Evaluation of Contact Area and Pressure After Malreduction in Isolated Medial Malleolar Fractures With 2 mm of Displacement: A Cadaveric Study

This study was performed to evaluate the changes in contact area and pressure in the tibiotalar joint, with a 2 mm displacement after IMMF (isolated medial malleolar fracture). Ten cadavers with pairs were used to establish a situation in which IMMF occurred during ankle injury. We performed IMMF corresponding to types C and D of the Herscovici classification, and it was displaced by 2 mm. The normal group was defined as a normal tibiotalar joint, the TF (transverse fracture) group as a 2 mm transverse displacement corresponding to the Herscovici classification type C, and the OF (oblique fracture) group as a 2 mm oblique displacement corresponding to the Herscovici classification type D. We measured the contact area and pressure at the tibiotalar joint. The film was scanned and analyzed using the digital imaging software, Scion Image (Scion Crop. Frederick, MD). In normal group, the average contact area of the tibiotalar joint was 317 mm2 (IQR; interquartile range, 256; 347) and 308 mm2 (IQR, 262; 364), average pressure was 2.19 N/mm2 (IQR, 1.94; 2.27) and 2.15 N/mm2 (IQR, 2.06; 2.53). In the TF and OF groups, the average contact area of the tibiotalar joint decreased by 9% and 12%, respectively, and the average pressure increased by 8% and 14%, respectively. There was no statistical difference in peak pressure between the normal, TF, and OF groups. In the case of transverse and oblique fractures, a 2 mm displacement showed significant changes in contact area and contact pressure compared to the normal tibiotalar joint, but there were no significant changes pertaining to type, between the 2 fractures.

Clinical utility of skin perfusion pressure measurement in diabetic foot wounds: An observational study

The degree of blood vessel stenosis significantly influences diabetic foot treatment. This study aimed to investigate the association between computed tomography angiography (CTA) stenosis and skin perfusion pressure (SPP), which are noninvasive vascular assessments used to evaluate diabetic foot wounds. Forty patients who reported diabetic foot wounds between November 2016 and December 2017 were included in the study. SPPand CTA were performed to evaluate the blood flow, and the rate of decrease in wound size was measured for the wounds corresponding to Meggitt-Wagner grade 1 at the first evaluation and 4-week intervals. The P value of the association between the degree of CTA stenosis and the SPP value was 0.915, and the P value of the association between CTA stenosis and decreasing rate of wound size was .235. There was no statistically significant association between SPP and the decreasing rate of wound size according to the degree of CTA stenosis. The association between SPP value and the decreasing rate of wound size was statistically significant (P < .05). The decreasing rate in diabetic foot wound size was significantly associated with SPP but not with CTA stenosis.

A Huge Plantar Intramuscular Hemangioma in the Plantar Area Treated Surgically: A Case Report and Literature Review

Intramuscular hemangioma (IH) is rare, accounting for only 0.8% of all hemangioma cases. In particular, IH of the foot has only been reported a few times. In such cases, the symptoms typically include tenderness and swelling, often in relation to physical activity, but tingling or impaired function may also be present. Here, we report a patient who presented with a significant IH in the plantar area treated surgically. A 25-year-old female visited our hospital with pain in the plantar aspect of the right foot. She had noticed a mass about 10 years prior. She had previously experienced pain only when pressing the mass, but the pain subsequently became more regular pain and was exacerbated by exercise. In fact, the pain became so intense that she could not sleep well. Upon physical examination, mild swelling and tenderness of the plantar area were noted in the second to the fourth metatarsal. Sensation and motor reflexes were normal and the results of Tinel’s test were negative. Plain radiographs of the right foot revealed phleboliths scattered throughout the first to third intermetatarsal spaces. Magnetic resonance imaging revealed a space-occupying multilobulated mass (5.6 × 2.8 × 2.5 cm) located in the flexor digitorum brevis (FDB) muscle, which penetrated the plantar fascia and spread to the subcutaneous layer. In T2-weighted images, the lesion displayed a hyperintense signal compared to the surrounding skeletal muscle. Based on radiological findings, we suspected IH. The mass surrounded by the FDB muscle was exposed and completely removed via wide excision. IH consisting of cavernous-like vascular structures was diagnosed on pathology. At 1-year follow-up, the patient was almost asymptomatic and had recovered almost full range of motion in the plantar area. Histological analysis and surgery are recommended to remove intramuscular hemangiomas in the plantar area, but if the patient is not suitable for surgery, sclerotherapy or combination treatment should also be considered.

Knotless All-Inside Arthroscopic Modified Broström Procedure for Lateral Ankle Instability

One reported complication of the arthroscopic modified Broström operation is pain caused by the suture anchoring knot. We hypothesized that a knotless technique could reduce such pain. Therefore, in this study we evaluated the clinical and radiological outcomes after knotless all-inside arthroscopic modified Broström operation for lateral ankle instability. From July 2017 to November 2017, 28 patients were treated. Clinical and radiological features were evaluated preoperatively and 3, 6, and 12 months postoperatively using the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale score, visual analogue scale score for pain, anterior talar drawer test, and talar tilt angle. The mean age of the 28 patients (14 men, 14 women) was 41.71 ± 17.19 years. Three (10.7%) complications, but no knot-associated pain, occurred. The clinical and radiological outcomes were significantly improved 12 months postoperatively compared with preoperative outcomes (all p < .05). Knotless all-inside arthroscopic modified Broström operation for lateral ankle instability avoided knot-associated pain and improved not only patient satisfaction but also clinical and radiological outcomes.

