Isolated Subtalar Repositional Arthrodesis Compared With Triple Arthrodesis for the Treatment of Progressive Collapsing Foot Deformity.

The optimal extent of arthrodesis for severe and rigid progressive collapsing foot deformity is controversial. Traditionally, triple arthrodesis has been recommended; however, good results have been reported using subtalar arthrodesis only. We compared the results of triple arthrodesis and isolated subtalar repositional arthrodesis. A total of 22 symptomatic feet were evaluated retrospectively. Isolated subtalar repositional arthrodesis was performed in 13 cases (the subtalar group) and double or triple arthrodesis in 9 cases (the triple group). Various radiographic variables for assessing flatfoot and osteoarthritic changes in ankle and tarsal joints were measured and compared between the 2 groups at 3 time points: preoperatively, 3 months postoperatively, and 4 y postoperatively. Additionally, we analyzed various factors that affect postoperative valgus talar tilt in the ankle joint, which has been associated with poor prognosis. There were no differences in preoperative demographic data and the severity of the disease between the 2 groups; both groups showed improvement in radiographic parameters postoperatively compared with preoperative results. With the numbers available, no significant differences could be detected in postoperative radiographic measurements between the 2 groups. Of all the variables analyzed, postoperative hindfoot alignment angle was associated with postoperative talar tilt development. Additionally, postoperative talar tilt was observed more in triple group than in subtalar group. In conclusion, isolated subtalar repositional arthrodesis is an effective procedure to correct advanced progressive collapsing foot deformity. In addition, Chorpart joint arthrodesis with improper position can cause valgus talar tilt in the ankle joint.

Treatment of intractable septic ankle arthritis with a continuous closed irrigation system.

OBJECTIVES: The study aimed to evaluate the efficacy of a continuous closed irrigation system (CCIS) after open debridement for patients with intractable septic ankle arthritis. PATIENTS AND METHODS: The retrospective study analyzed the intractable septic arthritis of 12 (6 males, 6 females; mean age: 64.1±14.7 years; range, 33 to 80 years) patients managed by CCIS between July 2015 and July 2020. All patients had previously undergone operations to treat septic ankle arthritis without resolution of the infection. After open debridement, the CCIS was usually equipped with two outflow tubes and one inflow tube. Saline inflow was about 1 L per day. RESULTS: The mean follow-up period was 30.8±14.9 (range, 15 to 70) months. The CCIS was maintained for a mean of 5.1±2.1 (range, 3 to 7) days. The mean number of operations the patients had previously undergone was 2.83±1.5 (range, 1 to 6). For 11 (91.6%) out of 12 patients, infection did not recur after one-time CCIS, and laboratory test results remained normal. Six patients had previously undergone total ankle replacement arthroplasty. These patients underwent antibiotics-mixed cement arthroplasty after CCIS. For five of six with infected total ankle replacement arthroplasty, infection did not recur after CCIS. However, one patient without the removal of both implants experienced recurrence at the same site after four postoperative months. In the reoperation, after the removal of both implants and the application of antibiotics-mixed cement arthroplasty, the infection was cleared. CONCLUSION: Use of CCIS after open debridement for intractable septic ankle arthritis is a good treatment option since it is relatively simple and safe, with good results.

Excision with Temporary Interphalangeal Joint Pin Fixation for Toe Ganglion Cysts.

Background: Toe ganglion cysts are often symptomatic and recurrent. Communicating lesions between ganglion cysts and the interphalangeal joint (IPJ) or tendon sheath make it difficult to prevent a recurrence. Temporary restriction of the joint and tendon motion can facilitate surgical site healing. This study analyzed the clinical results of temporary pin fixation of the IPJ after toe ganglion cyst excision. Methods: Sixteen patients with symptomatic toe ganglion cysts underwent surgical treatment. Excision alone was initially performed on 10 patients. Six patients underwent temporary pin fixation of the IPJ after ganglion cyst excision. Repeat excision with pin fixation was performed for recurrence in two patients after excision only. Clinical evaluations and postoperative complications were analyzed. Results: Fourteen of 16 toe ganglion cysts were located near the IPJ. Two cysts not adjacent to the joint completely healed after excision alone. Seven of 14 cysts near the joint recurred after initial excision alone and required repeated reoperation. Eight cysts did not recur after excision with pin fixation, including 2 that recurred after excision alone. Conclusions: Temporary IPJ pin fixation after excision for ganglion cysts can be effective for preventing the recurrence of ganglion cysts adjacent to toe IPJ.

