Return to Sports Activity After Microfracture for Osteochondral Lesion of the Talus in Skeletally Immature Children

BACKGROUND

Osteochondral lesions of the talus (OLTs) are among the common sports-related injuries. However, there are few reports on the return to sports after OLT surgery in skeletally immature children. This study was performed to evaluate the return to sports after microfracture for OLTs in skeletally immature children.

METHODS

This study involved 17 ankles of 16 patients (mean age, 13.2 years; range, 10-16 years) with open tibial epiphyses on magnetic resonance imaging (MRI) who underwent microfracture for OLTs <10 mm in diameter and confirmation of lesion instability under arthroscopy. Nine of 17 ankles had additional lateral ankle ligament stabilization. All patients were participating in some form of sports. The Japanese Society for Surgery of the Foot (JSSF) score, Ankle Activity Score (AAS), return to sports rate, lesion size, grade of subchondral bone marrow edema, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score on MRI were evaluated after microfracture. The mean postoperative follow-up period was 53.5 months.

RESULTS

The mean JSSF score significantly improved from 76.1 points preoperatively to 94.9 points at the final follow-up (P < .01). The mean AAS showed no change from preoperative state to final follow-up. The return to sports rate was 100%. The lesion size significantly decreased from 76.3 to 56.7 mm2 in area (P = .02) and from 283.2 to 185.6 mm3 in volume (P = .05). The bone marrow edema grade decreased in 8 of 17 ankles. The total MOCART score showed a significant improvement from 6 months to 1 year postoperatively (P = .05).

CONCLUSION

All skeletally immature children who underwent microfracture for OLTs in this study were able to return to sports activity and showed improvements in clinical scores and MRI parameters. Microfracture may be considered an effective first-line treatment for OLTs <10 mm in diameter in skeletally immature athletes.

LEVEL OF EVIDENCE

Level IV, retrospective case-control study.

Evidence-Based Treatment Algorithm for Freiberg Disease

Freiberg disease is a type of osteonecrosis of the metatarsal head that predominantly occurs in young females and adolescents, although it may occur at any age. The pathophysiology is multifactorial and may involve trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. The most typical location is the second metatarsal head, but Freiberg disease may also occur in other lesser toes. Nonoperative treatment is best applied in the early stage of the disease; if this is ineffective, surgical treatment is recommended. Currently available surgical procedures include debridement, osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, and metatarsal shortening arthroplasty. In this article, we propose a treatment algorithm for Freiberg disease based on the current literature and expert opinion.

Side-to-side variability in the femoral neck anteversion angle: A study of the Japanese population with osteonecrosis of the femoral head

BACKGROUND

Side-to-side variability in the femoral neck anteversion angle (FA) reportedly varies from 0.0° to 17.3°. To investigate the side-to-side variability in the FA and the relationship between the FA and the morphology of the acetabulum in the Japanese population, we performed a three-dimensional computed tomography (CT)-based study involving patients with osteonecrosis of the femoral head (ONFH).

METHODS

CT data were obtained from 170 nondysplastic hips of 85 patients with ONFH. The FA and acetabular coverage parameters, including the acetabular anteversion angle, acetabular inclination angle, and acetabular sector angle in the anterior, superior, and posterior directions, were measured using three-dimensional CT. The distribution of the side-to-side variability in the FA was evaluated separately for each of the five degrees.

RESULTS

The mean side-to-side variability in the FA was 6.7° ± 5.3° (range, 0.2°-26.2°). The distribution of the side-to-side variability in the FA was 0.0°-5.0° in 41 patients (48.2%), 5.1°-10.0° in 25 patients (29.4%), 10.1°-15.0° in 13 patients (15.3%), 15.1°-20.0° in 4 patients (4.7%), and >20.1° in 2 patients (2.4%). There was a weak negative correlation between the FA and anterior acetabular sector angle (r = -0.282, P < 0.001) and a very weak positive correlation between the FA and acetabular anteversion angle (r = 0.181, P < 0.018).

CONCLUSIONS

The mean side-to-side variability in the FA was 6.7° ± 5.3° (range, 0.2°-26.2°) in Japanese nondysplastic hips, and about 20% of the patients had a side-to-side variability of >10°.

Ankle bone morphology affects the size of non-trauma related osteochondral lesions of the talus in skeletally immature children

BACKGROUND

This study aimed to elucidate the relationship between ankle morphology and the size of non-trauma related osteochondral lesions of the talus (OLT), because approximately half the OLT found in children is of unknown origin.

METHODS

34 ankles in 30 skeletally immature children with OLTs who underwent preoperative magnetic resonance imaging (MRI) were evaluated. Parameters measured included area of the OLT, tibial axis-medial malleolus angle (TMM), malleolar width (MalW), and talar surface angle (TSA; defined as the angle between the line perpendicular to the mid-diaphysis of the tibia and the talar joint surface; medial inclination, positive). The ankles were divided into two groups: the trauma group had a history of injury and the idiopathic group had no history of injury. The correlation between lesion area and MRI parameters were evaluated in each group.

RESULTS

Thirteen ankles in 13 patients comprised the trauma group, while 21 ankles in 17 patients were in the idiopathic group. Of the 17 patients in the idiopathic group, four had bilateral OLT. In the trauma group, MalW was significantly correlated with the area (r = 0.827, P = 0.0001). In the idiopathic group, TMM and MalW were significantly correlated with the area (r = 0.608, P = 0.003 and r = 0.566, P = 0.008). TSA was positively correlated with area in the idiopathic group (r = 0.516, P = 0.017), but negatively correlated with area in the trauma group (r = -0.609, P = 0.027). The other parameters showed no significant correlation.

CONCLUSIONS

The size of non-trauma related OLTs may have been affected by an ankle morphology showing poor bone conformity, such as an open medial malleolus and inclined talar joint surface. In addition, the evaluation of the contralateral ankle joint may be crucial when patients with OLT have no specific history of trauma.

Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children

Various surgical treatments are available for a symptomatic AN, including percutaneous drilling (PD). PD is reportedly effective for ANs in skeletally immature children. However, no reports have described the foot alignment after PD in skeletally immature children. This study was performed to compare the radiographic parameters between the preoperative period and the final follow-up after PD for symptomatic ANs in skeletally immature children. From October 2013 to December 2020, PD was performed on 13 feet in 10 skeletally immature children. The patients comprised 5 boys and 5 girls with a mean age at surgery of 11.9 years. The mean follow-up period was 14.8 months. We measured 5 radiographic findings preoperatively and at the final follow-up: calcaneal pitch angle (CPA), talocalcaneal angle (TCA), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (ATMA), and lateral talo-first metatarsal angle (LTMA). Ten feet were assessed as excellent, 1 as fair, and 2 as poor. Ten unions (76.9%) were achieved among the 13 feet. The mean CPA improved from 16.4 ± 4.1 degrees preoperatively to 18.2 ± 3.4 degrees at the final follow-up, the TCA improved from 43.0 ± 3.7 to 45.2 ± 4.4 degrees, and the TNCA improved from 19.9 ± 4.4 to 15.4 ± 5.0 degrees (P < .05). The ATMA and LTMA were not significantly different between the preoperative period and final follow-up. We found that PD for symptomatic ANs in skeletally immature children was effective treatment, and some radiographic parameters showed significant differences between the preoperative period and final follow-up.

Arthroscopic ankle arthrodesis in two alkaptonuria patients

Alkaptonuria is a very rare disorder in which homogentisic acid accumulates due to a deficiency in the activity of homogentisic acid 1,2 dioxygenase. This deficiency results in deposition of a yellowish-brown pigment in connective tissue. Such deposition is termed 'ochronosis' and leads to deterioration in the formation and structure of proteoglycans in hyaline cartilage. These actions lead to fragmentation and rapid destructive arthritis. Often, ochronotic arthritis appears at 40-60 years of age, and many patients are treated symptomatically. Here, we report two patients (three ankles) with ochronotic arthritis who were treated with ankle arthrodesis. In all cases, the postoperative clinical score improved, but the time needed for fusion was prolonged and symptomatic subtalar arthropathy developed in the early postoperative period.

