Comparison of Radiological and Clinical Outcomes in Patients Treated with Standard Plating versus Intramedullary Nailing in Distal Tibial Fracture.

OBJECTIVE: To evaluate clinical and radiological outcomes including hindfoot alignment after plate vs intramedullary nailing (IMN) for distal tibia fracture and to define radiologic parameters that influence changes in hindfoot alignment. METHODS: Among 92 patients with distal tibia metaphyseal fractures treated from 2002 to 2015, 39 cases of intramedullary nailing and 53 cases of standard plate osteosynthesis were performed. Union rate and complication rate were compared in both groups. Radiographic measurements including hindfoot angulation, moment arm, calcaneal pitch angle, and Meary angle were evaluated at a minimum of 1-year follow-up. Hindfoot alignment changes after surgery were compared between both groups using student t-test. Correlation and regression were analyzed between fracture alignment parameters and hindfoot alignment. RESULTS: All patients ultimately healed, with an average union period of 26 weeks in both groups. The AOFAS and VAS scores were not significantly different between the two groups. Complications were similar between the two groups. Hindfoot alignment angle, calcaneal pitch, and Meary angle showed no significant differences between the groups. The hindfoot moment arm increased with valgus in the IMN group. A low correlation was detected between angulation at the fracture site in the coronal view and hindfoot alignment (angulation and moment arm) changes (R = 0.38). A significantly high correlation was noted only between transverse rotation and hindfoot alignment changes (R = 0.79). CONCLUSIONS: Rotation in the transverse plane notably influenced changes in hindfoot alignment. And this suggests that patients with distal tibia fracture should be closely monitored for hindfoot alignment changes caused by intraoperative transverse rotation regardless of the fixation method.

Trends of Total Knee Arthroplasty According to Age Structural Changes in Korea from 2011 to 2018.

Total Knee Arthroplasty (TKA) is one of the most commonly performed surgeries worldwide since it can improve pain, quality of life, and functional outcome. Due to the expansion of hospitals specialized in joint surgery, the topography of TKA implementation in Korea is changing. This study analyzed longitudinal trends of TKA based on changes in age distribution, sex, hospital, and region based on the Health Insurance Review and Assessment Service (HIRA) of Korea database. Data were collected from the National Health Insurance Service (NHIS), the Korean Statistical Information Service (KOSIS), and the Health Insurance Review and Assessment Service (HIRA) in Korea for the period 2011-2018. Results show the total number of surgeries increased and the number of patients by age decreased in those under the age of 70, while the number of patients over 70 years of age increased. A remarkable increase in women was found, and there was no significant difference between regions. TKA is spreading in a more universal and easily accessible form in Korea and has increased more in other relatively small medical institutions compared to tertiary referral medical centers. Due to the increase of orthopedics' specialized hospitals and clinics, TKA is becoming more prominent in those hospitals.

Adult Stature Estimation from Radiographic Metatarsal Length in a Contemporary Korean Population.

The ability to estimate stature can be important in the identification of skeletal remains. This study aims to develop a Korean-specific equation predicting stature using radiographic measurements in the contemporary Korean population. 200 healthy Korean adults, including 102 males and 98 females, were randomly selected (age, range 20-86 years). The first and second metatarsals of the foot were measured by a standing X-ray using a digital medical image viewer. The result showed a statistically significant correlation between metatarsal length and stature in Korean populations (male, R = 0.46, p < 0.001; female, R = 0.454, p < 0.001). Values of correlation coefficients (R) of the equations were 0.431 to 0.477. Compared to equations derived from other races, the Korean-specific equation showed significantly lower error values for estimating the actual height of Koreans through cross-validation. In conclusion, this study is the first to propose a Korean-specific regression formula for estimating stature using metatarsal length and a verified formula for precise application to the Korean population. However, given the relatively low correlation coefficient, the stature estimation formula derived from this study can be utilized when other bones that allow more accurate stature estimation are not available.

Surgical Treatment Using Sinus Tarsi Approach with Anterolateral Fragment Open-Door Technique in Sanders Type 3 and 4 Displaced Intraarticular Calcaneal Fracture.

