Loosening of the anterolateral capsule affects the stability after arthroscopic lateral ankle ligament repair of chronic ankle instability.

PURPOSE: Arthroscopic anterior talofibular ligament (ATFL) repair for chronic lateral ankle instability (CLAI) has been widely performed. The recurrence of the instability after the surgery sometimes occurs, which may cause the development of osteoarthritis. Therefore, it is important to elucidate the factors of the recurrence. This study aimed to evaluate the loosening of the capsule in the MRI and whether it affected clinical outcomes or not in arthroscopic ATFL repair. MATERIALS AND METHODS: Thirty-eight ankles in 35 patients with CLAI treated by arthroscopic lateral ligament repair were included. The capsule protrusion area defined as the area that protruded ATFL laterally from the line connecting the fibula and talus attachment on MRI was measured. Capsule protrusion area in ankles with or without CLAI was compared and the relationships between it and clinical outcomes were assessed. RESULTS: The capsule protrusion area in the CLAI group (74.2 ± 36.4 mm2) was significantly larger than that in the control (25.5 ± 14.3 mm2) (p < 0.01). The capsule protrusion area in the poor remnant group (93.8 ± 36.4 mm2) was significantly larger than that in the excellent (53.2 ± 40.3 mm2) (p < 0.05). The capsule protrusion area in the patients with recurrent instability (99.8 ± 35.2 mm2) was significantly larger than that without recurrent instability (62.4 ± 30.9 mm2) (p < 0.01). Clinical scores in the recurrent group were significantly lower than those in the non-recurrent group (p < 0.05). CONCLUSIONS: Capsule loosening would be one of the causes of the recurrence of instability after arthroscopic lateral ankle ligament repair. Evaluation of the capsule protrusion area on MRI is helpful to choose appropriate surgical procedures for CLAI patients.

Risk Factors for the Recurrence of Instability After Lateral Ankle Ligament Repair.

BACKGROUND: Arthroscopic anterior talofibular ligament (ATFL) repair is widely performed for chronic lateral ankle instability (CLAI). Although many studies have reported excellent outcomes with this procedure, the recurrence of instability remains a common concern. Therefore, this study aimed to analyze the risk factors for the recurrence of instability after arthroscopic repair for CLAI. METHODS: Fifty-six ankles of 53 patients with a mean age of 31.8 ± 14.7 years were retrospectively reviewed. All patients underwent arthroscopic ATFL repair. If instability remained immediately after ATFL repair, calcaneofibular ligament (CFL) repair was performed. The Ankle Activity Score (AAS) was assessed preoperatively, and clinical outcomes including the Japanese Society for Surgery of the Foot scale, Karlsson-Peterson scores, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were evaluated preoperatively and at the final follow-up. Talar tilt angle (TTA) was assessed preoperatively and 1 year postoperatively. Ankles were divided into 2 groups-nonrecurrence (postoperative TTA, <6 degrees) and recurrence (postoperative TTA, ≥6 degrees)-and clinical outcomes were compared. RESULTS: Sixteen ankles showed recurrent instability, whereas 40 did not. AAS, TTA, and social functioning in the SAFE-Q were significantly higher in the recurrence group than those in the nonrecurrence group preoperatively. In addition, the rate of poor ATFL remnant quality and the number of CFLs not repaired despite the preoperative injury diagnosis were significantly higher in the recurrence group than in the nonrecurrence group. CONCLUSION: Arthroscopic repair for ATFL and CFL deficiencies with preoperative high activity, poor remnant quality, and neglected CFL injury can result in the recurrence of instability. Appropriate surgical procedures to prevent the recurrence of instability should be selected for these ankles. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Pure ligamentous ankle dislocation: A case report.

