A Minimally-Invasive, Simple, Rapid, and Effective Surgical Technique for the Treatment of Ingrown Toenails: A Reminder of the Original Winograd Procedure

(1) Background: Ingrown toenail is a common disorder of the toe that induces severe toe pain and limits daily activities. The Winograd method, the most widely used operative modality for ingrown toenails, has been modified over years to include wedge resection of the nail fold and complete ablation of the germinal matrix. We evaluated the outcomes of original Winograd procedure without wedge resection with electrocautery-aided matrixectomy. (2) Methods: We retrospectively analyzed the outcomes of patients who underwent surgery for ingrown toenails at a university hospital for two years from November 2015 to October 2017. Surgery was performed in 76 feet with a mean operation time of 9.34 min. (3) Results: The minimal interval from surgery to return to regular activities was 13.26 (range 7 to 22) days. Recurrence and postoperative wound infections were found in 3 (3.95%) and 2 (2.63%) patients, respectively. Evaluation of patient satisfaction at one-year follow-up showed that 40 (52.63%) patients were very satisfied, 33 (43.42%) were satisfied, 3 (3.95%) were dissatisfied, and none of them were very dissatisfied. The average follow-up duration was 14.66 (range 12 to 25) months. (4) Conclusions: Therefore, it is believed that this less-invasive and simple procedure could be easily performed by clinicians, with satisfactory patient outcomes.

Disability and Risk Factors of Drinking Behavior: Health Informatics Analysis

It is well reported that obesity, smoking, and drinking were cardiovascular risk factors for disabled people. Among them, drinking is the one of the greatest risk factor for disabled. On the other hand, a recent study found that regular physical exercise prevents the health problems from drinking unhealthy people. Even though problem drinking is seriously affected by the disability of a person, research on the influence of the disabled person on their drinking problem is very limited. Therefore, this study used the National Health and Nutrition Survey, which is a statistical data designated by the government, in order to investigate the factors influencing problem drinking of disabled people, as well as promote their healthy living and prevent more diseases. Therefore, we used the National Health and Nutrition Examination Survey, which is a statistical data designated by the Government of the Republic of Korea. This study implemented descriptive statistics and frequency analysis in order to find the influencing factors of the relationship between individual problem drinking status and variable. A logistic regression model was adopted in order to analyze an individual problem drinking status factoring in dependent variable. STATA/MP 13.0 were used for the analysis. The analysis results were shown as follows. The influencing factor of the drinking problem status was an existing common factor without reference to disability status, and the factor in discrimination appeared depending on the disability status. Smoking was found to have a strong influence in every population without age in this study. Furthermore, weight control status was verified as appearing with a dissimilar effect as per disability status. In the non-disability group, having experience to try weight control was predicted to have a relatively higher problem drinking possibility than not having an experience in trying weight control. Nevertheless, in disability the group, the relationship between the two variables was not found to be of statistical significance.

Closed atraumatic complete rupture of the flexor halluces longus tendon during forward lunge exercise: A case report

RATIONALE

Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise.

PATIENT CONCERNS

A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion.

DIAGNOSIS

Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region.

INTERVENTIONS

Complete rupture of the FHL tendon was treated with a primary suture.

OUTCOMES

At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal.

LESSONS

We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.

Trends in Lower Limb Amputation in Patients with Diabetic Foot Based on Vascular Intervention of Peripheral Arterial Disease in Korea: a Population-based Nationwide Study

BACKGROUND

Peripheral arterial disease (PAD) is known as the greatest risk factor affecting the amputation of diabetic foot. Thus, it is crucial to understand the epidemiology of PAD associated with diabetic foot and the relationship between PTA and amputation in predicting prognosis. However, no such multi-year data are available in Korea. Thus, the purpose of this study was to investigate trends of amputation involving diabetic foot based on vascular interventions for PAD in Korea.

METHODS

This study was conducted using six-year data obtained from Health Insurance Review and Assessment Service from January 1, 2011 to December 31, 2016. Our study included data pertaining to diabetic foot, PAD, and vascular intervention codes (percutaneous transluminal angioplasty [PTA, M6597], percutaneous intravascular installation of stent-graft [PIISG, M6605], and percutaneous intravascular atherectomy [PIA, M6620]). We analyzed the number of vascular interventions and minor and major amputations each year. The relationship between annual amputation and vascular intervention was analyzed using χ² test.