Although various outcomes of the sinus tarsi approach have been reported, these are limited to the Sanders type 2 displaced intraarticular calcaneal fractures (DIACF) because of the limited visibility of the posterior facet joint. In this study we aimed to (1) introduce a sinus tarsi approach combined with an anterolateral fragment open-door technique that enables adequate visibility of the innermost and middle portion of the posterior facet joint, and (2) evaluate the radiographic and clinical outcomes of the patients treated with that technique. This is a retrospective case-series study performed on medical records of 25 patients who presented with the Sanders type 3 or 4 DIACF and were treated with the sinus tarsi approach. The radiologic measurements showed significant corrections of the Bohler's angle, calcaneal width, length, height, and articular step-off in both X-rays and CTs in the last follow-up period. The mean AOFAS score was 90.08 ± 6.44 at the last follow-up. Among all the follow-up patients, two cases (8%) had acute superficial infections, and no other wound complications occurred. Therefore, we suggest that the Sanders type 3 or 4 DIACF could be successfully treated with the proposed technique with low complications and bring out effective clinical and radiologic outcomes.

Diurnal Temperature Ranges in Relation to Lower Limb Amputation Rate of Diabetic Foot in South Korea: A Population Based Nationwide Study.

The evidence for the association between diurnal temperature range (DTR) and diabetic foot amputations is limited. We aimed to investigate the region-specific association between DTR and the amputation rate of diabetic foot in Korean national-wide data. Daily data on DTR and the rate of diabetic foot amputations from 16 provincial capital cities in Korea were obtained (2011-2018). In this study, the latitude ranged from 33°11' N to 38°61' N, and we classified each region according to latitude. Region 1, which was located at a relatively high latitude, included Seoul, Incheon, Gyeonggi-do, and Gangwon-do. Region 2, which was located at a relatively low latitude, included Busan, Ulsan, Gyeonsannam-do, Gwangju, Jeollanam-do, Jeollabuk-do, and Jeju-do. The region-specific DTR effects on the amputation rate were estimated based on a quasi-Poisson generalized linear model, combined with a distributed lag non-linear model based on the self-controlled case series design. The DTR impacts were generally limited to a period of nine days, while significant effects during lag days 7-14 were only found in the cities of Seoul, Incheon, and Gyeonggi-do (10th lag day: RR [95% CI]; Seoul: 1.015, [1.001-1.029]; Incheon: 1.052 [1.006-1.101]; Gyeonggi-do: 1.018 [1.002-1.034]). In the subgroup analysis (according to the latitude), an increase of 1 °C in DTR was associated with the risk of diabetic foot in relatively high latitude regions. DTR has considerable effects on the risk of diabetic foot amputation in various provinces in Korea, and it was particularly affected by latitude. The results can inform the decisions on developing programs to protect vulnerable subpopulations from adverse impacts.

Association between Bone Mineral Density and Fracture Characteristics in the 5th Metatarsal Bone Base Fracture in Elderly for Prediction of Osteoporotic Fracture.

BACKGROUND: This study aimed to analyze the correlation between bone mineral density (BMD) and the type of 5th metatarsal fracture, as well as to demonstrate whether there is a difference in radiological findings (heel alignment angle [HAA], heel moment arm [HMA], and metatarsus angle) between fracture types. METHODS: A total of 87 patients were enrolled in the study and allocated into 3 groups: the Zone 1 group (N=36), the Zone 2 group (N=33), and the Zone 3 group (N=18). The participants' demographic data, T-scores, existing fracture or osteoporosis medications, and radiologic parameters including HAA, HMA, and metatarsus adductus angle were analyzed and compared. RESULTS: There was a significant difference between the mean age of the participants, with the highest age in the Zone 1 group and the lowest in the Zone 3 group. Regarding the history of concurrent fracture or osteoporosis medications, there was no significant difference between the 3 groups. Similarly, no significant difference was observed between the 3 groups about the BMD values. In contrast, the HAA was statistically significant in all groups with a positive correlation of -8.9 in the Zone 1 group, a negative correlation of 3.55 in the Zone 2 group, and an inverse relationship of 6.1 in the Zone 3 group. The metatarsus adductus angle was significantly higher in the Zone 3 group than the Zone 1 and Zone 2 groups. CONCLUSIONS: The location of a 5th metatarsal bone fracture is not significantly associated with BMD. However, mechanical influences, such as hindfoot varus or forefoot adductus, have a significant correlation with fracture types.

