The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection

We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.

A Novel Model for Predicting the Sagittal Length of the Distal Tibia Using CT Imaging and Statistics

The purpose of this study was to determine the ratio of sagittal length to coronal length of the distal tibia for predicting the sagittal length of the distal tibia. A total of 202 ankles were measured based on CT imaging availability. We measured the coronal length (Width, W) parallel to the Chaput tubercle from CT scans. Sagittal length was divided into 3 points (Diameter D1, D2, D3) in the axial plane on the same level. The relationship between coronal length and each sagittal length was determined through correlation analysis. A prediction model was then developed using multiple regression. We also analyzed the quality of the prediction model and validated the prediction model with a validation cohort. Each sagittal length (D1, D2, D3) and coronal length had a significant positive correlation (p < .01). In the prediction model, sex, height, and W were significantly associated with D1, D2, and D3 (p < .05). Prediction models were made for each sagittal length (D1, D2, D3). Concordance correlation coefficient (CCC) values of prediction models for D1, D2, and D3 were 0.78, 0.72, and 0.72 for the derivation cohort and 0.69, 0.63, and 0.61 for the validation cohort, respectively. Accuracies of models as ± 2SD for D1, D2, and D3 were 93.9%, 94.9%, and 94.9%, respectively. This study predicted the sagittal length of the distal tibia for preoperative planning by measuring the coronal length of the distal tibia. Prediction of the sagittal length of the distal tibia can help foot and ankle surgeons fixate screws stably to prevent iatrogenic injury of posterior structures of the distal tibia.

Management and rehabilitation of moderate-to-severe diabetic foot infection: a narrative review

Diabetic foot is one of the most devastating consequences of diabetes, resulting in amputation and possibly death. Therefore, early detection and vigorous treatment of infections in patients with diabetic foot are critical. This review seeks to provide guidelines for the therapy and rehabilitation of patients with moderate-to-severe diabetic foot. If a diabetic foot infection is suspected, bacterial cultures should be initially obtained. Numerous imaging studies can be used to identify diabetic foot, and recent research has shown that white blood cell single-photon emission computed tomography/computed tomography has comparable diagnostic specificity and sensitivity to magnetic resonance imaging. Surgery is performed when a diabetic foot ulcer is deep and is accompanied by bone and soft tissue infections. Patients should be taught preoperative rehabilitation before undergoing stressful surgery. During surgical procedures, it is critical to remove all necrotic tissue and drain the inflammatory area. It is critical to treat wounds with suitable dressings after surgery. Wet dressings promote the formation of granulation tissues and new blood vessels. Walking should begin as soon as the patient's general condition allows it, regardless of the wound status or prior walking capacity. Adequate treatment of comorbidities, including hypertension and dyslipidemia, and smoking cessation are necessary. Additionally, broad-spectrum antibiotics are required to treat diabetic foot infections.

A Neglected Extensor Hallucis Longus Tendon Rupture Caused by Arthritic Adhesion

Extensor hallucis longus tendon injury is relatively rare and is principally caused by a laceration when a sharp object is dropped on the instep. Primary suturing is possible if the injury is acute, but if the tear is chronic, tendon contracture causes the space between the edges of the tear to widen, disrupting the end-to-end connection. In particular, a claw toe or checkrein foot deformity may develop over time due to adhesion of the lower leg tendons near the fracture site or scar. We report on a 44-year-old man who visited our outpatient clinic complaining of pain in the right foot and a hindered ability to extend his great toe. He had enjoyed playing soccer during his schooldays; since that time, the extension of that toe had become somewhat difficult. T2-weighted sagittal magnetic resonance imaging revealed that the continuity of the extensor hallucis longus tendon had been lost at the distal phalangeal base attachment site, and that the region of the proximal tendon was retracted to level of the middle shaft of the proximal phalanx. The findings allowed us to diagnose extensor hallucis longus tendon rupture accompanying osteoarthritic changes in the joint and soft tissues. We performed surgical tenorrhaphy and adhesiolysis. This is a rare case of extensor hallucis longus tendon rupture caused by minor trauma. Arthritis that developed at a young age caused the adhesions. If patients with foot and ankle arthritis show tendon adhesion at the arthritic site, tendon rupture can develop even after minor trauma or intense stretching.

Comparison of Radiological and Clinical Outcomes in Patients Treated with Standard Plating versus Intramedullary Nailing in Distal Tibial Fracture

Objective

To evaluate clinical and radiological outcomes including hindfoot alignment after plate vs intramedullary nailing (IMN) for distal tibia fracture and to define radiologic parameters that influence changes in hindfoot alignment.

Methods

Among 92 patients with distal tibia metaphyseal fractures treated from 2002 to 2015, 39 cases of intramedullary nailing and 53 cases of standard plate osteosynthesis were performed. Union rate and complication rate were compared in both groups. Radiographic measurements including hindfoot angulation, moment arm, calcaneal pitch angle, and Meary angle were evaluated at a minimum of 1‐year follow‐up. Hindfoot alignment changes after surgery were compared between both groups using student t‐test. Correlation and regression were analyzed between fracture alignment parameters and hindfoot alignment.

Results

All patients ultimately healed, with an average union period of 26 weeks in both groups. The AOFAS and VAS scores were not significantly different between the two groups. Complications were similar between the two groups. Hindfoot alignment angle, calcaneal pitch, and Meary angle showed no significant differences between the groups. The hindfoot moment arm increased with valgus in the IMN group. A low correlation was detected between angulation at the fracture site in the coronal view and hindfoot alignment (angulation and moment arm) changes (R = 0.38). A significantly high correlation was noted only between transverse rotation and hindfoot alignment changes (R = 0.79).

Conclusions

Rotation in the transverse plane notably influenced changes in hindfoot alignment. And this suggests that patients with distal tibia fracture should be closely monitored for hindfoot alignment changes caused by intraoperative transverse rotation regardless of the fixation method.