RESULTS

The overall number of vascular interventions increased from 253 (PTA, 111; PIISG, 140; and PIA, 2) in 2011 to 1,230 (PTA, 745; PIISG, 470; and PIA, 15) in 2016. During the same period, the number of minor amputations increased from 2,534 to 3,319 while major amputations decreased from 980 to 956. The proportion of minor amputations among patients who underwent vascular intervention was significantly increased from 19.34% in 2011 to 21.45% in 2016 while the proportion of major amputations among these patients was significantly reduced from 9.88% to 4.27%. In addition, the association between vascular intervention and amputation increased from 0.56 (spearman correlation coefficient) in 2011 to 0.62 in 2016.

CONCLUSION

In diabetic foot patients, increase in vascular intervention resulted in a change in amputation pattern, showing statistically significant correlation.

Survivorship and Complications after Hip Fracture Surgery in Patients with Chronic Kidney Disease

The aim of this study was to investigate survival rate, complications and associated risk factors after hip fracture surgery in patients with chronic kidney disease (CKD) by comparing to non-CKD patients. A total of 119 patients (130 hips, 63 hips CKD group, 67 hips non-CKD) who underwent hip fracture surgery were included. We assessed variables including age, gender, CKD, comorbidities, operation delay and operation time as risk factors for survival and complications after hip fracture surgery. The survival rate was 55.8% at 1-year, 45.8% at 3-year, and 31.4% at 5-year in CKD group, whereas 82.1%, 60.7%, and 36.8%, respectively in non-CKD. Age (more than 85) (hazard ratio [HR], 3.238; 95% confidence interval [CI], 1.736-6.042; P < 0.001), stages 4, 5 of CKD (HR, 2.004; 95% CI, 1.170-3.433; P = 0.001), cerebrovascular disease (HR, 2.213; 95% CI, 1.196-4.095; P = 0.001), and malignancy (HR, 3.086; 95% CI, 1.553-6.129; P = 0.001) were significant risk factors. Complications occurred in 17 hips of CKD group and 8 hips of non-CKD. Stage 4-5 of CKD (odds ratio [OR], 3.401; 95% CI, 1.354-8.540; P = 0.001), malignancy (OR, 3.184; 95% CI, 0.984-10.301; P = 0.050) were significant risk factor. When performing hip fracture surgery in patients with CKD, surgeons should consider age, severity of CKD, and presence of other comorbid disease, such as cerebrovascular disease and malignancy, as patients with these risk factors will need more intensive preoperative and postoperative care.

Fatal pulmonary thromboembolism after Achilles tendon open repair: A rare case report

RATIONALE

The operative procedure for Achilles tendon rupture is relatively simple, but venous thromboembolism is serious complication with a high incidence after Achilles tendon rupture. However, the guideline for thromboprophylaxis in Achilles tendon rupture is unclear.

PATIENT CONCERNS

The patient was 32-year-old male and underwent Achilles tendon open repair surgery. He was healthy and there are no abnormal findings other than Achilles tendon rupture. At 3 weeks after operation, the episode of loss of consciousness with convulsive movement occurred. The next day, suddenly cardiac arrest occurred.

DIAGNOSES

Extensive pulmonary thromboembolism in both pulmonary arteries was identified in chest computed tomography and thrombus was also identified at the left popliteal vein on ultrasonography.

INTERVENTION

Anticoagulant therapy with heparin sodium was performed to manage the pulmonary thromboembolism.

OUTCOMES

Brain swelling after ischemic brain damage, acute kidney injury, and pneumonia gradually occurred and aggravated. His condition became worse and he died about 2 weeks after the cardiac arrest episode.

LESSONS

Although the incidence of venous thromboembolism in Achilles tendon rupture is higher than that in lower leg injury patients, guideline for thromboprophylaxis is unclear. We suggest that thromboprophylaxis for Achilles tendon rupture should be considered and appropriate guidelines should be established.

Morphological Characteristics of the Posterior Malleolus Fragment According to the Ankle Fracture Patterns by Lauge-Hansen

Category:

Trauma

Introduction/Purpose:

The posterior malleolus fragment (PMF) of an ankle fracture occurs in various shapes with regard to injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the posterior malleolus fragment according to the ankle fracture pattern by Lauge-Hansen classification using computer tomographic images.

Methods:

We retrospectively analyzed computer tomography data of 107 patients (107 ankles) who underwent surgery for tri- malleolus fracture from January 2012 to December 2014. A total of 76 ankles belong to Supination-Exorotation stage IV (SER group), 31 belong to Pronation- Exorotation stage IV (PER group). The type of PMF of two groups was respectively assessed by Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle and fragment height (FH) were measured as morphologic assessments.

