Management of the Diabetic Foot Ulcer in Elderly Patients Using the Anterolateral Thigh Perforator Free Flap / 대한족부족관절학회지

PURPOSE: To evaluate the results of anterolateral thigh perforator free flap for reconstruction of foot and ankle in old diabetic patients. MATERIALS AND METHODS: Fifteen diabetic foot ulcer patients over the age of 55 were operated with anterolateral thigh perforator free flap. Hematological, hemodynamic, diabetic, bacteriologic and radiologic tests were checked with examination of blood vessel state in both the donor site and the recipient site. After surgery, serial check-up was performed at 6 week, 6 month, and 1 year postoperatively on the survival of transplantation tissue, condition of foot, and condition of walking. RESULTS: There are one case of transplantation failure and four cases of partial tissue-necrosis. Delayed wound-healing was observed both recipient and donor tissue sites. At the final follow up, three cases of small ulcer were found at junction of flap and recipient tissue in plantar area. Fourteen out of fifteen patients could walk without any brace or walking aids. CONCLUSION: Reconstruction of foot and ankle region in old diabetic patients with the anterolateral thigh perforator free flap is a useful method which can prevent the amputation of foot and ankle

A New Treatment for Severe Incurved Toenail(2 Cases Report) / 대한족부족관절학회지

Partial toenail ablation on both sides of the great toenail, unfolding the severely curved toenail, and application of a simple device for maintaining the unfolded state of the incurved toenail is described to treat severely incurved toenails (pincer nails). This technique alleviated symptoms and improved the shape of severely curved toenails of the greater toe.

Operative Treatment for Neuropathic Diabetic Foot Ulcer: Usefulness of V-Y Advancement Flap for Unhealing Plantar Ulcer / 대한정형외과학회잡지

PURPOSE: This study examined the results of a single or double V-Y advancement flap, which was found to be technically simple for the management of chronic plantar ulcer in patients with neuropathic diabetic foot. MATERIALS AND METHODS: From January 2004 to December 2005, 29 patients who were hospitalized for the management of a neuropathic diabetic foot plantar ulcer were examined. All patients underwent single- or double-V-Y advancement flap for the management of the ulceration. Hematological, hemodynamic, diabetic, bacteriologic, and radiological tests wereperformed prior to surgery. The condition of the wound was checked during surgery, and the healing rate, healing time and recurrence during the follow-up examinations were evaluated after surgery. RESULTS: The mean age of the patients was 53.4 years (36-69). The plantar ulcers were the most commonly found in the forefoot area (12 cases). Nine cases showed ulcers in the hindfoot area, 6 cases were found are in the lateral foot area, and 2 cases were identified in the medial foot area. The area covered with the V-Y advancement flap averaged 2.05 cm(2) (0.8-3.9). The mean healing time of the wound was 4.7 weeks (3-8). One day after surgery, there were 7 cases of partial circulation disturbance that were managed with a partial stitch out and secondary intension wound healing. There were 5 cases of recurrence of the wound. CONCLUSION: A V-Y advancement flap to manage chronic diabetic plantar ulcers can produce excellent or good results. However, a high incidence of delay in healing of the surgical wound can be expected, and a longer period is needed to protect the wound comparing with normal patients.

The Validity and Reliability of the EMC Device; For the Checking ofthe Mobility of the First Ray of the Foot / 대한정형외과학회잡지

PURPOSE: To evaluate the validity and intra-rater, inter-rater reliability of the EMC device used to check the mobility of the first ray of the foot. MATERIALS AND METHODS: Sixty-nine cases (43 patients) of mild to severe hallux valgus feet were enrolled in this study. For an analysis of the validity of the EMC device, the dorsal mobility of the first ray of the foot was measured using the modified Coleman block test and EMC device. The intra- and inter-rater reliability of EMC device was evaluated by measuring the dorsal mobility of the first ray of the foot twice with three independent raters blinded to other's results. The results were analyzed for the intra-rater reliability and for inter-rater reliability. RESULTS: The mean value of the dorsal mobility of the first ray of the foot by the EMC device and modified Coleman block test was 8.3 mm (range; 4.3-12.3 mm) and 7.4 mm (range; 3.4-10.3 mm), respectively. There was a significant difference between the EMC device and modified Coleman block test (p<0.05). However, both the measured data, showed a good correlation (Pearson correlation coefficient=0.84). The paired t-test for intra-rater reliability and ANOVA testing for inter-rater reliability showed no statistically significant difference. CONCLUSION: The EMC device is reliable and valid for measuring the mobility of the first ray of the foot.

