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.

Surgical Treatment of Chronic Lateral Ankle Instability: Repair versus Reconstruction / 대한족부족관절학회지

Surgical treatment to restore stability in the ankle and hindfoot and prevent further degenerative changes may be necessary in cases in which conservative treatment has failed. Anatomical direct repair using native ligament remnants with or without reinforcement of the inferior retinaculum is the so-called gold standard operative strategy for the treatment of lateral ankle instability. Non-anatomical lateral ligament reconstruction typically involves the use of the adjacent peroneus brevis tendon and applies only those with poor-quality ligaments. On the other hand, anatomic reconstruction and anatomic repair provide better functional outcomes after the surgical treatment of chronic ankle instability patients compared to a non-anatomic reconstruction. Anatomical reconstruction using an autograft or allograft applies to patients with insufficient ligament remnants to fashion direct repair, failed previous lateral ankle repair, high body mass index, or generalized ligamentous laxity. These procedures can provide good-to-excellent short-term outcomes. Arthroscopic ligament repair is becoming increasingly popular because it is minimally invasive. Good-to-excellent clinical outcomes have been reported after short and long-term follow-up, despite the relatively large number of complications, including nerve damage, reported following the procedure. Therefore, further investigation will be needed before widespread adoption is advocated.

Early Transformed Diabetic Foot Ulcer into a Malignancy: A Case Report / 대한족부족관절학회지

This paper presents a case of an early malignant transformation of untreated ulcers in a patient with diabetes. This case shows that Marjolin's ulcer can occur not only after chronic injury, but can also develop in the early stages after the onset. Hence, an early biopsy for diabetic foot ulcers that fail to heal with acute treatment can enable an earlier diagnosis and treatment without amputation, resulting in a better quality of life for the patient.

Reconstruction of a Mangled Foot with an Anterolateral Thigh Free Flap

PURPOSE: In recent decades, amputation is still recommended for patients with extensive lower extremity wounds requiring coverage. Although the feet contribute relatively little to total body surface area, they are essential organ for ambulation, and a high mortality rate after amputation has been reported. We report on 10 challenging cases of a mangled foot which was reconstructed using an anterolateral thigh (ALT) free flap, and analyze the advantages and disadvantages of this technique. MATERIALS AND METHODS: This retrospective study was conducted on 10 patients who underwent reconstructive surgery on a foot. Patients' charts were reviewed for age, sex, causes, defect size and site, flap size and type, flap type, and complications. Cases with a defect size of >100 cm2 were included. RESULTS: Seven of the 10 patients were male, and overall mean age was 38.5 years (range, 22 to 61 years). Mean defect size was 179.6 cm2 (range, 104 to 330 cm2), and mean flap size was 193 cm2 (range, 120 to 408 cm2). Three cases were reconstructed with a musculocutaneous free flap and seven cases were reconstructed with a fasciocutaneous free flap. There were two occurrences of local wound complication. All ten flaps survived well, however five patients underwent a debulking procedure to reduce flap volume. CONCLUSION: Reconstruction of a near completely degloved soft tissue defect or a wide defect containing two or more surfaces of extremity with an ALT free flap was performed. The purpose of this case study is to report on free tissue transfer using the ALT flap for salvage of the lower extremity.

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.

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.

Pseudoaneurysm after Proximal Metatarsal Osteotomy for Hallux Valgus Correction: A Case Report / 대한족부족관절학회지

Occurrence of pseudoaneurysm in the foot and ankle is rare, and is usually caused by traumatic injury or by iatrogenic intervention. Iatrogenic pseudoaneurysms in the foot and ankle have been observed after rearfoot and ankle fusions, ankle arthroscopy, endoscopic and open plantar fasciotomy, tibial osteotomy with limb lengthening, midfoot amputation, and Lapidus procedure. We report on a patient who developed a pseudoaneurysm of the dorsal metatarsal artery following correction of hallux valgus. The patient underwent proximal chevron osteotomy and Akin phalangeal osteotomy. The feeding artery was ligated and the pseudoaneurysm was excised.

