Prevalence and risk factors of wound complications after transtibial amputation in patients with diabetic foot

BACKGROUND

Diabetic foot (DMF) complications are common and are increasing in incidence. Risk factors related to wound complications are yet to be established after trans-tibial amputation under the diagnosis of DMF infection.

AIM

To analyze the prognosis and risk factors related to wound complications after transtibial amputation in patients with diabetes.

METHODS

This retrospective cohort study included seventy-two patients with DMF complications who underwent transtibial amputation between April 2014 and March 2023. The groups were categorized based on the occurrence of wound complications, and we compared demographic data between the complication group and the non-complication group to analyze risk factors. Moreover, a multivariate logistic regression analysis was performed to identify risk factors.

RESULTS

The average follow-up period was 36.2 months. Among the 72 cases, 31 (43.1%) had wound complications. Of these, 12 cases (16.7%) received further treatment, such as debridement, soft tissue stump revision, and re-amputation at the proximal level. In a group that required further management due to wound complications after transtibial amputation, the hemoglobin A1c (HbA1c) level was 9.32, while the other group that did not require any treatment had a 7.54 HbA1c level. The prevalence of a history of kidney transplantation with wound complications after transtibial amputation surgery in DMF patients was significantly greater than in cases without wound complications (P = 0.02). Other factors did not show significant differences.

CONCLUSION

Approximately 43.1% of the patients with transtibial amputation surgery experienced wound complications, and 16.7% required additional surgical treatment. High HbA1c levels and kidney transplant history are risk factors for postoperative wound complications.

Closed reduction and internal fixation for tillaux fractures, based on pre-operative three-dimensional computed tomography

OBJECTIVE

This study aimed to propose treatment protocol and identify patterns of tillaux fractures using three-dimensional (3D) computed tomography (CT) analysis and to describe an effective reduction technique.

METHODS

Forty-two juvenile patients with tillaux fractures were evaluated with 3D-CT scan for fracture displacement pattern and received surgical treatment. Tillaux fragment was reduced by pushing the superomedial quadrant part of the fragment slightly downward towards the ankle joint from anterolateral to posteromedial through 5-mm skin incisions with mosquito forceps. A 4.0 cannulated screw was subsequently inserted from the anterolateral to the posteromedial side parallel to the ankle joint. We analysed the distance and direction of fracture displacement with 3D-CT before the surgery. Pre-operative and post-operative plain radiographs were evaluated.

RESULTS

Pre-operative 3D-CT analysis revealed a common fracture pattern, varus tilt, and external rotation of fragment. We achieved satisfactory reduction with residual fracture gaps less than 2 mm in 42 cases. Two cases had a 13-mm anterior gap that was reduced by mini-open reduction because of periosteal impingement. No significant clinical complications were found.

CONCLUSION

The closed reduction technique developed based on the fracture pattern identified by 3D-CT anatomical analysis is safe and effective in treating tillaux fractures.

Nail-preserving excision of glomus tumor in the second toe: Case report and literature review

INTRODUCTION

This case report describes the diagnosis of a glomus tumor in the second toe of a 38-year-old female, followed by surgical treatment utilizing a transungual approach to preserve the nail. This study highlights the diagnostic challenges and surgical strategies to treat such tumors while preserving nail integrity.

PATIENT CONCERNS

Pain occurred once a week, but over time, it increased, and just before seeking medical attention, she experienced pain more than 5 times a day. The pain worsened when cold water touched her toe.

DIAGNOSIS

We observed a slight hump indicating nail plate deformity, and the patient exhibited severe pinpoint tenderness (positive Love test) in the affected area. Color duplex ultrasound was performed for further investigation, revealing a hypervascular hypoechoic nodule measuring 0.5 cm in size at the nail bed of the right second toe.

INTERVENTION

The surgery was performed under digital nerve block anesthesia using a modified transungual nail-preserving approach for the excision of the glomus tumor.

OUTCOMES

The pain that was reported prior to the surgery has improved postoperatively, and the recovery has been uneventful without any other complication.

CONCLUSION

This paper provides a comprehensive examination of a rare glomus tumor in the second toe, elucidating both diagnostic intricacies and treatment modalities. It emphasizes the dual necessity of achieving total tumor excision while also considering aesthetic outcomes. The insights presented herein are intended to serve as valuable guidance for clinicians confronted with similar clinical scenarios, underlining the delicate interplay between effective tumor management and the preservation of cosmetic integrity.

Analgesic effectiveness of continuous versus single-injection adductor canal block in addition to continuous popliteal sciatic nerve block for bimalleolar and trimalleolar ankle fracture surgery: Prospective randomized controlled trial

BACKGROUND

The adductor canal block is a well-known procedure for controlling postoperative pain after medial malleolus fracture surgery. Continuous nerve block is a viable option for blocking pain for a longer period although the literature on this subject is scarce. Therefore, this study aimed to compare continuous adductor canal block (cACB) group to single-injection adductor canal block (sACB) group in those with bimalleolar or trimalleolar ankle fractures. The procedure was performed in addition to a continuous sciatic nerve block for postoperative pain relief and patient satisfaction.

METHODS

The study included 57 patients who had bimalleolar or trimalleolar ankle fractures and underwent open reduction and internal fixation between August 2016 and June 2018. Each patient received a continuous sciatic nerve block and was divided into two groups: those who received cACB and those who received sACB. Each postoperative pain was scored at 4, 8, 12, 24, 48, and 72 h after surgery. Additionally, the consumption of rescue medications and patient satisfaction were evaluated.

RESULTS

The two groups displayed no disparity in medial side ankle pain at 4 h and 8 h after surgery, but significantly higher pain in the sACB group at 12, 24, 48, and 72 h after surgery. However, there was no difference in the pain at the lateral side of ankle and consumption of rescue medication. In addition, the cACB group showed more satisfaction than the sACB group did.

CONCLUSION

CACB is better than sACB in terms of postoperative pain control and patient satisfaction. cACB can be used for postoperative pain control in ankle fractures involving the medial malleolus.

LEVEL OF EVIDENCE

Prospective Randomized Controlled Trial, Level 2.

Intraoperative assessment of hindfoot alignment using C-arm fluoroscopy

BACKGROUND

Hindfoot malalignment can cause various foot and ankle problems. For better surgical performance and correction of hindfoot malalignments, reliable intraoperative determination of hindfoot alignment is essential. However, there is no standard method for the intraoperative assessment of hindfoot alignment. We devised an intraoperative modified Méary posteroanterior (IOPPA) view to assess intraoperative hindfoot alignment. This study aimed to compare this intraoperative method with other radiographic hindfoot alignment measurements.

METHODS

Thirty-seven patients (47 feet) with various foot and ankle conditions scheduled to undergo surgery were prospectively recruited. Before surgery, the Saltzman, long axial, and modified Méary views were taken in a controlled and standardized fashion. IOPPA views were obtained under simulated weight bearing conditions using C-arm fluoroscopy in the operating room before surgery. The relationship between the IOPPA view and the three radiographic hindfoot alignments was evaluated using Pearson's correlation.