Comparison of Open Anterior Syndesmotic Repair Augmented With Suture-Tape and Trans-syndesmotic Screw Fixation: A Biomechanical Study

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.

Pure isolated medial talonavicular joint dislocation following low-energy trauma: a case report

Midtarsal dislocations are relatively rare injuries secondary to high-energy trauma and are typically accompanied by disruption of ligamentous structures and fractures of the midfoot. We herein present a case of a pure isolated medial swivel dislocation of the talonavicular joint (TNJ) that was sustained following low-energy trauma without an associated fracture. A 78-year-old woman visited our emergency department with severe pain in the midfoot area of the right foot without neurovascular deficits. She had sustained this injury after severe ankle inversion while going downstairs. Plain radiographs of the right foot showed that the navicular was dislocated medially on the talus; no other malalignments were present. Three-dimensional computed tomography revealed dislocation of the TNJ, but no other tarsal or midtarsal bone fractures or dislocations. A medial dorsal incision was made to expose the TNJ. The dorsal talonavicular ligament was ruptured and interposed between the navicular and talus. The ligament was removed and the TNJ was reduced. The clinical outcome at the 1-year follow-up was satisfactory with no limitations in daily activities. In summary, we have reported an extremely rare case of a pure isolated medial TNJ dislocation in which the interposed dorsal talonavicular ligament served as an obstacle to reduction.

Comparison of Outcome of Deltoid Ligament Repair According to Location of Suture Anchors in Rotational Ankle Fracture

BACKGROUND

The suture anchors for the repair of deltoid ligament in rotational ankle fracture are inserted mostly into the medial malleolus, but sometimes are placed into the talus depending on the rupture site. This study sought to compare the radiological and clinical outcomes of deltoid ligament repair according to using these 2 locations for suture anchor placement.

METHODS

The cases of 131 patients (114 patients with suture anchors on the medial malleolus and 17 patients with suture anchors on the talus) who underwent deltoid ligament repair along with ankle fracture fixation were retrospectively reviewed. Medial clear space oblique (MCSo), medial clear space perpendicular (MCSp), tibiofibular clear space (TFCS), and tibiofibular overlap (TFO) were measured as radiological outcomes, while the Olerud-Molander Ankle Score (OMAS) and visual analog scale (VAS) score for pain were calculated as clinical outcomes. The follow-up period did not differ between the 2 groups (16.8 ± 10.9 months in the medial malleolus group vs 17.9 ± 14.3 months in the talus group; P = .670).

RESULTS

There were no differences in MCSo, MCSp, TFCS, and TFO at 3 months after surgery and final follow-up. The OMAS and VAS for pain did not show intergroup differences at final follow-up.

CONCLUSION

The surgical outcome of deltoid ligament repair in rotational ankle fracture did not differ whether the suture anchors were inserted into the medial malleolus or into the talus.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Direct reconstruction of chronic extensor digitorum longus tendon rupture using interposed scar tissue in the foot: A case report

RATIONALE

Primary repair of acute ligament injury is possible due to the proximity of the ends. In the case of chronic injury, however, primary repair is difficult because the ends of ruptured ligament will have receded, and tendon graft, transfer, or reconstruction is needed. Satisfactory clinical results have been reported after reconstruction with newly formed interposed scar tissue between the ends of the ruptured tendon in chronic Achilles tendon injury and chronic extensor halluces longus (EHL) tendon injury. Here, we report a patient treated with reconstructive surgery using well-formed scar tissue between the ends in a case of chronic EDL tendon rupture.

PATIENT CONCERNS

A 34-year-old woman visited the clinic with pain in the dorsum aspect of the right foot associated with weakness and loss of extension of the second toe. She had sustained an injury to the dorsal aspect of her foot by falling on broken glass 3 months before coming to our clinic. The patient reported pain and limitation of the extension of the second toe for 2 months. Her pain continued to worsen, and 1 month later she was transferred to our hospital because a different local clinician suspected she had ruptured her second EDL tendon.

DIAGNOSIS

Magnetic resonance imaging (MRI) revealed complete rupture of the second EDL tendon at the metatarsal neck junction, with displacement of the distal end to the proximal phalanx shaft area and of the proximal end to the metatarsal shaft area.

INTERVENTIONS

Chronic rupture of the EDL tendon was treated with direct reconstruction using interposed scar tissue.

OUTCOMES

At the 3-month follow-up, the patient was almost asymptomatic and had nearly full range of motion in dorsiflexion of the second toe. She has no discomfort in her daily life and has returned to almost her preoperative level of functional activities.

LESSONS

Here, we presented an extremely rare case of reconstruction using interposed scar tissue in a patient with neglected EDL tendon rupture. Direct reconstruction using interposed scar tissues located between the ends of the ruptured tendon is considered a reliable method with satisfactory clinical results in carefully selected patients.

Tarsal tunnel syndrome caused by posterior facet talocalcaneal coalition: A case report

RATIONALE

Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve and its branches. Tarsal coalition is defined as a fibrous, cartilaginous, or osseous bridging of 2 or more tarsal bones. TTS with tarsal coalition is uncommon. Here, we present a rare example of successful surgical management of TTS with posterior facet talocalcaneal coalition.