Results:

The PMF type in SER group had mainly the posterolateral shape, while that in PER group had mainly the psotermedial two parts or large, posterolateral triangular shape (P= 0.02). The average cross angle (α) was no significant difference between two groups (SER group = 19.4°, PER group = 17.6°). The fragment length ratio and fragment height in PER group were significantly larger than that in SER group (P= 0.024, P=0.006). The fragment in PER group was significantly more vertical than that in SER group (P= 0.017).

Conclusion:

Morphological characteristics of the posterior malleolus fragment are different between SER group and PER group in trimalleolar ankle fracture. The SER type fractures are associated with smaller “rotational” fragment, while the PER type fractures are associated with larger “rotational and vertical” fragment with regard to the fragment volume and articular involvement.

Clinical Analysis of the Conservative Treatment for Treating Diabetic Foot Osteomyelitis

Category:

Diabetes

Introduction/Purpose:

The question of surgical versus non-surgical treatment for diabetic foot osteomyelitis remains subject to debate. The aims of this study were to analyze the outcome of conservative treatment (antibiotics treatment and conservative surgery) for diabetic foot osteomyelitis and identify the predictive factors of remission in conservative treatment of diabetic foot osteomyelitis.

Methods:

77 patients with diabetic foot osteomyelitis who were initially treated by conservative treatment from January 2004 to July 2013 were identified, and their medical records were reviewed. We defined diabetic foot osteomyelitis by imaging studies or histological evidence. Remission was defined as the absence of any sign of infection at the initial or contiguous site assessed at least 12 months after the end of treatment. The demographic, clinical and therapeutic factors were analyzed.

Results:

The mean age of the patients was 62.6 years(SD=12.20), and 47(61.0%) of these patients were male. The median diabetes duration was 15.6 years(SD=11.20) and mean HbA1c was 8.7%(SD=2.40). Forty-eight (62.3%) patients healed with conservative treatment (antibiotics treatment and conservative surgery). Twenty-five(32.5%) patients underwentamputation. Inthe multivariate analysis, concomitant peripheral artery diseaseand inadequate antibiotics therapywere associated with failure of conservative treatment.

Conclusion:

Antibiotics alone, or with conservative surgery, were successful in treating diabetic foot osteomyelitis in 62.3% of the patients. Concomitant peripheral artery diseaseand inadequate antimicrobial therapy were risk factors for remission in diabetic foot osteomyelitis treated conservatively.

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

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

Flipping method of a RetroButton during ACL reconstruction with outside-in femoral drilling using a FlipCutter

Little information exists on the intraoperative difficulties and complications of using a RetroButton (Arthrex, Inc, Naples, Florida), which is a new suspensory device. However, some difficulties are encountered, such as incomplete sitting, pulling at the outside portion of the iliotibial band, or slipping during distal pulling due to incomplete transverse flipping. These problems can be avoided if the mechanism can be understood and some technical tips are practiced. The goal of this study was to determine the difficulties encountered during RetroButton femoral fixation and prevent iatrogenic complications with the RetroButton devices by offering some technical tips.

Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees

This study was performed to identify the mechanoreceptors in the tibial remnants of ruptured human anterior cruciate ligaments (ACL) by immunohistochemical staining. Thirty-six specimens of tibial ACL remnants were obtained from patients with ACL ruptures during arthroscopic ACL reconstruction. As control, two normal ACL specimens were taken from healthy knee amputated at thigh level due to trauma. The specimen was serially sectioned at 40 mum. In control group, the average number of sections per specimen was 132, and a total of 264 slices were available. In remnant group, the average number of sections per specimen was 90, and a total of 3,251 slices were available. Immunohistochemical staining was performed to detect the neural element of mechanoreceptors. Histologic examinations were performed under a light microscope and interpreted by a pathologist. Nineteen (8 Ruffini, 11 Golgi) mechanoreceptors were identified in the two normal ACLs, which were evenly distributed at both tibial and femoral attachments. In the remnant group, mechanoreceptors were observed in 12 out of 36 cases (33%), and a total of 17 (6 Ruffini and 11 Golgi) mechanoreceptors observed. No significant differences in the harvest volume, number of sections, age, or time between injury to surgery was observed between the 12 mechanoreceptor-present and the 24 mechanoreceptor-absent ones. The presence of mechanoreceptor at the tibial remnants of torn ACLs was verified. The immunohistochemical staining methodology proved useful, but requires further refinement. Although the mechanoreceptors were detected relatively less frequently than expected, the authors consider that it does not negate the necessity of remnant-preserving ACL reconstruction.