RESULTS

The mean hindfoot alignment angle was varus 3.50° (CI, varus 1.91 to 5.08) on the Saltzman view, varus 2.00° (CI, varus 0.60 to 3.39) on the long axial view, varus 0.13° (CI, valgus 1.41 to varus 1.67) on the modified Méary view, and varus 1.32° (CI, valgus 0.02 to varus 2.65) on IOPPA view. The IOPPA view and the three other hindfoot alignment views were found to be significantly correlated (r = 0.60 for the Saltzman view, r = 0.50 for the long axial view, r = 0.71 for the modified Méary view, P < .05). The intraobserver ICC (Intraclass Correlation Coefficient) value was 0.974 and interobserver ICC (Intraclass Correlation Coefficient) value was 0.988 for the IOPPA view (P < .001).

CONCLUSION

There was a statistically significant correlation between the IOPPA view and the other three hindfoot alignment views. We also found that interobserver and intraobserver ICC values were excellent. This study proposes that the IOPPA view can be used as a reliable intraoperative assessment tool for hindfoot alignment.

LEVEL OF EVIDENCE

Prospective study.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Use of an aiming drill guide and ankle arthroscopy for reduction of depressed articular surface in posterior malleolar fractures

PURPOSE

We describe a novel technique that uses an aiming drill guide and ankle arthroscopy for direct visualization and reduction of the depressed articular surface located between the posterior tibia and the fractured posterior malleolus. This technique requires less soft tissue dissection to visualize and reduce the depressed articular surface.

METHODS

Between June 2014 and May 2019, 126 patients were surgically treated for trimalleolar fractures. Among them, 11 had depressed articular fragment between the posterior tibia and the fractured posterior malleolus reduced using our novel technique. The study included six men and five women, with a mean age of 46.5 (range: 23-62) years.

RESULTS

In eight (73%) cases, the articular surface was reduced, with the articular surface step-off being less than 2 mm, as noted on postoperative computed tomography (CT). Syndesmosis congruity within an anterior-to-posterior difference of less than 2 mm was confirmed in nine (82%) cases via postoperative CT. The mean 100-mm visual analog scale (VAS) and the mean Olerud-Molander ankle score at the final follow-up were 16.6 ± 14.5 and 87.7 ± 7.5, respectively.

CONCLUSIONS

The depressed articular fragment located between the posterior tibia and the fractured posterior malleolus can be treated using an aiming drill guide and ankle arthroscopy. Ankle arthroscopy is used for direct visualization of the depressed articular surface, and the aiming drill guide can guide the bone plunger precisely to the depressed articular surface for reduction. This technique requires less soft tissue dissection than conventional techniques to visualize and reduce the depressed articular surface.

Screw stripping and its prevention in the hexagonal socket of 3.5-mm titanium locking screws

There have been several reports about the difficulties in removing 3.5-mm titanium locking screws from plates due to the stripping or rounding of the hexagonal screw socket. We investigated whether stripping the locking screw sockets can be prevented by using different screwdrivers or interposing materials into the socket during removal. We overtightened 120 3.5-mm titanium locking screws (Depuy Synthes, Paoli, PA) equally into locking plates on sawbone tibia models, applying a uniform torque of 4.5 Nm, exceeding the recommended torque of 1.5 Nm. Twenty screws each were removed using a straight-handle 2.5-mm screwdriver, T-handle screwdriver, hex key wrench, and straight-handle screwdriver with a non-dominant hand. In addition, 20 screws were removed using foil from a suture packet inserted into the screw socket or using parts of a latex glove inserted into the screw socket. The incidence rates of screw stripping using the straight-handle screwdriver, T-handle screwdriver, hex key wrench, non-dominant hand, foil interposition, and latex glove interposition were 75%, 40%, 35%, 90%, 60%, and 70%, respectively. When a T-handle screwdriver or hex key wrench was used, the probability of screw stripping was 4.50 times (odds ratio = 4.50, 95% confidence interval = 1.17 to 17.37, p = 0.03) and 5.57 times (odds ratio = 5.57, 95% confidence interval = 1.42 to 21.56, p = 0.01) lower than that with the straight-handle screwdriver, respectively. Foil or latex glove interpositions did not prevent screw stripping. Thus, in the current experimental study, T-handle screwdriver or hex key wrench usage decreased the incidence rate of screw stripping during removal compared to straight-handle screwdriver use.

Use of a Locking Plate and Drill Sleeves to Guide Dome-Shaped Supramalleolar Osteotomy: Technique Tip

Level of Evidence: Level V, expert opinion.

Adverse events involving hallux metatarsophalangeal joint implants: Analysis of the United States Food and Drug Administration data from 2010 to 2018

BACKGROUND

The prevalence of osteoarthritis of the hallux metatarsophalangeal joint (MTPJ) is 1 in 40 people over the age of 50. Surgical treatment options for MTPJ arthritis include joint preservation, joint resurfacing, and arthrodesis. Hallux MTPJ implants have evolved over the past several decades, but are associated with various complications. The aim of this study was to examine the MAUDE database to determine reported adverse events for hallux MTPJ implants.

MATERIALS AND METHODS

The US Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database was reviewed from 2010 to 2018 to review voluntary reported adverse event reports for approved implants within the United States. We recorded the type of adverse event and excluded duplicate reports and those extracted from already published literature.

RESULTS

Among 64 reported hallux MTPJ implant adverse events, the most common modes of adverse events were component loosening (34%), infection (14.1%), component fracture (9.4%), inflammation (9.4%), and allergic reaction (7.8%). Regarding implant type, Cartiva SCI had the highest percentage of adverse events (23.4%), followed by Arthrosurface ToeMotion (20.3%), Ascension MGT (12.5%), Arthrosurface HemiCAP® (10.9%), Futura primus (9.4%), and Osteomed Reflexion (6.3%). There was an increase in reported adverse events after 2016. The MAUDE database does not report the total incidence of implant insertion.

CONCLUSION

Our study of the MAUDE database demonstrated that component loosening and infection are the most common modes of adverse events for hallux MTPJ implants. Cartiva accounted for one-fourth of the implant-related adverse events during our study period, followed by ToeMotion, and Ascension MGT implants. Continued reporting of adverse events will improve our understanding on short and long-term complications of various hallux MTPJ implants.

LEVEL OF EVIDENCE

Level IV; Case Series from Large Database Analysis; Treatment Study.

Intermediate-term Patient-Reported Outcomes and Radiographic Evaluation Following Intramedullary- vs Extramedullary-Referenced Total Ankle Replacement

BACKGROUND

The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) vs intramedullary-referenced (IMr) total ankle replacement (TAR).

METHODS

From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR was enrolled in this study. Analyses were performed comparing IMr vs EMr components for patient-reported outcomes data, pre- and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years (±2.5, range 2-12).

RESULTS

The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; P < .0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; P = .6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; P < .0001). There were similar improvements in patient-reported outcome scores at 1 year and final follow-up (all P > .05). The 5-year implant survivorship was 98.6% for IMr vs 97.5% for EMr at final follow-up.

CONCLUSION

The IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. The 5-year implant survivorship was similar between the IMr and EMr groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures

Background

Nonunion is a rare complication for distal fibular fractures. However, when there is a high degree of comminution, nonunion may occur. In this article, we describe a novel technique that uses the oblong hole of a locking plate to lengthen the fibula for fracture reduction. This technique is straightforward and allows for easy control of the comminuted fracture to restore length and rotation at the time of plate application without opening the fracture site.