Anatomical Study of Interdigital Neuroma Occurring Site and the Deep Transverse Metatarsal Ligament (DTML) / 대한족부족관절학회지

PURPOSE: We examined the relationship of interdigital neuroma occurring site and the surrounding structures, including the deep transverse metatarsal ligament (DTML) by cadaver study and clinical results. MATERIALS AND METHODS: Seventeen fresh frozen cadavers study were done to evaluate the relationship of interdigital neuroma occuring site and the DTML at two phase of the gait cycle with 60 degree of metatarsophalangeal dorsiflexion and with 15 degrees of ankle dorsiflexion. We measured the distance from interdigital nerve bifurcation of the common digital nerve to anterior margin of the DTML and longitudinal length of DTML itself. Clinically, we checked the location of interdigital neuroma and DTML length during surgery in 32 feet. RESULTS: In the second and third web space, the mean distance from bifurcation of the common digital nerve of foot to the anterior margin of DTML was 16.7 mm, 15.1 mm in the mid-stance position, and 15.9 mm. 14.6 mm in heel-off position. Second, Third web space ligament itself length were average 12.8 mm, 10.6 mm. Clinically, all of the cases of interdigital neuroma started at the bifurcation area of the common digital nerve and interdigital neuroma was average 7.5 mm (range; 6-11 mm). CONCLUSION: Interdigital neuroma were located more distally than DTML in both the mid-stance and heel off stage. The main lesion was located between metatarsal head and metatarsophalangeal joint and more distal than the DTML anterior margin.

Treatment of Bunionette Deformity with Distal Chevron Osteotomy / 대한정형외과학회잡지

PURPOSE: To evaluate a symptomatic bunionette managed by a distal chevron osteotomy. MATERIALS AND METHODS: From 1997, among eighty-three patients who had been treated for a bunionette deformity with a distal chevron osteotomy, 17 patients, who had no other associated diseases, were reviewed retrospectively. The VAS pain score and AOFAS score, the patient satisfaction level, shoe selectability and disappearance of the callus on the foot were examined. The 5th metatarso-phalangeal angle and 4th and 5th intermetatarsal angle were measured using AP plain radiography. The bunionette was classified as types 1, 2, and 3 and the treatment results were analyzed. RESULTS: 8 male and 9 female patients were enrolled in this study. The mean age of the patients was 33.6 years (21-49 years). The mean follow-up period was 37.6 months (20-62 months). The pain VAS scores were 7.9 preoperatively and 1.2 postoperatively. The last follow-up AOFAS score was 94.7, and all patients were ranked at the very satisfied or satisfied level. All patients had also good shoe selectability and the callus on the lateral sole had disappeared. The preoperative 4th and 5th intermetatarsal angle (mean 10.2 degrees) and the 5th metatarso-phalangeal angle (mean 21.4 degrees) improved to 2.7 degrees and 7.2 degrees after surgery, respectively. There was a type 1, 2 and 3 deformity in 2 (12%), 1 (6%) and 14 patients (82%), respectively. The results among the types were satisfactory. CONCLUSION: A distal chevron osteotomy for the treatment of a symptomatic bunionette is safe, easy and can reduce the signs and symptoms. Regardless of the types of deformity, a distal chevron osteotomy can obtain satisfactory results.

