to 58). There was one case of nonunion and one case of superficial peroneal nerve injury. CONCLUSION: The MIPO technique, using the oblong hole of a locking plate, achieved satisfactory restoration of length and rotation, bone union, and clinical outcomes for the comminuted distal fibular fractures.

Intermediate-term Patient-Reported Outcomes and Radiographic Evaluation Following Intramedullary- vs Extramedullary-Referenced Total Ankle Replacement.

BACKGROUND: The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR). METHODS: From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12). RESULTS: The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P < .0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P = .6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P < .0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P > .05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up. CONCLUSION: The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018.

BACKGROUND: The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants. MATERIALS AND METHODS: The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature. RESULTS: Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion. CONCLUSION: Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants. LEVEL OF EVIDENCE: Level IV; Case Series from Large Database Analysis; Treatment Study.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy.

BACKGROUND: This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy. METHODS: This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination. RESULTS: The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography. CONCLUSIONS: Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Use of External Fixators as a 3-Dimensional Navigation Drill Guide for Arthroscopic Ankle Arthrodesis.

In this article, we describe a novel technique using external fixators and cannulated screws to construct a 3-dimensional navigation drill guide to predict the screw trajectory before screw insertion that can prevent screw collision during arthroscopic ankle arthrodesis. Four orthopedic residents who had no prior experience of ankle arthrodesis were instructed on how to use the 3-dimensional navigation drill guide and where to insert the screws for ankle arthrodesis. Each resident inserted 6.5 cannulated screws on 8 sawbone ankle models using the device and the C-arm fluoroscopy. An experienced attending surgeon also inserted the same screws on 2 sawbone ankle models to find out if there is any difference between the experienced and inexperienced surgeons. All four residents and an attending surgeon did not experience any collision of screws for the three cannulated screws. Notably, one resident had collision of the 4th screw on his first sawbone model. On the second saw bone model, all surgeons could insert 5 screws without redrilling. A 3-dimensional navigation drill guide constructed with external fixators can assist surgeons in implementing percutaneous screws for arthroscopic ankle arthrodesis.

Conservative treatment of refractures after modified tension band wiring of fifth metatarsal base stress fractures in athletes.

OBJECTIVE: Recurrent fifth metatarsal base stress fractures (MT5-BSF) in athletes present a challenging problem. The aim of this study was to evaluate the result of conservative treatment for the refracture of MT5-BSF after modified tension band wiring (MTBW). MATERIALS AND METHODS: The outcomes of 15 elite athletes undergoing conservative treatment for refracture of MT5-BSF after MTBW were retrospectively reviewed. They were instructed to avoid weight-bearing with short leg cast for 6 weeks. After that, they started partial weight with a postop shoe. Stepwise exercise followed bone union by radiographs. RESULTS: Thirteen cases (86.6%) had a complete bone union after a mean of 18.9 ± 8.6 weeks. Twelve cases (80%) returned to their previous activity level and maintained for at least two consecutive seasons. CONCLUSION: Eighty percent of all athletic patients with the conservative treatment for refractures with healed MT5-BSF after MTBW on the plantar-lateral side could maintain and return to their previous sports activity for at least 2 years.

Operative Results of Plantar Plating for Fifth Metatarsal Stress Fracture.

BACKGROUND: The treatment of fifth metatarsal stress fractures can be challenging. Various operative fixation methods have been reported for fracture management. Among them, intramedullary screw fixation has become increasingly popular. However, recent reports have described failures after screw fixation in athletes. The aim of this study was to determine the rates of clinical and radiographic healing, time to return to sport, and complications of elite athletes with proximal fifth metatarsal fractures treated with plantar plating. METHODS: Thirty-eight athletes with fifth metatarsal stress fractures treated using a plantar plating technique in 3 hospitals from 2013 to 2018 were evaluated retrospectively. Demographic data, radiographic evaluation, and the time until union and return to sports activities were collected and analyzed. A total of 38 patients underwent the plantar plating for a fifth metatarsal stress fracture with a mean follow-up of 23 (range, 12-49) months. RESULTS: The mean time to the radiologic union, as determined by plain radiography, was 9.3 (range, 8-16) weeks. Although there were no nonunions or delayed unions during follow-up, 4 refractures developed (10.5%). All but 1 patient were able to return to their previous levels of sporting activity at 22.2 ± 4.5 (range, 12-40) weeks. CONCLUSION: With a minimum of 1-year follow-up, the described plantar plating technique could be an alternative method for the operative treatment of fifth metatarsal stress fractures without nonunion problems. LEVEL OF EVIDENCE: Level IV, case series.

Multivariate analyses of MRI findings for predicting osteomyelitis of the foot in diabetic patients.