Practical Entropy Accumulation for Random Number Generators with Image Sensor-Based Quantum Noise Sources.

The efficient generation of high-quality random numbers is essential in the operation of cryptographic modules. The quality of a random number generator is evaluated by the min-entropy of its entropy source. The typical method used to achieve high min-entropy of the output sequence is an entropy accumulation based on a hash function. This is grounded in the famous Leftover Hash Lemma, which guarantees a lower bound on the min-entropy of the output sequence. However, the hash function-based entropy accumulation has slow speed in general. For a practical perspective, we need a new efficient entropy accumulation with the theoretical background for the min-entropy of the output sequence. In this work, we obtain the theoretical bound for the min-entropy of the output random sequence through the very efficient entropy accumulation using only bitwise XOR operations, where the input sequences from the entropy source are independent. Moreover, we examine our theoretical results by applying them to the quantum random number generator that uses dark shot noise arising from image sensor pixels as its entropy source.

Relationship Between Hallux Valgus Recurrence and Sesamoid Position on Anteroposterior Standing Radiographs After Distal Chevron Metatarsal Osteotomy.

BACKGROUND: Recurrence of the hallux valgus deformity has various causes, and the incomplete reduction of sesamoids may be one of the important issues. However, we have seen several patients with postoperative lateral sesamoid displacement on anteroposterior (AP) standing radiographs who did not experience hallux valgus recurrence. Therefore, we hypothesized that lateral displacement of the sesamoid on AP standing radiographs does not cause hallux valgus recurrence. METHODS: The study included 269 feet (185 patients) with hallux valgus treated with distal chevron metatarsal osteotomy. Mean patient age was 64.26 (range, 15-80) years. Patients were followed up for an average of 33.85 (range, 12-228) months between April 2002 and December 2019. The patients were divided into 4 groups, according to the presence or absence of hallux valgus recurrence and sesamoid reduction. RESULTS: During outpatient follow-up, we discovered 99 feet (42.1%) in which hallux valgus did not recur despite lateral sesamoid displacement (grade IV-VII) on AP standing radiographs. Hallux valgus angle (HVA, 2.7 to 7.9 degrees), intermetatarsal angle (IMA, 4.6 to 6.2 degrees), and sesamoid grades (2.1 to 3.5) all deteriorated over time after surgery, and each indicator was statistically significantly altered, and changes in the 3 indicators had a statistically significant positive correlation. Changes in HVA and IMA between feet with and without sesamoid reduction on AP standing radiographs increased over time, with the differences in HVA (2.9 degrees) and IMA (0.9 degrees) being significant at final follow-up (P < .05 for each). Regardless of whether sesamoid reduction was achieved on AP standing radiographs, the final analysis showed that HVA and IMA in both groups worsened over time. Further, there were no differences between the 2 groups in the patterns of change over time. CONCLUSION: In our cohort, postoperative sesamoid position on AP standing radiographs was not associated with hallux valgus recurrence based on radiographic criteria. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Clinical Features and Treatment of Intra-Tendinous Suture Reaction Following Achilles Tendon Repair Using Nonabsorbable Suture Material: A Retrospective Case Series Study.