Methods

Thirty-five consecutive patients, who were treated with the minimally invasive plate osteosynthesis (MIPO) technique for comminuted distal fibular fractures were retrospectively studied. The study included 19 men and 16 women, with a mean age of 47.0 years (range, 20 to 72). There were 3 lateral malleolar fractures with deltoid injury, 11 bimalleolar fractures, 7 trimalleolar fractures, and 14 distal tibiofibular fractures. The quality of fracture reduction was assessed by comparing the radiologic parameters (fibular length, talocrural angle, and medial clear space) between the affected ankle and the contralateral uninjured ankle.

Results

Two patients were not reachable and 5 declined to visit the clinic. For these 7 patients, the latest outcomes that were measured prospectively were used. Postoperative radiographs showed well-aligned ankle mortise, with fibular length restoration. The mean Olerud-Molander ankle score was 82.1 ± 10.7 at a mean of 27.2 months (range, 12 to 58). There was one case of nonunion and one case of superficial peroneal nerve injury.

Conclusion

The MIPO technique, using the oblong hole of a locking plate, achieved satisfactory restoration of length and rotation, bone union, and clinical outcomes for the comminuted distal fibular fractures.

Conservative treatment of refractures after modified tension band wiring of fifth metatarsal base stress fractures in athletes

OBJECTIVE

Recurrent fifth metatarsal base stress fractures (MT5-BSF) in athletes present a challenging problem. The aim of this study was to evaluate the result of conservative treatment for the refracture of MT5-BSF after modified tension band wiring (MTBW).

MATERIALS AND METHODS

The outcomes of 15 elite athletes undergoing conservative treatment for refracture of MT5-BSF after MTBW were retrospectively reviewed. They were instructed to avoid weight-bearing with short leg cast for 6 weeks. After that, they started partial weight with a postop shoe. Stepwise exercise followed bone union by radiographs.

RESULTS

Thirteen cases (86.6%) had a complete bone union after a mean of 18.9 ± 8.6 weeks. Twelve cases (80%) returned to their previous activity level and maintained for at least two consecutive seasons.

CONCLUSION

Eighty percent of all athletic patients with the conservative treatment for refractures with healed MT5-BSF after MTBW on the plantar-lateral side could maintain and return to their previous sports activity for at least 2 years.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

Background

This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy.

Methods

This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination.

Results

The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography.

Conclusions

Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Multivariate analyses of MRI findings for predicting osteomyelitis of the foot in diabetic patients

BACKGROUND

There have been no previous magnetic resonance imaging (MRI) studies using multivariable analysis to diagnose osteomyelitis in patients with diabetic foot.

PURPOSE

To retrospectively investigate the MRI findings of osteomyelitis in patients with diabetic foot using multivariate analyses.

MATERIAL AND METHODS

From November 2015 to March 2018, 118 patients who underwent MRI of the foot to evaluate suspected osteomyelitis were included in this study. The patients were categorized into the presence or absence of osteomyelitis. The primary and secondary MRI findings were retrospectively reviewed. To identify independent predictive MRI findings, multivariate analyses with binary logistic regression and receiver operating characteristic curve analyses were performed including all 118 patients and 93 patients presenting decreased T1 signal intensity, respectively.

RESULTS

T1 signal intensity, T1 marrow pattern, T1 marrow distribution, T2 signal intensity, concordance of marrow signal intensity, cortical interruption, ulcer depth, abscess, and wet gangrene were significantly different between the two groups (P < 0.05). Multivariate analyses indicated that fluid equivalent T2 signal intensity, deep ulcer, and confluent T1 marrow pattern were major factors associated with osteomyelitis. The area under the curve of predicted probabilities for the combination of these factors was 0.799 across all 118 patients and 0.761 across 93 patients with decreased T1 signal intensity.

CONCLUSION

Confluent T1 marrow pattern is a reliable finding to suggest osteomyelitis in patients with diabetic foot. In addition, fluid equivalent T2 signal intensity and deep ulcer are important findings that may suggest osteomyelitis, irrespective of T1 signal intensity change.

Operative Results of Plantar Plating for Fifth Metatarsal Stress Fracture

BACKGROUND

The treatment of fifth metatarsal stress fractures can be challenging. Various operative fixation methods have been reported for fracture management. Among them, intramedullary screw fixation has become increasingly popular. However, recent reports have described failures after screw fixation in athletes. The aim of this study was to determine the rates of clinical and radiographic healing, time to return to sport, and complications of elite athletes with proximal fifth metatarsal fractures treated with plantar plating.

METHODS

Thirty-eight athletes with fifth metatarsal stress fractures treated using a plantar plating technique in 3 hospitals from 2013 to 2018 were evaluated retrospectively. Demographic data, radiographic evaluation, and the time until union and return to sports activities were collected and analyzed. A total of 38 patients underwent the plantar plating for a fifth metatarsal stress fracture with a mean follow-up of 23 (range, 12-49) months.

RESULTS

The mean time to the radiologic union, as determined by plain radiography, was 9.3 (range, 8-16) weeks. Although there were no nonunions or delayed unions during follow-up, 4 refractures developed (10.5%). All but 1 patient were able to return to their previous levels of sporting activity at 22.2 ± 4.5 (range, 12-40) weeks.

CONCLUSION

With a minimum of 1-year follow-up, the described plantar plating technique could be an alternative method for the operative treatment of fifth metatarsal stress fractures without nonunion problems.

LEVEL OF EVIDENCE

Level IV, case series.

Comparison Between Early Functional Rehabilitation and Cast Immobilization After Minimally Invasive Repair for an Acute Achilles Tendon Rupture

The purpose of the present study was to compare the outcomes of patients with Achilles tendon rupture treated with minimally invasive repair and early functional rehabilitation with the outcomes of similar patients treated with cast immobilization. After undergoing minimally invasive surgery, a below-knee splint with the foot in 30° of plantarflexion was applied to each patient for the first week. Patients were then assigned to a cast immobilization group (IG; n = 25) or a functional group (FG; n = 16). Data were collected during outpatient checks at 6 weeks, 3 months, 6 months, and 1 year. Outcomes of interest included range of motion (ROM), heel height, calf circumference, pain and functional score, return to work and light sports activity, and complications. The time interval for return to work in the FG was faster than that in the IG (p = .026). There was no clinically important difference between the 2 groups with regard to heel height, ROM, return to sports, calf circumference, visual analog scale, American Orthopaedic Foot and Ankle Society score, or Achilles tendon Total Rupture Score at every outpatient check except ROM difference at 6 weeks and heel height at 3 months. Rerupture occurred in 2 patients (1 [4%] in the IG and 1 [6.25%] in the FG). Early functional rehabilitation seemed to be as safe as traditional postoperative immobilization with a similar functional result and complications, but it was advantageous for the early phase of rehabilitation only.