PATIENT CONCERNS

A 74-year-old woman presented with hypoesthesia, numbness, and an intermittent tingling sensation on the plantar area over the right forefoot to the middle foot area. The hypoesthesia and paresthesia of the right foot began 6 years previously and were severe along the lateral plantar aspect. The symptoms were mild at rest and increased during daily activities. Tinel sign was positive along the posteroinferior aspect of the medial malleolus.

DIAGNOSIS

Lateral ankle radiography showed joint-space narrowing and sclerotic bony changes with a deformed C-sign and humpback sign. Oblique coronal and sagittal computed tomography revealed an irregular medial posterior facet, partial coalition, narrowing, and subcortical cyst formation of the posterior subtalar joint. Magnetic resonance imaging showed an abnormal posterior talocalcaneal coalition compressing the posterior tibia nerve. Electromyography and nerve conduction velocity studies were performed, and the findings indicated that there was an incomplete lesion of the right plantar nerve, especially of the lateral plantar nerve, around the ankle level.

INTERVENTIONS

Surgical decompression was performed. Intraoperatively, the lateral plantar nerve exhibited fibrotic changes and tightening below the posterior facet talocalcaneal coalition. The coalition was excised, and the lateral plantar nerve was released with soft-tissue dissection.

OUTCOMES

The patient's symptoms of tingling sensation and hypoesthesia were almost relieved at 4 months postoperatively, but she complained of paresthesia with an itching sensation when the skin of the plantar area was touched. The paresthesia had disappeared almost completely at 8 months after surgery. She had no recurrence of symptoms at the 1-year follow-up.

LESSONS

The TTS with tarsal coalition is rare. Supportive history and physical examination are essential for diagnosis. Plain radiographs and computed tomography or magnetic resonance imaging are helpful to determine the cause of TTS and verify the tarsal coalition. After diagnosis, surgical excision of the coalition may be appropriate for management with a good outcome.

Presence of Subfibular Ossicle Does Not Affect the Outcome of Arthroscopic Modified Broström Procedure for Chronic Lateral Ankle Instability

PURPOSE

To evaluate the clinical and radiological outcomes of the all-inside, arthroscopic, modified Broström procedure (MBP) used to treat chronic lateral ankle instability (CLAI) according to subfibular ossicle (SFO) status.

METHODS

Between January 2013 and September 2016, we retrospectively analyzed CLAI patients who underwent the arthroscopic MBP. When performing the arthroscopic MBP, SFO was removed with all inside technique regardless of size. Patients who were not followed for more than a minimum of 12 months after surgery were excluded. The patients were divided into 2 groups: ankles with SFOs were assigned to the SFO group and the others to the non-SFO (NSFO) group. The evaluation tools used included the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, a pain visual analog scale, and the talar tilt angle.

RESULTS

Following the inclusion criteria, we included 125 patients (125 ankles) in this study. The SFO group consisted of 26 patients and the NSFO group consisted of 99 patients. The preoperative scores in the 2 groups shows no significant difference except for AOFAS scores. The final AOFAS scores in both groups improved compared with the preoperative scores (18.4 ± 16.3 and 22.1 ± 21.6 for the SFO and NSFO groups, respectively). The final follow-up visual analog scale scores also improved in both groups (5.0 ± 1.7 and 5.2 ± 1.4, respectively). The mean ± standard deviation talar tilt improved from 8.7 ± 5.0° preoperatively to 4.6 ± 3.6° at the final follow-up in the SFO group, and from 7.3 ± 4.4° preoperatively to 3.2 ± 3.0° at the final follow-up in the NSFO group. Neither the preoperative nor final talar tilt angle differed between the 2 groups (P = .300 and P = .072, respectively).

CONCLUSIONS

All-inside arthroscopic MBP after SFO resection was as successful as the same surgery without SFO resection. The clinical outcomes of the SFO and NSFO groups did not differ. Both groups achieved successful radiological outcomes at the last follow-up. All-inside arthroscopic MBP is a reliable treatment for CLAI patients regardless of SFO status.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Retracted: Degree of the Hazards of Silver-Containing Dressings on MRSA-Infected Wounds in Sprague-Dawley and Streptozotocin-Induced Diabetic Rats

The Editor and Publisher regretfully have to retract the following two publications due to faulty study design.

Retracted: Comparison of DNA Damage and Apoptosis Induced By Silver Nanoparticle-containing Dressing Materials During Wound Healing

The Editor and Publisher regretfully have to retract the following two publications due to faulty study design.

Infiltrating angiolipoma of the foot: magnetic resonance imaging features and review of the literature

Angiolipoma is a benign soft tissue tumor with two subtypes: non-infiltrating and infiltrating. Although histologically benign, infiltrating angiolipoma can invade surrounding structures. The foot is a very rare location for angiolipoma, with only four cases reported in the English literature, including one infiltrating type. Here, we report a very rare case of infiltrating angiolipoma of the foot with magnetic resonance imaging (MRI) and ultrasonography (US) findings. A 7-year-old boy presented with a slowly growing foot mass. MRI showed an unencapsulated mass involving the third web space extending to the foot dorsum and sole. The mass was isointense to subcutaneous fat and was mixed with internal T1 low-signal-intensity enhancing areas. On US, we observed a heterogeneously hypoechoic mass with internal vascularity. Imaging and clinical features of angiolipoma and the radiologic differential diagnoses of a fat-containing mass in the pediatric foot are reviewed here. When there is an ill-defined foot mass with a fat component and variable enhancing portions in a child, infiltrating angiolipoma should be included in the differential diagnosis along with other fat-containing tumors.