We aimed to investigate the clinical manifestations, radiological findings, and therapeutic outcome of treatment for patients with surgically confirmed foreign body reaction following an Achilles tendon repair using non-absorbable suture material. Eight consecutive patients who were confirmed as having an intra-tendinous suture foreign body reaction in the histopathological report were enrolled in this study. Medical records of all patients in terms of clinical and radiological features were retrieved. Also, the outcome of treatment was evaluated at a follow-up of at least 12 months. All the patients complained of pain and a palpable mass around a previous surgical site at mean 25.1 months (range, 4-72 months) after the initial surgery. Magnetic resonance imaging (MRI) or ultrasound were used to detect the lesion. All the patients underwent surgical excision of foreign body reaction tissue and primary repair using absorbable suture material. After the treatment, the wounds were healed completely in all, and the average FAOS (foot and ankle outcome score) was 91.32 at mean follow-up for 22.4 months. In conclusion, intra-tendinous suture reaction is a rare complication following an Achilles tendon repair using nonabsorbable suture material, but it can be treated adequately with only surgical excision of foreign body reaction tissue and primary repair using absorbable suture material.

Management of talar lesions with cement augmentation and autologous bone graft.

BACKGROUND: Treatment of bone lesions involved with the articular cartilage at the talus is challenging. We report the management of talus lesions, particularly tumors and avascular necrosis (AVN), at the articular surface through treatment with cement augmentation and autologous bone graft. METHODS: Eight benign bone tumors and three cases of AVN were reviewed retrospectively at a mean follow-up of 56 months (range, 12-162). The mean age of all patients was 36.1 years old (range, 15-73) when assessed between February 2005 and November 2021. Curettage of tumorous and necrotic lesions resulted in significant bone defects filled with bone cement augmentation. Cartilage defects of the talar dome were supported with autologous cancellous bone graft. Tolerable weight-bearing ambulation was permitted immediately after surgery. Radiological and functional evaluations were recorded. RESULTS: We observed an increase in the average The American Orthopaedic Foot and Ankle Score (AOFAS) (p = .003) and a decrease in the average Visual Analogue Scale pain score (p = .003). There was no statistically significant decrease in ROM before or after surgery (p = .114). Additionally, no talus collapse of the ankle joint occurred. Talar dome status did not aggravate before or after surgery, except for one patient. Despite no radiographic osteoarthritis exacerbation before or after surgery in six patients, five patients had osteoarthritic change. CONCLUSION: Cement implantation and autologous bone graft performed simultaneously for benign bone tumors with joint cartilage damage and AVN are technically simple, have good outcomes, and may be a suitable alternative to standard treatments.

Contribution Ratio of Metatarsal Osteotomy and First Tarsometatarsal Joint Reduction in Moderate to Severe Hallux Valgus Correction.

Hallux valgus is a common foot and ankle disease, for which numerous surgical procedures were introduced. So, understanding the mechanism of deformity reduction is important to select the proper method. Intermetatarsal angle (IMA) determines the severity of hallux valgus, which is influenced by the translated metatarsal head and the reduction of the first tarsometatarsal joint. We hypothesized that both of the mechanisms simultaneously contribute to the correction of IMA. Hallux valgus (70 feet) operated with a Scarf osteotomy with the Akin procedure were reviewed. Hallux valgus angle (HVA), IMA (mechanical and anatomical), hallux valgus interphalangeal angle (HVIP), distal metatarsal articular angle (DMAA), and sesamoid position were checked. The ratio of contributions to the IMA changes were calculated and compared. When the individual contributions by metatarsal head translation and first tarsometatarsal joint reduction were compared, metatarsal head translation contributed by 82%, whereas first tarsometatarsal joint reduction contributed by 18%. Both were responsible for mechanical IMA correction. However, IMA change by metatarsal head translation was a major correction mechanism compared to anatomical IMA change by first tarsometatarsal joint reduction.

Analysis of repeated lesions after diabetic forefoot amputation.

AIM: This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation. METHODS: The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined. RESULTS: Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer. CONCLUSIONS: Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.

Early Return to Daily Life through Immediate Weight-Bearing after Lateral Malleolar Fracture Surgery.