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.

Ultrasonographic Evaluation of Flexor Hallucis Longus Tenosynovitis in Sports Players / 대한스포츠의학회지

The purpose of this study was to investigate the ultrasonographic features of flexor hallucis longus (FHL) tenosynovitis in sports players. High-resoluted ultrasound was used to measure the thickness and echogenicity of the flexor hallucis longus at the posteromedial ankle, especially the fibro-osseous tunnel, for 60 sports players (120 feet). They were compared with their asymptomatic feet. There were two group; group 1 was symptomatic feet, 2 was asymptomatic. The 36 males (72 feet) and 24 females (48 feet) had an average age of 21.3 years (range, 18.23 years). Thickness, echogenicity of the tendon on each group were evaluated by the ultrasonography and the results were statistically analyzed. The mean thickness of the FHL on group 1 was 3.4+/-1.2 mm, 2.1+/-1.3 mm on group 2. There was significant difference between two groups (p=0.002). The thickness of FHL based on gender and location was not significant different (p>0.05). For group 1, increased thickness of the FHL and reduced echogenicity, peritendious fluid collection were observed in ultrasonographic findings.Increased thickness (>3 mm) and hypoechoic lesion, peritendinous fluid collection of the tendon were sonographic findings at the posteromedial ankle in the FHL tenosynovitis. The authors suggested that Ultrasonography is a valuable and alternative tool for the evaluation of FHL tenosynovitis.

Fifth Metatarsal Stress Fracture / 대한족부족관절학회지

Fractures located at the metaphyseal/diaphyseal junction at the base of the fifth metatarsal were first described by Sir Robert Jones in 1902. However, ever since, there has been disagreement and debate regarding the diagnosis, classification, pathomechanics, the incidences, and potential causes of delayed unions and nonunions, and the optimal method of treatment. It appears to be widely agreed that proximal fractures of the metaphyseal/diaphyseal region of the fifth metatarsal are prone to delayed union or even nonunion. Several classifications of proximal fifth metatarsal stress fractures have been devised. Torg et al. classified fractures involving the proximal part of the diaphysis of the fifth metatarsal into three types. The Torg classification is a good grading system that can be used to determine the type of surgery needed as well as for the prediction of prognosis. The "plantar gap" might add to the decision-making process for surgery and improve the prediction of patient prognosis. In addition, the new classification using 'plantar gap' might be used for classification of fifth metatarsal stress fracture. Fifth metatarsal stress fractures can be treated conservatively or surgically, and excellent results have been reported for surgery with rapid recovery in athletes. Intramedullary screw fixation has become a popular form of fixation for fifth metatarsal stress fractures. Bone grafting presents the problems of a longer recovery time and additional skin incision for harvesting. The modified tension band wiring is an useful and simple option for surgical treatment of challenging fifth metatarsal stress fractures.

Surgical Excision of Symptomatic Non United Fragment of Anterior Process Fractures of the Calcaneus / 대한스포츠의학회지

A fracture of the anterior process of the calcaneus has been considered unusual injury. A clinically missed diagnosis is often, that had gone on to non united fragment. Particularly if the patient has calcaneocuboid pain and disability, and that early excision of the fragment is usually advisable. There were 12 cases with performing the simple excision. The fracture characteristics were analyzed by Degan's classification; type 1 was 1case (8.3%), type 2 was 6 cases (50.0%) and type 3 was 5 cases (41.7%); and their morphology; elongation was 3 cases (50.0%) and fragmentation 3 cases (50.0%). And, the pre and post operative American Orthopedic Foot and Ankle Society midfoot score and visual analog scale was evaluated; 66.0 and 5.8 was significantly improved to 90.1 (p=0.007) and 2.2 (p=0.003), respectively. Postoperative Excellent and good satisfaction with possible return to previous sports activity was 10 cases (83.3%). Conclusively, simple excision of non united fragment of anterior process of the calcaneus is a successful clinical option.

