Surgical Procedures for Chronic Lateral Ankle Instability / 대한족부족관절학회지

Surgical treatments for chronic lateral ankle instability include anatomic repair, anatomic reconstruction using an auto or allograft, nonanatomic reconstruction, and arthroscopic repair. Open anatomic repair using the native ligament with or without reinforcement of the inferior extensor retinaculum is commonly performed in patients with sufficient ligament quality. Non-anatomical reconstruction using the adjacent peroneus brevis tendon is typically used only in patients with poor-quality ligament remnants or when previous repair failed. Anatomical reconstruction can be considered in patients in whom anatomical repair is expected to fail and when performed using auto or allografts can provide good to excellent short-term results, although the long-term outcomes of these methods remain unclear. Arthroscopic repair can provide good to excellent short-term clinical outcomes, but evidence supporting this technique is limited.The advantages and disadvantages of various surgical methods should be compared, and appropriate treatment should be implemented based on patient characteristics.

Current Trends in the Treatment of Osteochondral Lesion of the Talus:Analysis of the Korean Foot and Ankle Society (KFAS) Member Survey / 대한족부족관절학회지

Purpose@#Given the lack of definite evidence-based guidelines in clinical practice, there may be a wide variation in treatment protocols for osteochondral lesions of the talus (OLT). Based on the Korean Foot and Ankle Society (KFAS) member survey, this study aimed to report the current trends in the management of OLT. @*Materials and Methods@#A web-based questionnaire containing 30 questions was sent to all KFAS members in September 2021. The questions were mainly related to clinical experience and preferences in diagnosis, conservative, and surgical treatments for patients with OLT. Answers with a prevalence of ≥50% of respondents were considered a tendency. @*Results@#Sixty-two (11.3%) of the 550 surgeons queried responded to the survey. The responses to 9 (30.0%) of the total of 30 questions established a tendency. Answers exhibiting a tendency were as follows; additional diagnostic tools except for plain radiograph (magnetic resonance imaging), most common conservative treatment method (oral medication, rest), most important radiological factor in decision making for surgical treatment and method (size of the lesion, ankle instability, loose bodies), most important patient factors in decision making for surgical treatment and method (age, activity or occupation), infrequently requiring posterior arthroscopy (less than 3%), most common revision surgery for failed bone marrow stimulation procedure (osteochondral autograft transplantation [OAT]), not requiring additional procedure for donor site in OAT, the main reason for unsatisfactory result after OAT (persistent pain without radiological abnormality), no generalization of autologous chondrocyte implantation or chondrogenesis using stem cells. @*Conclusion@#This study presents updated information on current trends in the management of OLT in Korea. Both consensus and variations in the approach to patients with OLT were revealed through this survey. Since recent biologic efforts to regenerate cartilage have been unsuccessful, further studies to identify clinical evidence would be needed.

Freer Test for an Intraoperative Evaluation of a Lisfranc Joint Injury: A Technical Report / 대한족부족관절학회지

Failure to achieve stable fixation during surgery for a Lisfranc joint injury leads to subtle instability that causes dysfunction and posttraumatic osteoarthritis. Therefore, it is important to check for appropriate fixation during surgery. This paper reports a test that evaluates the joint instability dynamically during the open reduction of the Lisfranc joint and checks the stability after fixation. a Freer elevator was inserted into the interosseous area between the medial cuneiform and second metatarsal base, and a twisting force was applied to evaluate the dynamic instability of the Lisfranc joint. After fixation of the Lisfranc joint, the stability of the fixation could be tested by trying this maneuver with the Freer elevator. Overall, the Freer test can be considered a valuable test in open surgery for a Lisfranc joint injury.

Treatment of Acute Achilles Tendon Rupture

There is no clear consensus on the optimal treatment of acute Achilles tendon rupture. Recently, studies have demonstrated the critical role of functional rehabilitation in the treatment of ruptured Achilles tendons. Hence, conservative treatment is preferred by a growing number of surgeons seeking to treat the condition without the risk of complications from surgery. However, operative treatment is still considered as a more reliable treatment option for acute Achilles tendon rupture. In this review article, we provide an overview of recent treatment strategies for acute rupture of the Achilles tendon.

