Joint-Preserving Surgery for Hallux Valgus Deformity in Rheumatoid Arthritis.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that frequently causes forefoot deformities. Arthrodesis of the first metatarsophalangeal joint is a common surgery for severe hallux valgus. However, joint-preserving surgery can maintain the mobility of the joint. This study aimed to investigate the clinical and radiographic outcomes of distal chevron metatarsal osteotomy (DCMO) for correcting hallux valgus deformity associated with RA. Methods: Between August 2000 and December 2018, 18 consecutive patients with rheumatoid forefoot deformities (24 feet) underwent DCMO for hallux valgus with/without lesser toe surgery. Radiological evaluations were conducted, assessing the hallux valgus angle, the intermetatarsal angle between the first and second metatarsals, and the Sharp/van der Heijde score for erosion and joint space narrowing. Clinical outcomes were quantified using a visual analog scale for pain and the American Orthopaedic Foot and Ankle Society forefoot scores to measure function and alignment. Results: The mean hallux valgus angle decreased from 38.0° (range, 25°-65°) preoperatively to 3.5° (range, 0°-17°) at the final follow-up (p < 0.05). The mean intermetatarsal angle decreased from 14.9° (range, 5°-22°) preoperatively to 4.3° (range, 2°-11°) at the final follow-up. (p < 0.05). Regarding the Sharp/van der Heijde score, the mean erosion score (0-10) showed no significant change, decreasing from 3.83 (range, 0-6) preoperatively to 3.54 (range, 0-4) at the final follow-up (p = 0.12). Recurrent hallux valgus was observed in 1 patient and postoperative hallux varus deformity was observed in 2 feet. Spontaneous fusion of the metatarsophalangeal joint developed in 1 case. Conclusions: DCMO resulted in satisfactory clinical and radiographic outcomes for correcting RA-associated hallux valgus deformity.

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.

Factors influencing successful bone union of isolated subtalar arthrodesis for posttraumatic subtalar arthritis: a multicenter case series.

BACKGROUND: The purpose of this study was to find the factors influencing successful bone union for isolated subtalar arthrodesis in posttraumatic subtalar arthritis following calcaneal fracture. MATERIAL AND METHODS: We retrospectively analyzed the rate of successful bone union of 119 cases of isolated subtalar arthrodesis for posttraumatic subtalar arthritis performed at five university hospitals between January 2010 and December 2019. Multivariate logistic regression analysis was used to find the factors associated with successful bone union. Successful bone union was defined as resolution of hindfoot pain with the presence of osseous trabecular bridging involving more than 50% of the posterior facet within 6 months postoperatively. RESULTS: There were 77 (64.7%) cases of successful bone union, 11 (9.2%) cases of delayed union, 8 (6.7%) cases of questionable union, and 23 (19.3%) cases of nonunion. Use of fully threaded screws was 5.90 times [odds ratio (OR) = 5.90, 95% confidence interval (CI) = 1.42-24.49, p = 0.02] more likely to achieve successful bone union compared to the use of partially threaded screws. Use of two parallel screws or the two divergent screws were 3.71 times (OR = 3.71, 95% CI = 1.05-13.14, p = 0.04) and 4.65 times (OR = 4.65, 95% CI = 1.23-17.53, p = 0.02) more likely to achieve successful bone union compared to the use of a single screw. Use of cancellous autograft or structural autograft was 4.72 times (OR = 4.72, 95% CI = 1.17-19.06, p = 0.03) and 7.12 times (OR = 7.12, 95% CI = 1.46-34.68, p = 0.02) more likely to achieve successful bone union compared to no graft use. CONCLUSION: Use of fully threaded screws, autograft, and two screws compared to a single screw were the factors associated with successful bone union within six postoperative months after subtalar arthrodesis for the posttraumatic arthritis.

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.

Automated diagnosis of flatfoot using cascaded convolutional neural network for angle measurements in weight-bearing lateral radiographs.

