The Rotational Effect of Scarf Osteotomy With Transarticular Lateral Release on Hallux Valgus Correction.

The purpose of this study was to explore the rotational effect of scarf osteotomy with transarticular lateral release (TALR) on hallux valgus correction. From January 2016 to January 2018, 28 consecutive patients (30 feet) were included in this study. The first intermetatarsal angle (IMA), hallux valgus angle (HVA), and round-shaped lateral edge of the first metatarsal head (R sign), and sesamoid rotation angle (SRA) were recorded prior to and 3 months after the surgery. The rotation of the capital fragment of the first metatarsal was termed the capital rotation angle (CRA) and was measured intraoperatively after the completion of scarf osteotomy. The IMA, HVA, and SRA were significantly reduced from 13.9 ± 4.9°, 34.6 ± 7.4°, and 28.7 ± 9.8° to 2.4 ± 2.3°, 7.3 ± 4.7°, and 13.4 ± 8.8°, respectively (p < .01 for all). The mean CRA was 7.0 ± 3.4° and was not significantly correlated with the reduction of IMA and SRA (p > .05 for all); nor was it significantly correlated with IMA preoperatively and postoperatively (p > .05 for all) or the reduction of SRA and IMA (p > .05). The R sign was positive in 40% (12/30) of the feet preoperatively compared to 13.3% (4/30) postoperatively (p < .001). Scarf osteotomy produced a supination effect on the capital fragment of the first metatarsal and supinated the sesamoids via lateral translation of the first metatarsal head. These changes may contribute to the correction of the pronation component of hallux valgus deformity.

Anatomic structures at risk in anteroposterior screw fixation of posterior malleolar fractures: A cadaver study.

INTRODUCTION: Percutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the mean of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement. MATERIALS AND METHODS: Eleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry points were selected as medial to the anterior tibial tendon (ATT), lateral to the ATT, and lateral to the extensor digitorum longus (EDL). Three AP screws were placed under guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Distances were calculated and damage to structures was documented. RESULTS: Mean, minimum, and maximum distances from the medial screw to the greater saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12-25) mm, 2.0 (0-5) mm, 13.6 (9-20) mm, 16.6 (9-25) mm, and 20.1 (12-27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0-3) mm, 4.9 (3-9) mm, 3.8 (1-7) mm, 0.4 (0-2) mm, and 13.6 (10-18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0-16) mm, 1.2 (0-4) mm, 15.9 (11-25) mm, 19 (15-27) mm. The SPN was found partially cut by the lateral screw on 1 specimen. CONCLUSIONS: Lateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures. LEVEL OF EVIDENCE: IV.

Hypoxia-Induced MicroRNA-429 Promotes Differentiation of MC3T3-E1 Osteoblastic Cells by Mediating ZFPM2 Expression.

BACKGROUND/AIMS: Hypoxia has been reported to regulate osteoblastic differentiation of bone cells and cartilage development. However, information concerning the molecular mechanisms remains largely unknown. METHODS: The expression of miR-429 was evaluated by quantitative real-time PCR analysis. To test whether miR-429 directly regulate the expression level of ZFPM2 at transcription level, dual-luciferase reporter gene assay was performed. Western blotting was performed to detect osteogenesis related protein expression. The cell proliferation, apoptosis, alkaline phosphatase activity and matrix mineralization were performed to assess the functions of miR-429 in vitro and in vivo the effects of miR-429 on fracture healing. RESULTS: Expression of miR-429 was increased in MC3T3-E1 cells treated with 200 µM CoCl2 by qRT-PCR, and overexpression of miR-429 promoted cell differentiation, and enhanced alkaline phosphatase activity and matrix mineralization. Luciferase reporter assays suggested that miR-429 directly targets the 3'UTR of ZFPM2. In addition, knockdown of ZFPM2 could phenocopy the effects of miR-429 expression. Furthermore, overexpression of ZFPM2 in miR-429-expressing MC3T3-E1 cells suppressed cell differentiation. CONCLUSIONS: Our results provide valuable insight into the potential role of hypoxia in regulation of osteoblastic cell differentiation.

Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study.

BACKGROUND: Gastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion. METHODS: Ten fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion. RESULTS: Overall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively. CONCLUSION: Increased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.