Freer Test for an Intraoperative Evaluation of a Lisfranc Joint Injury: A Technical Report / 대한족부족관절학회지

Failure to achieve stable fixation during surgery for a Lisfranc joint injury leads to subtle instability that causes dysfunction and posttraumatic osteoarthritis. Therefore, it is important to check for appropriate fixation during surgery. This paper reports a test that evaluates the joint instability dynamically during the open reduction of the Lisfranc joint and checks the stability after fixation. a Freer elevator was inserted into the interosseous area between the medial cuneiform and second metatarsal base, and a twisting force was applied to evaluate the dynamic instability of the Lisfranc joint. After fixation of the Lisfranc joint, the stability of the fixation could be tested by trying this maneuver with the Freer elevator. Overall, the Freer test can be considered a valuable test in open surgery for a Lisfranc joint injury.

Peroneal Tendon Repair in Sports Injury / 대한족부족관절학회지

PURPOSE: This study examined the clinical outcomes and assessed the average time to return to play following a peroneal tendon repair in Korean athletes. MATERIALS AND METHODS: Between March 2004 and February 2017, a total of 30 athletes underwent peroneal tendon repair for a peroneal tendon tear. The indications of surgical treatment were chronic pain or intractable symptoms after a previous ankle sprain affecting sports activity refractory to conservative treatment for at least six months. The patient underwent tubulization for a longitudinal tendon rupture. Peroneus longus to peroneus brevis tenodesis was performed when tendon repair was impossible due to total rupture or multiple longitudinal rupture. RESULTS: Twenty patients not included in this study were as follows: insufficient follow-up, previous surgery, and additional bone surgery. All 10 patients had a previous ankle sprain history, tenderness and swelling on the retromalleolar area. In the 10 patient population, there were five peroneus brevis tendon tears, three peroneus longus tendon tears, one peroneus longus and brevis tendon tear, and one peroneus brevis and superior peroneal retinaculum tear. In the 10 patients, six cases of peroneal brevis tendon repair and four cases of peroneal longus to brevis tenodesis were performed. The preoperative American Orthopaedic Foot and Ankle Society score was improved from a mean of 60.6 (standard deviation [SD], 8.64) to a mean of 90.2, postoperatively (SD, 4.4; p<0.012). The preoperative visual analogue scale was improved from a mean of 5.43 (SD, 1.2) to 0.5 (SD, 0.16), postoperatively (p<0.023). The mean length of time to return to play was 12.2 weeks (range, 8~16 weeks). CONCLUSION: Peroneal tendon tear can occur due to sports injuries. If there is tenderness at the retromalleolar area, the surgeon should consider a peroneal tendon lesion. Surgical repair of the peroneal tendon can be an effective treatment to help athletes to return to play.

Modified Proximal Scarf Osteotomy for Hallux Valgus

BACKGROUND: We developed a modified proximal scarf osteotomy technique for moderate to severe hallux valgus in an attempt to obtain better correction of the deformity. In addition, we compared the clinical and radiographic results of this modified technique with those of the classic scarf osteotomy reported in other studies. METHODS: Between December 2004 and July 2009, 44 cases of modified proximal scarf osteotomy was performed in 35 patients with moderate hallux valgus. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, range of motion of the first metatarsophalangeal joint, and radiographic results were evaluated. RESULTS: The mean hallux valgus angle and the mean first intermetatarsal angle improved from an average of 32.2° and 14.3°, respectively, to an average of 12.5° and 8.6°, respectively. The distal metatarsal articular angle improved from an average of 18.7° to 12.4°. The preoperative mean AOFAS and VAS scores were 47 points and 7 points, respectively, which improved to 86 points and 1 point, respectively, at the final follow-up. Limited range of motion occurred in two cases postoperatively. The height of the first metatarsal-cuneiform joint, which was an average of 15.9 mm preoperatively, did not change. The first metatarsal-talus angle increased from an average of 4.1° to 7.1°. CONCLUSIONS: The modified proximal scarf osteotomy for the treatment of moderate hallux valgus showed similar results with the classic scarf osteotomy with regard to changes in the first intermetatarsal angle and postoperative satisfaction. Therefore, we suggest the modified proximal scarf osteotomy be considered as well as other proximal osteotomy in the treatment of moderate to severe hallux valgus.