OBJECTIVES: Diagnosis of flatfoot using a radiograph is subject to intra- and inter-observer variabilities. Here, we developed a cascade convolutional neural network (CNN)-based deep learning model (DLM) for an automated angle measurement for flatfoot diagnosis using landmark detection. METHODS: We used 1200 weight-bearing lateral foot radiographs from young adult Korean males for the model development. An experienced orthopedic surgeon identified 22 radiographic landmarks and measured three angles for flatfoot diagnosis that served as the ground truth (GT). Another orthopedic surgeon (OS) and a general physician (GP) independently identified the landmarks of the test dataset and measured the angles using the same method. External validation was performed using 100 and 17 radiographs acquired from a tertiary referral center and a public database, respectively. RESULTS: The DLM showed smaller absolute average errors from the GT for the three angle measurements for flatfoot diagnosis compared with both human observers. Under the guidance of the DLM, the average errors of observers OS and GP decreased from 2.35° ± 3.01° to 1.55° ± 2.09° and from 1.99° ± 2.76° to 1.56° ± 2.19°, respectively (both p < 0.001). The total measurement time decreased from 195 to 135 min in observer OS and from 205 to 155 min in observer GP. The absolute average errors of the DLM in the external validation sets were similar or superior to those of human observers in the original test dataset. CONCLUSIONS: Our CNN model had significantly better accuracy and reliability than human observers in diagnosing flatfoot, and notably improved the accuracy and reliability of human observers. KEY POINTS: • Development of deep learning model (DLM) that allows automated angle measurements for landmark detection based on 1200 weight-bearing lateral radiographs for diagnosing flatfoot. • Our DLM showed smaller absolute average errors for flatfoot diagnosis compared with two human observers. • Under the guidance of the model, the average errors of two human observers decreased and total measurement time also decreased from 195 to 135 min and from 205 to 155 min.

Long Hallucal Tendon Force Vectors and First Metatarsophalangeal Deformity After Hallux Valgus Surgery.

BACKGROUND: Recurrence is one of the most common complications following hallux valgus surgery. Moreover, hallux varus occurs in cases of overcorrection. We aimed to quantitatively measure, using radiographic examination, the dynamics of the soft tissues that act on deformities (recurrence of valgus and occurrence of varus) after the surgery. METHODS: This retrospective single-institution study included 60 patients (98 feet) who underwent hallux valgus surgery between 2009 and 2018. According to radiographic findings of the foot under weightbearing conditions at postoperative month 1, we examined the tendons' pathway and calculated the forces on the first metatarsophalangeal joint, which we termed the deformity force angle (DFA). We compared whether there was a significant difference in DFAs between the groups in which deformities occurred and those in which deformities did not occur after correction. In addition, the DFA was compared to known radiographic measurements of hallux valgus recurrence (hallux valgus angle, distal metatarsal articular angle, intermetatarsal angle, and sesamoid position) to assess association with recurrence. RESULTS: We observed a significant difference in the DFA between patients with and without hallux valgus recurrence (P < .001) and between those with and without hallux varus (P < .001) based on standing radiographs taken at a minimum of 6 months postoperation. For predicting the deformities, the areas under the curve were 0.863 (hallux valgus recurrence) and 0.831 (hallux varus occurrence), respectively, which was greater than other factors evaluated. The DFA values greater than 9.5 degrees and less than 5.5 degrees were associated with the recurrence of valgus and occurrence of varus, respectively. CONCLUSION: In our study, DFA was associated with hallux valgus recurrence when it exceeded 9.5 degrees and hallux varus when it was less than 5.5 degrees. Moreover, in the hallux valgus surgery we performed, a DFA from 5.5 to 9.5 degrees appeared to be a "safe zone" for preventing early deformity after surgery. LEVEL OF EVIDENCE: Level III, prognostic.

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.

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.

Second-look arthroscopic and magnetic resonance analysis after internal fixation of osteochondral lesions of the talus.