Trends of Total Knee Arthroplasty According to Age Structural Changes in Korea from 2011 to 2018

Total Knee Arthroplasty (TKA) is one of the most commonly performed surgeries worldwide since it can improve pain, quality of life, and functional outcome. Due to the expansion of hospitals specialized in joint surgery, the topography of TKA implementation in Korea is changing. This study analyzed longitudinal trends of TKA based on changes in age distribution, sex, hospital, and region based on the Health Insurance Review and Assessment Service (HIRA) of Korea database. Data were collected from the National Health Insurance Service (NHIS), the Korean Statistical Information Service (KOSIS), and the Health Insurance Review and Assessment Service (HIRA) in Korea for the period 2011-2018. Results show the total number of surgeries increased and the number of patients by age decreased in those under the age of 70, while the number of patients over 70 years of age increased. A remarkable increase in women was found, and there was no significant difference between regions. TKA is spreading in a more universal and easily accessible form in Korea and has increased more in other relatively small medical institutions compared to tertiary referral medical centers. Due to the increase of orthopedics' specialized hospitals and clinics, TKA is becoming more prominent in those hospitals.

Fixation of isolated Lisfranc ligament injury with the TightRope™: A technical report

Treatment of Lisfranc ligament injury is still debatable. For this reason, we applied a standard suture button (TightRope™, Arthrex, Naples, FL), a device originally designed for syndesmosis fixation, in treating isolated Lisfranc ligament (ILL) injuries. Twelve patients diagnosed as having an ILL injury were recruited. All patients regained their previous activity level within 3 months after the surgery without any complications. We propose that standard suture button device in an ILL injury is an easy technique to perform with short learning curve, accompanied with satisfactory outcomes.

Adult Stature Estimation from Radiographic Metatarsal Length in a Contemporary Korean Population

The ability to estimate stature can be important in the identification of skeletal remains. This study aims to develop a Korean-specific equation predicting stature using radiographic measurements in the contemporary Korean population. 200 healthy Korean adults, including 102 males and 98 females, were randomly selected (age, range 20–86 years). The first and second metatarsals of the foot were measured by a standing X-ray using a digital medical image viewer. The result showed a statistically significant correlation between metatarsal length and stature in Korean populations (male, R = 0.46, p < 0.001; female, R = 0.454, p < 0.001). Values of correlation coefficients (R) of the equations were 0.431 to 0.477. Compared to equations derived from other races, the Korean-specific equation showed significantly lower error values for estimating the actual height of Koreans through cross-validation. In conclusion, this study is the first to propose a Korean-specific regression formula for estimating stature using metatarsal length and a verified formula for precise application to the Korean population. However, given the relatively low correlation coefficient, the stature estimation formula derived from this study can be utilized when other bones that allow more accurate stature estimation are not available.

Association between Bone Mineral Density and Fracture Characteristics in the 5th Metatarsal Bone Base Fracture in Elderly for Prediction of Osteoporotic Fracture

Background

This study aimed to analyze the correlation between bone mineral density (BMD) and the type of 5th metatarsal fracture, as well as to demonstrate whether there is a difference in radiological findings (heel alignment angle [HAA], heel moment arm [HMA], and metatarsus angle) between fracture types.

Methods

A total of 87 patients were enrolled in the study and allocated into 3 groups: the Zone 1 group (N=36), the Zone 2 group (N=33), and the Zone 3 group (N=18). The participants’ demographic data, T-scores, existing fracture or osteoporosis medications, and radiologic parameters including HAA, HMA, and metatarsus adductus angle were analyzed and compared.

Results

There was a significant difference between the mean age of the participants, with the highest age in the Zone 1 group and the lowest in the Zone 3 group. Regarding the history of concurrent fracture or osteoporosis medications, there was no significant difference between the 3 groups. Similarly, no significant difference was observed between the 3 groups about the BMD values. In contrast, the HAA was statistically significant in all groups with a positive correlation of −8.9 in the Zone 1 group, a negative correlation of 3.55 in the Zone 2 group, and an inverse relationship of 6.1 in the Zone 3 group. The metatarsus adductus angle was significantly higher in the Zone 3 group than the Zone 1 and Zone 2 groups.

Conclusions

The location of a 5th metatarsal bone fracture is not significantly associated with BMD. However, mechanical influences, such as hindfoot varus or forefoot adductus, have a significant correlation with fracture types.

Diurnal Temperature Ranges in Relation to Lower Limb Amputation Rate of Diabetic Foot in South Korea: A Population Based Nationwide Study

The evidence for the association between diurnal temperature range (DTR) and diabetic foot amputations is limited. We aimed to investigate the region-specific association between DTR and the amputation rate of diabetic foot in Korean national-wide data. Daily data on DTR and the rate of diabetic foot amputations from 16 provincial capital cities in Korea were obtained (2011-2018). In this study, the latitude ranged from 33°11' N to 38°61' N, and we classified each region according to latitude. Region 1, which was located at a relatively high latitude, included Seoul, Incheon, Gyeonggi-do, and Gangwon-do. Region 2, which was located at a relatively low latitude, included Busan, Ulsan, Gyeonsannam-do, Gwangju, Jeollanam-do, Jeollabuk-do, and Jeju-do. The region-specific DTR effects on the amputation rate were estimated based on a quasi-Poisson generalized linear model, combined with a distributed lag non-linear model based on the self-controlled case series design. The DTR impacts were generally limited to a period of nine days, while significant effects during lag days 7-14 were only found in the cities of Seoul, Incheon, and Gyeonggi-do (10th lag day: RR [95% CI]; Seoul: 1.015, [1.001-1.029]; Incheon: 1.052 [1.006-1.101]; Gyeonggi-do: 1.018 [1.002-1.034]). In the subgroup analysis (according to the latitude), an increase of 1 °C in DTR was associated with the risk of diabetic foot in relatively high latitude regions. DTR has considerable effects on the risk of diabetic foot amputation in various provinces in Korea, and it was particularly affected by latitude. The results can inform the decisions on developing programs to protect vulnerable subpopulations from adverse impacts.

Calcifying aponeurotic fibroma around posterior tibialis tendon in an elderly patient with flatfoot: A case report

RATIONALE

Calcifying aponeurotic fibroma (CAF) is a rare benign fibroblastic tumor that is commonly in the hand or foot of children or adolescents.

PATIENT CONCERNS

A 74-year-old female presented with a progressive pain on the medial foot for 3 years ago. The pain aggravated while walking or in a standing position for more than 20 minutes. She also complained of skin contact along the medial aspect of the foot while trying to wear a shoe.

DIAGNOSIS

Physical examination revealed a firm, immobile, nontender mass accompanied with flexible flatfoot. On the single heel raise test, loss of the balance and intensification of the pain were observed. Faintly calcified soft tissue mass is shown in plain radiographs without bone involvement. Magnetic resonance imaging revealed a subcutaneous mass with ill-defined circumscribed subcutaneous mass adherent to the thickened PTT.