Lateral malleolus fracture is one of the most common fractures. However, there is controversy regarding the rehabilitation protocols used after surgery. In particular, the initiation point for weight-bearing has not been standardized. In the present study, we investigated the prognostic difference between immediate and delayed weight-bearing on lateral malleolus fractures. The medical records of matched patients in the immediate and delayed weight-bearing groups (50 and 50, respectively) were reviewed retrospectively. All patients were treated with open reduction and internal fixation using an anatomical locking compression plate with a lag screw. In the immediate weight-bearing group (IWB), tolerable weight-bearing (i.e., what can be endured immediately after surgery with crutches) was permitted. In the delayed weight-bearing group (DWB), weight-bearing was completely restricted for 4 weeks after surgery. Ankle motion exercise was permitted in both groups, starting from the day after surgery. Radiographic assessment data and clinical outcomes were reviewed between the two groups. No significant differences in radiographic assessments and complications were found between the two groups. Significant differences in terms of a shortened length of hospital stay and time to return to work with the IWB rehabilitation protocol compared with DWB were confirmed (6.0 vs. 9.2 days, p = 0.02 and 6.1 vs. 8.3 weeks, p = 0.02, respectively). A significant difference in sport factor was observed in the Foot and Ankle Outcome Score at 3 months postoperatively (72.3 vs. 67.4, p = 0.02). We found no significant differences between the two groups concerning postoperative radiological outcomes and complications. The benefits of shortening the time to return to work and length of hospital stay associated with the IWB rehabilitation protocol were confirmed. In conclusion, immediate weight-bearing is recommended in patients with lateral malleolus fracture after anatomical reduction and firm fixation by surgery.

Radiographic parameters of the normal ankle syndesmosis: Comparison between hindfoot alignment view and anteroposterior view.

OBJECTIVE: To compare the parameters associated with the normal ankle syndesmosis between the hindfoot alignment view (HAV) and anteroposterior (AP) view and determine which view is more accurate for comparing the left and right ankles. METHODS: This study involved 61 subjects without syndesmosis injury who had radiographs of both ankles. The tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS) were measured in each view. Intraclass correlation coefficients were used to assess the agreement between the two ankles. Difference ratios for the measured parameters between the ankles were also compared. RESULTS: The agreement for TFCS showed wide disparity between the two ankles (AP view, 0.576; HAV, 0.858). The highest degree of agreement was seen for TFO (AP view, 0.733; HAV, 0.926). The agreement for MCS was low in both groups. The mean difference ratio for TFCS was also lower in the HAV group (9.9%) than in the AP view group (16.4%); a similar result was observed for TFO (16.4% vs. 25.8%). CONCLUSIONS: For evaluation of the syndesmosis, use of the HAV showed increased accuracy and few measurement errors when comparing the left and right ankles relative to use of the AP view.

Does repair of deltoid ligament contribute to restoring a mortise in SER type IV ankle fracture with syndesmotic diastasis?

PURPOSE: To analyze the radiographic and clinical outcomes of deltoid ligament repair, we studied 34 supination external rotation type IV ankle fracture patients with deltoid ruptures who required syndesmosis fixation. METHODS: We retrospectively evaluated 34 cases of ruptured deltoid ligaments with associated supination external rotation type IV ankle fractures with a widening of the syndesmosis between 2011 and 2017. All of the ankle fractures were treated with a similar surgical protocol (plate and screw fixation). Syndesmotic fixations were performed on all patients. The deltoid ligaments were surgically repaired in 19 patients and in 15 patients, they were not. The preoperative, immediate postoperative, and final follow-up radiographic outcomes (medial clear space, overlap space, and clear space) and clinical scores (Foot and Ankle Outcome Scores and the Foot Function Index) were compared. Patients were followed for an average of 13.6 months. RESULTS: There was no significant difference in radiographic and clinical outcomes between the deltoid repair group and the unrepair group (P > 0.05). In both groups, the mean immediate postoperative radiographic outcomes were satisfactory, showing reduced MCS, reduced CS, and increased OS to within-normal ranges that were maintained at the final follow-up. Clinical outcomes were similar between the two groups (P > 0.05). The rate of complications, such as intra-articular lesions, malunions, nonunions, and arthrosis was comparable between the two groups. CONCLUSION: In both groups, the postoperative and final follow-up radiographic measures were within normal ranges and the radiographic and clinical outcomes were not significantly different between the two groups. Syndesmotic reduction could be much more important than deltoid repair in regard to mortise restoration and medial stability.

Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation.

INTRODUCTION: This study aimed to analyze the clinical and radiological outcomes of early weight-bearing and rehabilitation after open reduction and internal fixation (OR/IF) of calcaneal fracture. MATERIALS AND METHODS: This retrospective study was conducted on 78 patients with unilateral calcaneal fracture who underwent OR/IF. A mean follow-up period was 45.8 months (range 12-135). Two weeks after surgery, the range of motion (ROM) exercise was started, brace or heel off shoe was applied, and forefoot weight-bearing was allowed. Four weeks after surgery, tolerable weight-bearing ambulation without crutch was allowed. When the patient was not walking, the braces were removed to perform peritalar ROM exercises. Radiologic evaluation was performed by measuring the Böhler angle and incongruency of the subtalar joint surface. Paley grade was used to assess traumatic arthritis. Clinical evaluation was performed by measuring the foot and ankle outcome score (FAOS) and ankle ROM. RESULTS: The mean postoperative Böhler angle was 31.7° (P < 0.001) at 2 weeks, 31.2° at 3 months, and 30.1° at the last (P = 0.4). The average Paley grade of the subtalar OA was 1.12. CT imaging revealed that the average step-off of the subtalar joint was 1.26 mm in coronal and 0.84 mm in sagittal. The average ROM results were as follows (contralateral, affected side): there was no significant difference in dorsiflexion [16.9° vs. 16° (P = 0.6)], whereas plantarflexion and inversion were significantly decreased [39.5° vs. 35.3° (P = 0.049) and 50.5° vs. 34.8° (P = 0.04)]. The average FAOS score was 86.1 points, and the highest score was "function" (mean 92.5 points). CONCLUSIONS: Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture.

Osteochondral lesion of talus with gout tophi deposition: A case report.

BACKGROUND: Osteochondral lesion of talus is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. It arises from diverse causes, and although trauma is implicated in many cases, it does not account for the etiology of every lesion. Gout is a chronic arthritic disease caused by excess levels of uric acid in blood. Intraosseous deposition of monosodium urate in the clavicle, femur, patella and calcaneus was reported previously. Gout is common disease but rare at a young age, especially during teenage years. Osteochondral lesion caused by intra-articular gouty invasion is very rare. CASE SUMMARY: We encountered a rare case of a 16-year-old male who has osteochondral lesion of the talus (OLT) with gout. He had fluctuating pain for more than 2 years. We could see intra-articular tophi with magnetic resonance image (MRI) and arthroscopy. We performed arthroscopic exploration, debridement and microfracture. Symptoms were resolved after operation, and bony coverage at the lesion was seen on postoperative images. We had checked image and uric acid levels for 18 mo. CONCLUSION: It is rare to see OLT with gouty tophi in young adults. While it is challenging, the accuracy of diagnosis can be improved through history taking, MRI and arthroscopy.

Comparison between an electronic version of the foot and ankle outcome score and the standard paper version: A randomized multicenter study.

To prove the equivalence of the Korean version of the Foot and Ankle Outcome Score (FAOS) in the printed (PFAOS) vs the electronic (EFAOS) form in a multicenter randomized study.Overall, 227 patients with ages ranging from 20 to 79 years from 16 dedicated foot and ankle centers were included. Patients were randomized into either a 'paper first' group (P-F group, n = 113) or an 'electronic device (tablet computer) first' group (E-F group, n = 114). The first evaluation either by paper (P-F group) or tablet (E-F group) was followed by a second evaluation the following day. The difference between the PFAOS and EFAOS results in each group was calculated and analyzed. To evaluate the benefit of each methodology, the time consumed per evaluation was compared and patients were asked which methodology they preferred and which was the easiest to use.There were no significant differences in age or sex between the groups. An intraclass correlation coefficient (ICC) value of 0.934 (95% confidence interval [CI]: 0.912-0.950, P < .001) was confirmed in PFAOS and EFAOS, showing a significant correlation between the 2 methodologies. EFAOS was completed in a shorter amount of time than PFAOS. The majority of patients agreed that EFAOS was easier to complete than PFAOS.The paper or electronic forms of the Korean adaptation of FAOS were considered equivalent. The shorter time of completion and the preference for the electronic version over paper by patients deems the electronic FAOS a promising option to consider in future.