Comparison of DNA Damage and Apoptosis Induced By Silver Nanoparticle-containing Dressing Materials During Wound Healing

INTRODUCTION

Silver nanoparticle (AgNP)-containing dressings are used worldwide for the treatment of wounds; however, many studies have indicated that AgNPs are toxic to humans and cause cell death, primarily via apoptosis.

OBJECTIVE

In this study, the investigators compare the apoptotic effects of various AgNP dressing materials, with the hypothesis that nanosilver would be less toxic than ionic silver.

MATERIALS AND METHODS

For the in vivo experiments, Sprague-Dawley (SD) and streptozotocin (STZ)-induced diabetic rats were treated with 5 dressing materials: Aquacel Ag (product A, silver ion; ConvaTec, Berkshire, UK), Acticoat (product B, AgNP; Smith & Nephew, Fort Worth, TX), Medifoam Silver (product C, silver ion; Genewel Science Co Ltd, Seongnam, South Korea), PolyMem Silver (product D, AgNP; Ferris Mfg Corp, Fort Worth, TX), and Vaseline-impregnated dressing gauze (control; Unilever, London, UK). All treatments were applied 3 times per week. After 14 days of treatment, the SD and STZ rats were euthanized, and wound samples were examined for apoptosis. The analysis included immunohistochemistry, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining, Western blotting, and reverse transcription polymerase chain reaction for a semiquantitative evaluation of apoptosis.

RESULTS

The AgNP-containing dressing materials were more cytotoxic than the silver dressings. Compared with the AgNP dressing materials, no significant levels of apoptotic factors were observed in the silver dressing-treated wounds. The TUNEL staining showed that product C-dressed wounds contained the most apoptotic cells, while some apoptotic cells were observed in product B-dressed wounds. Moreover, apoptotic gene expression was altered, including a decline in B-cell lymphoma-2 and activation of caspase-3. This was most evident in wounds treated with product C. Interestingly, apoptotic gene expression was not induced in product A-treated wounds. Finally, product D had a relatively lower silver concentration and was less toxic than products A-C.

CONCLUSIONS

Dressing materials containing AgNP have an antimicrobial effect. However, the authors observed that some AgNP dressings induced DNA damage and apoptosis. Although AgNP dressings did not cause significant acute apoptotic effects, they should be examined for cytotoxic effects in chronic wounds and should be used with caution when treating chronic wounds and those with low bacteria counts.

Comparison of Outcomes in Patients With Generalized Ligamentous Laxity and Without Generalized Laxity in the Arthroscopic Modified Broström Operation for Chronic Lateral Ankle Instability

BACKGROUND

The arthroscopic modified Broström operation (MBO) has been frequently used to treat chronic lateral ankle instability (CLAI). However, no reports comparing the clinical outcomes between patients with or without generalized ligamentous laxity (laxity or no laxity, respectively) currently exist. The purpose of this study was to compare the clinical outcomes of the 2 groups with CLAI.

METHODS

Between January 2013 and November 2015, arthroscopic MBO was performed on 99 patients with CLAI. Patients were divided into 2 groups: the laxity group (24 ankles) and no laxity group (75 ankles). Generalized ligamentous laxity was defined as a Beighton score of 4 or more points. Evaluation tools included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot ankle score, a pain visual analog scale (VAS), and talar tilt angle.

RESULTS

The change in talar tilt angle from preoperative to 12 months postoperative was significantly greater in the laxity group (-6.9 ± 5.2) compared with the no-laxity group (-4.2 ± 4.2) ( P = .03). The final follow-up AOFAS hindfoot ankle score and pain VAS in both groups showed improvement compared with the preoperative values.

CONCLUSION

All groups achieved successful clinical and radiological final follow-up outcomes. Arthroscopic MBO should be considered a reasonable method in patients who have chronic lateral ankle instability, regardless of generalized ligamentous laxity.

LEVEL OF EVIDENCE

III, comparative study.

Changes in ankle joint motion after Supramalleolar osteotomy: a cadaveric model

Background

Malalignment of the ankle joint has been found after trauma, by neurological disorders, genetic predisposition and other unidentified factors, and results in asymmetrical joint loading. For a medial open wedge supramalleolar osteotomy(SMO), there are some debates as to whether concurrent fibular osteotomy should be performed. We assessed the changes in motion of ankle joint and plantar pressure after supramalleolar osteotomy without fibular osteotomy.

Methods

Ten lower leg specimens below the knee were prepared from fresh-frozen human cadavers. They were harvested from five males (10 ankles)whose average age was 70 years. We assessed the motion of ankle joint as well as plantar pressure for SS(supra-syndesmotic) SMO and IS(intra-syndesmotic) SMO. After the osteotomy, each specimen was subjected to axial compression from 20 N preload to 350 N representing half-body weight. For the measurement of the motion of ankle joint, the changes in gap and point, angles in ankle joint were measured. The plantar pressure were also recorded using TekScan sensors.

Results

The changes in the various gap, point, and angles movements on SS-SMO and IS-SMO showed no statistically significant differences between the two groups. Regarding the shift of plantar center of force (COF) were noted in the anterolateral direction, but not statistically significant.