Passive Ankle Plantarflexion Position and Skin Surface Blood Flow Adjacent to the Achilles Tendon

BACKGROUND

Open repair of the Achilles tendon carries a risk of wound complications and infection. The Achilles tendon is covered by a thin layer of skin and subcutaneous tissue, which has a fragile blood supply. The full plantarflexion position may cause sustained blanching of the skin above the Achilles tendon. However, no reports have described the in vivo blood flow (BF) changes at the skin surface with ankle position. This study aimed to use laser Doppler flowmetry to evaluate the in vivo BF at the skin surface and thereby clarify the changes in BF with ankle position.

METHODS

The study cohort comprised 30 feet in 15 participants with no history of Achilles tendon rupture. Laser Doppler flowmetry was used to measure the BF at the skin surface above the medial Achilles tendon in the natural plantarflexion (NP) and full plantarflexion (FP) positions.

RESULTS

In the NP and FP positions, the BF at 5 cm proximal to the calcaneal insertion (frequent site of Achilles tendon rupture) was 1.50 ± 0.32 and 0.97 ± 0.28 mL/min/100 g, respectively (P < .0001).

CONCLUSION

The BF at the skin surface adjacent to the medial Achilles tendon at 5 cm proximal to the calcaneal insertion was significantly less in the FP position than the NP position.

Effect of plantar fascia-specific stretching and Achilles tendon stretching on shear wave elasticity of the plantar fascia in healthy subjects

BACKGROUND

The effect of stretching on the mechanical properties of the plantar fascia (PF) remain unclear. This study was performed to determine the effect of PF-specific stretching (PFSS) and Achilles tendon stretching (ATS) on the viscoelastic properties of the PF with shear wave elastography (SWE).

METHODS

We recruited 14 participants (8 men, 6 women) with no history of PF disorders or painful episodes. The mean age of the participants was 30.9 ± 4.8 (range, 25-41) years. All participants performed sustained PFSS (sPFSS) on one foot and intermittent PFSS (iPFSS) on the other foot. Two weeks later, all participants performed sustained ATS (sATS) on one foot and intermittent ATS (iATS) on the other foot. SWE measurements were performed immediately after each stretching.

RESULTS

The PF elasticity immediately before stretching ranged from 133.8 kPa to 144.7 kPa. The PF elasticity after stretching ranged from 158.9 kPa to 215.8 kPa. There was a significant increase in PF elasticity after sPFSS, iPFSS, sATS, and iATS (P < .01). The elasticity after sATS was greater than that after iATS (P = .03). In contrast, there were no differences in PF elasticity after stretching between sPFSS and iPFSS (P = .13), sPFSS and sATS (P = .17), or iPFSS and iATS (P = .50).

CONCLUSIONS

PF elasticity increased after stretching regardless of the frequency and type of PFSS and ATS.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Influence of hindfoot alignment on postoperative lower limb alignment in medial opening wedge high tibial osteotomy

INTRODUCTION

We have experienced unexpected under-correction after medial opening wedge high tibial osteotomy (MOWHTO). Although the tibia was corrected accurately, the postoperative mechanical axis (MA) was less than 57%. The purpose of this study was to evaluate the relationship between hindfoot alignment and postoperative lower limb alignment, and to reveal whether hindfoot alignment affects lower limb alignment after MOWHTO. Our hypothesis was that hindfoot alignment influences the postoperative MA in MOWHTO.

MATERIALS AND METHODS

This study was a retrospective comparative study. The study cohort comprised 43 knees in 43 patients who underwent MOWHTO and had standing long-leg anteroposterior view and hindfoot alignment view radiographs taken preoperatively and at 3 months postoperatively. To evaluate the hindfoot alignment, the absolute value of the ankle joint line orientation relative to the ground was added to the absolute value of the hindfoot angle. We defined a postoperative MA of 57-67% as acceptable correction (A group) and a MA of < 56% as under-correction (U group). The two groups were analyzed to identify factors that affected postoperative limb alignment.

RESULTS

The preoperative hindfoot alignment angle was significantly larger in the U group than the A group. The preoperative hindfoot alignment angle was a significant predictive factor of the postoperative MA, and the cut-off value that distinguished under-correction from acceptable correction was 15.9 degrees.

CONCLUSION

Abnormal hindfoot alignment is one of the causes of under-correction after MOWHTO. Attention should be paid to the preoperative ankle joint line orientation relative to the ground and hindfoot angle. If the preoperative hindfoot alignment angle is ≥ 15.9 degrees, surgeons should reconsider the operative procedure and correction angle.

LEVEL OF EVIDENCE

Therapeutic level III, retrospective study.

Soft tissue stabilization of the hinge position in medial closed wedge distal femoral osteotomy: an anatomical study

BACKGROUND

Soft tissue has an important role in stabilizing the hinge point of medial closed wedge distal femoral osteotomy (MCWDFO). However, there are conflicting data on the soft tissue anatomy around the hinge point of MCWDFO and, therefore, further anatomical data are needed. The purposes of the study were to: 1) anatomically analyze the soft tissue around the hinge point of MCWDFO; 2) radiologically define the appropriate hinge point to prevent an unstable hinge fracture based on the result of the anatomical analysis; and 3) histologically analyze the soft tissue based on the result of the anatomical analysis.

METHODS

In 20 cadaveric knees, the capsule attachment of the distal lateral side of the femur was marked with a radiopaque ball bearing. A digital planning tool was used to calculate the area of the marked capsule attachment around the ideal hinge point of MCWDFO on radiographs. The soft tissue around the hinge point was histologically examined and the periosteal thickness was measured and visualized graphically. The graph and radiograph were overlayed using image editing software, and the appropriate hinge position was determined based on the periosteal thickness.

RESULTS

As a result, the periosteal thickness of the distal lateral femur tended to rapidly decrease from the metaphyseal region toward the diaphyseal region. The overlayed graph and radiograph revealed that the periosteal thickness changed in the region corresponding to the apex of the turning point of the femoral metaphysis in all cases.

CONCLUSIONS

In conclusion, the periosteum might support the hinge of MCWDFO within the area surrounded by the apex of the turning point of the femoral metaphysis and the upper border of the posterior part of the lateral femoral condyle.

Utility of anterior wall of greater trochanter in predicting femoral anteversion angle: a three-dimensional computed tomography-based simulation study

Background

The femoral anteversion angle is an important factor in performing surgery in the proximal part of the femur. Predicting the femoral anteversion angle based on the morphology of the proximal femur is clinically useful. The purpose of this study was to investigate whether an anatomical landmark can be used to predict the femoral anteversion angle intraoperatively.

Materials and methods

We analysed CT data obtained from 100 hips in 69 patients with osteonecrosis of the femoral head with no more than 2 mm collapse and no evidence of osteoarthritic changes. The measured variables were the femoral anteversion angle, the femoral neck-shaft angle, and the AW angle (defined as the angle between the femoral shaft axis and the tangential line of the anterior wall of the greater trochanter). The correlations between variables were also investigated. Multiple regression analysis by the forced input method was performed for the degree of femoral anteversion angle, using sex and the AW angle as explanatory variables.

Results

On CT, the mean femoral anteversion angle was 14.8° ± 10.8°, the mean AW angle was 17.5° ± 8.0°, and the mean femoral neck-shaft angle was 127.3° ± 5.4°. There was a positive correlation between the femoral anteversion angle and the AW angle. The approximation equations based on the multiple regression analysis were as follows: male femoral anteversion angle = AW angle × 0.7 − 0.7 and female femoral anteversion angle = AW angle × 0.7 + 4.3.

Conclusions

Femoral anteversion angle can be predicted based on the AW angle of the greater trochanter.