Impact of two- and three-dimensional computed tomography use on intraobserver and interobserver reliabilities of pilon fracture classification and treatment recommendation.

BACKGROUND: Two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) have been increasingly used in various intra-articular fractures including pilon fracture. However, no study has investigated intraobserver and interobserver reliabilities of pilon fracture classification using 3D CT images. HYPOTHESIS: (1) Intraobserver and interobserver agreements of fracture classifications and treatment recommendations will improve by using 2D CT images compared to using plain radiographs only; (2) agreements will improve by adding 3D CT images compared to adding 2D CT images; and (3) agreements of orthopedic residents rather than specialists will be influenced more by imaging modality. MATERIALS AND METHODS: Ten orthopedic specialists and 10 residents completed a survey to classify the fractures according to the Rüedi-Allgöwer and AO/OTA classifications and to select treatment options using 25 pilon fracture images. The survey was conducted using plain radiographs, with 2D and 3D CT images introduced 3 and 6weeks later, respectively. Kappa coefficients were calculated to determine reliabilities. RESULTS: Intraobserver reliabilities for fracture classifications in specialists significantly improved by using 2D images compared to using plain radiographs only. Addition of 3D CT did not significantly improve intraobserver reliabilities compared to those with 2D CT. Use of 2D CT images significantly improved overall interobserver agreement of both classifications, with the improvement being greater for residents. Use of 3D CT images did not improve the interobserver reliability of both classifications. Overall interobserver reliabilities for treatment recommendations did not significantly differ according to the imaging modality. However, interobserver agreement among residents significantly improved from slight agreement using radiographs only to fair agreement using 2D CT images. DISCUSSION: Intraobserver and interobserver reliabilities of pilon fracture classification and treatment recommendations did not improve between using 3D and 2D CT. Using 2D CT images improved the intraobserver and interobserver reliabilities of the fracture classifications in specialists and the interobserver reliabilities of the fracture classifications and the treatment recommendations in residents. LEVEL OF EVIDENCE: IV, case control study.

Estimated radiation dose according to the craniocaudal angle in cerebral digital subtraction angiography: Patient and phantom study.

BACKGROUND AND PURPOSE: Routine use of cranial angulation with 15-20 degrees, craniocaudal angled (CC) view, for cerebral digital subtraction angiography (DSA) helps minimize bone subtraction artifacts with less overlapping of the vessels, however, it may increase the radiation dose. We designed the phantom and patient studies to determine the effect of the angulation to the radiation dose and the feasibility of true posteroanterior angled (PA) view, in cerebral DSA. MATERIALS AND METHODS: In the phantom study, frontal DSA was simulated with variable angulations. In the patient study with thirty-one subjects, one internal carotid arteriogram was obtained with the CC view and the other, PA view in every patient. The dose-area product (DAP) and reference air-kerma (AK) were measured and compared between the angles. A qualitative analysis was performed to assess the diagnostic performance of the DSA over the angles. RESULTS: The phantom study confirmed that the greater craniocaudal angles caused higher radiation exposure. Especially, the radiation dose (AK) of the CC view was 5.4% higher than that of the PA view. In the patient study, the radiation dose of the PA view was significantly lower compared to the CC view (1.44 vs. 1.63 mGy, AK). In 4 patients, the dose particularly jumped when applying the CC view as the copper filter was automatically removed. The diagnostic ability of the DSA with the PA view tended to be higher without significance. CONCLUSIONS: In a daily routine cerebral angiography, a simple modification of the angle may help to minimize the radiation dose.