Open Ostectomy of Anterior Impingement Syndrome: Comparison of Athletes and Nonathletes / 대한정형외과학회잡지

PURPOSE: To analyse the clinical results of open treatment of anterior impingement syndrome of the ankle and to determine if being athletics or nonathletics affects the result. MATERIALS AND METHODS: This study included 54 consecutive patients who had undergone surgery with an open modality. All had been diagnosed with anterior impingement syndrome and received conservative therapy for more than at least 3 months prior to surgery. Among them, 22 patients were high-level athletes. The patients were evaluated with a physical examination and simple radiograph. A bone scan or MRI were added if necessary. The patients were categorized into four groups according to the McDermott's grading system based on the lateral radiograph. Patients with McDermott's grade 4 change and with osteochondral lesions were excluded. The results of the Ogilvie-Harris score, a visual analogue scale of the patient satisfaction and the time to return to full activity were assessed. RESULTS: The mean follow-up was 32 months, 82% of patients had good or excellent results. In general, the Ogilvie Harris score improved postoperatively. However, there was no significant difference between groups. There was no statistical significance between the athletics and non-athletics in terms of the improvement in the Ogilvie-Harris score. 91% of patients were satisfied in the final follow-up (more than 80% in the visual analogue scale). The mean time to return to full activity was 10.5 weeks with the athletes and 8.8 weeks with the nonathletes. CONCLUSION: Open surgical treatment for anterior impingement syndrome may be an effective modality regardless of the patient being an athlete or non-athlete.

Distal Tibial Articular Surface Angle in the Coronal Plane in Koreans / 대한족부족관절학회지

PURPOSE: The purpose of this study is to find out the normal distal tibial articular surface angle in coronal plane in Koreans. This would be helpful as the basic data for ankle reconstruction after trauma or deformity correction. MATERIALS AND METHODS: Weight bearing anteroposterior radiographs of 123 normal ankles were reviewed. A line parallel to the shaft of the tibia was made. Another line was drawn parallel to the articular surface of the distal tibia. The superolateral angle that subtended by these two lines was measured. RESULTS: There were 72 males and 51 females. The mean age overall was 35.7 years old. The mean age for males was 31.9 (28~36) years old. The mean age for females was 41.1 (37~45) years old. The mean distal tibial articular surface angle was 90.8 degrees. The mean distal tibial articular surface angle for males was 91.5 degrees and for females 89.9 degrees. CONCLUSION: The mean distal tibial articular surface angle in coronal plane for Koreans is 90.8 degrees. We can avoid the error of the varization at the ankle alignment when the correction was performed vertical or minimal valgus to tibia tuberosity axis in Korean people.

The Comparison of Ultrasonographic Size of Morton's Neuroma measured to Actual Size / 대한족부족관절학회지

PURPOSE: To compare ultrasonographic size of morton's neuroma measured to actual size MATERIALS AND METHODS: Thirty-two (twenty-eight patients) of symptomic Morton's neuroma were measured by ultrasonography preoperatively and by manual method that designed by authors intraoperatively from January, 2002 to May, 2003. Two results were stastically compared by paired T-test RESULTS: Except one, all of cases were women and the mean age of patients was 50.6 years (32-62 years). The most common associated disease was hallux valgus deformity (17 cases). Six of Morton's neuromas located on second intermetatarsal space, sixteen of them did third intemetatarsal space and ten of neuromas located simultaneously second and third intermetatarsal space. The ultrasonographic size of neuroma averaged 3.48 mm and real size was 3.99 mm. The size checked by manual method was larger than by ultrasound with statical meaning CONCLUSION: The size of Morton's interdigital neuroma checked by ultrasonography on plantar aspect is smaller than real size. If you checked Morton's interdigital neuroma size by ultrasonography, you can suspect that real size of Morton's interdigital neuroma is larger than that size.

Extensor Hallucis Longus Tendon Rupture in TaeKwonDo Players: Two Case Report / 대한족부족관절학회지

Occasionally, extensor hallucis longus tendon (EHL) ruptures becames open by laceration and spontaneous rupture of EHL that has previous story of diabetes mellitus, steroid injection, systemic steroid administration, operation and rheumatoid arthritis. But, closed traumatic EHL ruptures are reported rarely. Especially, we diagnosed the closed EHL ruptures in TaeKwonDo players. We reported the 2 patients, differently treated end to end anastomosis and EHL transfer, had the course and treatment methods. Be care the prognosis can be altered according to the treatment time and method.

Treatment of Postoperative Tarsal Tunnel Syndrome with Autogeneous Vein Wrapping Graft / 대한족부족관절학회지

Management of postoperative tarsal tunnel syndrome is a perplexing problem to the surgeons. Autogenous vein wrapping graft is a effective method to decompress the tarsal tunnel. We treated 2 cases of postoperative tarsal tunnel syndrome with autogenous saphenous vein wrapping graft technique, and could get good results. Autogenous vein wrapping graft seems to be a good technique for tarsal tunnel syndrome with severe adhesion, particularly after surgery, and postoperative nerve adhesion can be prevented.