INTERVENTIONS

The patient underwent a complete excisional biopsy, followed by medial displacement calcaneal osteotomy.

OUTCOMES

The excised mass was diagnosed to be CAF on the histologic examination. At the 1-year follow-up, patient remained asymptomatic with no evidence of recurrence and all the radiographic parameters demonstrating flat foot improved.

LESSONS

This is the first case of CAF located at PTT presenting with both foot pain and functional disability. In this case, complete excision of the causative structure along with alignment correction can contribute to successful postoperative outcome.

A Novel Prediction Model for Determining Coronal Length of Calcaneus Using CT: A Guide for Surgery of Calcaneal Fracture

The objective of this study was to determine the anatomical relationship between the calcaneus and its neighboring bones. Furthermore we tested a prediction model that enables to estimate safe screw length during the surgery of calcaneus fractures. A total of 169 feet were used for the study based on CT scans. We measured two horizontal and two parallel lines. The coronal length of the cuboid bone (CL) was a horizontal line anterior to the calcaneocuboidal joint, and W1 of calcaneus was a horizontal line posterior to the articular surface of the calcaneocuboidal joint. The subtalar articular length (STA) was a parallel line above the talocalcaneal joint, and W2 of calcaneus was a parallel line below to the talocalcaneal joint. Relationship of each measurement was determined through correlation analysis. A prediction model was developed based on observed correlations and the quality analyzed and validated. The CL and W1 had a significant positive correlation (r = 0.899, p < .001). The STA and W2 also had a significant positive correlation (r = 0.939, p < .001). Based on these correlations, the prediction model was made. In the quality analysis, the values of concordance correlation coefficient (CCC) for W1 and W2 were 0.894, and 0.937 respectively. In the validation analysis, the values of CCC for W1, W2 were 0.79, and 0.8, respectively. This study made it possible to predict the anatomical reference point using preoperative coronal length of the calcaneus to guide safety margin of screw length, and thereby to prevent the iatrogenic injuries on medial neurovascular structures of the calcaneus.

Three-Dimensional Anatomically Pre-Contoured Locking Plate for Isolated Weber B Type Fracture

We aimed to evaluate the functional and radiographic outcomes of a three-dimensionally (3D) pre-contoured lateral locking plate fixation for isolated Weber B type fractures and to evaluate the necessity of an interfragmentary lag screw in the use of the plate. Patients who underwent surgery for isolated Weber B type fracture were divided into two groups: 41 patients treated with the 3D plate and lag screw (Group A) and 31 patients treated with the 3D plate only (Group B). The included patients were evaluated regarding the functional and radiographic outcomes. According to the McLennan and Ungersma criteria, the majority of patients showed good or fair outcomes in both groups. Comparing the two groups, Group B showed better functional outcomes (p < 0.0046), while no difference between the two groups was found in terms of the radiographic outcomes (p = 0.143). The operation time was significantly shorter in Group B (p < 0.001) and the time to bony union was within 14 months in all patients with no significant difference between the two groups (p = 0.0821). No postoperative complication was observed in both groups. In conclusion, the use of a 3D pre-contoured lateral locking plate fixation for isolated Weber B type fractures demonstrated satisfactory functional and radiographic outcomes, regardless of lag screw insertion.

Suture Button vs Conventional Screw Fixation for Isolated Lisfranc Ligament Injuries

BACKGROUND

Suture buttons have been used for isolated Lisfranc ligament (ILL) fixation. However, no study has reported on its clinical and radiologic outcomes.

METHODS

In this retrospective comparative study, patients with ILL injuries were divided into 2 groups according to the treatment method: 32 conventional screw group and 31 suture button group. The clinical and radiologic outcomes at preoperation, 6 months and 1 year postoperation, and last follow-up period were measured. Plantar foot pressure was measured at postoperative month 6 months. Postoperative complications at the last follow-up were evaluated.

RESULTS

The suture button group showed better American Orthopaedic Foot & Ankle Society midfoot scale (P < .001) and visual analog scale (P < .001) scores compared with the conventional screw fixation group at the postoperative month 6 period before screw removal. However, no significant difference in clinical outcome between the 2 groups was found at postoperative year 1 or last follow-up. No differences in radiologic outcomes were found between the 2 groups. Plantar foot pressure was significantly elevated in the conventional screw group at the great toe and first metatarsal head area compared with the contralateral foot just before screw removal. Recurrent Lisfranc joint diastasis was found in a single case in the conventional screw group and 2 cases in the suture button group.

CONCLUSION

Suture button fixation in the treatment of ILL injuries may provide comparable fixation stability and clinical outcome with conventional screw fixation in the early postoperative period.

LEVEL OF EVIDENCE

Level III, retrospective case-control study, therapeutic.

Changes in Coronal Alignment of the Knee Joint after Supramalleolar Osteotomy

BACKGROUND

Assessing knee joint orientation changes after SMO may help clinical advancement in managing patients with ipsilateral ankle and knee joint arthritis. However, knee joint changes after supramalleolar osteotomy (SMO) have not been reported. We investigated changes in coronal alignment of the knee joint after SMO.

METHODS

In this multicentre study, from January 2014 to December 2018, 47 ankles with varus osteoarthritis treated with SMO were retrospectively identified. Ankle joint changes were assessed using the tibiotalar angle, talar tilt angle, and lateral distal tibial angle (LDTA); knee joint changes using the medial proximal tibial angle (MPTA), medial and lateral joint space widths (mJSW and lJSW, respectively), and medial and lateral joint line convergence angles (JLCA); and lower limb alignment changes using mechanical axis deviation angle (MADA) and the hip-knee-ankle (HKA) angle measured on full-length anteroposterior radiographs of the lower extremity. Correlation analysis and binary logistic regression analysis were performed.

RESULTS

Postoperatively, LDTA (p < 0.001) and tibiotalar angle (p < 0.001) significantly changed, indicating meaningful improvement in the ankle joint varus deformity. Regarding the knee joint changes, JLCA significantly changed into valgus direction (p = 0.044). As for lower limb alignment changes, MADA significantly decreased (p < 0.001), whereas the HKA angle significantly increased (p < 0.001). In univariate and multivariate logistic regression analyses, changes in the MADA (p < 0.001) and the HKA angle (p < 0.001) were significantly correlated with the correction angle.