The purpose of this study was to evaluate cartilage quality after internal fixation of osteochondral lesion of the talus (OLT) using second-look arthroscopies and MRIs. Thirty-four patients underwent internal fixation of OLTs involving large bone fragments. Twenty-one of these patients underwent second-look arthroscopies and 23 patients underwent MRIs postoperatively. The arthroscopic findings were assessed using the International Cartilage Repair Society (ICRS) grading system, and the MRI findings were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Five of the patients who underwent second-look arthroscopies showed normal cartilage, 12 showed nearly normal cartilage, 3 showed abnormal cartilage, and 1 showed severely abnormal cartilage, according to the overall ICRS repair grades. All the patients who achieved bone fragment union showed normal, or nearly normal cartilage upon second-look arthroscopy. The ICRS and MOCART scores were significantly higher for the patients with bone fragment union compared to those with nonunion (ICRS scores: 10.3 ± 1.5 vs. 6.0 ± 2.0, p < 0.001, MOCART score: 88.3 ± 10.0 vs. 39.0 ± 20.4, p < 0.001). Low signal intensities of the bone fragments on preoperative T1-weighted MRIs were not associated with nonunion (Fisher's exact test, p = 0.55), and the signal intensities increased postoperatively to levels similar to the underlying talus when bone union was achieved. Second-look arthroscopy and MRI showed normal, or nearly normal, cartilage after internal fixation of OLTs when bone union was achieved. The nonunion of bone fragments resulted in inferior cartilage quality.

Treatment of Recurrent Peroneal Tendon Dislocation by Peroneal Retinaculum Reattachment Without Fibular Groove Deepening.

There are numerous studies recommending fibular groove deepening in the surgical treatment of peroneal tendon dislocation; however, there are some disadvantages to fibular groove deepening procedures. In this study, we evaluated the results of anatomic reattachment of the peroneal retinaculum without fibular groove deepening as a treatment for traumatic peroneal tendon dislocation. Thirty-six patients with recurrent peroneal tendon dislocation, who underwent retinaculum repair without a fibular groove deepening procedure performed by 2 surgeons between March 2004 and March 2017, were enrolled in this study. Resubluxation of tendon, pain on inversion and eversion power of the ankle were monitored. The range of motion of inversion and eversion were measured and then compared to that of the contralateral side. American Orthopedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), Foot Function Index (FFI) scores were obtained for all patients preoperatively and at the final follow-up. Postoperative complications such as infection, sural nerve injury, and recurrence were monitored. Thirty-four patients fully recovered without resubluxation of tendon. Two patients were injured again while playing soccer 6 months after the surgery and fast running 20 months after the surgery respectively. One patient had sural nerve injury. But the symptom was relieved at 6 months after the surgery. None of the patients had weakness of evertor. None of the patients had limited ankle motion. Mean AOFAS, VAS, FFI score improved significantly (p = .02, .01, .02). In conclusion, for the treatment of recurrent dislocation of the peroneal tendon reattachment of the superior retinaculum only without groove deepening followed by proper rehabilitation is sufficient.

Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial.

BACKGROUND: Acute ankle fractures can occur during sports activities, and unstable ankle fractures are commonly treated operatively. However, controversy exists about the optimal time to allow weightbearing. HYPOTHESIS: Early weightbearing after the stable fixation of an ankle fracture is not inferior to nonweightbearing in terms of ankle function assessed at 12 months after injury. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 258 patients were assessed for eligibility. Of these patients, 194 were randomly allocated to either the early weightbearing group (95 patients who were allowed weightbearing at 2 weeks postoperatively) or the nonweightbearing group (99 patients who were not allowed weightbearing until 6 weeks postoperatively). The primary outcome measure was the mean difference in the Olerud-Molander ankle score (OMAS) between the groups, assessed at the 12-month follow-up examination. The secondary outcome measures were the time to return to preinjury activities and patients' subjective satisfaction. Complications such as hardware loosening or failure, fracture displacement, and nonunion were evaluated. RESULTS: The mean difference in the OMAS for the early weightbearing group compared with the nonweightbearing group was 1.6 (95% CI, -1.9 to 5.0) in the intention-to-treat analysis. The lower limit of the 95% CI (-1.9) exceeded the noninferiority margin of -8, indicating that early weightbearing was not inferior to nonweightbearing. The difference in the proportion of patients who were satisfied or very satisfied with their treatment was not statistically significant (84.3% vs 76.2%; P = .19); however, the time taken to return to preinjury activities was shorter with early weightbearing than with nonweightbearing (9.1 ± 3.0 vs 11.0 ± 3.0 weeks; P < .001). No cases of nonunion were observed in either group. CONCLUSION: Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. The patients' subjective satisfaction was similar between the groups, although the time taken to return to preinjury activities was shorter in the early weightbearing group. REGISTRATION: NCT02029170 (ClinicalTrials.gov identifier).