Biomechanical Comparison Study of Three Fixation Methods for Proximal Chevron Osteotomy of the First Metatarsal in Hallux Valgus

BACKGROUND: Fixation of proximal chevron metatarsal osteotomy has been accomplished using K-wires traditionally and with a locking plate recently. However, both methods have many disadvantages. Hence, we developed an intramedullary fixation technique using headless cannulated screws and conducted a biomechanical study to evaluate the superiority of the technique to K-wire and locking plate fixations. METHODS: Proximal chevron metatarsal osteotomy was performed on 30 synthetic metatarsal models using three fixation techniques. Specimens in group I were fixated with K-wires (1.6 mm × 2) and in group II with headless cannulated screws (3.0 mm × 2) distally through the intramedullary canal. Specimens in group III were fixated with a locking X-shaped plate (1.3-mm thick) and screws (2.5 mm × 4). Eight metatarsal specimens were selected from each group for walking fatigue test. Bending stiffness and dorsal angulation were measured by 1,000 repetitions of a cantilever bending protocol in a plantar to dorsal direction. The remaining two samples from each group were subjected to 5 mm per minute axial loading to assess the maximal loading tolerance. RESULTS: All samples in group I failed walking fatigue test while group II and group III tolerated the walking fatigue test. Group II showed greater resistance to bending force and smaller dorsal angulation than group III (p = 0.001). On the axial loading test, group I and group II demonstrated superior maximum tolerance to group III (54.8 N vs. 47.2 N vs. 28.3 N). CONCLUSIONS: Authors have demonstrated proximal chevron metatarsal osteotomy with intramedullary screw fixation provides superior biomechanical stability to locking plate and K-wire fixations. The new technique using intramedullary screw fixation can offer robust fixation and may lead to better outcomes in surgical treatment of hallux valgus.

Morton's Neuroma / 대한정형외과학회잡지

Morton's neuroma, also known as interdigital neuroma, is a common cause of forefoot pain. It is a compressive neuropathy of the interdigital nerve, which is compressed by the overlying transverse metatarsal ligament. It is not a true tumor. The symptoms are forefoot pain that radiates into the toes, according to the involved nerve branches. Its histological findings are fibrosis around the nerve, demyelination. The clinical diagnosis can be obtained from a detailed history and physical examination, such as the compressive test. Moreover, ultrasonography and magnetic resonance imaging can also be used. Conservative treatment is the common initial treatment modality for interdigital neuroma. Surgical excision or decompression is indicated after a failure of conservative treatments.

The Operative Management of Navicular Stress Fractures in Adolescence / 대한족부족관절학회지

PURPOSE: The aim of this study is to evaluate the effectiveness of surgical treatment in adolescent patients suffering from navicular stress fracture. MATERIALS AND METHODS: A total of 11 adolescent patients aged 14 to 19, who underwent an operation for navicular stress fracture between 2005 and 2008 were recruited. Clinical outcomes were evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and visual analogue scale (VAS) score. RESULTS: The mean VAS score before the operation was 7.7. A score of 2.9 was confirmed at final follow up after the operation. The mean final follow-up period was 22.1 months. There was a statistically significant improvement in the VAS score between before and after the operation (p=0.01), and similarly, the AOFAS score also showed an improvement, from 46.5 to 80.7 (p=0.01). The pain that remained after the operation, according to the VAS score, was severe in three patients (27.3%), tolerable in seven patients (63.6%), and free of pain in one patient (9.1%). CONCLUSION: In navicular stress fracture in adolescents, careful selection of patients who could benefit from surgical treatment is recommended.

Total Ankle Arthroplasty: An Imaging Overview

With advances in implant technology, total ankle arthroplasty (TAA) has become an increasingly popular alternative to arthrodesis for the management of end-stage ankle arthritis. However, reports in the literature do not focus on the imaging features of TAA. Through a literature review, we demonstrate basic design features of the current ankle arthroplasty system, and the normal and abnormal postoperative imaging features associated with such devices. Pre- and postoperative evaluations of ankle arthroplasty mainly include radiography; in addition, computed tomography and magnetic resonance imaging provide further characterization of imaging abnormalities. Familiarization with multimodal imaging features of frequent procedural complications at various postoperative intervals is important in radiological practice.

Misdiagnosis of Talar Body or Neck Fractures as Ankle Sprains in Low Energy Traumas

BACKGROUND: The talus has a very complex anatomical morphology and is mainly fractured by a major force caused by a fall or a traffic accident. Therefore, a talus fracture is not common. However, many recent reports have shown that minor injuries, such as sprains and slips during sports activities, can induce a talar fracture especially in the lateral or posterior process. Still, fractures to the main parts of the talus (neck and body) after ankle sprains have not been reported as occult fractures. METHODS: Of the total 102 cases from January 2005 to December 2012, 7 patients had confirmed cases of missed/delayed diagnosis of a talus body or neck fracture and were included in the study population. If available, medical records, X-rays, computed tomography scans, and magnetic resonance imaging of the confirmed cases were retrospectively reviewed and analyzed. RESULTS: In the 7-patient population, there were 3 talar neck fractures and 4 talar body fractures (coronal shearing type). The mechanisms of injuries were all low energy trauma episodes. The causes of the injuries included twisting of the ankle during climbing (n = 2), jumping to the ground from a 1-m high wall (n = 2), and twisting of the ankle during daily activities (n = 3). CONCLUSIONS: A talar body fracture and a talar neck fracture should be considered in the differential diagnosis of patients with acute and chronic ankle pain after a minor ankle injury.