Three-Dimensional Anatomically Pre-Contoured Locking Plate for Isolated Weber B Type Fracture.

We aimed to evaluate the functional and radiographic outcomes of a three-dimensionally (3D) pre-contoured lateral locking plate fixation for isolated Weber B type fractures and to evaluate the necessity of an interfragmentary lag screw in the use of the plate. Patients who underwent surgery for isolated Weber B type fracture were divided into two groups: 41 patients treated with the 3D plate and lag screw (Group A) and 31 patients treated with the 3D plate only (Group B). The included patients were evaluated regarding the functional and radiographic outcomes. According to the McLennan and Ungersma criteria, the majority of patients showed good or fair outcomes in both groups. Comparing the two groups, Group B showed better functional outcomes (p < 0.0046), while no difference between the two groups was found in terms of the radiographic outcomes (p = 0.143). The operation time was significantly shorter in Group B (p < 0.001) and the time to bony union was within 14 months in all patients with no significant difference between the two groups (p = 0.0821). No postoperative complication was observed in both groups. In conclusion, the use of a 3D pre-contoured lateral locking plate fixation for isolated Weber B type fractures demonstrated satisfactory functional and radiographic outcomes, regardless of lag screw insertion.

Fixation of isolated Lisfranc ligament injury with the TightRope™: A technical report.

Treatment of Lisfranc ligament injury is still debatable. For this reason, we applied a standard suture button (TightRope™, Arthrex, Naples, FL), a device originally designed for syndesmosis fixation, in treating isolated Lisfranc ligament (ILL) injuries. Twelve patients diagnosed as having an ILL injury were recruited. All patients regained their previous activity level within 3 months after the surgery without any complications. We propose that standard suture button device in an ILL injury is an easy technique to perform with short learning curve, accompanied with satisfactory outcomes.

Suture Button vs Conventional Screw Fixation for Isolated Lisfranc Ligament Injuries.

BACKGROUND: Suture buttons have been used for isolated Lisfranc ligament (ILL) fixation. However, no study has reported on its clinical and radiologic outcomes. METHODS: In this retrospective comparative study, patients with ILL injuries were divided into 2 groups according to the treatment method: 32 conventional screw group and 31 suture button group. The clinical and radiologic outcomes at preoperation, 6 months and 1 year postoperation, and last follow-up period were measured. Plantar foot pressure was measured at postoperative month 6 months. Postoperative complications at the last follow-up were evaluated. RESULTS: The suture button group showed better American Orthopaedic Foot & Ankle Society midfoot scale (P < .001) and visual analog scale (P < .001) scores compared with the conventional screw fixation group at the postoperative month 6 period before screw removal. However, no significant difference in clinical outcome between the 2 groups was found at postoperative year 1 or last follow-up. No differences in radiologic outcomes were found between the 2 groups. Plantar foot pressure was significantly elevated in the conventional screw group at the great toe and first metatarsal head area compared with the contralateral foot just before screw removal. Recurrent Lisfranc joint diastasis was found in a single case in the conventional screw group and 2 cases in the suture button group. CONCLUSION: Suture button fixation in the treatment of ILL injuries may provide comparable fixation stability and clinical outcome with conventional screw fixation in the early postoperative period. LEVEL OF EVIDENCE: Level III, retrospective case-control study, therapeutic.

Bone Mineral Density in Diabetes Mellitus Foot Patients for Prediction of Diabetic Neuropathic Osteoarthropathic Fracture.