GnRH impairs diabetic wound healing through enhanced NETosis

It has been reported that neutrophil extracellular traps (NETs) impair wound healing in diabetes and that inhibiting NET generation (NETosis) improves wound healing in diabetic mice. Gonadotropin-releasing hormone (GnRH) agonists are associated with a greater risk of diabetes. However, the role of GnRH in diabetic wound healing is unclear. We determined whether GnRH-promoted NETosis and induced more severe and delayed diabetic wound healing. A mouse model of diabetes was established using five injections with streptozotocin. Mice with blood glucose levels >250 mg/dL were then used in the experiments. GnRH agonist treatment induced delayed wound healing and increased NETosis at the skin wounds of diabetic mice. In contrast, GnRH antagonist treatment inhibited GnRH agonist-induced delayed wound healing. The expression of NETosis markers PAD4 and citrullinated histone H3 were increased in the GnRH-treated diabetic skin wounds in diabetic mice and patients. In vitro experiments also showed that neutrophils expressed a GnRH receptor and that GnRH agonist treatment increased NETosis markers and promoted phorbol myristate acetate (PMA)-induced NETosis in mouse and human neutrophils. Furthermore, GnRH antagonist treatment suppressed the expression of NETosis markers and PMA-induced NETosis, which were increased by GnRH treatment. These results indicated that GnRH-promoted NETosis and that increased NETosis induced delayed wound healing in diabetic skin wounds. Thus, inhibition of GnRH might be a novel treatment of diabetic foot ulcers.

Complications After Multiple-Site Peripheral Nerve Blocks for Foot and Ankle Surgery Compared With Popliteal Sciatic Nerve Block Alone

BACKGROUND

Single or combined multiple-site peripheral nerve blocks (PNBs) are becoming popular for patients undergoing surgery on their feet or ankles. These procedures are known to be generally safe in surgical settings compared with other forms of anesthesia, such as spinal block. The purposes of this study were to assess the incidence of complications after the administration of multiple PNBs for foot and ankle surgery and to compare the rates of complications between patients who received a single PNB and those who received multiple blocks.

METHODS

Charts were reviewed retrospectively to assess peri- and postoperative complications possibly related to the PNBs. The records of 827 patients who had received sciatic nerve blocks, femoral nerve blocks adductor canal blocks, or combinations of these for foot and/or ankle surgery were analyzed for complications. The collected data consisted of age, sex, body mass index, presence of diabetes mellitus, smoking history, tourniquet time, and complications both immediately postoperatively and 1 year later.

RESULTS

Of these 827 patients, 92 (11.1%) developed neurologic symptoms after surgery; 22 (2.7%) of these likely resulted from the nerve blocks, and 7 (0.8%) of these were unresolved after the patients' last follow-up visits. There were no differences in complication rates between combined blocks and single sciatic nerve blocks.

CONCLUSION

There were more complications, both transient and long term, after anesthetic PNBs than previous literature has reported. Combined multiple-site blocks did not increase the rate of neurologic complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Adductor canal block versus femoral nerve block combined with sciatic nerve block as an anesthetic technique for hindfoot and ankle surgery: A prospective, randomized noninferiority trial

BACKGROUND

A femoral nerve block (FNB) in combination with a sciatic nerve block (SNB) is commonly used for anesthesia and analgesia in patients undergoing hindfoot and ankle surgery. The effects of FNB on motor function, related fall risk, and rehabilitation are controversial. An adductor canal block (ACB) potentially spares motor fibers in the femoral nerve, but the comparative effect on hindfoot and ankle surgeries between the 2 approaches is not yet well defined. We hypothesized that compared to FNB, ACB would cause less weakness in the quadriceps and produce similar pain scores during and after the operation.

METHODS

Sixty patients scheduled for hindfoot and ankle surgeries (arthroscopy, Achilles tendon surgery, or medial ankle surgery) were stratified randomized for each surgery to receive an FNB (FNB group) or an ACB (ACB group) combined with an SNB. The primary outcome was the visual analog scale (VAS) pain score at each stage. Secondary outcomes included quadriceps strength, time profiles (duration of the block procedure, time to full anesthesia and time to full recovery), patients' analgesic requirements, satisfaction, and complications related to peripheral nerve blocks such as falls, neurologic symptoms, and local anesthetic systemic toxicity were evaluated. The primary outcome was tested for the noninferiority of ACB to FNB, and the other outcomes were tested for the superiority of each variable between the groups.

RESULTS

A total of 31 patients received an ACB and 29 received an FNB. The VAS pain scores of the ACB group were not inferior during and after the operation compared to those of the FNB group. At 30 minutes and 2 hours after anesthesia, patients who received an ACB had significantly higher average dynamometer readings than those who received a FNB (34.2 ± 20.4 and 30.4 ± 23.7 vs 1.7 ± 3.7 and 2.3 ± 7.4, respectively), and the results were similar at 24 and 48 hours after anesthesia. There were no differences between the 2 groups with regard to time profiles and patient satisfaction. No complications were noted.

CONCLUSION

ACB preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain. Therefore, ACB may be a good alternative to FNB for reducing the potential fall risk.

Accessory Navicular Syndrome in Athlete vs General Population

BACKGROUND

Symptomatic accessory navicular syndrome (ANS) typically develops in young athletes. The symptoms are exacerbated during exercise or while walking, affecting the sports performance of athletes. The purpose of this study was to evaluate the radiologic findings and clinical course in athletes with accessory navicular syndrome (ANS) in comparison with a nonathletic population.

METHODS

Seventy-nine patients with ANS between August 2012 and August 2013 were included. Overall, 29 were athletes and 50 were not athletes, and 19 (2 athletes and 17 nonathletes) of them improved after at least 6 months of conservative treatment. The records of 60 patients (64 consecutive feet) of ANS treated by modified Kidner operation were evaluated retrospectively. The study population included 27 athletes (31 feet) and 33 nonathletes (33 feet). Clinical features and radiologic findings were compared between them.

RESULTS

Overall, 34% of the nonathletes improved after conservative treatment, but only 6.9% of athletes improved (P < .001). Mean age at surgery in the athlete group was 16.1 years (range, 12-26), and 24.3 years (range, 12-52) in the nonathlete group (P < .001). There was a history of trauma in 23 feet (74%) of the athlete group and in 13 feet (39%) of the nonathlete group (P = .006). Eighteen feet (58%) in the athlete group and 11 feet (32%) in the nonathlete group showed movement between the 2 bones (P = .047). Bone marrow edema was observed in both navicular and accessory navicular in all of the athletes (27/27, 100%). But it was only present in 80% (16/20) for nonathletes (P = .012).

CONCLUSION

The radiologic findings and clinical course of athletes were different from that of the general population. Their symptoms were more refractory to conservative treatment than the nonathletes group. Therefore, early operative treatment could be considered in cases of symptomatic ANS especially for athletes.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Consequences of Avulsion Fracture of the Proximal Phalanx Caused by a Technical Failure of Hallux Valgus Surgery

Several cases of avulsion fracture of the proximal phalanx of the big toe during the lateral capsular release procedure were observed. However, these fractures have not been reported as a complication of hallux valgus surgery. The purpose of the present study was to report the proximal phalanx base fracture as an unrecognized complication and to evaluate the clinical and radiographic consequences of this complication. We retrospectively reviewed 225 feet that had undergone hallux valgus surgery involving proximal chevron osteotomy and distal soft tissue release from May 2009 to December 2012. Of these 225 feet (198 patients), 12 (5.3%) developed proximal phalanx base fracture postoperatively. These patients were assigned to the fracture group. The remaining patients were assigned to the nonfracture group. Patients were followed to observe whether the fractures united and whether degenerative changes developed at the first metatarsophalangeal joint because of this fracture. The mean follow-up period was 36 (range 12 to 72) months. All the subjects in the fracture and nonfracture groups underwent weightbearing anteroposterior and lateral radiographs of the foot at the initial presentation and final follow-up point. The 2 groups were compared with respect to the hallux valgus angle, intermetatarsal angle, range of motion, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes. No significant differences were found in age, follow-up period, hallux valgus angle, intermetatarsal angle, range of motion of the first metatarsophalangeal joint, American Orthopaedic Foot and Ankle Society score, satisfaction, and degenerative changes between the 2 groups. Ten (83.3%) of the 12 fractures healed, 2 (16.7% of the fractures, 0.89% of the operated feet) progressed to asymptomatic nonunion, and 3 (1.33%) developed first metatarsophalangeal joint degeneration. Avulsion fracture of the proximal phalanx of the big toe is an uncommon complication of hallux valgus surgery. It seems to be caused by excessive tension placed on the lateral soft tissues that attach to the base of the proximal phalanx at the time of plantarlateral soft tissue release. However, this fracture does not seem to cause significant clinical problems.

Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy

PURPOSE

Clinicians frequently diagnose chronic ankle instability using the manual anterior drawer test and stress radiography. However, both examinations can yield incorrect results and do not reveal the extent of ankle instability. Stress ultrasound has been reported to be a new diagnostic tool for the diagnosis of chronic ankle instability. The purpose of this study was to assess the diagnostic value of stress ultrasound for chronic ankle instability compared to the manual anterior drawer test, stress radiography, magnetic resonance imaging (MRI), and arthroscopy.

METHODS

Twenty-eight consecutive patients who underwent ankle arthroscopy and subsequent modified Broström repair for treatment of chronic ankle instability were included. The arthroscopic findings were used as the reference standard. A standardized physical examination (manual anterior drawer test), stress radiography, MRI, and stress ultrasound were performed to assess the anterior talofibular ligament (ATFL) prior to operation. Ultrasound images were taken in the resting position and the maximal anterior drawer position.

RESULTS

Grade 3 lateral instability was verified arthroscopically in all 28 cases with a clinical diagnosis (100%). Twenty-two cases showed grade III instability on the manual anterior drawer test (78.6%). Twenty-four cases displayed anterior translation exceeding 5 mm on stress radiography (86%), and talar tilt angle exceeded 15° in three cases (11 %). Nineteen cases displayed a partial chronic tear (change in thickness or signal intensity), and nine cases displayed complete tear on MRI (100%). Lax and wavy ATFL was evident on stress ultrasound in all cases (100 %). The mean value of the ATFL length was 2.8 ± 0.3 cm for the stressed condition and 2.1 ± 0.2 cm for the resting condition (p < 0.001).

CONCLUSION

Stress ultrasound may be useful for the diagnosis of chronic ankle instability in addition to the manual anterior drawer test and stress radiography.

LEVEL OF EVIDENCE

III.

Concomitant Syndesmotic Instability and Medial Ankle Instability Are Risk Factors for Unsatisfactory Outcomes in Patients With Chronic Ankle Instability

PURPOSE

To determine whether concomitant chronic syndesmotic injury or chronic medial ankle instability is associated with unsatisfactory outcomes in patients with chronic lateral ankle instability (CAI).

METHODS

We conducted a retrospective review of prospectively collected data from 276 male military patients with CAI who had undergone a modified Broström procedure between May 2007 and March 2010 and had been followed up for a mean of 26.7 months (range, 22 to 41 months). We evaluated clinical outcomes using American Orthopaedic Foot & Ankle Society ankle-hindfoot, visual analog scale, and ankle functional satisfactory scale scores. Possible associations with concomitant instability were reconstructed and investigated using the Pearson correlation coefficient and multivariate logistic regression analysis.

RESULTS

Of the 236 patients with satisfactory outcomes, 19 (8%) had medial ankle instability and 13 (6%) had syndesmotic instability; in contrast, of the 40 patients with unsatisfactory outcomes, 14 (35%) had medial ankle instability and 12 (30%) had syndesmotic instability. The mean American Orthopaedic Foot & Ankle Society scores for patients with satisfactory and unsatisfactory outcomes increased from 68.1 to 92.8 (P < .001) and from 65.9 to 76.8 (P < .001), respectively. The mean visual analog scale scores for the groups with satisfactory and unsatisfactory outcomes decreased from 5.8 to 2.1 (P < .001) and from 6.2 to 4.8 (P < .001), respectively. The mean ankle satisfaction score was 27.8 for patients with satisfactory outcomes and 18.7 for those with unsatisfactory outcomes (P < .001). Multivariate logistic regression analysis showed a 4-fold higher risk of dissatisfaction (95% confidence interval [CI], 0.81 to 20.07; P = .0880) with CAI and syndesmotic instability, a 3.8-fold higher risk (95% CI, 0.96 to 15.07; P = .0576) with CAI and medial ankle instability, and an 11.7-fold higher risk (95% CI, 2.60 to 52.70; P = .0014) with CAI and both syndesmotic and medial ankle instability.

CONCLUSIONS

Chronic syndesmotic instability and chronic medial ankle instability are significantly associated with unsatisfactory outcomes in patients with CAI.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Osteoarthritis of the second metatarsophalangeal joint associated with hallux valgus deformity

BACKGROUND

Hallux valgus is speculated to increase the load on the second metatarsophalangeal (MTP) joint, possibly inducing degenerative osteoarthritis. In addition, the severity of arthritis may be correlated with the severity of hallux valgus. This study evaluated the association of arthritis of the second MTP joint in hallux valgus patients and the relationship between arthritis of the second MTP joint and hallux valgus deformity.

METHODS

A total of 382 patients (509 feet) underwent surgery for symptomatic hallux valgus deformities by the 2 senior authors (KTL, YUP) from November 2011 to December 2012. A total of 54 patients (61 feet), all female, were included in the osteoarthritis (OA) group. The rest were assigned to the nonosteoarthritis (NOA) group. There were 328 patients (448 feet) consisting of 16 men and 432 women. Osteoarthritis patients were then evaluated and classified according to joint space narrowing (JSN) and osteophyte (OP) formation. A statistical analysis was conducted to compare the 2 groups in terms of their hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), hypermobility of the first metatarsal ray, the length of the second metatarsal bone, and the length ratio of the first and second metatarsal bones. Correlation coefficients were calculated to compare the severity of hallux valgus and the degree of osteoarthritis of the second MTP joint.

RESULTS

The IMA of the OA group was 16.2 ± 2.9 degrees, and that of the NOA group was 15.4 ± 3.3 degrees (P = .034, Mann-Whitney U test). The DMAA of the OA group was 18.2 ± 8.3 degrees, and that of the NOA group was 16.1 ± 8.0 degrees (P = .029, Mann-Whitney U test). There were no significant differences between the 2 groups in terms of the HVA, hypermobility, the length of the second metatarsal bone, and the length ratio of the second and first metatarsal bones. In the OA group, there was a positive correlation between the HVA and the degree of osteoarthritis (osteophyte formation) (ɣ = 0.278, P = .030). In addition, there was a positive correlation between the IMA and the degree of osteoarthritis (ɣ = 0.284 [JSN], 0.327 [OP] for the HVA, P = .026 [JSN], .010 [OP]). However, there was no significant difference between hypermobility and the degree of osteoarthritis (P = .356 [JSN], .635 [OP], Mann-Whitney U test). Furthermore, there were no positive correlations between the DMAA, the length of the second metatarsal bone, and the metatarsal length ratio.