CONCLUSIONS

SMO remarkably improves ankle joint varus deformity, followed by significant lower limb alignment changes. Despite meaningful changes in JLCA, the relationship between the amount of osteotomy near the ankle joint and improvement in knee joint radiographic parameters was not significant. Radiographic parameters of the knee joint would less likely be changed following SMO.

Staged patellar tendon reconstruction using doubled bone-patellar tendon-bone allograft for infected patellar tendon rupture: a rare case report of three years follow-up

BACKGROUND

Patellar tendon rupture is a relatively rare injury that usually requires surgical treatment. The optimal therapeutic strategy is still controversial, especially when either concomitant patellar tendon infection or soft tissue infection surrounds the patellar tendon. Until recently, most reported reconstruction methods are extensive and difficult to apply because of the poor condition of the soft tissue surrounding the patellar tendon.

CASE PRESENTATION

A 19-year-old male patient presented to our clinic three weeks following a motorcycle accident. There was a 5 x 4 cm sized skin defect with soft tissue infection below the inferior pole of patella. We performed a staged patellar tendon reconstruction using a doubled bone-patellar tendon-bone allograft (BPTB) to the infected patellar tendon rupture, following local random fasciocutaneous flap and split-thickness skin graft. Three months following surgery, the patient was able to perform an active knee motion with no extension lag and excellent clinical functional result.

DISCUSSION AND CONCLUSIONS

Our technique introduced in this specific case is a relatively simple method to reconstruct chronic patellar tendon defects with limited incision exposing only the patellar tendon areas. We expect it can be less invasively performed on patients who have a soft tissue problem and cannot have extensive surgery.

Comparison of functional outcomes between single-radius and multi-radius femoral components in primary total knee arthroplasty: a meta-analysis of randomized controlled trials

PURPOSE

Our purpose in the current meta-analysis was to compare the functional outcomes in patients who have received single-radius (SR) or multi-radius (MR) femoral components in randomized controlled trials (RCTs) for primary total knee arthroplasty (TKA). The hypothesis was that there would be no statistically significant difference between two groups in terms of functional outcomes.

MATERIALS AND METHODS

We searched the international electronic databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to February 2020 for RCTs that compared functional outcomes of SR and MR femoral component designs after primary TKA. We performed a meta-analysis of nine RCTs using the Knee Society Score for the knee (KSS-knee), KSS-function, Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), degree of knee flexion, extension, and complications, including postoperative infection and revision surgery.

RESULTS

The meta-analysis revealed no statistically significant differences in all the analyzed variables, including KSS-knee, KSS-function, KOOS, OKS, knee flexion, and knee extension. For postoperative complications, no statistically significant differences were detected for femoral component designs in postoperative infection or incidence of revision surgery between the two groups.

CONCLUSIONS

The current meta-analysis of RCTs did not show any statistically significant differences between SR and MR femoral component designs in terms of postoperative functional outcomes. Evaluated outcomes included functional outcome scores, degree of knee flexion, extension, and complications. However, because of the limited clinical evidence of this study owing to the heterogeneity between the included RCTs, a careful approach should be made in order not to arrive at definite conclusions.

Acute Traumatic Arterial Occlusions Combined with Massive Morel-Lavallée Lesions Treated by Percutaneous Angioplasty, Multiple Debridements and Skin Grafts

Morel-Lavallée lesions (MLL) create pre-fascial space by shearing the subcutaneous tissues away from the underlying fascia, in a patient with trauma. Necrosis of the overlying skin can develop over a wide area of the lesion. The lesion might be contaminated by the surgical site due to careless intrusion when treating the combined arteriopathy. A 70-year-old woman presented with avulsion of the skin over the right foot and bilateral leg pain following a car accident. Computed tomography showed bilateral popliteal artery occlusion with large hematoma on both legs. Percutaneous angioplasty was performed with successful restoration of the flow. However, the skin color changes over time. Necrosis of the skin occurred over a wide area of the right leg. Extensive debridement was performed, and the defect was covered with a skin graft. MLLs can occur in patients with multiple traumas, multiple vascular injuries, and complex skeletal injury. Vascular surgeons treating multiple traumas should be aware of the diagnostic and management options for MLL. It should be diagnosed early because it can be difficult to manage once the overlying skin develops necrosis.

Bone Mineral Density in Diabetes Mellitus Foot Patients for Prediction of Diabetic Neuropathic Osteoarthropathic Fracture

Background

Diabetic neuropathic osteoarthropathy (DNOAP) is known as debilitating diabetes complications. The aim of study is to compare bone mineral density (BMD) among diabetic foot and DNOAP, and investigate the impact of BMD proceeded from diabetic foot to DNOAP.

Methods

A DNOAP group (subgroup A and subgroup B) and control group were examined for this study. Subgroup A (n=21) were patients diagnosed with DNOAP with the development of new foot and ankle fractures, whereas subgroup B (n=4) were patients being managed with the diabetic foot before a diagnosis of DNOAP. BMD was also evaluated before the diagnosis. Control group (n=30) was diabetic foot patients without DNOAP. The demographic data, clinical and radiologic data, comorbidities, and BMD were compared for each group. And optimal BMD score was reviewed to predict fractures in neuropathic arthropathy.

Results

BMD was significantly lower in DNOAP group (group A and B) compared with control group. Also neuropathic arthropathy group showed poor radiological results. After comparisons of 2 group lumbar and femur BMD was significantly different, but logistic regression analysis revealed that low femur T-score could be risk predictors of the condition. Base on the data of group B and control group, the cut-off point for predicting foot and ankle fracture-related with DNOAP was -1.65 of femur BMD.

Conclusions

Low BMD shows greater incidence in foot and ankle fracture patients associated with neuropathic arthropathy. A femur T score can be a risk predictor of diabetic neuropathic arthropathy for diabetic foot patients.

Tarsal tunnel syndrome secondary to osteochondroma of the calcaneus: a case report

Background

Tarsal tunnel syndrome is an entrapment neuropathy that can be provoked by either intrinsic or extrinsic factors that compresses the posterior tibial nerve beneath the flexor retinaculum. Osteochondroma, the most common benign bone tumor, seldom occur in foot or ankle. This is a rare case of tarsal tunnel syndrome secondary to osteochondroma of the sustentaculum tali successfully treated with open surgical excision.