Surgical Excision of Symptomatic Nonunion of Fifth Metatarsal Base Avulsion Fracture in Athletes / 대한스포츠의학회지

The purpose of this study was to evaluate the clinical results of surgical excision of symptomatic nonunion of fifth metatarsal base avulsion fracture in athletes. From February 2008 to December 2009, six athletic patients who had a symptomatic nonunion of fifth metatarsal base avulsion fracture underwent surgical excision of ununited bony fragment and they were followed for more than 12 months. The mean age was 18.5 years and the mean follow-up period was 13 months. The clinical results were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) forefoot scoring system and Visual Analogue Scale (VAS) scoring system and statistically analyzed (SPSS ver. 18.0). The AOFAS and VAS score was improved in all patients. The mean AOFAS forefoot score was improved from 58.6+/-5.7 preoperatively to 95+/-5.4 postoperatively, which indicated significant difference (p=0.024). The mean preoperative VAS score was 8.0+/-0.6 and the mean postoperative VAS score was 1.6+/-0.5 cm, which indicated significant difference (p=0.023). There were no postoperative problems and functional loss on the operation lesions. The surgical excision of symptomatic nonunion of fifth metatarsal base avulsion fracture in athletes was found to be one of the ideal treatment option for early return to full activity and relief of pain.

Chronic Lateral Ankle Instability: Efficacy of Combination of Ankle Arthroscopic Exploration and Modified Brostrom Operation / 대한족부족관절학회지

PURPOSE: To evaluate the efficacy of the arthroscopic exploration combined with modified Brostrom operation (MBO) for the treatment of chronic lateral ankle instability (CAI). MATERIALS AND METHODS: Sixty patients who diagnosed a CAI were performed MBO. We divided to 2 groups, whether simultaneously inspected by arthroscopy (group B) or not (group A). The both group's results were compared according to American Orthopedic Foot and Ankle Society Ankle-hindfoot score (AOFAS), functional ankle score and visual analog scale (VAS) at preoperative and final follow-up period. RESULTS: There were no significant differences of AOFAS, functional ankle score and VAS between both groups at final follow-up. However, in group A, 2 cases associated with medial ankle instability and syndesmotic injuries were did not diagnosed preoperatively, showed poor prognosis. In group B, one case had a permanent peroneal nerve symptom. The match rate of intra-articular lesions between preoperative diagnosis and postoperative arthroscopic diagnosis was 30% in group B. CONCLUSION: Combination of arthroscopic exploration and MBO is effective strategy for intra-operatively discrimination of intra-articular associated lesions for CAI.

Common Foot and Ankle Disease

Participation of the population in sports activity is increasing. The life expectancy is also on the rise. In addition, the average initial age of women who wear heels is decreasing. For this reason, the incidence of foot disease such as ankle instability, foot deformity, and degenerative joint disease is becoming increasingly common. There is a wide spectrum of foot disease. Common foot disease that can be treated from outpatient base will be discussed in this review.

Effect of TGF-beta(1) and Chitosan-TGF-beta(1) Conjugate on Collagenase Induced Arthritis of the Knee in Rabbits

PURPOSE; To evaluate the effects of the chitosan-TGF-beta(1) conjugate and TGF-beta(1) on osteoarthritic rabbit cartilage induced by collagenase type II. MATERIALS AND METHODS; Chemical arthritis was induced in right knee of 15 rabbits by injection of collagenase type II (4 mg/mL, 0.25 cc) twice at day 1 and 4, and then each 5 rabbits were treated by intra-articular injection of TGF-beta(1) (15 ng/mL, 1 mL, group I), chitosan-TGF-beta(1) conjugate (Chitosan: 5.8 g/mL, TGF-beta(1): 15 ng/mL, group II) and PBS (1 mL, group III) at 10 days later in the same knees. The appearance of the injected knee joints and lameness were observed weekly. The articular cartilage and synovium obtained at 4 weeks were analysed by gross findings (India ink), histological examinations (H&E, Safrainin O) and evaluation through the Kikuchi score. RESULT; The osteoarthritic sign about knee joints was the most severe at 1 weeks after the initiation of collagenase injections, but there wasere no difference of 3 groups in osteoarthritic sign and lameness was most severe in group 3. Group 2 showed the most superior results in gross findings using india ink and the these results were more prominent in the evaluation of histological scoring (average scores of each group I:14+/-2.7, II:10.3+/-1.2, III:20.3+/-3.7). CONCLUSION; These results might suggest that, in the rabbit osteoarthritic knee model induced by collagenase, Chitosan-TGF-beta(1) conjugate is more effective than only TGF-beta(1) in inhibiting cartilage degeneration.