CONCLUSION

Our study demonstrated a positive correlation between HVA, IMA, and osteoarthritis of the second MTP joint. Other studies will be needed to determine the factors that are responsible for this correlation.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Femoral and sciatic nerve block for hindfoot and ankle surgery

BACKGROUND

The use of regional anesthesia, such as ankle block or sciatic nerve block, has gained in popularity due to considerations of patient comfort and safety in foot and ankle surgery. However, if the operation extends above the midfoot or if a thigh tourniquet is required, general or spinal anesthesia is needed. The authors aimed to determine by prospective study whether a 'double block', involving femoral and sciatic nerve blocks, is advantageous under such conditions.

MATERIALS AND METHODS

The effectiveness of a preoperative double block was prospectively evaluated in 26 consecutive patients undergoing a variety of foot and ankle procedures, compared with 32 patients with sciatic nerve block alone. Time of analgesia onset, length of block coverage, and complications were noted. Degree of pain was measured using VAS (Visual Analog Scale) scores at the operation, just after surgery, and at 2 h, 1 day, and 2 days after surgery.

RESULTS

The surgical procedures performed under double block were ankle arthroscopy and medial ankle ligament reconstruction, and Achilles tendon repair, and the following conditions were treated; surgery for medial ankle fracture, ankle fusion, subtalar fusion, and surgery for hindfoot diseases, such as, talocalcaneal coalition. The average time required to analgesia onset was 63 min for a double block and 61 min for sciatic nerve block alone. Analgesia time lasted 12.0 h for a double block and 12.4 h for sciatic nerve block alone. Average VAS scores at the operation and immediately after the operation were 0.03 (range 0-1) and 0.16 (range 0-2) for sciatic nerve block, and 0.35 (range, 0-4), 0.31 (range 0-2) for double block. Average VAS scores at 2 h, 1 day, and 2 days postoperatively were 0.28 (range, 0-2), 2.16 (range 0-6), and 1.63 (range 0-5) for sciatic nerve block, and 0.42 (range 0-5), 2.27 (range 0-7), and 1.72 (range 0-8), respectively, for double block.

CONCLUSION

The results of this prospective study suggest that double block provides good surgical anesthesia and good postoperative pain control for hindfoot and ankle surgery.

New method of diagnosis for chronic ankle instability: comparison of manual anterior drawer test, stress radiography and stress ultrasound

PURPOSE

To diagnose chronic ankle instability, clinicians frequently use manual anterior drawer test and stress radiography. However, both exams can yield incorrect results and do not reveal the extent of ankle instability. The use of stress ultrasound during a manual anterior drawer stress procedure might enable the diagnosis of chronic ankle instability.

METHODS

Seventy-three patients with chronic ankle pain or laxity after remote ankle sprain were included. The study population included 41 males and 32 females. The mean age of the patients at the time of the operation was 29 years. A standardized physical examination (manual anterior drawer test), stress radiography and stress ultrasonography were performed to assess the anterior talofibular ligament (ATFL). Ultrasound images were taken in the resting position and the maximal anterior drawer position. The statistical significance of stress ultrasound among the three groups according to manual anterior drawer test and a specific degree (5 mm) of anterior translation of stress radiography were analysed. Correlation coefficients between stress ultrasound, stress radiography and manual anterior drawer test were calculated.

RESULTS

There was a significant difference for ATFL length (ATFL stress) and ATFL ratio (ATFL stress/ATFL resting) among the three groups (both p < 0.001). However, there was no significant difference for anterior translation of stress radiography among three groups according to manual anterior drawer test (p = 0.159). There was a significant difference for ATFL length (ATFL stress) and ATFL ratio between two groups with 5-mm anterior translation of stress radiography (p = 0.002 and p = 0.011, respectively). The mean value of grade of manual anterior drawer test between the two groups also differed (p = 0.021). There was a moderately positive linear relationship between stress ultrasound and manual anterior drawer test. Also, there was a positive linear relationship between stress ultrasound and stress radiography.

CONCLUSION

The results suggest that the value of ATFL length (ATFL stress) and ATFL ratio of stress ultrasound could be used for diagnosis of chronic ankle instability in addition to manual anterior drawer test and stress radiography.

A modified technique for flexor-to-extensor tendon transfer to correct residual metatarsophalangeal extension in the treatment of hammertoes

A variety of surgical procedures exist for the correction of hammertoe deformities, and several different methods of flexor tendon transfer have been described for the correction of hammertoes associated with extension contracture of the corresponding metatarsophalangeal joint. In the present report, we have described a variation of flexor tendon tenodesis we have found useful.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Characteristics of male adolescent-onset hallux valgus

BACKGROUND

Several studies show that hallux valgus has a female preponderance and that approximately 50% of patients have an adolescent onset of deformity. However, little is known about male adolescent-onset hallux valgus. We evaluated the radiologic characteristics and the result of deformity correction in male adolescent-onset hallux valgus (MAHV).

METHODS

We evaluated 31 feet with MAHV that received corrective osteotomies (16 scarf, 11 distal chevron, 4 proximal chevron, and 21 Akin). The patients' mean age was 22 years. Using standard weight-bearing radiographs, we measured hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), proximal phalangeal angle (PPA), metatarsus adductus angle (MAA), and congruency, preoperatively and at an average of 21 months after surgery. We assessed the clinical outcome at follow-up with regard to patient satisfaction using the American Orthopedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal score.

RESULTS

The mean HVA, IMA, DMAA, and PPA decreased from 28.8, 12.0, 11.9, and 6.5 degrees to 10.9, 4.2, 9.7, and 6.3 degrees, respectively (P < .05). Preoperative congruency was 68% (21 of 31 feet). All feet had metatarsus adductus, and the mean MAA was 26.7 degrees. The mean AOFAS score increased from 64.3 to 92.7. Excellent and good satisfaction rate was 94% (29 of 31 feet). We had 2 complications: 1 patient with acute deep infection and 1 patient with complex regional pain syndrome type II accompanying neuralgia of the hallux.

CONCLUSIONS

Most of the patients with MAHV had congruent first metatarsophalangeal joints consistent with increased MAA and DMAA. They also had high PPA and relatively lower IMA. Metatarsal osteotomy with lateral translation and phalangeal corrective osteotomy for MAHV was a reliable technique with successful outcomes and low complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Prognostic classification of fifth metatarsal stress fracture using plantar gap

BACKGROUND

There have been diverse results even in same Torg type of fifth metatarsal stress fractures.

METHODS

Eighty-six cases with a fifth metatarsal stress fracture that were treated with modified tension band wiring from January 2003 to May 2009 were evaluated retrospectively. Each case was classified according to Torg's classification and a new classification. Using the new proposed classification, cases were subdivided into complete fracture and incomplete fracture. The cases of incomplete fracture were subdivided based on presence or absence of plantar gap more than 1 mm. After surgery, bone union was determined by CT. Statistical analysis of the Torg classification and time for bone union as well as the proposed new classification and time for bone union was performed.