Case presentation

A 15-year-old male presented with the main complaint of burning pain and paresthesia on the medial plantar aspect of the forefoot to the middle foot region. Hard mass-like lesion was palpated on the posteroinferior aspect of the medial malleolus. On the radiological examination, 2.5 × 1 cm sized bony protuberance was found below the sustentaculum tali. Surgical decompression of the posterior tibial nerve was performed by complete excision of the bony mass connected to the sustentaculum tali. The excised mass was diagnosed to be osteochondroma on the histologic examination. After surgery, the pain was relieved immediately and hypoesthesia disappeared 3 months postoperatively. Physical examination and radiographic examination at 2-year follow up revealed that tarsal tunnel was completely decompressed without any evidence of complication or recurrence.

Conclusions

As for tarsal tunnel syndrome secondary to the identifiable space occupying structure with a distinct neurologic symptom, we suggest complete surgical excision of the causative structure in an effort to effectively relieve symptoms and prevent recurrence.

Open ligamentous complex disruption of the lateral ankle without dislocation or fracture: Two case reports

INTRODUCTION

Lateral ligamentous complex injury without fracture or dislocation is rare in the literature. Due to the rare injury, it is not clear yet about the proper treatment. This case report suggests a specific diagnosis of this injury as well as an appropriate surgical method.

PATIENT CONCERNS

In one-month period of time, 2 male soldiers participating in recreational basketball game presented with open wound on the lateral aspect of ankle without associated dislocation or fracture when they attempted to rebound the ball which consequently made them land on another player's foot.

DIAGNOSIS

Total rupture of the lateral ligament complex with open wound was found without any associated fracture or dislocation.

INTERVENTIONS

Open repair of the ruptured ligaments and capsule was performed.

OUTCOMES

Patients returned to his own job's duty with none to minimal limitation in sport and activities of daily living at 9 to 10 months after the injury.

CONCLUSION

Although open disruption of the lateral ligamentous complex without fracture or dislocation is rare, an adequate assessment and prompt surgical repair led to satisfactory outcome.

Can sural nerve injury be avoided in the sinus tarsi approach for calcaneal fracture?: A cadaveric study

There is no consensus regarding the references to determine the exact location of the skin incision to minimize iatrogenic sural nerve injury in the sinus tarsi approach for calcaneal fracture.The purpose of this cadaveric study was to describe the anatomical course of the sural nerve in relation to easily identifiable landmarks during the sinus tarsi approach and to provide a more practical reference for surgeons to avoid sural nerve injury.Twenty-four foot and ankle specimens were dissected. The bony landmarks used in the following reference points were the tip of the lateral malleolus (point A), lateral border of the Achilles tendon on the collinear line with point A (point B), posteroinferior apex of the calcaneus (point C), inferior margin of the calcaneus on the plumb line through point A (point D), and tip of the fifth metatarsal base (point E). After careful dissection, the distances of the sural nerve to points A and B in the horizontal direction (lines D1 and D2), points A and C in the diagonal direction (lines D3 and D4), points A and D in the vertical direction (lines D5 and D6), and points A and E in the diagonal direction (lines D7 and D8) were measured.The median ratio of D1 to D1+D2, D3 to D3+D4, D5 to D5+D6, and D7 to D7+D8 were 0.37 (range, 0.26-0.50), 0.23 (range, 016-0.33), 0.35 (range, 0.25-0.45), and 0.32 (range, 0.20-0.45), respectively.The distance ratios from this study can be helpful to avoid sural nerve injury during the sinus tarsi approach for calcaneal fractures. Established standard incision may have to be modified to minimize sural nerve injury.

Diagnostic Accuracy of Radiologic Methods for Ankle Syndesmosis Injury: A Systematic Review and Meta-Analysis

: Misdiagnosis and inadequate treatment of syndesmosis could result in significant long-term morbidity including pain, instability, and degenerative changes of the ankle joint. The objective of this systematic review and meta-analysis was to determine whether radiologic tests accurately and reliably diagnose ankle syndesmosis injury. Medline, Embase, and Cochrane were searched. The database search resulted in 258 full text articles that we assessed for eligibility, we used eight studies that met all the inclusion criteria. In subgroup meta-analysis, the sensitivity analysis showed significant differences only in the MRI (Magnetic Resonance Imaging), and specificity was not statistically significant. In diagnostic meta-analysis, the pooled sensitivity and specificity were 0.528 and 0.984 for X-rays, 0.669 and 0.87&nbsp;for CT (Computed Tomography), and 0.929 and 0.865 for MRI, all respectively. For sensitivity, MRI showed significantly sensitivity as higher than the other methods, and we detected no significance for specificity. Syndesmosis injuries differed significantly in the accuracy of radiological methods according to the presence of accompanied ankle fractures. In patients with fractures, simple radiography has good specificity, and CT and MRI have high sensitivity and specificity irrespective of fracture; in particular, MRI has similar accuracy to gold standard arthroscopic findings.

Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures

BACKGROUND

Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT).

METHODS

All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided.

RESULTS

A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively.

CONCLUSIONS

CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.

Impact on Bisphosphonate Persistence and Compliance: Daily Postprandial Administration

Background

Bisphosphonate (BP) is an effective drug for the prevention and treatment of osteoporosis. However, gastrointestinal distress caused by BP is a well-known side effect for low compliance. The aim of our study was to compare the 1-year persistence, compliance and T-scores between the aperitif medication group and the postprandial medication group.

Methods

Three hundred patients were included in this study to determine their persistence and compliance with the prescribed daily BP (Maxmarvil®, alendronate 5 mg and calcitriol 0.5 µg; YuYu Pharm) following distal radius fractures. Patients in Group 1 (aperitif medication) were asked to adhere to the general guidelines for BPs before breakfast. Patients in Group 2 (postprandial medication) were recommended medication after breakfast. We compared the persistence and compliance of this daily BP therapy using the medication possession ratio (MPR) and T-scores between the 2 groups after 1 year.

Results

Bone mineral density in hip and lumbar spine was improved significantly in 2 groups (P<0.001). Significant differences existed between 2 groups, including 73 of 150 patients (48.7%) in Group 1, and 111 of 150 patients (73.3%) in Group 2 for 1-year persistence (P=0.001). The mean MPR is 0.66 in Group 1 (range, 0.50–0.86) and 0.71 in Group 2 (range, 0.54–0.87). A significant difference was detected between the 2 groups (P=0.002).