Mode of Fixation Failures of Dynamic Hip Screw with TSP in the Treatment of Unstable Proximal Femur Fracture: Biomechanical Analysis and a Report of 3 Cases / 대한정형외과학회잡지

There are few reports of the failure mode of a dynamic hip screw with a trochanteric stabilizing plate (TSP) in the treatment of unstable proximal femur fractures. We present 3 cases of fixation failure of a TSP used to treat unstable intertrochanteric fractures. All cases had the same type of failure mode, which represented a fatigue fracture of the distal screw at the junction of a plate and screw. Non-union occurred in 2 cases, and one case was an incidental finding 4 years after union. Biomechanical analysis and SEM (scanning electron micrograph) examination was also performed. Adding TSP to the plate might increase the level of shear stress and slip motion in the distal screw followed by a fatigue fracture. SEM of the surface of the broken screw revealed a multiple cycle and low stress fatigue fracture. Recommendations are made regarding the implant design and surgical technique.

The Study of Sodium-Hyaluronate to the Expression of MMP-2 during Healing Process of the Acute Rotator Cuff Tear in Rats / 대한정형외과학회잡지

PURPOSE: To evaluate the effect of HA on the MMP-2 expression level during the healing process of an acute rotator cuff tear in rats by immunohistochemistry and RT-PCR. MATERIALS AND METHODS: Mature Sprague-Dawley rats were used in this animal study. In each rat, 2x2mm partial thickness defect of the rotator cuff was made. The rats were assigned to receive either subacromial injection of HA (HA group) or saline (saline group). The rotator cuff was examined by immunohistochemistry and RT-PCR at 4 weeks after surgery and the results were compared the results. RESULTS: A gross inspection showed that the defects were covered with granulation tissue, which were similar in both groups. The histopathological findings from the HA group revealed collagen bundles with a more dense regular arrangement and small number of inflammatory cells. Semiquantitative RT-PCR for MMP-2 in the HA group demonstrated a higher expression level than in the saline group. CONCLUSION: A subacromial injection of extrinsic HA increased MMP-2 expression level during the healing process of a rotator cuff tear in rats and might play a key role in the acute healing process of an injured rotator cuff.

The Effect of Chitosan-TGF-beta1 Conjugate on Full Thickness Articular Cartilage Defect in the Rabbit Knee Model (Preliminary Report) / 대한정형외과연구학회지

PURPOSE: To evaluate the effect of the chitosan-TGF-beta1 conjugate on articular cartilage defects of rabbits' knees MATERIALS AND METHODS: Full thickness cartilage defect(6mm, round shape) was made at both knees of 20 rabbits and, after the lapse of 3 days, chitosan-TGF-beta1(15ng/ml, 1ml) was injected into one side(experimental group) of knees and PBS(1ml) was injected into the other side(control group). 5 rabbits were sacrificed 6 weeks after the injection and the rest of 15 rabbits 12 weeks later. Then, gross morphology and histological evaluation(Mendelson scoring) was conducted. RESULTS: No arthritic findings was observed and histological results in the experimental group at 6(Ave. 11.3+/-1.5) and 12(Ave. 4.5+/-1.9) weeks postoperatively were superior to those in the control group at 6(Ave. 14.6+/-1.7) and 12(Ave. 9.8+/-2.2) weeks. Especially at 12 weeks, the experimental group was superior to the control group statistically in results of 5 subgroups except for filling of defects. The difference of two groups at 12 weeks was more remarkable than those at 6 weeks. CONCLUSION: Regeneration of something very close to normal cartilage was observed in the experimental group. It shows that the biological activity of TGF-beta1 is sustained by the action of conjugate with chitosan, through prolonged half life of TGF-beta1.