The Results of Subtalar Arthroereisis for Flexible Flatfoot of Children / 대한족부족관절학회지

PURPOSE: We evaluate the results of subtalar arthroereisis with Kalix(R) implant (Newdeal, Lyon, France) that were performed in painful flatfoot deformity. MATERIALS AND METHODS: We performed the subtalar arthroereisis on 16 feet of children symptomatic flexible flat feet after more than 6 months of conservative treatment. Average age was 11 years (8-14 years) old. We checked the functional status with AOFAS functional score in pre-operatively and at final follow-up. Radiologically, we took weight bearing anterior to posterior and lateral view of the feet, and measured the talo-1st metatarsal angle, calcaneal pitch angle, cuboid-surface height. Finally, we asked to patient's parents for satisfaction of the surgery. RESULTS: Mean follow up period was 34.1 months. Average AOFAS score improved from preoperatively 71.9 to postoperatively 91.3. Only one patient has subtalar pain. Average lateral 1st metatarsal angle reduced from -18.2 degrees preoperatively to -4.6 degrees at final follow-up. Average anterior to posterior 1st metatarsal angle was reduced from 18.9 degrees preoperatively to 6.5 degrees at final follow-up. Average calcaneal pitch angle was increased from 8.6 degrees preoperatively to 12.6 degrees at final follow-up. Average cuoboid-surface height was improved from 12.1 mm preoperatively to 16.0 mm at final follow-up. All patients had excellent or good satisfaction. CONCLUSIONS: Subtalar arthroereisis with Kalix(R) implant is a viable surgical alternative for painful flatfoot deformity of children.

The Result of Total Contact Cast with High Concentrate Silver (Ag+) Coated Foam Dressing in Diabetic Foot Ulcers / 대한족부족관절학회지

PURPOSE: The treatment of diabetic foot ulcers with total contact cast has been reported to be associated with numerous undesirable complications. This study shows that our technique of total contact casting that incorporates high concentration silver coated foam dressing. MATERIALS AND METHODS: Forty-four diabetic foot ulcers were treated with total contact cast along with high concentration silver coated foam dressing. Complication and healing rates were evaluated. RESULTS: Eighty five percent of the ulcers healed within 6 weeks with an overall complication rate of 7%. There were only two cases (5%) of infection and no recurrent ulceration and no another site new pressure ulcer in our study. CONCLUSION: Total contact casting incorporates high concentration silver coated foam dressing resulted in fewer complications rate and healing rate that is comparable to other studies.

Treatment of 4th & 5th Metatarsotarsal Joint Arthritis with Anchovy Tendon Interposition Arthroplasty: Cases Report / 대한족부족관절학회지

The 4th and 5th metatarsocuboid joint arthritis causes moderate functional deficit during walking. It is difficult to obtain good results with conservative treatment. The arthrodesis of the affected joints can be a possible surgical option, but with a limited success. We report two cases of the 4th and 5th metatarsocuboid joint arthritis managed with anchovy tendon interposition arthroplaty.

Treatment of Large Heel Defect in Diabetic Patients; Use of Artificial Bypass Graft and Antero-lateral Thigh Perforator Flap: A Case Report / 대한족부족관절학회지

In diabetic foot with arterial occlusive disease, skin defect on heel was tried to treat with free flap or local flap, but couldn't be treated well. Therefore below knee amputation was perfomed mostly. But we treated a patient of large heel defect with using of artificial bypass graft and antero-lateral thigh perforator flap.

Surgical Treatment of Tuberculous Achilles Tendinitis: Case Report / 대한족부족관절학회지

Although Achilles tendinitis is a relatively common disease, tuberculous involvement of Achilles tendon is rare. We report a case of tuberculous Achilles tendinitis, which was successfully treated with chemotherapy and a combined surgical procedure (Achilles tendon parital excision and FHL tendon transfer).