BACKGROUND: Diabetic neuropathic osteoarthropathy (DNOAP) is known as debilitating diabetes complications. The aim of study is to compare bone mineral density (BMD) among diabetic foot and DNOAP, and investigate the impact of BMD proceeded from diabetic foot to DNOAP. METHODS: A DNOAP group (subgroup A and subgroup B) and control group were examined for this study. Subgroup A (n=21) were patients diagnosed with DNOAP with the development of new foot and ankle fractures, whereas subgroup B (n=4) were patients being managed with the diabetic foot before a diagnosis of DNOAP. BMD was also evaluated before the diagnosis. Control group (n=30) was diabetic foot patients without DNOAP. The demographic data, clinical and radiologic data, comorbidities, and BMD were compared for each group. And optimal BMD score was reviewed to predict fractures in neuropathic arthropathy. RESULTS: BMD was significantly lower in DNOAP group (group A and B) compared with control group. Also neuropathic arthropathy group showed poor radiological results. After comparisons of 2 group lumbar and femur BMD was significantly different, but logistic regression analysis revealed that low femur T-score could be risk predictors of the condition. Base on the data of group B and control group, the cut-off point for predicting foot and ankle fracture-related with DNOAP was -1.65 of femur BMD. CONCLUSIONS: Low BMD shows greater incidence in foot and ankle fracture patients associated with neuropathic arthropathy. A femur T score can be a risk predictor of diabetic neuropathic arthropathy for diabetic foot patients.

Tarsal tunnel syndrome secondary to osteochondroma of the calcaneus: a case report.

BACKGROUND: Tarsal tunnel syndrome is an entrapment neuropathy that can be provoked by either intrinsic or extrinsic factors that compresses the posterior tibial nerve beneath the flexor retinaculum. Osteochondroma, the most common benign bone tumor, seldom occur in foot or ankle. This is a rare case of tarsal tunnel syndrome secondary to osteochondroma of the sustentaculum tali successfully treated with open surgical excision. CASE PRESENTATION: A 15-year-old male presented with the main complaint of burning pain and paresthesia on the medial plantar aspect of the forefoot to the middle foot region. Hard mass-like lesion was palpated on the posteroinferior aspect of the medial malleolus. On the radiological examination, 2.5 × 1 cm sized bony protuberance was found below the sustentaculum tali. Surgical decompression of the posterior tibial nerve was performed by complete excision of the bony mass connected to the sustentaculum tali. The excised mass was diagnosed to be osteochondroma on the histologic examination. After surgery, the pain was relieved immediately and hypoesthesia disappeared 3 months postoperatively. Physical examination and radiographic examination at 2-year follow up revealed that tarsal tunnel was completely decompressed without any evidence of complication or recurrence. CONCLUSIONS: As for tarsal tunnel syndrome secondary to the identifiable space occupying structure with a distinct neurologic symptom, we suggest complete surgical excision of the causative structure in an effort to effectively relieve symptoms and prevent recurrence.

Diagnostic Accuracy of Radiologic Methods for Ankle Syndesmosis Injury: A Systematic Review and Meta-Analysis.

: Misdiagnosis and inadequate treatment of syndesmosis could result in significant long-term morbidity including pain, instability, and degenerative changes of the ankle joint. The objective of this systematic review and meta-analysis was to determine whether radiologic tests accurately and reliably diagnose ankle syndesmosis injury. Medline, Embase, and Cochrane were searched. The database search resulted in 258 full text articles that we assessed for eligibility, we used eight studies that met all the inclusion criteria. In subgroup meta-analysis, the sensitivity analysis showed significant differences only in the MRI (Magnetic Resonance Imaging), and specificity was not statistically significant. In diagnostic meta-analysis, the pooled sensitivity and specificity were 0.528 and 0.984 for X-rays, 0.669 and 0.87 for CT (Computed Tomography), and 0.929 and 0.865 for MRI, all respectively. For sensitivity, MRI showed significantly sensitivity as higher than the other methods, and we detected no significance for specificity. Syndesmosis injuries differed significantly in the accuracy of radiological methods according to the presence of accompanied ankle fractures. In patients with fractures, simple radiography has good specificity, and CT and MRI have high sensitivity and specificity irrespective of fracture; in particular, MRI has similar accuracy to gold standard arthroscopic findings.