Evaluation of the hindfoot alignment before and after total knee arthroplasty

BACKGROUND

Open wedge high tibial osteotomy (OWHTO) and total knee arthroplasty (TKA) alter the ankle joint line obliquity (AJLO) to be more horizontal relative to the ground and aligns the valgus subtalar joint (SJ) neutrally. A previous study of the hindfoot alignment angle (HAA) showed that lower limb alignment after OWHTO becomes under-corrected because of abnormal compensation by the SJ. However, because TKA can exclude effects of femorotibial joint instability, analysis of a post-TKA cohort enables a more accurate evaluation of SJ compensation than analysis of a post-OWHTO cohort. In the present study, we performed radiographic evaluations before and after TKA to analyze SJ compensation.

METHODS

Lower limb and hindfoot alignment were measured on plain radiographs in 46 patients (48 knees) who underwent TKA in our department. The patients were divided into Group A (postoperative AJLO within ±1°) and Group B (postoperative AJLO greater than ±1°), and various parameters were compared between the groups. The preoperative HAA that resulted in an abnormal postoperative AJLO was investigated.

RESULTS

Group A had a significantly smaller preoperative HAA (p = 0.03) and postoperative HAA (p < 0.01) than Group B. Differences in the preoperative HAA between the two groups showed a cut-off value of 9.06°.

CONCLUSION

Patients with an HAA of more than 9.06° are likely to have abnormal hindfoot compensation.

Straight Form of Calcaneofibular Ligament as a Three-Dimensional Magnetic Resonance Imaging Sign in Diagnosis of Calcaneofibular Ligament and Anterior Talofibular Ligament Inferior Fascicle Injury

The present study was performed to investigate the morphological characteristics of the calcaneofibular ligament (CFL) and evaluate its relationship to the anterior talofibular ligament (ATFL) in patients with lateral ankle ligament injury using 3-dimensional magnetic resonance imaging (3D-MRI). This retrospective study involved 35 patients with lateral ankle ligament injury and 24 patients without a history of ankle trauma and a bone abnormality as controls. Reconstructed 3D-MRI was used to classify the form of the CFL as curved, wavy, or straight. The presence/absence of continuity between the fibula and CFL was evaluated in the 35 patients with injury, who were divided into 2 groups (continuity and discontinuity groups). The number of fascicles in the ATFL and the continuity between the distal end of the fibula and the proximal end of the ATFL were then evaluated. Among the patients with injury, 54.3% had the curve type of CFL, 34.3% had the wave type, and 11.4% had the straight type. In the control group, 62.5% had the curve type, 37.5% had the wave type, and none had the straight type. Continuity between the fibula and CFL was seen in 88.6%, and discontinuity was seen in 11.4%. Additionally, 85.7% had double fascicles in the ATFL. Inferior fascicle discontinuity between the ATFL and fibula was found in 13.3% with a double-fascicle ATFL; in all of these patients, the form of the CFL was straight and exhibited inferior fascicle discontinuity. The straight form of CFL could be a 3D-MRI sign in the diagnosis of CFL and ATFL inferior fascicle injury.

Influence of scapular neck length on the extent of impingement-free adduction after reverse total shoulder arthroplasty

BACKGROUND

Following reverse total shoulder arthroplasty, a short scapular neck length (SNL) decreases postoperative impingement-free adduction, and impingement between the neck of the scapula and the humeral polyethylene cup may cause scapular notching. However, no reports have evaluated the influence of SNL on impingement-free adduction. The purposes of this study were to evaluate the influence of SNL on impingement-free adduction and to examine the effect of glenoid component lateralization and inferiorization on impingement-free adduction.

METHODS

By use of 3-dimensional templating software, a virtual reverse total shoulder arthroplasty model was created in 15 patients who had no osteoarthritic change or any other bony deformity. We measured SNLs separately before implant placement (preoperative SNL) and after implant placement (postoperative SNL). The implant used was the Comprehensive Reverse Shoulder System (Zimmer Biomet, Warsaw, IN, USA), and baseplate bony lateralization of 0, 5, and 10 mm, with inferior eccentricity of 0.5 or 4.5 mm, was tested for impingement-free adduction. Correlations between the preoperative and postoperative SNLs and impingement-free adduction were analyzed.

RESULTS

The mean preoperative SNL was 8.2 ± 1.9 mm (range, 5.0-11.7 mm), and the mean postoperative SNL was 6.0 ± 2.0 mm (range, 2.1-9.8 mm). There was a moderate correlation between the preoperative SNL and impingement-free adduction (r = 0.628, P = .12) and a strong correlation between the postoperative SNL and impingement-free adduction (r = 0.771, P = .001). Use of the model with 10 mm of bony lateralization and 4.5 mm of inferior eccentricity provided the best results in terms of impingement-free adduction.

CONCLUSION

There were correlations between both the preoperative and postoperative SNLs and impingement-free adduction. Although the lateralized and inferiorized center of rotation may increase the risk of loosening of the glenoid component, this offset significantly increased impingement-free adduction.

Morphology of Anterior Talofibular Ligament After Arthroscopic Lateral Ankle Ligament Repair

BACKGROUND

Arthroscopic lateral ankle ligament repair for chronic lateral ankle instability (CLAI) yields good clinical results. However, the healing process of the ligament after anatomical repair remains unclear. This study evaluated the functional and patient-based outcomes for CLAI patients who underwent arthroscopic lateral ankle ligament repair and the morphological condition of the repaired anterior talofibular ligament (ATFL).

METHODS

We retrospectively reviewed 47 patients (50 ankles) who underwent arthroscopic lateral ankle ligament repair for CLAI (mean follow-up, 14 months). The Japanese Society for Surgery of the Foot Ankle-Hindfoot (JSSF) scale score and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) were assessed preoperatively and 12 months postoperatively. Magnetic resonance imaging (MRI) was performed preoperatively and at 6 and 12 months postoperatively to evaluate the ATFL. The functional and patient-based outcomes were compared between the group with repaired ATFLs and high signal intensity and the group with repaired ATFLs and low signal intensity.

RESULTS

The mean JSSF score improved significantly from 72.3 ± 11.6 preoperation to 95.3 ± 5.4 at 12 months postoperation. The MRI findings at 12 months postoperation showed that each repaired ATFL had a linear band structure from the talar to the fibular attachment site, and 41 of 50 ankles (82%) had low signal intensity of the ligament. On the SAFE-Q, the social functioning scores at 12 months postoperation were significantly higher in the low signal intensity group than in the high signal intensity group.

CONCLUSION

Arthroscopic lateral ankle ligament repair for CLAI yielded good functional and patient-based outcomes and restored the morphological condition of the ATFL.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Retrograde Drilling for Osteochondral Lesions of the Talus in Skeletally Immature Children

BACKGROUND

Osteochondral lesions of the talus (OLTs) involve damage to the cartilage and subchondral bone and are infrequent in children. Clinicians usually attempt nonsurgical treatment of OLTs first, and subsequently progress to surgical treatments, including retrograde drilling (RD), if the initial outcomes are insufficient. Good clinical outcomes of RD have been reported. However, the clinical outcomes of RD in skeletally immature children remain unclear, and the associated preoperative and postoperative computed tomography (CT) findings have not been reported. The purpose of this study was to evaluate the clinical outcomes and CT findings and clarify the efficacy of RD for OLTs.

METHODS

From January 2015 to April 2018, RD was performed on 8 ankles in 6 skeletally immature children. The patients comprised 4 boys and 2 girls with a mean age at surgery of 11.1 years. The mean follow-up was 22.8 months. The clinical outcomes were evaluated according to the Japanese Society for Surgery of the Foot (JSSF) scale. Preoperative and final follow-up CT findings were used to determine the degree of healing.

RESULTS

The mean JSSF scale in all ankles improved from 79.4 (range, 69-90) points preoperatively to 98.4 (range, 87-100) points at final follow-up (P < .05). In the preoperative CT findings, 3 ankles had no bone fragmentation, 4 had partial bone fragmentation, and 1 had whole fragmentation. In the final follow-up CT findings, 4 ankles demonstrated good healing, 3 were fair, and 1 was poor.