Conclusions

Postprandial administration improved persistence and compliance with daily BP therapy, resulting in better clinical outcomes.

Retrospective analysis of culture-negative versus culture-positive postoperative spinal infections

Retrospective analysis.This study aimed to investigate the characteristics, clinical features, and outcomes of culture-negative (CN) and culture-positive (CP) postoperative spinal infections (PSIs).Causative organism cultures and the use of adequate antibiotics are essential for treating postoperative spinal wound infections. However, managing infected surgical sites with negative wound culture results is a common clinical problem. Although the outcomes of microbiologically confirmed PSIs have been well studied, the outcomes and clinical characteristics of CN PSIs have not been previously published.Between January 1995 and December 2014, 69 patients diagnosed with PSIs were enrolled. Enrolled patients were classified into 2 groups: CN (28 patients) and CP (41 patients). Baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared with the groups.The overall rate of CN PSI was 40.6% (28/69). Baseline data and clinical manifestations were similar between the 2 groups. There were no significant differences in the duration of parenteral antibiotic use between the CN and CP groups. Revision surgery was required less often for the CN group (64.3%) than for the CP group (87.8%) (P = .020). Revision surgeries were repeated 0.82 times/case in the CN group and 1.34 times/case in the CP group (P = .014). Treatment outcomes, such as poor radiologic findings, need for additional anterior surgery, extension of fusion to adjacent segment surgery, and total length of hospital stay, were not different between groups.Revision surgery was performed less often for the CN group than for the CP group. From the perspective of revision surgery, CN PSIs have better prognosis than CP PSIs. However, clinical presentations and radiologic prognoses were not different between the two groups. We suggest that CN PSIs may be treated in the same way as CP PSIs.

Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study

Background

The posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images.

Methods

We retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF.

Results

The PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape (P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group (P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group (P = 0.017).

Conclusions

With regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.

Amputation of multiple limbs caused by use of inotropics: Case report, a report of 4 cases

RATIONALE

We present 4 cases of symmetrical peripheral gangrene (SPG) associated with use of inotropic agent to elevate blood pressure. SPG is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 4 SPG cases of the multiple limbs amputation, associated with inevitable use of inotropic agents.

PATIENT CONCERNS

Inotropic agents including dopamine and norepinephrine are used frequently in the treatment of hypotension, and its effectiveness in treating shock is firmly established. However, it can be caused peripheral gangrene by prolonged administration of high dose inotropics, inducing the constant contraction of the peripheral blood vessels.

DIAGNOSIS

These 4 patients had different clinical histories and background factors, but each experienced sepsis. The level of amputation is determined by the line of demarcation in concert with considerations of the biomechanics of stump stability, weight bearing, and ambulation.

INTERVENTIONS

After recovering of general conditions and completion of demarcation, these 4 patients underwent the amputation of multiple limbs.(bilateral amputations of upper extremities or bilateral amputations of lower extremities).

OUTCOMES

In each patient, there was no additional amputation caused by extension of SPG, and the rehabilitation with appropriate orthosis was performed. Treatment of underlying disease were continued too.

LESSONS

It is important to alert the possibility of amputations, according to the use of inevitable inotropics. We recommended the careful use of the inotropic agents to the physicians in treating septic shock.

Does uneven geographic distribution of urologists effect bladder and prostate cancers mortality? National health insurance data in Korea from 2007-2011

The relationship between distribution of urologists and mortality of bladder and prostate cancers has not been clearly established. The aim of this study was to investigate the relationship between uneven distribution of urologists and urologic cancer specific mortality at country level. Data from the National Health Insurance Service and National Statistical Office in Korea from 2007 to 2011 were analyzed in this ecological study. Univariate and multivariable regression analyses were performed to determine risk factors for age standardized mortality rates (ASMR) of bladder and prostate cancers. Linear regression analysis showed a markedly (p < 0.001) uneven distribution of urologists between metropolitan and non-metropolitan areas. There was no significant difference in cancer specific ASMRs for either bladder cancer or prostate cancer. Univariate analysis after adjusting for time showed that country area, urologist density, and income were significant factors affecting bladder cancer incidence (p < 0.001, p = 0.013, and p < 0.001, respectively). It also showed that the number of training hospitals was a significant factor for prostate cancer incidence (p = 0.002). Although country area showed borderline significance (p = 0.056) for ASMR of bladder cancer, urologist density was not related to ASMR of bladder cancer or prostate cancer. Although there was a marked difference in urologist density between metropolitan and non-metropolitan areas for these years analyzed, mortality rates of bladder and prostate cancers were not significantly affected by country area or urologist density.

Clinical Outcomes of the Modified Broström Procedure Using Distal Fibular Periosteal Flap Augmentation for Chronic Lateral Ankle Instability

Category:

Sports

Introduction/Purpose:

Modified Broström procedure (MBP) is the most widely accepted primary operative treatment for the operative treatment of chronic lateral ankle instability (CLAI). However, in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity, unsatisfied results of the MBP have been reported. We hypothesized that if the soft tissue can be augmented enough to support body activity, the clinical outcomes are comparable with those of the anatomical reconstruction. The purpose of this study is to compare the clinical results between the MBP using a distal fibular periosteal flap augmentation and anatomical reconstruction using free tendon allograft for CLAI in cases of concerning poor outcome by MBP.

Methods:

Thirty-eight patients [(39 ankles), (25 men, 13 women) (mean age: 27.6 years)] who underwent both procedures were retrospectively analyzed. The mean symptom duration before surgery was 31.7 months and the mean follow up duration was 21.6 months. The indications for operation were: (1) severe subjective ankle instability feeling and objective ankle instability, (2) previous failed MBP, (3) generalized joint laxity, (4) obesity, (5) severe attenuation of the ligament. The patients were divided into 2 groups: a group of anatomical lateral ligament reconstruction (reconstruction group, 17 ankles) and a group of MBP using distal fibular periosteal flap augmentation (augmentation group, 22 ankles). Radiographic assessments were made with weightbearing anteroposterior, lateral radiographs of the ankle, hindfoot alignment radiographs, and stress radiographs using a Telos device. Clinical evaluations were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Karlsson-Peterson score.