Conclusions

SS-SMO and IS-SMO with intact fibula showed similar biomechanical effect on the ankle joint. We propose that IS-SMO should be considered carefully for the treatment of osteoarthrosis when fibular osteotomy is not performed because lateral cortex fracture was less likely using the intrasyndesmosis plane because of soft tissue support.

Evaluation of the Effects of Air Pollutants on Diabetic Wounds

BACKGROUND

Although air pollution containing fine dust particles is gaining attention worldwide, little is known about the effects of such pollutants on diabetic wounds. Air pollutants from diesel exhaust particles (DEPs) cause inflammation, resulting in an increased expression of pro-inflammatory cytokines and chemo- kines, which attract monocytes and T cells to the sites of inflamma- tion. The authors evaluated the effects of air pollutants on diabetic wounds.

MATERIALS AND METHODS

Fibroblast cells were derived from streptozotocin-induced diabetic rats. Cell Counting Kit-8 assays were used to determine cell viability. The expression of pro-inflammatory cytokines including tumor necrosis factor-α (TNF-α), cyclooxygen- ase-2 (COX-2), and interleukin-6 (IL-6) was evaluated by reverse transcription polymerase chain reaction and western blot analysis.

RESULTS

The proliferation of DEP-treated fibroblasts decreased with time. The messenger ribonucleic acid expression of TNF-α and COX- 2 in DEP-treated fibroblasts increased in both normal and diabetic fibroblasts, while IL-6 expression remained unchanged. The protein expression of TNF-α, COX-2, and IL-6 in DEP-treated fibroblasts increased compared to samples not exposed to DEP.

CONCLUSIONS

Diesel exhaust particles regulate the expression of pro-inflammatory cytokines such as IL-6, TNF-α, and COX-2, which may impede dia- betic healing in vitro.

Comparison of All-Inside Arthroscopic and Open Techniques for the Modified Broström Procedure for Ankle Instability

BACKGROUND

No reported study has compared clinical and radiologic outcomes between an all-inside arthroscopic modified Broström operation (MBO) and an open MBO. The purpose of this study was to compare clinical and radiologic outcomes of all-inside arthroscopic and open MBOs.

METHODS

From August 2012 to July 2014, 48 patients were included. They were divided into 2 groups: all-inside arthroscopic MBO (25 patients) and open MBO (23 patients). The American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score, and Karlsson score were used to evaluate clinical outcomes. Anterior talar translation and talar tilt were used to evaluate radiologic outcomes. All patients had lateral ankle instability. MBO was performed in 87 patients. Of these, 50 patients met the inclusion criteria. All patients had giving way, persistent pain, and an inability to resume their preinjury activity level for more than 6 months. Patients were randomized into 2 groups, all-inside arthroscopic MBO and open MBO, using a permuted block randomization method. Clinical outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum of 12 months postoperatively using the Karlsson score, the AOFAS ankle-hindfoot score, and pain VAS scores. Radiologic outcome evaluations were performed preoperatively and at 1 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle.

RESULTS

After randomization, 25 ankles were allocated to the all-inside arthroscopic MBO group and 25 to the open MBO group. Two ankles in the open MBO group were excluded from the analysis because they were lost to follow-up. Thus, evaluations were performed for 25 ankles in the all-inside arthroscopic MBO group and 23 in the open MBO group. There was no difference in age, gender, symptom duration, preoperative AOFAS, VAS, Karlsson scores, anterior talar translation, or talar tilt between the 2 groups (all P > .05). At the final follow-up, the AOFAS, VAS, and the Karlsson scores had improved significantly in both groups (P < .001). There was no difference in the Karlsson, AOFAS, or VAS scores, anterior talar translation, or talar tilt between the 2 groups at final follow-up (all P > .05).

CONCLUSIONS

There was no difference in the clinical or radiologic outcome between the all-inside arthroscopic MBO and open MBO for the treatment of lateral ankle instability at up to 1 year after surgery. An all-inside arthroscopic MBO should be considered carefully in patients who have lateral ankle instability.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

2016 Roger A. Mann Award - Comparison of All-Inside Arthroscopic and Open Techniques in Treatment for Chronic Lateral Ankle Instability

Category:

Sports.

Introduction/Purpose:

The modified Broström operation (MBO) is frequently used to treat chronic lateral ankle instability. The open MBO is currently the gold standard procedure for treatment of chronic lateral ankle instability. The all-inside arthroscopic MBO has been developed for chronic lateral ankle instability. Clinical outcome of all-inside arthroscopic MBO was reported as good or excellent. Biomechanically, the stiffness, torque to failure, and degree to failure of all-inside arthroscopic MBO and open MBO have the same results. But there were no report about comparison of clinical outcome between all-inside arthroscopic MBO and open MBO for chronic lateral ankle instability. The purpose of this study is to compare the clinical outcomes of the all- inside arthroscopic MBO and open MBO for chronic lateral ankle instability.

Methods:

From September 2013 to August 2014, MBO was performed in 87 patients. Of these, 50 consecutive patients were included in terms of inclusion criteria. All patients had giving way, persistent pain and an inability to resume one’s preinjury activity level for more than 6 months. Patients were randomized into 2 groups: all-inside arthroscopic MBO and open MBO using permuted block randomization method. Evaluation was performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up a minimum of 12 months postoperatively using the Karlsson score, the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot ankle score, pain Visual Analogue Scale (VAS), anterior talar translation, and talar tilt angle.