CONCLUSION

The present findings suggest that RD is an effective surgical treatment for OLTs in skeletally immature children.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effect of minimally invasive distal first metatarsal osteotomy on blood flow of the metatarsal head

BACKGROUND

Distal first metatarsal osteotomy is an option for operative treatment of mild to severe hallux valgus (HV) deformities. Minimally invasive distal linear metatarsal osteotomy (DLMO) provides good outcomes without avascular necrosis (AVN) of the metatarsal head. However, no reports have described the in vivo blood flow changes in the metatarsal head after osteotomy. This study was performed to evaluate the in vivo blood flow of the pre- and post-osteotomy metatarsal head in patients with HV using laser Doppler flowmetry and thus clarify the effect of minimally invasive distal first metatarsal osteotomy on the change in blood flow.

METHODS

From April 2015 to October 2016, DLMO was performed on 13 feet with HV in 10 patients (2 men, 8 women). Blood flow measurements of the pre- and post-osteotomy first metatarsal head in all feet were performed by laser Doppler flowmetry. AVN was evaluated using plain radiographs at the final postoperative follow-up.

RESULTS

The median pre- and post-osteotomy blood flow was 1.5 (0.97-1.95) and 1.46 (0.98-1.77) ml/min/100 g, respectively (median change in blood flow, 0.00; 95% CI, -0.23-0.13; P = 0.72). The rate of change in the blood flow was 0.0% (95% CI, -11.9%-8.7%; range, -28.6%-64.7%), and only three patients (23.1%) showed a decrease of ≥10%. The median pre- and post-osteotomy systolic blood pressure was 90 (84.5-97) and 93 (84.5-95) mmHg, respectively (median change in blood pressure, 0.00; 95% CI, -3.0-2.0; P = 0.82). The rate of change in the systolic blood pressure was 0.0% (95% CI, -3.1%-2.2%; range, -9.1%-24.0%). No radiographic evidence of AVN was present at the final follow-up.

CONCLUSIONS

No significant difference was found in the rate of change in blood flow pre- and post-osteotomy, suggesting that minimally invasive distal first metatarsal osteotomy does not influence blood flow of the metatarsal head.

Distal Linear Metatarsal Osteotomy Combined with Akin Osteotomy for Hallux Valgus with Hallux Valgus Interphalangeus

Background:

Minimally invasive distal linear metatarsal osteotomy is commonly performed to correct mild-to-moderate hallux valgus. The technique is easy to perform, fast, and has a low complication rate with satisfactory clinical results. However, it has so far not been applied to hallux valgus with concomitant hallux valgus interphalangeus deformity.

Objective:

We aimed to investigate the short-term clinical results of distal linear metatarsal osteotomy combined with Akin osteotomy in hallux valgus with concomitant hallux valgus interphalangeus deformity.

Methods:

We retrospectively reviewed 10 patients (10 feet) who underwent surgery for hallux valgus with hallux valgus interphalangeus between 2012 and 2016. Akin osteotomy was performed and fixated with a screw/K-wire, followed by distal linear metatarsal osteotomy and K-wire fixation. Clinical evaluations pre- and postoperatively used the Japan Society for Surgery of the Foot (JSSF) scale and the Visual Analog Scale (VAS). Radiography pre-and postoperatively assessed the hallux valgus, hallux valgus interphalangeus, and the intermetatarsal angle.

Results:

The mean follow-up period was 20.2 months. Both the JSSF and VAS score improved significantly, from 64.5 to 90.0 and from 5.5 to 1.1, respectively. In all patients, bone healing was complete within four months with no osteonecrosis of the metatarsal head or malunion at the osteotomy site. The hallux valgus angle improved from 31.5° to 7.7°, the hallux valgus interphalangeus angle from 17.2° to 5.8°, and the intermetatarsal angle from 11.7° to 5.5°.

Conclusion:

Distal linear metatarsal osteotomy combined with Akin osteotomy safely and effectively corrects mild-to-moderate hallux valgus with hallux valgus interphalangeus deformity.

Effect of the adjacent-joint osteoarthritis after arthroscopic ankle arthrodesis

Category:

Ankle Arthritis

Introduction/Purpose:

Arthroscopic ankle arthrodesis (AAA) is a good clinical outcome, because the arthroscopic method has been deemed to have shorter union time, less blood loss, less morbidity, shorter hospital stays, and more rapid mobilization. However, it is unclear about the relationship between progression of adjacent-joint arthritis and clinical outcome at long-term follow-up. The purpose of this study was to investigate the relationship between AAA and adjacent-joint arthritis at 2 years postoperatively.

Methods:

We evaluated 17 feet of 17 patients at a minimum of two years after surgery that were able to be followed, from among 59 feet in 55 patients with ankle osteoarthritis who underwent AAA between January 2006 and April 2015. The mean age was 66.1 ± 8.1 (range, 57-79) years, and postoperative follow-up was performed at a mean of 4.5 ± 2.3 (range, 2-10) years after surgery. The radiographic evaluation examined a union rate of the ankle, and a progression of adjacent-joint osteoarthritis (OA) change. We examined the relationship between the presence of adjacent-joint OA and Japanese Society for Surgery of the Foot (JSSF) score before surgery and last follow up. Additionally, we examined the relationship between the presence of adjacent-joint OA and Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at last follow up.

Results:

JSSF score was improved to 56.9 points before surgery and 89.2 points last follow up, and the union rates was 17 feet of 17 feet (100%). At the last follow-up, radiographic signs of developed or progressing arthritis were observed in ten feet at subtalar joint (58.8%) and in three patients at talonavicular joint (17.6%). The postoperative JSSF scale regarding the presence or absence of the adjacent joint OA, there were no significant differences (89.3 ± 6.0 points in the absence group and 89.2 ± 6.1 points in the presence group). Postoperative SAFE-Q was not significantly different, pain and pain-related physical functioning and daily living, social functioning, shoe-related, and general health and well-being.

Conclusion:

There was no significant difference in the JSSF score of presence or absence of the adjacent-joint OA before surgery and at the final follow-up. Additionally, there was no significant difference in the SAFE-Q of presence or absence of the adjacent-joint OA at the final follow-up. The adjacent-joint OA was progressed after AAA, however clinical outcome was relatively maintained.

Optimal suture anchor direction in arthroscopic lateral ankle ligament repair

PURPOSE

In this study, the distance between the insertion point of the suture anchors and posterior surface of the fibula during arthroscopic lateral ankle ligament repair was investigated on computed tomography (CT) images. The hypothesis of this study was that there is an optimal insertional direction of the suture anchor to avoid anchor-related complications.

METHODS

One hundred eleven ankles of 98 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (59 males, 52 females; median age 25.5 years; age range 12-78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of the fossa/top of the convex aspect of the fibula was measured on the axial plane, tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. The distance from the insertion point of the suture anchor to the posterior surface of the fibula was also measured in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial plane, tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°.

RESULTS

The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in the parallel direction was 15.0 ± 3.4 mm at 90°, 17.5 ± 3.2 mm at 75°, 21.7 ± 3.3 mm at 60°, and 25.7 ± 3.6 mm at 45°. The posterior points in the parallel direction were located on the posterior fossa in 36.0% of cases at 90°, in 12.6% at 75°, and in 0.0% at 60° and 45°.

CONCLUSIONS

The suture anchor should be directed from anterior to posterior at an angle of <45° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, to avoid passing through the fibula.

LEVEL OF EVIDENCE

Cohort study, Level III.

Scaffold-Based Therapies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.

LEVEL OF EVIDENCE

Level V, expert opinion.

Post-treatment Follow-up, Imaging, and Outcome Scores: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on Post-treatment Follow-up, Imaging and Outcome Scores developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 12 statements on Post-treatment Follow-up, Imaging, and Outcome Scores reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. All 12 statements reached strong consensus (greater than 75% agreement).

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with post-treatment follow-up, imaging, and outcome scores after management of a cartilage injury of the ankle in the general population. Moreover, healing, rehabilitation, and final outcomes can be optimized for the individual patient.