BACKGROUND: There have been no previous magnetic resonance imaging (MRI) studies using multivariable analysis to diagnose osteomyelitis in patients with diabetic foot. PURPOSE: To retrospectively investigate the MRI findings of osteomyelitis in patients with diabetic foot using multivariate analyses. MATERIAL AND METHODS: From November 2015 to March 2018, 118 patients who underwent MRI of the foot to evaluate suspected osteomyelitis were included in this study. The patients were categorized into the presence or absence of osteomyelitis. The primary and secondary MRI findings were retrospectively reviewed. To identify independent predictive MRI findings, multivariate analyses with binary logistic regression and receiver operating characteristic curve analyses were performed including all 118 patients and 93 patients presenting decreased T1 signal intensity, respectively. RESULTS: T1 signal intensity, T1 marrow pattern, T1 marrow distribution, T2 signal intensity, concordance of marrow signal intensity, cortical interruption, ulcer depth, abscess, and wet gangrene were significantly different between the two groups (P < 0.05). Multivariate analyses indicated that fluid equivalent T2 signal intensity, deep ulcer, and confluent T1 marrow pattern were major factors associated with osteomyelitis. The area under the curve of predicted probabilities for the combination of these factors was 0.799 across all 118 patients and 0.761 across 93 patients with decreased T1 signal intensity. CONCLUSION: Confluent T1 marrow pattern is a reliable finding to suggest osteomyelitis in patients with diabetic foot. In addition, fluid equivalent T2 signal intensity and deep ulcer are important findings that may suggest osteomyelitis, irrespective of T1 signal intensity change.

GnRH impairs diabetic wound healing through enhanced NETosis.

It has been reported that neutrophil extracellular traps (NETs) impair wound healing in diabetes and that inhibiting NET generation (NETosis) improves wound healing in diabetic mice. Gonadotropin-releasing hormone (GnRH) agonists are associated with a greater risk of diabetes. However, the role of GnRH in diabetic wound healing is unclear. We determined whether GnRH-promoted NETosis and induced more severe and delayed diabetic wound healing. A mouse model of diabetes was established using five injections with streptozotocin. Mice with blood glucose levels >250 mg/dL were then used in the experiments. GnRH agonist treatment induced delayed wound healing and increased NETosis at the skin wounds of diabetic mice. In contrast, GnRH antagonist treatment inhibited GnRH agonist-induced delayed wound healing. The expression of NETosis markers PAD4 and citrullinated histone H3 were increased in the GnRH-treated diabetic skin wounds in diabetic mice and patients. In vitro experiments also showed that neutrophils expressed a GnRH receptor and that GnRH agonist treatment increased NETosis markers and promoted phorbol myristate acetate (PMA)-induced NETosis in mouse and human neutrophils. Furthermore, GnRH antagonist treatment suppressed the expression of NETosis markers and PMA-induced NETosis, which were increased by GnRH treatment. These results indicated that GnRH-promoted NETosis and that increased NETosis induced delayed wound healing in diabetic skin wounds. Thus, inhibition of GnRH might be a novel treatment of diabetic foot ulcers.

Prognostic factors of acute ankle sprain: Need for ultrasonography to predict prognosis.

BACKGROUND: Ankle sprains are one of the most common musculoskeletal injuries. To guide management decisions, a clear insight into the relevant subgroups of patients with a potentially better or worse prognosis is important. This study aimed to evaluate injury severity, using ultrasonography (US), as a prognostic factor of acute ankle sprain and other possible factors including age, sex, body mass index (BMI), level of job activity, and level of sports activity. MATERIALS AND METHODS: We retrospectively reviewed 28 patients with acute ankle sprain who reported at initial examination with an acutely twisted ankle. All patients had received a standard physical examination, radiography and standard ultrasound, to diagnose specific ligament injuries and their ankle sprain had been treated using standard conservative management. Various data including age, sex, BMI, level of sports activity, level of daily job activity, and final functional score (Foot and Ankle Outcome Scores, FAOS) were obtained. Mean comparison and correlations were used to assess risk factors. Risk factors associated with functional outcomes were evaluated using a multiple linear regression test. RESULTS: At final follow-up as 1 year after injury, FAOS differed significantly for injury severity, age, and BMI. There were no significant differences in sex, job activity, and exercise levels. The factor most affecting FAOS for both pain (FAOS-Pain) and symptoms (FAOS-Sx) was the number of completely torn ligaments. Age was the most important factor affecting the FAOS-Daily Living Activity (ADL). BMI was the most important factor for sports activity level (FAOS-Sports). Age and the number of completely torn ligaments were both important to FAOS-Sports and quality of life (FAOS-QOL). CONCLUSION: The severity of injury, defined using US, was a prognostic factor for long-term outcome following acute ankle sprain. Therefore, US imaging of acute ankle ligament injury may be important to predict prognosis of acute ankle sprain.