RESULTS

There was a significant difference in the time for bone union among the three Torg types (P = 0.004). The mean time for bone union in group A (complete fracture, n = 32) was 67.5 ± 28.8, and it was 103.2 ± 47.7 for group B (incomplete fracture, n = 54). There was a significant difference in time for bone union between them (P < 0.001). The mean time for bone union in group B1 (incomplete fracture, plantar gap less than 1 mm, n = 16) was 73.9 ± 26.7, and it was 115.5 ± 45.4 for group B2 (incomplete fracture, plantar gap 1 mm or more, n = 38). There was a significant difference in time for bone union between them (P < 0.001).

CONCLUSION

The results of this study suggest that the classification incorporating the plantar gap might be used for classification of fifth metatarsal stress fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Unilateral hallux valgus: is it true unilaterality, or does it progress to bilateral deformity?

BACKGROUND

This study was undertaken to determine whether unilateral hallux valgus progresses unilaterally and to evaluate the demographics, etiologies, and radiographic findings associated with symptomatic unilateral hallux valgus deformities.

METHODS

Patients treated for hallux valgus between January 2004 and December 2008 were identified, and of these, 33 patients with unilateral deformities were enrolled. Progression of deformities in normal feet were evaluated at last follow-up visit, and the clinical information and radiographic measurements of those with a deformed normal foot or an unchanged normal foot were compared.

RESULTS

Thirty-three patients (3.4%) had a unilateral hallux valgus deformity on preoperative radiographs. The mean length of follow up was 4.7 years (range, 2.4-11). Twenty-four cases had no deformity of the normal foot at last follow-up (the unchanged group), but 15 cases had developed hallux valgus deformity (the deformed group). No significant intergroup differences were found in terms of metatarsus adductus angle (P = .412), Meary angle (P = .771), talocalcaneal angle (P = 1.000), or calcaneal pitch angle (P = .267). However, members of the deformed group were significantly younger at disease onset (P = .045), exhibited a curved first metatarsal head (P = .046), and had a larger initial hallux valgus angle (P < .001).

CONCLUSIONS

The frequency of bilateral symptomatic hallux valgus was found to be over 97.3%, and significant differences were found between the deformed and unchanged groups in terms of age of onset, metatarsal head shape, and hallux valgus angle.

The mobility total ankle replacement: techniques and pitfalls

The Mobility total ankle replacement (DePuy, Leeds, United Kingdom) is an uncemented, 3-component, mobile-bearing design. This article highlights the design rationale and explains the surgical technique with the Mobility implant, as well as offering technical tips and pitfalls gained through personal experiences and literature review. The tibial component has a flat articular surface and a conical intramedullary stem on the tibial side.

Midterm outcome of modified Kidner procedure

BACKGROUND

The results of modified Kidner procedures have generally been satisfactory at short-term followup. The objective of this study was to evaluate the midterm followup results including medial longitudinal arch height.

METHODS

Forty-one patients (50 feet) with a symptomatic accessory navicular who underwent the modified Kidner procedure between July 1999 and February 2004 were evaluated. A midfoot AOFAS score, VAS score, and satisfaction rate were recorded. The talo-first metatarsal (T-MT1), talo-calcaneal (TC), and calcaneal pitch (CP) angles were measured on plain radiographs. Average clinical and radiological followup periods were 88.4 ±17.0 months and 85.7 ±15.0 months, respectively.

RESULTS

The mean preoperative and followup AOFAS scores were 40.8 ±7.1 (range, 32 to 57), and 88.4 ±7.9 (range, 72 to 100), respectively (p < 0.01). The mean preoperative and followup VAS scores were 7.1 ±1.0 (range, 4 to 9) and 1.8 ±1.0 (range, 0 to 5), respectively (p < 0.01). At last followup , the satisfaction rate was 82.0%. There were no significant differences between preoperative and followup T-MT1 (p = 1.00), TC (p = 0.84), and CP (p = 0.08) angles. Increased medial longitudinal arch was found in four of 16 feet in patients 15 years of age or younger with followup radiographs.

CONCLUSION

We found the modified Kidner procedure could result in symptomatic relief and high satisfaction rate without a loss of arch height in any patient.

Usefulness of oblique axial scan in magnetic resonance imaging evaluation of anterior talofibular ligament in ankle sprain

The purpose of the present study was to clarify the usefulness of the oblique axial scan parallel to the course of the anterior talofibular ligament in magnetic resonance imaging of the anterior talofibular ligament in patients with chronic ankle instability. We evaluated this anterior talofibular ligament view and routine axial magnetic resonance imaging planes of 115 ankles. We diagnosed the grade of the anterior talofibular ligament injury and confirmed full-length views of the anterior talofibular ligament. Associated lesions were also checked. The subjective diagnostic convenience of associated problems was determined. The full-length view of the anterior talofibular ligament was checked in 85 (73.9%) patients in the routine axial view and 112 (97.4%) patients in the anterior talofibular ligament view. The grade of injury increased in the anterior talofibular ligament view in 26 (22.6%) patients compared with the routine axial view. There were 64 associated injuries. The anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and posterior tibialis tendinitis were more easily diagnosed on the routine axial view than on the anterior talofibular ligament view. An additional anterior talofibular ligament view is useful in the evaluation of the anterior talofibular ligament in patients with chronic ankle instability.

Long-term results of neurectomy in the treatment of Morton's neuroma: more than 10 years' follow-up

PURPOSE

The objective of this retrospective study was to evaluate the long-term follow-up results of neurectomy clinical outcomes and complications in the treatment of Morton's neuroma.

MATERIALS AND METHODS

A total of 19 patients (19 different feet) were treated for Morton's neuroma by excision of the interdigital nerve at our institute between May 1997 and May 1999. Thirteen (13 feet) of them were followed up. The 13 patients were female and had an average age of 43 years (range 34-54 years) at the time of the operation. The patients were followed-up for a mean of 10.5 years (range 10.0-12.2 years) and scored using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot scoring system and Visual Analogue Scale (VAS) score. Subjective satisfaction was evaluated at the final follow-up.

RESULTS

Eight patients scored more than 90 on the AOFAS forefoot scoring system. The VAS score was improved in all patients. The mean preoperative VAS score was 8.6 ± 0.8 cm (7-10) and the mean follow-up VAS score was 2.4 ± 1.8cm (0-6), which indicated no significant difference (P > .05). The final follow-up satisfaction results indicated that 4 patients were completely satisfied with the operation, 4 were satisfied with minor reservations, 5 were satisfied with major reservations, and no patient was unsatisfied. Neurectomy to treat Morton's neuroma had a good satisfaction rate (61%). Eleven of the patients complained of numbness on the plantar aspect of the foot adjacent to the interspace, and 2 of these 11 patients complained of disability induced by severe numbness. There was a complaint of residual pain by 1 patient. There were no skin problems on the operation lesions.

CONCLUSION

The long-term results of neurectomy clinical outcomes in Morton's neuroma are slightly worse than the short- and mid-term results.

LEVELS OF EVIDENCE

Therapeutic, Level IV, Retrospective case series.

The plantar gap: another prognostic factor for fifth metatarsal stress fracture

BACKGROUND

There have been diverse results, even in the same Torg type classification, in cases with fifth metatarsal stress fracture.

HYPOTHESIS

The "plantar gap" is correlated with the time for bone union and complications. It might be used for a prognostic factor.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Seventy-five cases with a fifth metatarsal stress fracture treated with modified tension band wiring from January 2003 to December 2008 were evaluated retrospectively. This consecutive series of patients included 71 male and 2 female patients with a mean of 19.8 years of age at the time of surgery. All of the enrolled patients were elite-level athletes. Each case was classified according to Torg classification and the degree of plantar gap was also measured. After the surgery, bone union was determined by computed tomography findings. Statistical analysis of the Torg classification and time for bone union, as well as plantar gap and time for bone union, was performed.