Effect of subchondral bone sclerosis in repair tissue after bone marrow stimulation for osteochondral talar lesions

Category:

Arthroscopy

Introduction/Purpose:

The arthroscopic bone marrow stimulation (ABMS) technique is the first-line procedure for the treatment of osteochondral lesions of the talus (OLT). Recently, T2 mapping was used to evaluate repair cartilage tissue, but the prognostic factors for T2 values after ABMS have never been clarified. Some patients have OLT with sclerotic changes in the subchondral bone, and several articles have suggested that the subchondral bone condition affects the condition of the articular cartilage. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS.The purpose of this study was to investigate the relationship between subchondral bone sclerotic changes and repair tissue T2 values on MRI after ABMS.

Methods:

Twenty ankles in 20 patients treated with ABMS for OLT were evaluated. The patients included 7 males and 13 females (age, 30.52±21.44 years, lesion length 10.4±3.0mm, lesion area 55.7±26.5mm2). Repair tissue was assessed using a 3T MRI unit, and T2 maps were calculated at the one-year post-ABMS follow up. The patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. We investigated the relationship between T2 values and SBC. Clinical results were measured using the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale.

Results:

No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values; 48.2±3.3ms vs. 50.1±2.9ms, P=0.7 / JSSF scale score; 89.4±5.8 points vs. 93.3±8.2 points, P=0.25). Lesion length was correlated with the T2 values of repair tissue (Length; r=0.3 P=0.01). Age and BMI were not significantly correlated with T2 values of the repair tissue.

Conclusion:

The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, we believe that lesion size affected the condition of the repair tissue.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Return to sporting activity after osteochondral autograft transplantation for Freiberg disease in young athletes

INTRODUCTION

Freiberg disease is defined as osteochondrosis of the metatarsal head and typically occurs in adolescents with sporting activity. This study aimed to evaluate the sporting activity of young athletes after osteochondral autograft transplantation (OAT) for Freiberg disease.

MATERIALS AND METHODS

OAT for Freiberg disease was conducted in 12 consecutive patients between August 2008 and November 2014. The present study evaluated 10 of these patients who both undertook sporting activity preoperatively and were teenagers at the time of surgery. Clinical evaluations were performed based on the Japanese Society for Surgery of the Foot lesser metatarsophalangeal-interphalangeal scale (JSSF scale) and range of motion (ROM) of the operated metatarsophalangeal joint preoperatively and at the final follow-up (mean 24.6 months). Whether patients were able to return to sporting activity and time until return to sporting activity were evaluated, including the Halasi score to reflect the level of sporting activity. Regarding symptoms at the donor knee, the Lysholm knee scale score was evaluated at the final follow-up.

RESULTS

The mean JSSF scale showed a significant improvement at the final follow-up (p < 0.01). The mean ROM in extension and flexion improved at the final follow-up (p < 0.01, and p < 0.05, respectively). All patients were able to return to sporting activity at a mean time of 3.5 months postoperatively and the Halasi score showed no significant change. The mean Lysholm knee scale score was 97.9 (range 89-100) points at the final follow-up.

CONCLUSIONS

All young athletes who underwent OAT for Freiberg disease achieved early return to almost equal sporting activity postoperatively and exhibited a significant improvement of the ROM of the metatarsophalangeal joint with almost no knee pain.

Effect of Blood Flow of the Metatarsal Head with Hallux Valgas after Minimally Invasive Distal Linear Metatarsal Osteotomy

Category:

Hindfoot

Introduction/Purpose:

Distal first metatarsal osteotomies are recommended for surgical treatment of mild to severe hallux valgus (HV) deformities. Angthong et al. reported that minimally invasive distal linear metatarsal osteotomy (DLMO) exhibited good outcomes, with no major complications. However, avascular necrosis of the metatarsal head following a distal osteotomy has been reported, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. The purpose of this study was to evaluate the in vivo blood flow of the pre- and post-osterotomy metatarsal head in patients with HV using laser Doppler flowmetry (LDF).

Methods:

Between April and November 2015, DLMO was performed on seven patients with HV. The patients comprised one male and four females, with a mean age at surgery of 43.4 (21–62) years. The primary surgical indications for DLMO were all levels of severity of possible manual correction in patients with foot pain. The patients were placed in the supine position, and without a tourniquet, a 1.5-cm skin incision was centered over the medial aspect of the first metatarsal neck. A 2.0-mm Kirschner wire was inserted manually from the wound to the medial side of the hallux using a retrograde technique. Under direct vision, the Kirschner wire was introduced into the medullary canal of the first metatarsal shaft. Blood flow measurements of the pre- and post-osteotomy first metatarsal head in the seven patients were performed by LDF (ALF21 N; ADVANCE Co., Tokyo, Japan). The probe was touched to the first metatarsal head. The blood flow measurements were repeated three times, and the mean values were calculated.

Results:

On preoperative plain radiographs, the mean hallux valgus angle was 38.0° (range: 22.4–45.8°), and the mean intermetatarsal angle was 17.0° (range: 10.4–21.9°). The mean pre- and post-DLMO systolic blood pressure at the time of the measurements was 87.3±7.76 and 88.1±8.25 mmHg, respectively (P=0.85). The mean pre- and post-DLMO blood flow rate was 1.71±0.68 and 1.66±0.49 ml/min/100 g, respectively (P=0.90).

Conclusion:

Steven et al. reported that a distal osteotomy can lead to avascular necrosis of the metatarsal head, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. However, we found that blood flow of the pre- and post-osteotomy metatarsal head was present in all patients examined, with no significant difference in the blood flow rates of the metatarsal head before and after DLMO. Based on the present results, it is possible to avoid major complications, such as avascular necrosis of the metatarsal head, because DLMO is minimally invasive and involves less release of the soft tissue.

Stress Distribution within the Osteochondral Lesions of the Talus with Nonshoulder-type and Shoulder-type

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Arthroscopic bone marrow stimulation techniques including excision with curettage and microfracture are recommended as initial treatments for osteochondral lesions of the talus (OLT). However, several reports have indicated that lesion size and location are important prognostic factors for the clinical outcomes. A cutoff point regarding the risk of clinical failure exists for a lesion size of approximately 15 mm diameter or 150 mm2 area. A recent study reported that shoulder-type lesions had significantly worse clinical outcomes than nonshoulder-type lesions. However, to the best of our knowledge, no previous reports have provided biomechanical data for how nonshoulder-type and shoulder-type OLT affect the clinical outcomes. The purpose of this study was to clarify the stress distribution in articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using finite element (FE) analysis.

Methods:

The healthy 33-year-old male and 29-year-old female volunteers participated in the present study. They underwent computed tomography (CT) scans, and three-dimensional FE models of his ankle joint were created from the CT data using Mechanical Finder software (version 7.0, extended edition; Research Center of Computational Mechanics, Tokyo, Japan). Six different sizes of nonshoulder-type and shoulder-type OLT were simulated in the present study. For the nonshoulder-type lesion models, circular cartilage defects with diameters of 5, 7, 9, 11, 13, and 15 mm were created on the medial half of the talar dome using a cutting tool. The shoulder-type lesion models were created in the medial half of the talar shoulder, also with cartilage defect diameters of 5, 7, 9, 11, 13, and 15 mm. We set the loading condition at 686 N on the upper part of the tibia from the tibial axis for body-weight loading. The peak and average articular cartilage stress and defect rim stress were compared between the two models and among the six different defect sizes.

Results:

In both lesion models, stress concentration was seen at the cartilage defect rim. The peak and average cartilage stress and defect rim stress increased with increasing defect size of the two models. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models.

Conclusion:

Lesion size of OLT was the most powerful predictor of the clinical outcome by arthroscopic bone marrow stimulation. The shoulder-type OLT experience a worse clinical outcome than the nonshoulder-type OLT, even after adjustment for OLT size and regardless of location. In the present study evaluated the stress distribution in the articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using FE analysis. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models.