Results:

The mean AOFAS score significantly improved from 54.65 to 92.94 in the reconstruction group and from 60.14 to 94.86 in the augmentation group. (p=0.000, p=0.000) The mean Karlsson score also significantly improved from 46.41 to 92.65 in the reconstruction group and from 52.64 to 94.09 in the augmentation group. (p=0.000, p=0.000) There were no significant differences in the postoperative mean AOFAS and Karlsson score between the groups. (p=0.214, p=0.299)

Conclusion:

If satisfied results can be expected with both procedures, we believe that surgeons will prefer the MBP using periosteal augmentation, which is more familiar and less invasive. The MBP using distal fibular periosteal flap augmentation is an alternative surgical option for CLAI in cases of generalized ligament laxity, severe attenuation of the soft tissue, previous failed surgery, high demand activity, and obesity.

Does it Need Operation in Pediatric Triplane Fracture?

Category:

Ankle, Trauma

Introduction/Purpose:

The proper treatment of triplane fractures is still controversial. The purpose of this study was to compare the clinical and radiographic outcomes of nonoperative and operative treatments of triplane fractures and to clarify whether operative treatment is always necessary for triplane fractures with displacements of >2 mm.

Methods:

Thirty-three patients who were diagnosed as having triplane fractures between January 2007 and January 2014 were reviewed. The first 19 consecutive patients were treated conservatively with closed reduction regardless of age, sex, and fracture severity (nonoperative group), and the latter 14 patients were treated surgically (operative group). Clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and modified Weber protocol (MWP) scores. Bone union, plafond varus and valgus, presence of, leg-length discrepancy (LLD), premature closure of the growth plate, and posttraumatic arthritis were radiographically examined.

Results:

The mean AOFAS score was 100 for the nonoperative group and 98.1 for the operative group, showing no statistically significant difference between the groups (P = 0.304). The MWP scores were excellent in both groups. One patient in each group showed a LLD of >10 mm at the last follow-up. None of the patients had nonunion, plafond deformity, premature closure of the growth plate, and posttraumatic arthritis.

Conclusion:

Nonoperative treatment of triplane fracture is comparable with operative treatment in terms of clinical and radiographic results. Therefore, we suggest that nonoperative treatment may be a better option than operative treatment for triplane fracture, considering the risk of psychiatric trauma from surgery and the necessity of implant removal.

The Usefullness of Subtalar Arthroscopy in Surgical Treatment of Sanders Type 2 Calcaneal Fractures Using a Sinus Tarsi Approach

Category:

Ankle, Trauma

Introduction/Purpose:

The sinus tarsi approach was designed to provide a direct view of the posterior facet and reduce soft tissue and neurovascular injuries. However, it is difficult to expose posterior facet using sinus tarsi approach because of limited surgical view. Confirmation of reduction status in intra-articular calcaneal fractures has traditionally been performed by intraoperative fluoroscopy such as Brodens view. Recently some reports indicate that there is a role for subtalar arthroscopy in these fractures. We thought that combination of intraoperative fluoroscopy and subtalar arthroscopy could more accurately restore joint congruity and provide better clinical outcomes. The purpose of this study was to clarify whether this combined checking has better clinical and radiological results comparing with intraoperative fluoroscopy only.

Methods:

Forty-five displaced calcaneal fractures involving the posterior facet were consecutively treated using a sinus tarsi approach by a single surgeon. Among them, 25 fractures were confirmed reduction of posterior facet by fluoroscopy (Fluoroscopy group) and 20 fractures were confirmed by combined fluoroscopy and subtalar arthroscopy (Arthroscopy group). Clinical evaluations were performed using the visual analogue scale (VAS) and the Ankle-Hindfoot Scale developed by the American Orthopaedic Foot and Ankle Society (AOFAS), and short form (SF)-36 v2 questionnaires. Radiographic evaluations were performed using calcaneal lateral radiographs and CT. Changes in Böhler’s angle were evaluated from the preoperative and last follow-up lateral radiograph of calcaneus. Reduction of the posterior facet was graded according to articular step, defect, and angulation of the posterior facet in CT.

Results:

There were no significant differences in terms of VAS, AOFAS score, and SF-36 v2 between Fluoroscopy and Arthroscopy groups at the last follow-up. No significant difference was observed in change of Böhler’s angles between the groups. Reduction of the posterior facet was graded excellent in 5 feet (20%), good in 12 (48%), and fair in 8 (32%) in Fluoroscopy group and excellent in 7 feet (35%), good in 11 (55%), and fair in 2 (10%) in Arthroscopy on postoperative CT. Screw penetration of posterior facet were observed in 4 feet of Fluoroscopy group and 1 foot of Arthroscopy group on postoperative CT.

Conclusion:

Subtalar arthroscopy appears to be useful in detecting joint incongrucencies in sinus tarsi approach of intra-articular calcaneal fractures.

Rupture of the Extensor Hallucis Longus Muscle Secondary to Repetitive Overuse in a Taekwondo AthleteA Case Report

Closed rupture of the extensor hallucis longus (EHL) tendon is rare, with most cases caused by either direct penetrating trauma or predisposing factors such as corticosteroid injection and iatrogenic trauma incidences. Almost all of the previous case reports have reported on rupture of the EHL tendon rather than the EHL muscle. In this report, we highlight an unusual clinical presentation of a rupture of the EHL muscle and discuss its predisposing factors. This patient was a taekwondo athlete with EHL muscle rupture secondary to repetitive overuse without any underlying systemic or local predisposing factors or direct trauma. Fifteen months after successful surgical treatment, he became fully functional again as an elite taekwondo athlete.

Risk for Hip Fracture due to Alpha Blocker Treatment in Korean Women: National Health Insurance Database Study

OBJECTIVE

The aim of this study is to evaluate the risk for hip fracture associated with adverse drug reactions caused by α1-adrenergic (alpha) blockers to treat female voiding dysfunction.

METHODS

Information from the Health Insurance Review and Assessment Service database from January 1, 2008 to December 31, 2012 was used. Hip fracture women patients who received a prescription for an alpha blocker due to voiding dysfunction were the cases. A 30-day hazard period after administration of an alpha blocker was set. The 30-day control period was defined as 360 days before administration. The standardized incidence ratio and hazard ratio for the risk of hip bone fracture as related to alpha blocker use were analyzed.