INTRODUCTION AND IMPORTANCE: Pure ankle dislocation is a rare injury, and this injury is an orthopedic emergency requiring immediate reduction. In more common circumstances, this injury is usually associated with malleolar fractures. The standardized treatment protocol is still deficient. CASE PRESENTATION: We report a case of a 33-year-old woman who presented with an open ankle dislocation without concomitant malleolar fractures. Early extensive wound debridement, immediate reduction, and immobilization of the ankle joint using an external fixator were performed during the first surgery. During the second surgery, which was performed 3 weeks later, the medial and lateral ankle ligaments were repaired, and a suture tape internal brace was added. A good functional outcome with the American Foot and Ankle Society score of 87 was achieved at 1-year follow-up. DISCUSSION: In an open dislocation with massive ligamentous injury, staged surgery could be performed to prevent deep infection, with extensive debridement and immobilization using an external fixator in the first stage and ligament repair in the second stage. An internal brace using a suture tape is an option for ligament repair if the remnant is not sufficient to be repaired, as in this case. Early range of motion exercises should be initiated after second-stage surgery to prevent stiffness. CONCLUSION: Staged surgery using an external fixator and ligament repair using a suture tape and internal brace augmentation can be an effective option for a pure ligamentous ankle dislocation with an open wound and a poor remnant of ankle ligaments.

Primary dynamic interlocking nail in femoral shaft fracture: A case series.

INTRODUCTION AND IMPORTANCE: Femoral shaft fracture is one of the most frequent injuries encountered by an orthopedic surgeon. Surgical treatment is commonly needed. Intramedullary nailing remains the gold-standard in surgical treatment of femoral shaft fracture. One of the constant dilemmas in intramedullary nailing is whether to use a static or dynamic locking screw for treating femoral shaft fractures. CASE PRESENTATION: We reported three cases of simple femoral shaft fracture and surgically fixed with primary dynamic interlocking nail. Closed reduction with reamed nail was performed in 2 cases, and mini open reduction with un-reamed nail was performed to the other one. Early weight bearing was instructed at day 1 post-operative. Mean follow-up period was 12.6 months. A solid bony union was achieved by all patients, and no complications were observed at the final follow up. CLINICAL DISCUSSION: Intramedullary nailing can be made static or dynamic. It is thought that in static mode of the intramedullary nailing, the axial weight is transferred through the locking screws rather than the fracture site, thus altering the callus formation and delaying fracture healing. A prompt dynamization of the fragments allows the contact of both fragments during mobilization and promotes early callus formation. CONCLUSION: Primary dynamic interlocking nail is an effective option for surgical treatment in simple or short oblique femoral shaft fracture.

The Effect of Injection of Secretome of Umbilical Cord Mesenchymal Stem Cells in Articular Cartilage Repair in Sheep Model.

INTRODUCTION: Articular cartilage is an avascular, aneural, and lymphatic tissue with limited capacity to regenerate. Numerous techniques have been employed to repair or regenerate; however, the success rate varies. In fact, most of them result in the formation of fibrocartilage, not hyaline cartilage. The future of treating cartilage defects lies in providing biological solutions through cartilage regeneration. Mesenchymal stem cells (MSCs) represent a promising therapy for cartilage regeneration. These cells secrete factors that enhance cartilage repair. This study studied the effects of intra-articular injection of human umbilical cord MSC (hUC-MSC) secretome on cartilage damage in a sheep model. METHODS: Standardized rectangular (5x5 mm) full-thickness chondral defects were created in the lateral femoral condyle of 15 adult sheep and debrided down to the subchondral bone plate. Three treatment groups were tested: 4 microfracture perforations using 1.0mm diameter awls (group 1), intra-articular injection of hUC-MSC secretome (group 2), and a combination of microfracture and intra-articular injection of hUC-MSC secretome (group 3). The osteochondral repair was assessed at 6 months using an established macroscopic and histological analyses. RESULTS: Macroscopically, combined therapy application shows significant cartilage repair improvement compared to microfracture alone (p=0.004). Microscopically, the application of combined therapy shows significant improvement of cartilage repair compared to secretome injection alone (p=0.031). CONCLUSION: Microfracture combined with injection of hUCB-MSCs secretome could be an effective alternative for repairing articular cartilage defects in vivo.

Osteoarticular tuberculous infection of the first tarsometatarsal joint - a case report.

INTRODUCTION: The prevalence of osteoarticular tuberculosis is increasing. Tuberculous infection in midfoot is rare. Establishing the diagnosis is difficult, leading to delay in management and leave many complications. CASE PRESENTATION: An 18-year-old man presents to our clinic with pain on his foot for the last 1 year. No other remarkable signs and symptoms. X-ray of his foot shown destruction of the 1st tarsometatarsal joint, later confirmed with MRI that shown synovitis and bone edema. Mantoux test and biopsy were done and established the diagnosis of tuberculous infection. CLINICAL DISCUSSION: Intensive phase of anti-tuberculosis chemotherapy was given for 2 months, followed by continuation phase for 7 months. Surgical management of debridement and arthrodesis were performed as adjunctive treatment. At 10 months follow-up patient was pain free, fully weight-bearing and no signs of further destruction. CONCLUSION: Osteoarticular tuberculosis is difficult to diagnose, a high index of suspicion is required to avoid delay treatment and complications. Anti-TB chemotherapy is still the treatment of choice, with surgical management is reserved for advance case.