Optimum Insertional Direction of the Suture Anchor in Arthroscopic Lateral Ankle Ligament Repair

Category:

Arthroscopy

Introduction/Purpose:

The gold standard for chronic lateral ankle ligament injury is ligament repair via the modified Broström- Gould procedure. Recently, lateral ankle ligament repair has been performed arthroscopically. This requires the insertion of one to three suture anchors in the fibula from anterior to posterior via the accessory portal. It is important to insert the suture anchors completely into the fibula bone. Because the distal fibula is tapered and has a fossa on the posterior surface, unfavorable insertional direction of the suture anchor can lead to complications such as inadequate suture anchor stability or friction between the suture anchor and the peroneus tendons. This study aimed to investigate the distance between the insertion point of the suture anchors and the posterior surface of the fibula on computed tomography (CT) images.

Methods:

Twenty ankles from 16 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (10 male, 10 female; mean age, 32 years; age range, 12–78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of fossa/the top of the convex of fibula was measured on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. We also measured the distance from the insertion point of the suture anchor to the posterior surface of the fibula, in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°.

Results:

The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in a parallel direction was 15.6 mm at 90°, 18.0 mm at 75°, 21.5 mm at 60°, and 24.8 mm at 45°. The posterior points in a parallel direction were located on the posterior fossa in 40% of cases at 90°, in 10% at 75°, and in 0% at 60° and 45°.

Conclusion:

We suggest that the suture anchor should be directed from anterior to posterior at an angle of less than 60° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, in order to avoid passing through the fibula.

Neurectomy for Bilateral Morton's Neuroma A Case Report of a Male Patient

Morton's neuroma is a common condition that mainly affects middle-aged women, and many articles have addressed the surgical treatment of this condition. Previous reports have described bilateral neuroma excision in women but not in men. We report a rare case of bilateral neuromas in a male patient treated with simultaneous neurectomy.

Simultaneous use of lateral calcaneal ostectomy and subtalar arthroscopic debridement for residual pain after a calcaneal fracture

Inadequate primary treatment of calcaneal fractures frequently results in persistent, residual pain. This can be caused by subtalar arthritis, an increased calcaneal width, and/or calcaneal fibular impingement of the peroneal tendons. Many patients experience multiple disorders simultaneously, requiring a combination of procedures to treat the injury. The purpose of the present study was to evaluate the clinical outcomes of arthroscopic debridement with lateral calcaneal ostectomy for residual pain after a calcaneal fracture. Four feet (4 patients) were treated with arthroscopic debridement and lateral calcaneal ostectomy. The patients were 3 males and 1 female, with a mean age of 55.3 ± 14.1 years. The mean follow-up duration was 33.5 ± 10.5 months postoperatively. Three patients received worker's compensation as a result of their condition. The patients were examined for improvement in pain levels using the numeric pain intensity scale and healing was assessed using the Japanese Society of Surgery of the Foot score. The mean Japanese Society of Surgery of the Foot score improved from 64.5 ± 13.8 preoperatively to 82.5 ± 7.1 postoperatively. The mean postoperative numeric pain intensity scale score was 2.3 ± 1.9. No complications, such as deep infection or problems with wound healing, were observed in any of the patients. The simultaneous use of arthroscopic subtalar debridement and lateral calcaneal ostectomy is a valuable intervention for the treatment of residual pain after a calcaneal fracture in patients who present with increased calcaneal width and mild or no degenerative changes in the subtalar joint.

Does the addition of computed tomography to computed radiography provide more value to final outcomes and treatment decisions in displaced intra-articular calcaneal fractures?

BACKGROUND

Little is known about the additional prognostic value of computed tomography (CT) in addition to computed radiography in displaced intra-articular calcaneal fractures. Thepresent study was undertaken to examine and compare the final radiographic outcomes and the prevalence of treatment methods of displaced intra-articular calcaneal fractures in patients with preoperative computed radiography alone vs. a combination ofcomputed radiography and computed tomogra- phy.

MATERIAL AND METHOD

Thirty-four patients with 38 displaced intra-articular calcaneal fractures were divided into two groups: a group that was evaluated with computed tomography and computed radiography (17 patients; 20 fractures) and a group that was evaluated with computed radiography alone (17 patients; 18 fractures). Patient demographics, pre- operative and postoperative Bohler's angles, and fracture classifications were recorded. Postoperative outcomes were evaluated using calcanealfracture radiographic scores (modified Zwipp score).

RESULTS

The mean age ofour patients in the present study was 43.3 ± 12.3 years. The mean age ofthe patients in the computed tomography group (48.4 ± 11.6 years) was significantly higher than that of the non-computed tomography group (37.6 ± 10.7 years, p = 0.005). The mean follow-up time was 17.4 ± 9.8 months. There was a significantly higher prevalence of open reduction and internalfixation in the computed tomography group versus the non-computed tomography group (p = 0.019). However there was no significant difference observed for the mean radiographic scores. Postoperatively, outcomes were satisfactory in both groups, although intra-articular alignment was significantly better in the computed tomography group (p = 0.020).

CONCLUSION

The overall outcomes were comparable between the patient groups with computed tomography vs. those without computed tomography, exceptfor the superiority of postoperative intra-articular alignment in patients with computed tomography. Open reduction and internal fixation were more frequently performed in the patients with computed tomography than patients without computed tomography.

Critical three-dimensional factors affecting outcome in osteochondral lesion of the talus

PURPOSE

This study aimed to investigate the relationship between clinical outcomes, patient demographics and the 3D-geometric profiles of the osteochondral lesion of the talus (OLT) following arthroscopic debridement and bone marrow stimulation.

METHODS

Between 2005 and 2011, arthroscopic debridement and bone marrow stimulation were performed on 50 ankles with OLT mean age of 36.0 (19.1) years and mean follow-up time of 35.5 (20.2) months. Clinical data were assessed using validated Japanese Society of Surgery of the Foot scoring. An outcome was deemed unsatisfactory if the JSSF score was less than 80. Magnetic resonance imaging and X-rays were used to assess the 3D-geometric profiles of the OLT.

RESULTS

The mean preoperative and postoperative scores were 73.4 (13.6) and 89.6 (11.5), respectively (p < 0.001). Unsatisfactory outcomes were identified in 12 % of patients. Linear regression analyses showed that lesion depth and patient age were significantly negatively correlated with postoperative scores (p < 0.001). High prognostic significances were attributed to defect depth and age of patient, and cut-off values of 7.8 mm and 80 years, respectively, were recommended to avoid a postoperative score less than 80. No significant correlations between poor clinical outcome and the other lesion profiles or demographic factors were identified.

CONCLUSION

Using 3D-geometric and demographic profiles, defect depth and age of patient are essential prognostic factors in OLT and may act as a basis for preoperative surgical decisions. A lesion depth ≥ 7.8 mm and age ≥ 80 years predict an unsatisfactory outcome following arthroscopic debridement and bone marrow stimulation.

Arthroscopic bone marrow stimulation techniques for osteochondral lesions of the talus: prognostic factors for small lesions

BACKGROUND

The defect size of an osteochondral lesion of the talus is one of the most important prognostic factors for deciding clinical outcomes. However, the prognostic factors for small osteochondral lesions of the talus are unknown.

PURPOSE

To investigate the significant prognostic factors for small osteochondral lesions of the talus using arthroscopic bone marrow stimulation techniques.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifty ankles in 50 patients treated with arthroscopic bone marrow stimulation techniques for an osteochondral lesion of the talus (<150 mm(2)) were evaluated for prognostic factors. The patients were 22 men and 28 women (mean age, 35.0 years). Outcomes were measured using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, Berndt and Harty scale, and Saxena criteria.