Results:

After randomization, 25 ankles were allocated in the all-inside arthroscopic MBO group, and 25 ankles were placed in the open MBO group. Two ankles in the open MBO group were excluded from analysis due to loss of follow-up. Therefore the evaluation was performed for 25 ankles in the all-inside arthroscopic MBO group and 23 ankles in the open MBO group. There were no differences in age, sex, symptom duration, preoperative Karlsson, AOFAS, and VAS scores between the 2 groups (P >.05). At final follow-up, the Karlsson, AOFAS, and VAS scores were significantly improved in both groups (P < .001). There were no differences in the Karlsson, AOFAS, VAS scores, anterior talar translation and talar tilt angle between the 2 groups at final follow-up (P >.05).

Conclusion:

There was no difference in the clinical evaluation and radiologic evaluation between all-inside arthroscopic MBO group and open MBO group at a minimum 12 months follow-up. All-inside arthroscopic MBO should be carefully considered as a reasonable alternative method in patients who have chronic lateral ankle instability.

Relationship of Sesamoid Position and Other Radiographic Measurements in Hallux Valgus

Category:

Midfoot/Forefoot

Introduction/Purpose:

Many radiographic measurements have been developed and used for evaluating hallux valgus, but their relationships have not been clearly established. The purpose of the present study was to investigate the relationship and reliability of sesamoid position and other radiographic measurements in hallux valgus.

Methods:

We included 180 patients(mean age 52 years; 18 males and 162 females) with weightbearing plain radiograph. In anteroposterior view, hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, proximal phalangeal articular angle, hallux interphalangeal angle, sesamoid subluxation and metatarsophalangeal congruency were measured. In lateral view, Meary angle(tarso-1st metatarsal angle) was measured. 3 trained observers measured. Correlations among the radiographic measurements were analyzed. Relationship of sesamoid position and other radiographic measurements were evaluated using ANOVA or Fisher’s exact test.

Results:

The sesamoid subluxation had the correlation with the hallux valgus angle (p < 0.001), intermetatarsal angle (p < 0.001) and metatarso-phalangeal joint congruency (p < 0.001). As the sesamoid subluxation grade increased, the metatarso-phalangeal joint congruency was non-congruent joint. In intraobserver reliability, the hallux valgus angle showed the highest ICC value (0.989; 95% CI, 0.984–0.992)

Conclusion:

we suggest that the measurements of sesamoid subluxation in assessments of hallux valgus deformity may be helpful for operation and degree of metatarsophalangeal congruency.

Can Bassett's ligament be removed?

PURPOSE

To investigate the functional characteristics of Bassett's ligament in the ankle, focusing on mechanoreceptors and potential problems following resection of Bassett's ligament.

METHODS

Bassett's ligament, the anterior talofibular ligament (ATFL), and synovium were obtained from 20 ankles of 10 fresh-frozen cadavers. Histologically, mechanoreceptors were identified and classified as Ruffini (type I), Vater-Pacini (type II), Golgi-Mazzoni (type III) corpuscles, and free nerve endings (type IV). Differences in receptor densities were compared.

RESULTS

Type I clusters were observed with three to six ramifications; type II mechanoreceptors were encapsulated in clusters of two to four with ovoid or cylindrical shape; type III were amorphous, long and wide, and fusiform- or spindle-shaped; and type IV were long and fine without a defined shape. Differences in the densities of the mechanoreceptors inside three soft tissues (Bassett's ligament, ATFL, and synovium) were not significant.

CONCLUSION

There were no significant differences in the densities of the four types of mechanoreceptors among the soft tissues studied. In Bassett's ligament, type I mechanoreceptors were present at significantly higher densities than the other receptors.

Safe Zone for Medial Open-Wedge Supramalleolar Osteotomy of the Ankle: A Cadaveric Study

BACKGROUND

The purpose of this present study was to determine the incidence of lateral cortical fracture depending on the plane of osteotomy in medial open-wedge supramalleolar osteotomy (SMO) and to define a safe zone through which a medial open-wedge SMO could be performed with minimal risk of lateral cortical fracture.

MATERIALS AND METHODS

Matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from 7 males and 3 females (average age = 63.9 [range 49-75] years). In group A, a safe zone-level medial open-wedge SMO (plane of osteotomy oriented to the proximal one-third of the intrasyndesmosis) was performed, and in group B, a higher-level medial open-wedge SMO (plane of osteotomy oriented to the suprasyndesmosis) was performed.

RESULTS

In group A, 7 of the 10 limbs had no lateral cortical fracture, and 3 had lateral cortical fracture, but all of the fractured limbs were stable during the medial open-wedge SMO procedure. In group B, 2 of 10 limbs had no lateral cortical fracture and 8 had lateral cortical fracture. Three of the 8 fractured limbs were stable, but 5 were unstable during the medial open-wedge SMO procedure. The incidence of lateral cortical fracture in group B was significantly higher compared to group A (P = .04).

CONCLUSIONS

According to the present findings, lateral cortical fracture was less likely to occur when open-wedge SMO was at the plane of the proximal one-third of the intrasyndesmosis, the so-called "safe zone," than at the plane of the suprasyndesmosis.

CLINICAL RELEVANCE

A safe zone for medial open-wedge SMO to prevent lateral cortical fracture during the medial open-wedge SMO procedure was identified.