Management of Concomitant Posterolateral Rotatory Instability and Anterior Cruciate Ligament Injuries of the Knee / 대한정형외과학회잡지

PURPOSE: Many failures of anterior cruciate ligament (ACL) reconstruction are due to a failure to treat concomitant posterolateral rotatory instability (PLRI). We report the results of reconstruction in cases of combined PLRI and ACL injury. MATERIALS AND METHODS: From January 1998 to December 2002, 24 patients were followed-up for a mean of 25 months (range, 12 to 58), postoperatively. PLRI was treated using a biceps tenodesis or posterolateral corner sling (PLCS), through a proximal tibial or fibular head obliquely anteroinferiorly to posterosuperiorly. ACLs were reconstructed using autogenous hamstring 4 bundles with RIGIDfix(TM) on the femoral side and Intrafix(TM) with additional staple fixation on the tibial side. Clinical results were evaluated using the Orthopadishe Arbeitsgruppe Knie (OAK) and International Knee Documentation Committee (IKDC) knee scoring system. Stability was measured on pull varus stress radiographs using a Telos stress device and by using the manual maximum displacement test using a KT-1000(TM) arthrometer with 30 degrees of knee flexion. RESULTS: The mean side-to-side difference in anterior displacement measured on the pull stress radiographs was reduced from a preoperative 7.9+/-3.4 to 2.1+/-0.8 mm at the last follow-up, from 2.1+/-0.8 to 0.4+/-0.7mm on varus stress radiographs, and from 6.5+/-1.3 mm to 2.3+/-1.3 mm as measured using the KT-1000 arthrometer. The average OAK score improved from 64.1+/-11.9 to 84.4+/-9.2 points over the same period. At the final evaluation, 22 of the 24 patients (92%) had a satisfactory result according to the IKDC system. CONCLUSION: Based on our experience, we recommend arthroscopically assisted ACL reconstruction and the correction of concomitant PLRI in cases of combined ACL and posterolateral rotatory instability.

A Comparison of Modified Subvastus and Medial Parapatellar Approach in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study evaluated the difference between the modified subvastus approach in total knee arthroplasty (TKA) and the medial parapatellar approach in terms of the postoperative function of the knees. MATERIALS AND METHODS: From March to December 2002, 40 primary TKAs from 26 patients were divided into two groups by a prospective, randomized, blinded trial. The patients were followed up for more than 1 year. The modified subvastus approach was used in 21 knees, and the medial parapatellar approach was used in the remaining 19 knees. The time of postoperatively active straight-leg raise (SLR), and the range of flexion of the operated knee were assessed at postoperative 10 days, 6 weeks, 3, 6, and 12 months. The degree of the patellar tilt and subluxation was investigated at postoperative 12 months. The data collected was analyzed using a t-test. RESULTS: The patients with the modified subvastus approach performed active straight-leg raise sooner mean, 0.5 day) than the patients operated on using medial parapatellar approach (mean 2.2 days). Knee flexion was better at post-operative 10 days in the modified subvastus approach group than the medial parapatellar approach group. However, there was no statistical difference after 6 weeks, 3 months, 6 months, and 12 months after surgery. The level of patellar tilt and subluxation was similar in the two groups. CONCLUSION: The modified subvastus approach provided the advantage of early postoperative rehabilitation in terms of an earlier active SLR and greater knee flexion at 10 days compared with the medial parapatellar approach. The use of the modified subvastus approach in primary TKA is recommended.