RESULTS

The mean lesion size was 62 mm(2) (range, 7-119 mm(2)). The mean AOFAS score improved from 74 (range, 18-90) preoperatively to 90 (range, 67-100) postoperatively. The Saxena criteria results were excellent, good, fair, and poor in 36 (72%), 8 (16%), 5 (10%), and 1 (2%) patients, respectively. The Berndt and Harty scale results were good in 34 (68%), fair in 6 (12%), and poor in 10 (20%) patients. Linear regression analyses showed prognostic significance for lesion depth and outcome. Medial lesions had a significantly higher incidence of poor outcomes than lateral lesions (P < .05). Among the medial lesions, lesions uncovered with the medial malleolus had inferior outcomes compared with covered lesions (P < .0001). There was no association between clinical outcome and lesion size or body mass index. In older patients (≥40 years), there was a significant trend toward inferior clinical outcomes (P < .05).

CONCLUSION

Arthroscopic bone marrow stimulation techniques provided satisfactory clinical outcomes. However, older patients, deep lesions, and medial lesions uncovered with the medial malleolus were associated with inferior clinical outcomes.

Assessing the safe direction of instruments during posterior ankle arthroscopy using an MRI model

BACKGROUND

The safety of posterior ankle arthroscopy is still the subject of debate. The purpose of this study was to evaluate the anatomical relationship between the posterior portals and the neurovascular structures using magnetic resonance imaging (MRI) to determine the safety of posterior portals in posterior ankle arthroscopy.

METHODS

Forty ankles from 38 patients who had undergone MRI scanning for ankle disorders were assessed (18 males, 20 females). For each ankle, the angles of the presumed position of the portals to the posterior neurovascular structures and the malleoli were measured on 4-mm proximal slices from the anterior tip of the fibula. The shortest distance from the sural nerve and the tibialis posterior neurovascular bundle to the position of the posterior portals was measured.

RESULTS

The average distance between the posteromedial portal and the tibialis posterior neurovascular bundle was 18 ± 3 mm, whereas the average distance between the posterolateral portal and the sural nerve was 15 ± 3 mm. In 100% of ankles, there were no neurovascular structures lying within the region between the anterior tip of fibula and the posteromedial portal or between the posterior tip of fibula and the posteromedial portal. In 32 ankles (80%), the medial neurovascular structures were present on the medial side of the line running between the anterior tip of medial malleolus and the posteromedial portal.

CONCLUSION

The posterior neurovascular structures were not in immediate proximity to where we estimated the posteromedial and posterolateral portals to be located.

CLINICAL RELEVANCE

The findings of the present MRI-based study suggest that arthroscopic instruments oriented toward the fibula may be safely introduced into the posterior ankle without injuring the neurovascular structures.

The effect of screw position and number on the time to union of arthroscopic ankle arthrodesis

PURPOSE

This study aimed to investigate the factors that influence the time to union after arthroscopic ankle arthrodesis.

METHODS

From June 2005 to October 2010, 46 patients (50 ankles) underwent arthroscopic ankle arthrodesis with 6.0-mm cannulated cancellous screws. There were 22 men and 24 women (mean age, 63 years). Medical records and radiographs were retrospectively reviewed. Screw configurations used were as follows: 3 transmedial and translateral malleolar screws (ML3) in 12 ankles (24%), 2 transmedial and translateral malleolar screws (ML2) in 4 ankles (8%), 3 transmedial malleolar screws (M3) in 23 ankles (46%), and 2 transmedial malleolar screws (M2) in 11 ankles (22%).

RESULTS

Radiographic fusion was achieved in 46 (92%) of the 50 ankles. The mean time to fusion was 11.0 ± 4.5 weeks for ML3, 13.1 ± 3.3 weeks for ML2, 9.7 ± 2.7 weeks for M3, and 12.5 ± 3.5 weeks for M2 (P < .05). The mean American Orthopaedic Foot & Ankle Society scores were 81.3 ± 2.2 for ML3, 83.5 ± 4.4 for ML2, 88.3 ± 1.5 for M3, and 85.3 ± 2.2 for M2. The mean time until radiographic fusion was 10.2 ± 3.4 weeks for correction angles of less than 10° and 13.2 ± 3.4 weeks for angles of 10° or greater (P < .01). In obese patients a significant difference in ankle fusion time was observed (12.6 ± 3.5 weeks for patients with body mass index ≥25 v 9.4 ± 2.9 weeks for patients with body mass index <25, P < .01).

CONCLUSIONS

Overall, this study showed that arthroscopic ankle arthrodesis achieves a high rate of union, with fastest union achieved with 3 parallel screws placed medially from the distal tibia into the talus. Care should be taken when one is designing treatment strategies for obese patients and/or patients with large correction angles.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgical treatment of an osteochondral lesion associated with stress fracture of the tarsal navicular: a case report

We surgically treated an osteochondral lesion associated with a stress fracture of the tarsal navicular. The surgical procedure involved the confirmation and complete resection of the lesion under direct vision, followed by the transplantation of block-shaped iliac bone grafts. The postoperative computed tomography scan showed that the lesions had disappeared, the grafted bone had fused, and the stress fracture had healed. However, the tarsal navicular joint surface was slightly irregular. The patient was able to resume her sports activities 15 weeks after surgery. We have described a novel method to reconstruct the tarsal navicular after osteochondral lesion resection.

Subcutaneous rupture of the flexor hallucis longus tendon: a case report

It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.

Myxoid liposarcoma of the ankle: a case report

Myxoid liposarcoma occurs predominantly in the deep soft tissues of the extremities, and tends to metastasize to a wide range of soft tissue or bone locations. We report a case of myxoid liposarcoma arising in the ankle of a 19-year-old man. A diagnosis of myxoid liposarcoma was made by open biopsy, and a wide resection requiring plastic surgical reconstruction was performed. Cytogenetic analysis of the resected tumor exhibited a reciprocal translocation t(12;16)(q13;p11) as the sole anomaly, which is found in more than 90% of myxoid liposarcoma cases. The patient had no evidence of local recurrence or metastasis within 7 years of follow-up. Although myxoid liposarcoma is rare in the ankle, it should be considered in the differential diagnosis of a painless soft tissue mass in this region.

A case of angiomyolipoma of the renal sinus

The case of a 63-year-old woman with a relatively rapidly growing angiomyolipoma (AML) originating from the right renal sinus is presented. The tumor had enlarged to more than fivefold in volume (7.4 × 6.7 × 10.1 cm) in the 7 years following its detection (5.6 × 3.4 × 4.6 cm) and had significantly pushed aside the duodenum and the inferior vena cava. The tumor was surgically resected together with the right kidney, and pathological examination revealed AML originating from the renal sinus. An AML involving or originating from the renal sinus is exceedingly rare; only 14 cases have been reported. Rapidly growing AMLs of the renal sinus are difficult to differentiate from liposarcoma because of similar findings in imaging studies. It should be noted that AML of the renal sinus can be a differential diagnosis of retroperitoneal fatty mass. Furthermore, an enlarged AML in the renal sinus may push aside other organs, such as the ileum, pancreas, and major vessels. Clinicians should determine whether these patients should be placed under active surveillance or be treated with invasive measures, such as radical nephrectomy.

Arthroscopic treatment for an osteochondral defect of the talus after necrosis associated with acute lymphoblastic leukaemia: a case report

Osteonecrosis is a serious complication of acute lymphoblastic leukemia (ALL) therapy. The spontaneous regression or healing of osteonecrosis is rare. An unusual case of an osteochondral defect of the talus secondary to osteonecrosis is herein presented. We treated a 26-year-old female who presented with an osteochondral defect of the talus after necrosis. ALL had previously been diagnosed in 1994 and the patients had been treated with chemotherapy included corticosteroid. She was thereafter diagnosed to have bilateral osteonecrosis of the talus in 1996, and thus had been treated with weight-bearing restriction using a patellar tendon bearing brace. She felt pain in her right ankle in 2006. Magnetic resonance imaging (MRI) showed an osteochondral defect in the lateral aspect of the talus and normal bone marrow signal in the right ankle. We performed arthroscopic treatment by means of a bone marrow stimulation technique. At second-look arthroscopy, the aspect of the talus was completely covered by fibrocartilage like tissue. This procedure is therefore considered to be one option for the treatment of an osteochondral defect of the talus after necrosis in young patients.