Surgical Treatment of Tuberculous Achilles Tendinitis: Case Report / 대한족부족관절학회지

Although Achilles tendinitis is a relatively common disease, tuberculous involvement of Achilles tendon is rare. We report a case of tuberculous Achilles tendinitis, which was successfully treated with chemotherapy and a combined surgical procedure (Achilles tendon parital excision and FHL tendon transfer).

Os Submedialis Malleolare (OSM): the clinical characteristics and surgical results / 대한정형외과학회잡지

PURPOSE: The objective of this study was to define the Os Submedialis Malleolare (OSM) as an any ossicles below medial malleolus of tibia and to determine the characteristics of clinical and radiological characteristics and to evaluate results of surgical treatment of OSM. MATERIALS AND METHODS: Twenty-six patients with OSM were identified between November 1, 1998 and June 30, 2002. RESULTS: The mean age was 18.3 years. All patient except one were male and soccer players comprised 71% (20 cases). Associated disease were 8 cases (29%) of chronic ankle instabilities, one case (4%) of anterior impingement syndrome and one (4%) of plantar fascitis. The most common clinical symptom was pain during walking and sports activity and sign was tenderness around medial malleolus. Only simple radiograph could reveal presence of ossicle and differentiate with acute fracture. If symptom and sign obscured , Bone scan (7 cases) and MRI (3 cases) identify causes of pain and tenderness. As a surgical treatment, all bony fragment caused symptom and sign were eliminated and medial collateral ligament was reattached meticulously. Associated chronic ankle instability were present, modified Brostrom procedure was done simultaneously. On follow-up, The symptomatic pain were wholly disappeared at average 2.2 months (1-6 months) after operation. On one year follow-up, all patients have been daily life without any complaints and all soccer players go back to the game within three months. CONCLUSION: Os Submedialis Malleolare have relatively rare incidence and most common clinical symptom and sign is tenderness on medial malleolar area of ankle, can be diagnosed both physical examination and plain X-ray film. As a treatment, Removal of ossicle and meticulous repair or reattachment of deltoid ligament could obtain excellent or good results.

Open Treatment of Anterior Impingement Syndrome of the Ankle in Elite Level Soccer Players / 대한족부족관절학회지

PURPOSE: We assessed the results of open treatment of anterior impingement syndrome of the ankle in elite level soccer players and concomitant injuries were idenfied. MATERIALS AND METHODS: We retrospectively reviewed twenty one elite level soccer players diagnosed with anterior impingement syndrome who underwent open debridement between January 1997 and January 2002. All were men and the mean age at the operation was 21 years (range 16 to 27). The mean follow-up duration was 31 months (13 to 71). Concomitant abnormalities were idenfied through physical examination, bone scan and MRI. On a preoperative lateral radiograph, patients were classified according to McDermott's stage. Anteromedial or anterolateral approach was used at the operation and osteophyte was removed with osteotome and rongeur. When chronic ankle instability was accompanying, we performed Modified Brostrom-Gould procedure and for osteochondral lesion, multiple drilling was applied. The Ogilvie-Harris scoring system was used as a clinical scale to evaluate pain, swelling, stiffness and limitation of activity. The results were scored as excellent (15 to 16 points), good (13 to 14) and otherwise unsatisfactory. The time to return to full activity including sports activity was determined. RESULTS: Eighteen of twenty one patients had an excellent outcome. Three patients were graded unsatisfactory and two of them abandoned their career due to the persistence of residual pain. Concomitant abnormalities were found including twelve cases of chronic ankle instability, three cases of osteochondral lesion and two cases of flexor hallucis longus tendinitis. CONCLUSION: Open debridement was successfully applied to the elite level soccer player with anterior impingement syndrome of the ankle. Considerable coexistence of other abnormalities such as chronic ankle instability may encourage us to consider additional operative procedure.

Trigger Toe in Soccer Player: A Case Report / 대한족부족관절학회지

A 18-year-old male soccer player had painful triggering and occasional locking of the great toe caused by entrapment of the flexor hallucis longus tendon within the flexor sheath posterior to the right medial malleolus. After other treatment modalities failed, the condition was relieved by a surgical procedure that removed the nodule on the flexor hallucis longus tendon and the ganglion under flexor retinaculum. Tendon rupture was not found, although there was tendinitis.