Talocalcaneal coalition: A focus on radiographic findings and sites of bridging

BACKGROUND

Verifying the exact location of talocalcaneal (TC) coalition is important for surgery, but the complicated anatomy of the subtalar joint makes it difficult to visualize on radiographs. No study has used computed tomography (CT) or magnetic resonance imaging (MRI) to verify the radiological characteristics of TC coalition or those of different facet coalitions. Therefore, this study verified the radiological findings used to identify TC coalitions and those of different facet coalitions using CT and MRI.

MATERIALS AND METHODS

Plain with/without weight bearing anteroposterior and lateral radiographs, CT, and MRI of 43 feet in 39 patients with TC coalitions were reviewed retrospectively. CT or MRI was used to verify the location of the TC coalition. Secondary signs for the presence of a coalition in the anteroposterior and lateral plain radiographs, including talar beak, humpback sign, duck-face sign, and typical or deformed C-sign, were evaluated. Three independent observers evaluated the radiographs twice at 6-week intervals to determine intraobserver reliability. They examined the radiographs for the secondary signs, listed above, and coalition involved facets.

RESULTS

The average rates from both assessments were as follows: Middle facet 5%, middle and posterior facets 27%, and posterior facet 68%. The deformed C-sign is more prevalent in posterior facet coalitions. The posterior facet has the highest prevalence of involvement in TC coalitions, and the deformed C-sign and duck-face sign have high correlations with TC coalitions in the posterior subtalar facet.

CONCLUSION

A posterior facet is the most prevalent for TC coalition, and the C-sign is useful for determining all types of TC coalition.

A Specialized Fibular Locking Plate for Lateral Malleolar Fractures

We evaluated the outcomes and complications of a specialized fibular locking plate in the treatment of lateral malleolar fractures. The study included 27 patients (13 males and 14 females; mean age 46, range 16 to 73 years) with a minimum 1-year follow-up period. The study included 9 (33%) isolated lateral malleolar, 6 (23%) bimalleolar, 10 (37%) trimalleolar fractures, and 2 (7%) pilon fractures, all of which were treated using a specialized fibular locking plate for internal fixation. Bony union was monitored, and the patients' objective satisfaction was evaluated using the EQ-5D questionnaire (EuroQol Group). The patients were followed up after 1 year, and bony union was confirmed using a simple radiograph. The EQ-5D median ± standard deviation was 70 ± 15 (range 40 to 90) points at discharge, 80 ± 13 (range 40 to 90) at 6 weeks, 85 ± 11 (range 50 to 90) at 3 months, 90 ± 8 (range 60 to 90) at 6 months, and 90 ± 9 (range 70 to 95) at 1 year. Therefore, the EQ-5D score increased with time. No significant difference was found when stratified by sex or age (Mann-Whitney U test, p < .05). Eight complications (29%) developed: 1 superficial infection at the operative site, 1 case (3%) of osteomyelitis, 2 cases (7%) of an osteochondral lesion of the talus, and 5 cases (19%) of metallosis. A specialized fibular locking plate has the advantages of being an easy procedure, providing good patient satisfaction, and achieving complete bony union in all patients. However, additional complications developed compared with other well-known methods for fibular fracture treatment.

Degree of the hazards of silver-containing dressings on MRSA-infected wounds in Sprague-Dawley and streptozotocin-induced diabetic rats

Silver-containing dressings are commonly used on healing wounds, including diabetic ulcers. Some studies have shown that dressing materials with silver have negative effects on wound healing, specifically, that the wound healing process is inhibited by deposited silver. Therefore, the authors treated wounds infected with methicillin-resistant Staphylococcus aureus (MRSA) in Sprague-Dawley (SD) rats and streptozotocin (STZ)-induced diabetic rats with silver dressings to evaluate the risks of silver.

MATERIALS AND METHODS

The study used 54 SD rats and 54 STZ-induced diabetic rats. Full-thickness skin defects were created in all animals and then infected with MRSA. The rats were divided into 6 groups according to the dressing materials: nanocrystalline silver (Ac) (ACTICOAT, Smith and Nephew Healthcare, Hull, UK), silver carboxymethylcellulose (Aq) (AQUACEL Ag, ConvaTec, Bristol-Myers Squibb, Skillman, NJ), silver sulfadiazine (M) (Medifoam Silver, Biopol Global Co, Ltd, Seoul, Korea), nanocrystalline silver (P) (PolyMem Silver, Ferris Mfg Corp, Fort Worth, TX), Ilvadon cream (I) (Ildong Pharaceutical Co, Ltd, Seoul, Korea), and 10% povidone iodine (B) (Betadine, Sung Kwang Pharmaceutical Co Ltd, Gyeonggi-Do, Korea) as a control agent. Blood was collected from all animals to measure the hematological effects. The skin, spleen, liver, and kidneys of each rat were biopsied and used to make paraffin sections in which the silver deposition was measured using energy-dispersive spectrometry (EDS).

RESULTS

Fifteen days after wounding, only the Ac, P, and I groups differed significantly (P < 0.05) from the B group. The glutamic-oxaloacetic transaminase, blood urea nitrogen, and alkaline phosphatase levels differed significantly (P < 0.05) between the SD and STZ rats. No silver deposition was found in any organ.

CONCLUSION

The silver dressings induced slight liver damage in the STZ-rats. Although changes in serum chemistry caused by silver were seen, this did not indicate silver deposition in the organ as the EDS did not show excess levels. The risk of silver deposition appears to be low. The hazards of silver-containing dressing products in MRSA-infected wounds were insignificant.