Morphologic Analysis of the Fifth Metatarsal Stress Fracture: The Precise Coronal and Sagittal Location / 대한스포츠의학회지

From a biomechanical standpoint, the main pathologic abnormality of fifth metatarsal stress fracture is the location where repetitive tensile stress concentrated. Decreasing tensile force in this region would be a proper treatment. Therefore, the purpose of this study is to evaluate the precise sagittal and coronal location of the fifth metatarsal stress fracture. Between June 2012 and May 2013, 38 athletes with a fifth metatarsal stress fracture were treated. To evaluate the precise sagittal location of the fracture, the entire length of the fifth metatarsal was measured and the distance from tuberosity to the fracture line was measured. To evaluate the precise coronal location of the fractures, coronal computed tomography images were obtained for incomplete fracture cases. The fracture location was classified as four quadrants. Thirty patients were classified into zone III fracture. However, the fracture is located in zone II for remaining eight cases. The median value of ratio between whole length and the distance from tuberosity to the fracture was 0.35 (range, 0.29–0.40) Among 33 incomplete fracture cases, there were 28 patients whose fracture developed in plantolateral quadrant, four patients at the lateral side and a patient for plantar side. The main pathologic abnormality is at the plantar lateral side because of the repetitive stress concentrated there.

Deltoid Ligament and Tibiofibular Syndesmosis Injury in Chronic Lateral Ankle Instability: Magnetic Resonance Imaging Evaluation at 3T and Comparison with Arthroscopy

OBJECTIVE: To evaluate the prevalence of deltoid ligament and distal tibiofibular syndesmosis injury on 3T magnetic resonance imaging (MRI) in patients with chronic lateral ankle instability (CLAI). MATERIALS AND METHODS: Fifty patients (mean age, 35 years) who had undergone preoperative 3T MRI and surgical treatment for CLAI were enrolled. The prevalence of deltoid ligament and syndesmosis injury were assessed. The complexity of lateral collateral ligament complex (LCLC) injury was correlated with prevalence of deltoid or syndesmosis injuries. The diagnostic accuracy of ankle ligament imaging at 3T MRI was analyzed using arthroscopy as a reference standard. RESULTS: On MRI, deltoid ligament injury was identified in 18 (36%) patients as follows: superficial ligament alone, 9 (50%); deep ligament alone 2 (11%); and both ligaments 7 (39%). Syndesmosis abnormality was found in 21 (42%) patients as follows: anterior inferior tibiofibular ligament (AITFL) alone, 19 (90%); and AITFL and interosseous ligament, 2 (10%). There was no correlation between LCLC injury complexity and the prevalence of an accompanying deltoid or syndesmosis injury on both MRI and arthroscopic findings. MRI sensitivity and specificity for detection of deltoid ligament injury were 84% and 93.5%, and those for detection of syndesmosis injury were 91% and 100%, respectively. CONCLUSION: Deltoid ligament or syndesmosis injuries were common in patients undergoing surgery for CLAI, regardless of the LCLC injury complexity. 3T MRI is helpful for the detection of all types of ankle ligament injury. Therefore, careful interpretation of pre-operative MRI is essential.

Paratrooper's Ankle Fracture: Posterior Malleolar Fracture

BACKGROUND: We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. METHODS: Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. RESULTS: The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. CONCLUSIONS: Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs.

Checkrein Deformity Due to Flexor Digitorum Longus Adhesion after Comminuted Calcaneus Fracture: A Case Report / 대한족부족관절학회지

The checkrein deformity describes tethering of the flexor hallucis longus tendon, which mainly occurs after fracture of the distal tibia. The deformity increases with dorsiflexion of the ankle and decreases or disappears with plantarflexion of the ankle. In some cases, the deformity may occasionally include the second and third toes. In the current study, the authors experienced secondary checkrein deformity of all lesser toes after open reduction and plate fixation for comminuted fracture of the calcaneus. As a treatment, plate and screws were removed, followed by an additional medial incision which showed a partially ruptured flexor digitorum longus tendon with severe adhesion. Resection of the adhesed tendon and tenodesis of its distal portion to the flexor hallucis longus was performed for correction of the checkrein deformity. Then the lessor toe checkrein deformity recovered immediately. The authors report on this rare lessor toe checkrein deformity after calcaneal fracture fixation with a review of literature.