A posterior-only approach for treatment of severe adolescent idiopathic scoliosis with pedicle screw fixation: A case series.

INTRODUCTION: Adolescent idiopathic scoliosis (AIS) can lead to severe deformity. However, early detection and treatment can prevent its progression. Surgical instrumentation for scoliosis treatment has evolved from Harrington instrumentation to pedicle screws. However, there are still some concerns about the efficacy and long-term effects of pedicle screw fixation, and the clinical and radiographic outcomes of surgical treatment for severe AIS (>90°) by posterior spinal fusion alone need to be established. PRESENTATION OF CASE: Eight patients with severe and rigid idiopathic scoliosis were recruited for this study. All surgeries were performed by one senior spine surgeon between 2015 and 2018. Free hand technique, intraoperative neurophysiologic monitoring (IONM), and intraoperative fluoroscopy to assess the screw position was performed. DISCUSSION: Severe scoliosis results in a complex three-dimensional spinal deformity that often requires correction in multiple planes. Mean major coronal correction rate was 67% (45-80%). No major complications occurred during the perioperative period and after one year follow up. CONCLUSION: Pedicle screws provide three-dimensional deformity correction. There were no complications other than the low-grade late implant-associated infections. Posterior spinal fusion with pedicle screw-only instrumentation obtains a good and stable correction for severe scoliosis.

Intramuscular haemangioma of abductor hallucis muscle - A rare case report.

INTRODUCTION: Haemangioma is a slow growing benign soft tissue tumor and its presentation in the foot is rare. Intramuscular haemangioma (IH) are usually found before 30 years of age, with gender predominance is still inconclusive. PRESENTATION OF CASE: An 18-year-old woman came with pain and mass in the left foot for the past 3 years. Magnetic Resonance Imaging (MRI) of the left foot shown a heterogenous multilobulated mass, with previously thought originated from flexor digitorum brevis (FDB) muscle. Wide excision was performed and intraoperative findings showed that the mass actually originated from abductor hallucis muscle. Post-operative histopathological findings confirmed the diagnosis of cavernous-type of intramuscular haemangioma. DISCUSSION: The rare occurrence of intramuscular haemangioma of the foot can cause a delayed diagnosis and treatment to the patient. The differential diagnosis include lipoma, fibroma, enlargement of the lymph nodes, compartment syndrome, hematoma, hernia, and soft-tissue sarcoma. Anytime a soft tissue mass is identified in the skeletal muscle of a young adult, haemangioma should be considered. CONCLUSION: Literature research identified very few cases of intramuscular haemangioma of the foot. Wide excision of the muscle is a feasible surgical treatment option.

Diagnosis and treatment of Langerhans Cell Histiocytosis with bone lesion in pediatric patient: A case report.

BACKGROUND: Langerhans cell histiocytosis (LCH) is a rare group of disorders without a well understood etiology. Known formerly as histiocytosis X, the disease has a wide spectrum of clinical presentations, including eosinophilic granuloma (solitary bone lesion), diabetes insipidus, and exophthalmos. Many of these patients initially present to orthopaedic surgeons, and misdiagnosis is frequent. METHODS: We deliver a case of a 10-month-old boy who consulted to our department. Previously misdiagnosed as a Kawasaki syndrome, TORCH, and osteomyelitis. He had undergone several examinations and had been discussed in clinocipathological conference (CPC) to narrow down the diagnosis. RESULT: After serial examinations, the diagnosis of Langerhans Cell Histiocytosis was confirmed and chemotherapy was initiated. And after 6 cycles of chemotherapy, with 1-week interval of each therapy, the clinical appearance of this patient significantly improved. CONCLUSION: Despite major advances in our understanding and management of LCH, it remains one of the most challenging diagnoses for the orthopedic surgeon. By doing a comprehensive examination, it is possible to narrowing down the diagnosis and planning the accurate treatment.