Periacetabular osteotomy reduces the dynamic instability of dysplastic hips

We compared the dynamic instability of 25 dysplastic hips in 25 patients using triaxial accelerometry before and one year after periacetabular osteotomy. We also evaluated the hips clinically using the Harris hip score and assessed acetabular orientation by radiography before surgery and after one year. The mean overall magnitude of acceleration was significantly reduced from 2.30 m/s(2) (sd 0.57) before operation to 1.55 m/s(2) (sd 0.31) afterwards. The mean Harris hip score improved from 78.08 (47 to 96) to 95.36 points (88 to 100). The radiographic parameters all showed significant improvements. This study suggests that periacetabular osteotomy provides pain relief, improves acetabular cover and reduces the dynamic instability in patients with dysplastic hips.

Selective Gene Therapy for Prostate Cancer Cells Using Liposomes Conjugated with IgM Type Monoclonal Antibody against Prostate-Specific Membrane Antigen

Prostate cancer cells express prostate-specific membrane antigen (PSMA). We developed an IgM type monoclonal antibody against PSMA. The antibody was coupled to poly-L-lysine and thereafter this conjugate was mixed with cationic liposomes containing plasmid DNA. The antibody-liposome complex was tested whether it could deliver the gene of interest selectively to the PSMA positive cells. As assessed by beta-galactosidase reporter gene, the transfection efficiency was 13.2% with anti-PSMA-liposome complex as compared to 4% with control IgM liposome complex. In contrast, no such differences were observed in PSMA negative PC-3, DU145 and T24 cells. Furthermore, in the suicide gene therapy in vitro with thymidine kinase gene plus ganciclovir system, anti-PSMA liposome complex demonstrated a selective growth inhibitory effect on PSMA positive LNCaP cells but not on PSMA negative cell lines.

Novel mutations in Myoclonin1/EFHC1 in sporadic and familial juvenile myoclonic epilepsy

BACKGROUND

Juvenile myoclonic epilepsy (JME) accounts for 3 to 12% of all epilepsies. In 2004, the GENESS Consortium demonstrated four missense mutations in Myoclonin1/EFHC1 of chromosome 6p12.1 segregating in 20% of Hispanic families with JME.

OBJECTIVE

To examine what percentage of consecutive JME clinic cases have mutations in Myoclonin1/EFHC1.

METHODS

We screened 44 consecutive patients from Mexico and Honduras and 67 patients from Japan using heteroduplex analysis and direct sequencing.

RESULTS

We found five novel mutations in transcripts A and B of Myoclonin1/EFHC1. Two novel heterozygous missense mutations (c.755C>A and c.1523C>G) in transcript A occurred in both a singleton from Mexico and another singleton from Japan. A deletion/frameshift (C.789del.AV264fsx280) in transcript B was present in a mother and daughter from Mexico. A nonsense mutation (c.829C>T) in transcript B segregated in four clinically and seven epileptiform-EEG affected members of a large Honduran family. The same nonsense mutation (c.829C>T) occurred as a de novo mutation in a sporadic case. Finally, we found a three-base deletion (-364--362del.GAT) in the promoter region in a family from Japan.

CONCLUSION

Nine percent of consecutive juvenile myoclonic epilepsy cases from Mexico and Honduras clinics and 3% of clinic patients from Japan carry mutations in Myoclonin1/EFCH1. These results represent the highest number and percentage of mutations found for a juvenile myoclonic epilepsy causing gene of any population group.

Evaluation of dynamic instability of the dysplastic hip with use of triaxial accelerometry

BACKGROUND

Dysfunction of the hip secondary to dysplasia is a complex problem that includes excessive stresses on the articular cartilage, dynamic hip instability, and muscular fatigue, eventually leading to degenerative arthritis if left uncorrected. Mechanical stress on the dysplastic hip has been widely described, but dynamic instability requires further evaluation. The purpose of this study was to investigate dynamic instability of the dysplastic hip with use of triaxial accelerometry.

METHODS

We evaluated forty-eight hips of twenty-four patients with unilateral hip dysplasia (a center-edge angle of <25 degrees ). All contralateral hips were disease-free with normal radiographic findings. An accelerometer was used to record triaxial acceleration while the patient was walking (x-axis: superoinferior direction, y-axis: anteroposterior direction, and z-axis: mediolateral direction). Sensors were attached to the skin, with adhesive tape, over the greater trochanter and the anterior superior iliac spine bilaterally. The time of heel-strike was confirmed visually and by superoinferior acceleration. The averages of the peak values of the middle three gait cycles were used for data analysis. The overall magnitude of acceleration was calculated to evaluate hip instability. The overall magnitudes of acceleration of the dysplastic and contralateral, normal hips were compared with the radiographic data.

RESULTS

The three directions of acceleration were the same in all cases. The overall magnitude of acceleration of the dysplastic hips was significantly larger than that of the contralateral, normal hips (p < 0.0001). There was a negative correlation between the overall magnitude of acceleration and both the center-edge angle and the acetabular head index, and there was a positive correlation between the overall magnitude of acceleration and both the acetabular roof angle and the Sharp angle.

CONCLUSIONS

Hip instability is increased in proportion to the degree of dysplasia. Triaxial accelerometry is helpful in the evaluation of dynamic instability of the dysplastic hip. The center-edge angle can be used as an indicator of hip instability.

Targeting gene therapy for prostate cancer cells by liposomes complexed with anti-prostate-specific membrane antigen monoclonal antibody

Prostate-specific membrane antigen (PSMA) is a membrane-bound antigen expressed on the surface of prostate cancer cells, and this paper describes the use of an antibody against PSMA for targeting gene therapy. We coupled anti-PSMA monoclonal antibody with poly-L-lysine and then incubated it with plasmids. These complexes were then transfected with cationic liposomes into cells. The transfection efficiency of anti-PSMA- liposome complex was higher than that of normal IgG-liposome complex in PSMA-positive LNCaP cells. Furthermore, anti-PSMA-liposome complex containing a suicide gene, thymidine kinase, demonstrated a selective growth-inhibitory effect on LNCaP cells in vitro, but did not exert a significant effect on PSMA-negative cells. In an in vivo xenograft model of LNCaP cells in nu/nu mice, we administered the complexes via the tail vein. Judging on the basis of both 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside (X-Gal) staining and luciferase assay findings, a significant enrichment of plasmid DNA was observed in LNCaP xenografts with anti-PSMA-liposome complex in comparison with normal IgG-liposome complex. However, the distribution of plasmid DNA did not change substantially in any other organs including the liver, kidney, lung, and spleen. Moreover, in suicide gene therapy, anti-PSMA-liposome complex exerted a significant inhibitory effect on the growth of LNCaP xenograft, in contrast to normal IgG-liposome complex.

Mucoid pseudocyst of the obturator nerve

A 71-year-old man visited the outpatients' clinic of National Saitama Hospital, Japan, complaining of pain in the right leg. Magnetic resonance imaging (MRI) revealed a cystic mass adjacent to the right side of the urinary bladder. He underwent the removal of the cystic mass and the pathological diagnosis was a mucoid pseudocyst of the obturator nerve. After tumor resection, the pain was diminished and he has been free of disease for 3 years.

Retroperitoneoscopic partial nephrectomy using radiofrequency ablation

Two patients with renal tumors underwent retroperitoneoscopic partial nephrectomy. The renal tumors were initially treated with radiofrequency ablation. This method allowed tumor excision to be achieved without clamping the renal pedicle. Residual renal function was well maintained as determined by enhanced computed tomography scanning and measurement of the serum creatinine level. There were no complications such as vascular damage or collecting system injury. The pathological diagnosis was clear cell carcinoma (pT1) in Patient 1 and was not determined in Patient 2 because of entire ablation. No recurrence has been observed after 3 years and 2 years of follow up, respectively. Radiofrequency ablation was useful for control of local bleeding during retroperitonaoscopic partial nephrectomy.