Distal chevron metatarsal osteotomy is a viable treatment option for hallux valgus with metatarsus adductus-multicentre retrospective study.

PURPOSE: The purpose of this study was to evaluate the radiographic and clinical outcomes of patients with hallux valgus (HV) with concomitant metatarsus adductus (MA) treated with distal chevron metatarsal osteotomy (DCMO), without any procedure for the second or third metatarsal. METHODS: A multicentre retrospective study involving four hospitals was conducted. A total of 45 feet from 38 patients who had received DCMO for HV with MA with at least one year post-operative follow-up were analysed. HV angle (HVâ), inter-metatarsal angle (IMâ), MA angle (MAâ), and the lateral sesamoid grade were measured. Foot function index (FFI) and visual analogue scale (VAS) were recorded. Patients were divided into mild (18° ≤ MAâ < 20°) and moderate (20° ≤ MAâ) MA groups, and results were compared. RESULTS: The mean HVâ and IMâ improved significantly from 35.1° and 14.4° pre-operatively to 10.6° and 7.1° one year post-operatively (p < 0.001). There were no differences in pre-operative HVâ, IMâ, or the sesamoid grade, and also no difference in post-operative HVâ or the sesamoid grade between mild and moderate MA groups. Only the mean post-operative IMâ showed a difference between the two groups (8.3° vs. 6.3°; p = 0.019). All clauses of FFI and VAS improved significantly (p < 0.001). When the extent of improvement was compared between the two groups, there were no significant differences in any category (p > 0.05). The total rate of recurrence (HVâ ≥ 20°) was 11.1% (5/45), and although the moderate group (4/29, 13.8%) had a higher proportion than the mild group (1/16, 6.3%), this was not statistically significant (p = 0.641). CONCLUSION: DCMO for patients with HV with MA had satisfactory radiographic and clinical outcomes with minimal recurrence. Except in cases of severe combined deformity, we recommend performing DCMO alone without any additional procedure or manipulation of the other metatarsals as a viable treatment option.

Outcomes of Simultaneous Bilateral vs Unilateral Distal Chevron Metatarsal Osteotomy in Hallux Valgus Patients Aged ≥60 Years.

BACKGROUND: The purpose of this study was to compare radiographic outcomes of simultaneous bilateral and unilateral distal chevron metatarsal osteotomy (DCMO) in hallux valgus patients aged ≥60 years. METHODS: This retrospective study analyzed consecutive outcomes of simultaneous bilateral DCMO and unilateral DCMO performed between June 2010 and August 2018 in 90 feet of 60 patients. Thirty patients underwent simultaneous bilateral DCMO, and 30 underwent unilateral DCMO. Comparative analysis of radiographic and clinical parameters between a simultaneous bilateral DCMO group (SB) and a unilateral DCMO group (U) was performed. RESULTS: Mean age at surgery (65.7±4.8 vs 65.2±5.2 years), mean length of follow-up period (20.0 vs 18.6 months), and preoperative radiographic parameters were similar between the 2 groups (SB vs U). Mean hallux valgus angle (HVA) improved from 34.2 to 5.4 degrees (correction angle SB 28.8 vs U 28.8 degrees). Mean first-to-second intermetatarsal angle improved from 15.8 to 6.8 degrees (correction angle SB 8.9 vs U 8.9 degrees). Hallux varus deformity was observed in 4 feet (SB 3 vs U 1), and mechanical instability with callus formation in 1 foot in the unilateral group. CONCLUSION: DCMOs in patients aged ≥60 years were radiographically effective and safe, even performed in one stage bilaterally. Radiographic parameters were similar in patients who underwent simultaneous bilateral and unilateral DCMO. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Hard-Soled Shoe Versus Short Leg Cast for a Fifth Metatarsal Base Avulsion Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial.