Comparative Efficacy of Silver-Containing Dressing Materials for Treating MRSA-Infected Wounds in Rats with Streptozotocin-Induced Diabetes

OBJECTIVE

Silver plays an important part in severe wound management, mainly by reducing microbial growth within dressed wounds and wound beds. However, it is unknown how silver-coated dressing materials affect diabetic wounds. The purpose of this study is to evaluate the efficacy of silver-containing dressing materials for the treatment of methicillin-resistant Staphylococcus aureus (MRSA)-infected wounds in streptozotocininduced diabetic rats.

METHODS

Full-thickness skin defects were created on the backs of rats with streptozotocin (STZ)-induced diabetes (n = 108) and were infected with MRSA. The rats were assigned to 6 groups according to the wound dressing used: nanocrystalline silver (Acticoat, Smith & Nephew, Inc, London, UK), silver carboxymethylcellulose (Aquacel-Ag, ConvaTec, Skillman, NJ), silver sulfadiazine (Medifoam silver, Genewel Science Co Ltd, Seongnam, South Korea), nanocrystalline silver (Poly- Mem silver, Ferris Mfg Corp, Burr Ridge, IL), silver sulfadiazine (Ilvadon, Ildong Pharmaceuticals, Seoul, South Korea), and 10% povidone iodide (control). The wound size, histological findings, and bacterial colony count for each group was analyzed and compared to normal Sprague-Dawley rats.

RESULTS

Wound size decreased over time in every group. On day 10, a significant difference in wound area was detected between the silver dressing groups and the control group (P = 0.0040). In the wound biopsy, on days 4, 7, and 10, the would-healing effect increased in every group. However, between days 4 (P = 0.8250) and 10 (P = 0.9912), there was no statistical difference between groups. The number of bacteria in each group decreased with time in the bacterial wound culture. The silver dressing groups were more effective on antimicrobial efficacy, but there was no statistically significant difference between the silver dressing groups and the control group.

CONCLUSION

Silver-containing dressing materials are an effective method for MRSA-infected wounds, but nano silver-containing dressing materials did not have better results in a diabetic rat model compared to a normal rat model in historical review. Further investigation is necessary to determine the relative safety of these products on the healing wound. Once that is done, the relative value of the products can be determined by balancing their antimicrobial and cytotoxicity characteristics.

Comparison of sagittal subluxation in two different three-component total ankle replacement systems

BACKGROUND

Malalignment following total ankle arthroplasty (TAA) has been reported in 4% to 45% of patients. However, all reports to date have been related to coronal deformity. This study compared sagittal malalignment between the Mobility and Hintegra total ankle systems and assessed the positional stability of the implant components over time.

METHODS

The study included 50 cases each of total ankle replacement arthroplasty with the Hintegra and Mobility total ankle systems performed between May 2008 and June 2010. The Mobility group included 24 men and 25 women, and the mean age was 60.3 years (range, 50.7-70.0 years). The Hintegra group included 25 men and 25 women, and the mean age was 59.8 years (range, 50.8-68.7 years). The 2 groups did not differ in terms of gender (P = .76) or age (P = .77). Three independent observers with different levels of training evaluated the radiographs and performed the measurements independently. Each observer evaluated the radiographs twice at a 6-week interval to determine the intraobserver reliability, and the anteroposterior offset ratio was evaluated.

RESULTS

The anteroposterior offset ratio intra- and interobserver reliabilities all showed good or excellent levels of agreement in the Hintegra total ankle system and the Mobility total ankle system. With respect to the stability of sagittal translation of the talus, the Mobility system (0.08 ± 0.07 immediately, 0.0 ± 0.07 at 6 weeks postoperatively, and 0.01 ± 0.07 at 1 year postoperatively) was better than the Hintegra system (0.20 ± 0.08 immediately, 0.18 ± 0.11 at 6 weeks postoperatively, and 0.15 ± 0.10 at 1 year postoperatively) (P < .0001).

CONCLUSIONS

The Mobility system had less sagittal malalignment of the talus than the Hintegra system. Consequently, when treating ankles in patients with osteoarthritis using the Hintegra system, one must pay careful attention to sagittal malalignment during surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Evaluation of an antimicrobial silver foam dressing

CuraVAC Ag, a product that delivers negative pressure wound therapy through a polyurethane foam dressing, contains silver nanoparticles, which, when moistened with water, release silver ions onto a wound surface. The in vitro antimicrobial action of silver can destroy both gram-positive and gram-negative bacteria, as well as methicillin-resistant Staphylococcus aureus (MRSA). The purpose of this study was to assess the efficacy and in vivo outcomes of using the product.

METHODS

Thirty-six female Sprague-Dawley white rats, 8-weeks old and 250 g - 300 g in weight, were used. The experimental product was prepared using a vacuum-assisted closure (VAC) kit and coating it using the silver nanoparticles. For the control group, a 10% povidone-iodine solution was applied.

RESULTS

All groups showed decreases in wound area over time, in the order CuraVAC Ag (group A) > CuraVAC (group B) > control (group C). On the third, fifth, and seventh days, wound healing efficacy scores increased in both group A and group C. Groups A and B showed more rapid decreases than group C in bacterial culture from wounds.

CONCLUSION

CuraVAC Ag may be useful for treatment of wounds infected with bacteria..