Can Preoperative 3D Printing Change Surgeon's Operative Plan for Distal Tibia Fracture?

This study aimed to determine if 3D printing can affect surgeon's selection of plate for distal tibia fracture surgery and to find out whether orthopedic surgeons consider this technology necessary and would use it in their practice. A total of 102 orthopedic surgeons were asked to choose anatomically contoured locking plates among 5 most commonly used types for one simple and one complex distal tibia fracture based on X-ray and CT images. Next, they were provided real-size 3D printed models of the same fractures, allowed to apply each of the 5 plates to these models, and asked if they would change their choice of plate. A 10-point numeric rating scale was provided to measure the extent of the help that 3D printing provided on preoperative planning. Finally, we asked the surgeons if they would use 3D printing in their practice. Seventy-four percent of inexperienced surgeons changed their selection of plate after using 3D printed models for the complex fracture. In contrast, only 9% of experienced surgeons changed their selection of plate for the simple fracture. Surgeons rated the extent of usefulness of the 3D models in preoperative planning as a mean of 4.84 ± 2.54 points for the simple fracture and 6.63 ± 2.54 points for the complex fracture. The difference was significant (p < 0.001). Eighty-six percent of inexperienced surgeons wanted to use 3D models for complex fractures. However, only 18% of experienced surgeons wanted to use 3D printed models for simple fractures. The use of a real-size 3D-printed model often changed surgeon's preoperative selection of locking plates, especially when inexperienced surgeons evaluated a complex fracture. However, experienced surgeons did not find 3D models very useful when assessing simple fractures. Future applications of 3D models should focus on training beginners in fracture surgery, especially when complex fractures are concerned.

Correction to: Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus.

The original publication of this article [1] contained the wrong versions of tables 1, 2 and 3. In this correction the updated tables are published. The original publication has been updated.

Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus.

BACKGROUND: Calcaneal insufficiency avulsion (CIA) fractures often present with neuropathic etiology, such as Charcot neuroarthropathy (CN). Under the same surgical procedures, the outcomes of CIA fractures are less desirable, compared to the outcomes of the traumatic calcaneal avulsion fractures. Here, the study suggests Achilles tenodesis technique using suture anchor after resection of the CIA fracture fragments could provide satisfactory clinical results in the cases of surgically indicated CIA fractures. MATERIALS AND METHODS: This retrospective study included seven patients of calcaneal avulsion fracture who had underlying diabetes mellitus (DM) and no specific traumatic event. The patients were treated with Achilles tenodesis techniques for their CIA fractures. Achilles tenodesis was performed using suture anchor with removal of the fracture fragments. The patients were evaluated with the Foot and Ankle Outcome Score (FAOS), visual analogue scale (VAS), single-heel rise test, and X-ray images on their final follow-ups. RESULTS: Initially, three of the CIA fracture cases treated with traditional open reduction and internal fixation reported pullout failure. Consequently, all patients received Achilles tenodesis using suture anchor after bone fragment resection and had good clinical outcomes. Only one subject with low compliance reported poor outcome. The FAOS of each patient were obtained at a mean of 16.3 months after surgery. The results are as follows: pain 80.6 (SD = 6.2), symptom 83.8 (SD = 4.9), activities of daily living 80.5 (SD = 8.0), sport and recreation function 75.6 (SD = 11.93), and foot- and ankle-related quality of life 77.9 (SD = 6.7). On their final follow-ups, the average VAS was 2.6 (range, 1 to 4). CONCLUSION: Achilles tenodesis using suture anchor after bone fragment resection achieved competent clinical results in the patients with CIA fractures. The study proposes that this surgical procedure could be an appropriate treatment option for patients with CIA fractures. TRIAL REGISTRATION: The study was approved by the institutional review board (IRB) of our medical center (IRB File No. 2016-07-043), retrospectively registered.