RESULTS

The mean time for bone union for each Torg type was 71.05 ± 21.77 days for type I, 104.48 ± 54.62 days for type II, and 122.92 ± 51.75 days for type III. There was a significant difference in the time for bone union among the 3 Torg types (P = .008). The mean time for bone union in group A (plantar gap <1 mm) was 71.21 ± 29.95 days and it was 126.4 ± 51.99 days for group B (plantar gap ≥1 mm) (significantly different; P < .001). In addition, there was a positive correlation of the time for bone union with the degree of plantar gap (ρ = .661, P < .001). In cases with Torg type II classification, there was a significant difference in the time for bone union between groups A and B (P < .001) In addition, there was a strong correlation between the time for bone union and the degree of plantar gap (ρ = .657, P < .001). There were 8 cases of nonunion in Torg type II, and 1 case in Torg III. With regard to the plantar gap, there was 1 case of nonunion in group A, and 8 cases in group B.

CONCLUSION

The results of this study suggest that the plantar gap might be used for prognosis in cases with a fifth metatarsal stress fracture, even in patients with the same Torg classification.

Radiographic evaluation of foot structure following fifth metatarsal stress fracture

BACKGROUND

Correlation between foot structure and stress fracture risk has not been adequately evaluated or proven. The purpose of this study was to compare foot structure in fracture cases versus control with respect to radiological parameters in stress fractures of the fifth metatarsal.

MATERIALS AND METHODS

The study group consisted of 50 consecutive athletes with a diagnosis of fifth metatarsal stress fracture and a control group matched for sport type and age. Fifth metatarsophalangeal (MTP-5) angle, fourth-fifth intermetatarsal (IMA4-5) angle, fifth metatarsal lateral deviation (MT5-LD) angle were measured on standing antero-posterior (AP) radiographs. Talo first metatarsal (T-MT1) angle, talo-calcaneal (TC) angle, and calcaneal pitch (CP) angle were measured on a standing lateral view, and MT5-LD angle was measured on a 30-degree medial oblique view.

RESULTS

Significant inter-group differences were found for TC angle (p < 0.001) and calcaneal pitch angle (p < 0.001) on lateral radiographs, and for IMA4-5 angle (p = 0.003), MT5-LD angle (p = 0.002) on AP radiographs, and for MT5-LD angle (p < 0.001) on the 30-degree medial oblique radiographs.

CONCLUSION

Fifth metatarsal stress fractures were found to be associated with elevated T-MT1 angle and CP angle representing a cavus foot and the increased curvature of fifth metatarsal. In addition, the extent of fifth metatarsal curvature on a 30-degree medial oblique view was found to be more related to the risk of fracture than on the AP view.

Surgical results of 5th metatarsal stress fracture using modified tension band wiring

PURPOSE

The purpose of this study was to evaluate the surgical results of modified tension band wiring using two cortical screws for the treatment of fifth metatarsal stress fractures.

METHODS

Forty-two patients with Torg's type I and II fifth metatarsal stress fractures treated using the modified tension band wiring technique from 2005 to 2008 were evaluated retrospectively. All of the patients were elite athletes.

RESULTS

The mean length of follow-up was 26 ± 16 months (12-62 months). All patients were able to return to their previous levels of sporting activity. The mean time to union as determined by CT was 75 ± 25 days (40-150 days). However, during follow-up, there were 4 delayed unions, 1 nonunion, and 4 refractures.

CONCLUSION

The described modified tension band wiring technique is a good alternative method for the surgical treatment of Torg's type I and II fifth metatarsal stress fractures.

LEVEL OF EVIDENCE

Case series with no comparison group, retrospective case series, Level IV.

Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction

BACKGROUND

The short-term results of modified Brostrom procedures (MBP) have been satisfactory. However, the long-term results of anatomical reconstruction have been less frequently reported. We report on our long-term results in our patient group.

MATERIALS AND METHODS

Thirty patients with chronic ankle instability who were treated using the MBP without CFL reconstruction from March 1997 to June 1999 were evaluated retrospectively. This consecutive series of patients was comprised of 26 males and four females. The mean age of the patients at the time of operation was 23 years. The mean followup period was 10.6 years. Twenty-four of the 30 were high-level amateur or professional athletes. The operation procedure involved only ATFL imbrication with inferior extensor retinaculum (IER) reinforcement. Clinical outcomes were evaluated by reviewing clinical charts, retrospectively. Functional outcome scores were obtained using the Hamilton scale, a VAS, and AOFAS score at final followup visit, when each patient underwent a physical examination and stress radiography.

RESULTS

Mean AOFAS score was 91 and the mean VAS at final followup was 87. According to the Hamilton classification, 12 achieved an excellent result, 16 a good result, and two a fair result. Mean anterior translation values at final followup were 6.9 and 6.1 mm on ipsilateral and contralateral sides. Furthermore, mean talar tilt angles were 3.0 and 2.5 degrees for ipsilateral and contralateral sides. Twenty-eight of the 30 patients were restored to pre-injury activity levels.

CONCLUSION

The long-term surgical results of the MBP without CFL reconstruction for chronic lateral ankle instability were good to excellent in terms of functional, clinical, and radiographic assessments.

Reverse distal chevron osteotomy to treat iatrogenic hallux varus after overcorrection of the intermetatarsal 1-2 angle: technique tip

Level of Evidence: V, Expert Opinion

Mass-induced unilateral hallux valgus

Various causes of hallux valgus exist. However, mass-induced hallux valgus is a rare phenomenon. To the best of our knowledge, there has been 1 previous report on mass-induced hallux valgus in the English literature; however, that report described giant cell tumor of the extensor digitorum longus tendon sheath. We believe ours to be the first published case of osteochondroma of the second metatarsus-induced hallux valgus. A 19-year-old woman presented with pain and tenderness in the left hallux of 3 months' duration. After a diagnosis of bony mass with hallux valgus, an operative excision was performed through a dorsal approach on the first web space of the left foot. The histopathologic diagnosis was osteochondroma. One-year follow-up radiographs showed a decreased hallux valgus angle and intermetatarsal angle. Unilateral hallux valgus occurs in a mass area. After excision of the mass, hallux valgus angle and intermetatarsal angle decrease. The rotational deformity is not severe. There is little probability of discovering its etiology, but mass-like osteochondroma should be considered.

Neglected Sever's disease as a cause of calcaneal apophyseal avulsion fracture: case report

Level of Evidence; V, Expert Opinion

Acute lung injury after phosgene inhalation

Phosgene (COCl2) is a colorless oxidant gas which is heavier than air and the lethal exposure dose (LC50) in humans is 500 ppm/min. This gas was originally manufactured as an agent for chemical warfare during World War I and there had been a great deal of studies on phosgene poisoning during the early years of industrial use. It is still widely used in the synthesis of chemicals and plastics. In the modern era, however, phosgene poisoning is relatively uncommon except in accidental exposures. In Korea, there has been no report about lung injury from phosgene inhalation. We present a clinical experience with six patients accidentally exposed to phosgene.