Outcomes of Chronic Turf Toe Repair in Non-athlete Population: A Retrospective Study.

BACKGROUND: Turf toe injuries, though most common in athletes, can also occur in non-athletes. No study exists in the current literature investigating operative outcomes in non-athlete patients with chronic turf toe injury. In this study, we present our outcomes on operatively treated turf toe injuries in non-athletes in the only cohort yet studied. METHODS: Using ICD-10 codes, we assembled a cohort of 12 patients who underwent operative repair of chronic turf toe injury from January 2012 through January 2018 at the investigating institution. These 12 patients were evaluated to determine demographic information, method of injury, length of time from injury to surgery, clinical and radiologic characteristics of the injury, and operative outcomes including mean preoperative and postoperative VAS (Visual Analog Scale) scores, preoperative and postoperative FFI (Foot Function Index) scores, and postoperative complications. RESULTS: On initial clinical presentation, all 12 patients had local tenderness with associated painful range of motion. Four patients had restricted range of motion, all patients had a positive Lachman test, two had local edema, and eight had hallux valgus deformity. Mean VAS improved from 4.6 (range 2-9) to 1 (range 0-4). Mean FFI improved from 102.5 (range 56-177) to 61.75 (range 23-144). All patients had a negative Lachman test at final follow-up. No patients developed major complications or required revision surgery. CONCLUSIONS: Our study is the first to investigate operative outcomes following chronic turf toe injury in non-athlete patients. Based on our study, surgeons and patients can expect significant improvement in overall pain and function following surgery.

Is Fibular Sesamoidectomy a Viable Option for Sesamoiditis? A Retrospective Study.

Background Pathologic conditions of the sesamoids can be a source of disabling pain for patients, particularly during toe-off. Some underlying causes include osteonecrosis, inflammation, arthritis, and fracture. Nonoperative treatment is the initial standard of care, and has demonstrated satisfactory outcomes overall; however, operative management may be indicated in cases of pain refractory to conservative management. Sesamoidectomy is an uncommon procedure with risk of potential complications, but may be warranted in select cases of failed nonoperative treatment. Methods A retrospective chart review was conducted at one institution from 2009 to 2018. Twelve patients diagnosed with fibular sesamoiditis were treated with sesamoidectomy. Baseline patient demographics as well as postoperative outcomes were recorded. Results All 12 patients underwent fibular sesamoidectomy using the plantar approach following which their symptom (pain) resolved. Average follow-up for this cohort was 35 months. Of the sample, two patients experienced transient neuritis, one patient developed a superficial infection, and one had painful postoperative scarring. Hallux varus deformity was not observed in any patients. Conclusion Fibular sesamoidectomy may be a safe, viable procedure for patients with sesamoiditis who fail conservative measures.

Tibialis anterior tendinosis: Clinical characterization and surgical treatment.

BACKGROUND: Tibialis anterior (TA) tendinosis is rarely reported on in the literature. It is seen in patients older than 45 and causes weakness in dorsiflexion. This paper aims to describe surgical treatment and clinical outcomes. METHODS: Between 2015 and 2018, nine patients (six females, three males) with severe TA tendinosis with no tear (2), partial (1), or complete (6) underwent operative treatment. Patients underwent debridement and direct repair without augmentation, direct repair with fiber tape augmentation, tibialis posterior tendon (PTT) transfer, or tibialis anterior tendon (TAT) augmentation with a tendon autograft (n=4). Autografts consisted of extensor digitalis longus (EDL) tendon, plantaris tendon, or both. RESULTS: Mean postoperative follow-up was 21.3 (range 8-31) months. All patients had a concomitant gastrocnemius recession, and three had hindfoot arthrodesis. Preoperative dorsiflexion strength was 0/5 for all and improved to 5/5 postoperatively in seven. The only current smoker developed wound dehiscence 2 weeks postoperatively and healed by 4. One developed marginal skin necrosis 3 weeks postoperatively and was treated successfully with casting. CONCLUSION: Surgery reestablished function in individuals with TA tendinosis and allowed high level of satisfaction. Direct repair is possible. If the tendon gap is too large an autograft of EDL and plantaris tendon can be utilized. LEVEL OF EVIDENCE: Level III Retrospective Comparative Study.