BACKGROUND: The purpose of this study was to determine whether tolerated weight-bearing in a hard-soled shoe was noninferior to the use of a short leg cast for the treatment of a fifth metatarsal base avulsion fracture, as assessed with use of a 100-mm visual analog scale (VAS) for pain at 6 months after the fracture. METHODS: A total of 145 patients were assessed for eligibility. Of these, 96 patients were randomly assigned to either the hard-soled shoe group (46 patients) or the cast group (50 patients). The primary outcome measure was the mean difference on the 100-mm VAS between groups at 6 months after the fracture. Secondary outcome measures included the time to return to preinjury activity and patient-reported satisfaction. Analysis was performed according to both an intention-to-treat basis (i.e., patients were included in the assessment of their assigned treatment arm, even if they crossed over to the other treatment arm prior to completing the 6-month follow-up) and a per-protocol basis (i.e., patients who completed the 6-month follow-up were analyzed according to the treatment they received). RESULTS: At 6 months after the fracture, the mean 100-mm VAS was 8.6 ± 7.0 mm in the hard-soled shoe group and 9.8 ± 7.3 mm in the cast group (p = 0.41) according to intention-to-treat analysis. The mean difference in 100-mm VAS between the 2 groups was -1.3 mm (95% confidence interval, -4.3 to 1.8 mm). The upper limit of the 95% confidence interval did not exceed the noninferiority margin of 10 mm, indicating that treatment with the hard-soled shoe was noninferior to treatment with the short leg cast. The proportion of patients who reported satisfaction with their treatment was similar between the hard-soled shoe and cast groups (89.5% compared with 87.5%, respectively; p = 0.79), but the time to return to preinjury activity was significantly shorter in the hard-soled shoe group (37.2 ± 14.4 days compared with 43.0 ± 11.1 days in the cast group; p = 0.04). There were no cases of nonunion in either group. CONCLUSIONS: Weight-bearing as tolerated in a hard-soled shoe for a fifth metatarsal base avulsion fracture was noninferior to the use of a short leg cast as assessed with use of a 100-mm VAS at 6 months after the fracture. Patient-reported satisfaction was similar between groups, but the time to return to preinjury activity was shorter in the hard-soled shoe group. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

Distal chevron osteotomy with lateral release for moderate to severe hallux valgus patients aged sixty years and over.

PURPOSE: To analyze the outcome of distal chevron metatarsal osteotomy (DCMO) with lateral release for moderate to severe hallux valgus patients aged 60 years or more. METHODS: Consecutive 77 DCMOs in 54 patients were evaluated. Average age at operation was 65.1 ± 4.3 (range 60~79) years; the mean follow-up period was 20.5 ± 14.2 (range 12~93) months. Hallux valgus angle (HVA), first to second inter-metatarsal angle (IMA), and lateral sesamoid grades were measured. Considering the weak bone quality of the patients, fixation failures such as pin migration, callus formation, delayed union, and first metatarsal bone shortening were reviewed. Osteoarthritis (OA) of the first metatarsophalangeal joint (MTPJ), limitation of 1st MTPJ motion (LOM), and transfer metatarsalgia were also reviewed. RESULTS: HVA, IMA, and sesamoid grades were improved at three months and final follow-up. The mean HVA was 36.9° ± 7.0° preoperatively and 6.8° ± 7.1° at final follow-up. The mean correction angle of HVA was 31.3° ± 8.5° at three months and 30.1° ± 8.9° at final follow-up. The mean IMA was 16.3° ± 3.0° pre-operatively and 7.7° ± 2.7° at final follow-up. Hallux varus deformity was observed in three feet. Instability of osteotomy site was observed in one foot. Mean metatarsal shortening length was 1.26 ± 2.1 mm at three month follow-up. There were no cases of transfer metatarsalgia after operation. OA was observed in four feet post-operatively. LOM was observed in ten feet (13.0%). There were no instances of re-fracture or avascular necrosis (AVN). CONCLUSION: Despite concerns about aggravation of OA and fixation failure, distal chevron osteotomy with lateral release was safe on patients aged 60 years and over.