RESULTS

The study cohort included 287 383 subjects having a mean age of 65.1 ± 9.7 years in the study cohort. A total of 170 and 79 hip fracture cases were diagnosed in the hazard period and control period, respectively. The incidence of newly diagnosed hip fractures per 100 000 person-years was 763.4 in the hazard period and 348.5 in the control period. The hazard ratio for hip fracture after use of an alpha blocker was 2.19 (95% confidence interval, 1.74-2.77).

CONCLUSIONS

Alpha blockers to treat voiding dysfunction may have association with the risk for hip fracture in elderly women.

Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty: Its relationship to the axis of the tibia and the positioning of the talar component

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.

Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction With Remnant Preservation Using Outside-In Technique

This report describes a modified anatomic single-bundle anterior cruciate ligament (ACL) reconstruction technique using the FlipCutter guide pin (Arthrex, Naples, FL) as a retrograde drill and a cortical suspensory fixation device (TightRope; Arthrex) with an adjustable graft loop length. Preservation of the ACL remnant as a biological sleeve for the graft is an important issue from the viewpoints of acceleration of revascularization and ligamentization, preservation of the proprioceptive nerve fibers, enhancement of the biological environment for healing, and maintenance of the anchor point at the native tibial attachment, in addition to yielding a lower incidence of tibial bone tunnel enlargement. The goal of our technique is to obtain some advantages of the remnant-preserving technique through an anatomic single-bundle ACL reconstruction, which is performed to minimize damage to the ACL tibial remnant.

Change of the tunnel configuration in the non-anatomic trans-tibial double bundle ACL reconstruction

BACKGROUND

The objectives of this study were to evaluate tunnel widening and morphologic change at the tunnel aperture.

METHODS

A prospective study that included 17 trans-tibial double bundle anterior cruciate ligament (ACL) patients was conducted for the evaluation of serial computed tomography (CT) scan. The OsiriX was used for remodeling of CT images with a tunnel direction. Tunnel widening and change of the aperture morphology were assessed.

RESULTS

With regard to the comparison of tunnel widening of the anteromedial (AM) tunnel, the entrance (p=0.01) and mid (p=0.02) of the coronal image, and the entrance (p < 0.01) and mid (p < 0.01) of the sagittal image showed statistically significant differences. The entrance (p=0.01) of the sagittal image only showed statistical significance in the posterolateral (PL) tunnel. With regard to the comparison between the AM and PL tunnels, the mid-portion (p = 0.04) of the sagittal image showed statistical differences, and the AM tunnel showed larger widening than the PL tunnel. Change of tunnel aperture was observed in the posterior, medial, and lateral portions of the AM tunnel and the anterior, posterior, and lateral portions of the PL tunnel.

CONCLUSIONS

In some aspects, occurrence of tunnel widening was observed in most sites. Widening occurred mainly at the entrance and mid-portions of the AM tunnel and the entrance of the PL tunnel. Change of tunnel aperture was observed at most directions in both tunnels. This is a non-anatomic ACL reconstruction and similar study with anatomic ACL reconstruction would be required in the future.

Validation and reliability of a smartphone application for the International Prostate Symptom Score questionnaire: a randomized repeated measures crossover study

Background

Smartphone-based assessment may be a useful diagnostic and monitoring tool for patients. There have been many attempts to create a smartphone diagnostic tool for clinical use in various medical fields but few have demonstrated scientific validity.

Objective

The purpose of this study was to develop a smartphone application of the International Prostate Symptom Score (IPSS) and to demonstrate its validity and reliability.

Methods

From June 2012 to May 2013, a total of 1581 male participants (≥40 years old), with or without lower urinary tract symptoms (LUTS), visited our urology clinic via the health improvement center at Soonchunhyang University Hospital (Republic of Korea) and were enrolled in this study. A randomized repeated measures crossover design was employed using a smartphone application of the IPSS and the conventional paper form of the IPSS. Paired t test under a hypothesis of non-inferior trial was conducted. For the reliability test, the intraclass correlation coefficient (ICC) was measured.

Results

The total score of the IPSS (P=.289) and each item of the IPSS (P=.157-1.000) showed no differences between the paper version and the smartphone version of the IPSS. The mild, moderate, and severe LUTS groups showed no differences between the two versions of the IPSS. A significant correlation was noted in the total group (ICC=.935, P<.001). The mild, moderate, and severe LUTS groups also showed significant correlations (ICC=.616, .549, and .548 respectively, all P<.001).There was selection bias in this study, as only participants who had smartphones could participate.

Conclusions

The validity and reliability of the smartphone application version were comparable to the conventional paper version of the IPSS. The smartphone application of the IPSS could be an effective method for measuring lower urinary tract symptoms.

A pulled sutures technique for bony Bankart lesion

In an attempt to present a new surgical technique for arthroscopic bony Bankart fixation, the authors developed the pulled sutures technique. In executing the new method, the authors first passed several non-absorbable sutures through labroligamentous tissue with displaced articular fragment by mimicking transglenoid suture technique. Aimed at achieving a safe and stable fixation, using a knotless anchor rather than transglenoid suture, was deployed. Overall, this pulled sutures technique was shown to be effective with the result of direct reduction, stable, and safe fixation for bony Bankart's lesion.

Bilateral PCL hypoplasia resulting in posterior, posterolateral rotatory instability and tears of the lateral meniscus anterior horn

This article describes a case of bilateral sagged knees presenting as posterior, posterolateral rotatory instability with tears of the anterior horn of the lateral meniscus. Each knee had identical tears of the lateral meniscus anterior horn. A 42-year-old woman reported bilateral anterior knee pain and painful instability during running or jarring exercises. She reported no major trauma to her knees. Arthroscopic findings of her right knee revealed a posterior cruciate ligament that looked hypoplastic but was without acute injury, and the anterior horn of the lateral meniscus showed chronic complex tears with some degeneration. Posterior cruciate ligament reconstruction, posterolateral corner sling, and meniscal repair of the lateral meniscus anterior horn was performed on her right knee. Three months later, a similar operation was performed on her left knee. However, menisectomy was performed because the lateral meniscus anterior horn tear was in the junction of the red-white and white zones. At 18 months postoperatively, the patient reported no symptoms and was satisfied with her results. Physical examination showed no joint line tenderness, and posterior stress radiographs on both knees showed grade I posterior instability. She showed no posterolateral subluxaion by supine dial test, and her prone dial test also improved approximately 15° on both knees. Lysholm score was 74 preoperatively and improved to 92 postoperatively.