Epidermal Cyst in the Foot and Ankle / 대한정형외과학회잡지

PURPOSE: To document post-excision recurrence rates for epidermal cysts of the foot and ankle by location. MATERIALS AND METHODS: The authors retrospectively reviewed epidermal cysts confirmed histologically by excisional biopsy in 37 patients (male 20, female 17) from 2004 to 2011. Cyst locations and sizes were analyzed and preoperative and postoperative pain levels were compared using a visual analogue scale (VAS). Rates of recurrence and patient satisfaction levels were also measured. RESULTS: Epidermal cysts occurred most commonly on the 1st toe (15 cases, 40.6%), followed by the ankle (7 cases, 18.9%), 2nd toe (6 cases, 16.2%), 3rd toe (4 cases, 10.8%), 4th toe (1 case, 2.7%), 5th toe (2 cases, 5.4%), and heel (2 cases, 5.4%). Average cyst size in 35 cases was 15.5x15.0x7.9 mm. VAS reduced from 6.5 preoperatively to 1.0 postoperatively. Cysts recurred in 7 cases (18.9%); on the 1st toe in 5 and on the 2nd toe in 2. Thirty patients (81.0%) were very satisfied with treatment results, 2 patients (5.4%) were satisfied, and 5 (13.5%) were not satisfied. Recurrence occurred in 4 cases, and in one of these cases the cyst recurred after second excision. CONCLUSION: The excision of epidermal cysts in the foot and ankle area was found to have an 18.9% recurrence rate. To achieve good results, the precise location of cysts should be determined by imaging study before excision, and cysts must be excised completely.

The Size of Calcaneus in Koreans / 대한족부족관절학회지

PURPOSE: Open reduction and internal fixation of calcaneal fracture using plate has been used. While numerous plates have been manufactured, most of the conventional plates are designed for westerners, realistically the size is larger for Korean. The domestic products, on the other hand, often have the undesirable screw holes and path. Therefore, we measured the radiologic parameter of Korean calcaneus for providing the plate and screw hole placements. MATERIALS AND METHODS: We measured the outer lines and angles with over the 20 years old 291 females and 322 males. A: Length of inferior plane of calcaneus, B: Length of anterior plane of calcaneus, C: Length from line A to sinus tarsi, D: Length from line A to posterior point of posterior facet, E: Length from line A to calcaneal tuberosity, F: Length of posterior facet, G: Length from anterior point of line A to C, H: Length from line C to line D, a: Angle between A and B, b: Gissane angle, c: Bohler angle, d: Calcaneal pitch angle using Marosis m-view(R). RESULTS: Mean A, B, C, D, E, F, G, H were 63.6, 26.4, 23.2, 43.7, 40.5, 26.9, 12.8, 18.1 mm. Mean a, b, c, d angle were 105.8, 122.4, 32.4, 20.5degrees. Male's calcaneus is significantly bigger than female's (p<0.001). CONCLUSION: AP calcaneus length 63.6 mm, maximal height 43.7 mm is considered to be helpful in making the Korean calcaneal plate.

Breakage of Reamer during Tibia Intramedullary Nailing: A Case Report

The reamer crack, followed by breakage at its distal part occurred during intramedullary nailing of tibial shaft fracture. The broken reamer was trapped in the intramedullary canal, making it very difficult to pull out. We successfully extracted the broken reamer by retrograde impaction through the fracture site and completed intramedullary nailing procedure. Thus, we present this case with a review of the literature.

Treatment of a Chronic Gouty Ulcer on the Lateral Malleolus with Vacuum-Assisted Closure (VAC) Therapy

Gouty ulceration is a clinical manifestation of gout, which is a metabolic disease induced by disturbed purine metabolism. In general, protruded gout tophus and secondary infection made a gouty ulceration. It was generally treated with surgical debridement of the tophus and infected tissue. Inevitably, we make the skin defect if needed the wide surgical debridement. We waited for granulation tissue healing of the defect, then finished with a skin graft. However, larger sized gouty ulcerations require a longer period of healing time. We commonly used the vacuum assisted wound closer device (VAC) for shortening the healing time in diabetic foot ulceration. Use of VAC for a gouty ulceration was not nearly reported in literature. We report on the use of VAC after surgical debridement to heal a chronic gouty ulceration around the lateral malleolus.