Desmoplastic fibroblastoma mimicking tenosynovial giant cell tumor encasing a tendon of the foot.

Desmoplastic fibroblastoma is an uncommon, benign fibrous soft tissue tumor that usually occurs in the arms, shoulders, neck, hands, and feet in the fifth to seventh decades of life. In general, it is commonly located in the subcutaneous tissue and skeletal muscle. The authors report an unusual case of a desmoplastic fibroblastoma mimicking tenosynovial giant cell tumor encasing a tendon of the foot in a 72-year-old woman. Ultrasonography revealed an inhomogeneously hypoechoic lobulated soft tissue lesion completely wrapped around the extensor digitorum longus tendon. Color Doppler study revealed increased vascularity in the internal and peripheral portions of the lesion. Magnetic resonance imaging revealed a well-defined, lobulated soft tissue mass encasing the extensor digitorum longus tendon with predominantly isointense signal with some areas of hypointense signal on T1-weighted images, predominantly hyperintense signal with some areas of hypointense signal on T2-weighted images, and inhomogeneous enhancement on fat-suppressed contrast-enhanced T1-weighted images. Surgical excision was performed, and the mass was diagnosed on pathological examination as a desmoplastic fibroblastoma. There has been no previously published radiologic case of a desmoplastic fibroblastoma encasing a tendon of the foot in the literature.

A Case of Herpes Zoster Presented with Lower Limb Paresis.

Herpes zoster is a common viral disorder that typically shows characteristic painful skin lesion. Motor neuropathy rarely complicates herpes zoster infection, and it may be overlooked without suspicion. Here, we report a case of a herpes zoster patient who presented with sciatica and paresis, but without the typical skin lesion. The patient was initially misdiagnosed as having other disorders including trauma or spine lesion. Electrodiagnostic study and magnetic resonance imaging (MRI) helped to make an accurate diagnosis and localize the motor nerve involvement of herpes zoster.

Effect of metatarsal osteotomy and open lateral soft tissue procedure on sesamoid position: radiological assessment.

BACKGROUND: Incomplete sesamoid reduction is a potential risk factor for the recurrence of hallux valgus. The purpose of this study was to radiologically investigate changes in sesamoid position after chevron osteotomy and the open lateral soft tissue procedure. METHODS: Sixty-eight feet that underwent operative correction for hallux valgus deformity were reviewed consecutively. The hallux valgus angle (HVA), first to second intermetatarsal angle (IMA), tibial sesamoid position (TSP), distance of the fibular sesamoid (DFS), and translation of the metatarsal head (TMH) were evaluated preoperatively and at final follow-up. RESULTS: While most parameters were significantly decreased after surgery, no significant change in DFS (correction - 1.45 mm, p = 0.08) was noted. The difference between preoperative and postoperative TSP values (ΔTSP) has a moderately positive correlation with difference in TMH values (ΔTMH) (Rho 0.475, p = .000). Other parameters were similarly correlated. CONCLUSIONS: First, metatarsal bone realignment reduced the sesamoid, but its position, relative to the second metatarsal axis (DFS), was unchanged. The sesamoid is reduced by the lateral translation of the first metatarsal but not by medial sesamoid migration.