Morphological variations of the human talus investigated using three-dimensional geometric morphometrics

INTRODUCTION

The shape of the talus determines the positional and kinematic features of the subtalar, talonavicular, and talocrural joints during walking. Thus, detailed knowledge of the pattern of sexual dimorphism of the human talus may be useful for revealing the pathogenetic mechanism of foot and knee disorders, which are more prevalent in females. The aim of this study was to characterize and visualize the three-dimensional shape variations of the talus in relation to sex and age using geometric morphometrics.

MATERIALS AND METHODS

Computed tomography images of 56 feet without talar injuries or disorders were used in this study. Thirty-seven anatomical landmarks were identified on a bone model of the talus to calculate principal components (PCs) of shape variations among specimens. PC scores were compared between sexes, and their correlations with age were also investigated.

RESULTS

The female talus had a longer neck and narrower head width than the male talus. The superior trochlea was tilted more laterally in the frontal plane in females. Furthermore, the female talar head was more twisted and was more elongated in the dorsoplantar direction.

CONCLUSIONS

Morphological features of the talus in females could alter the subtalar and talonavicular joint kinematics during walking and could be a structural factor in the pathogenetic mechanism underlying foot and knee disorders. This study contributes to the comprehensive understanding of shape variations in the human talus.

Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In Situ Forces of the Reconstructed Graft

BACKGROUND

Although a variety of surgical procedures for anterior talofibular ligament (ATFL) reconstruction have been reported, the effect of initial graft tension during ATFL reconstruction remains unclear.

PURPOSE/HYPOTHESIS

This study investigated the effects of initial graft tension on ATFL reconstruction. We hypothesized that a high degree of initial graft tension would cause abnormal kinematics and laxity.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve cadaveric ankles were tested with a robotic system with 6 degrees of freedom to apply passive plantarflexion and dorsiflexion motions and a multidirectional load. A repeated measures experiment was designed with the intact ATFL, transected ATFL, and reconstructed ATFL at initial tension conditions of 10, 30, 50, and 70 N. The 3-dimensional path and reconstructed graft tension were simultaneously recorded, and the in situ forces of the ATFL and reconstructed graft were calculated with the principle of superposition.

RESULTS

Initial tension of 10 N was sufficient to imitate normal ankle kinematics and laxity, which were not significantly different when compared with those of the intact ankles. The in situ force on the reconstructed graft tended to increase as the initial tension increased. In situ force on the reconstructed graft >30 N was significantly greater than that of intact ankles. The in situ force on the ATFL was 19 N at 30° of plantarflexion. In situ forces of 21.9, 30.4, 38.2, and 46.8 N were observed at initial tensions of 10, 30, 50, and 70 N, respectively, at 30° of plantarflexion.

CONCLUSION

Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. Moreover, excessive initial graft tension during ATFL reconstruction caused excessive in situ force on the reconstructed graft.

CLINICAL RELEVANCE

This study revealed the effects of initial graft tension during ATFL reconstruction. These data suggest that excessive tension during ATFL reconstruction should be avoided to ensure restoration of normal ankle motion.

Denosumab prevents periprosthetic bone mineral density loss in the tibial metaphysis in total knee arthroplasty

BACKGROUND

Periprosthetic bone quality is one of the most important factors preventing early prosthesis migration and long-term failure. Although denosumab, which binds to the receptor activator of nuclear factor kappa-B ligand (RANKL), has been linked with periprosthetic bone mineral density (BMD), the effectiveness of denosumab against bone loss remains unclear. We hypothesized that denosumab treatment after total knee arthroplasty (TKA) could prevent periprosthetic bone resorption.

METHODS

In this prospective cohort study, 28 patients with primary knee osteoarthritis were divided into two groups: denosumab (denosumab and vitamin D) and control (vitamin D only) groups. All patients underwent TKA with the same implant model and received medication after surgery. We used dual-energy X-ray absorptiometry to measure periprosthetic BMD after TKA.

RESULTS

In the control group, the BMD of the proximal medial tibia decreased drastically at 12 months after TKA (-19.7%). Denosumab treatment significantly preserved this BMD loss (0.7%). The linear regression analysis revealed that denosumab intervention had the highest significantly positive relationship with BMD.

CONCLUSIONS

Our results indicate that denosumab treatment significantly reduces periprosthetic BMD loss, even at the early stages after TKA. This therapeutic strategy may facilitate early stable fixation of the prosthesis which, in turn, may help to prevent early implant migration and reduce the need for revision surgery.

Sex- and age-related morphological variations in the talar articular surfaces of the calcaneus

BACKGROUND

The prevalence of foot pathologies, such as flatfoot deformity and hallux valgus, is higher in women and increases with age. It has been reported that these types of foot disorders may also be linked to excessive mobility of the subtalar joint to the eversion direction during weight bearing. Given that the mobility of the joint is determined by its articular morphology, sex- and age-related variations in the subtalar articular surface morphology are possible. The purpose of this study was to investigate the orientation and the curvature radii of the talar articular facets of the calcaneus in relation to age and sex using three-dimensional computer tomography.

METHODS

Fifty-six feet without subtalar injuries or disorders were included in this study. The orientations of the talar articular surfaces of the calcaneus were quantified in the sagittal and coronal planes. The curvature radii of the articular surfaces of the calcaneus were also assessed based on the approximations of the sphere surfaces.

RESULTS

The talar articular surface was oriented more anteriorly and medially in the females than in the males. The curvature radius of the calcaneal posterior facet in the females exhibited a positive correlation with age, indicative of increased articular surface flattening.

CONCLUSIONS

The morphological features of the female calcaneus could induce excessive eversion and could lead to a higher prevalence of foot disorders, including flatfoot and hallux valgus, in elderly females. This study contributes to an understanding of the sexual dimorphism of the articular surfaces of the calcaneus and provides insight into the mechanisms that underline various foot disorders.

Three-Dimensional Morphological Variations of the Human Calcaneus Investigated Using Geometric Morphometrics

The shape of the calcaneus determines the mechanical interaction of the foot with the ground during the heel-strike in human walking. Detailed knowledge of the pattern of sexual dimorphism of the human calcaneus could help to clarify the pathogenetic mechanism of foot and knee disorders, which are more prevalent in females. Therefore, the aim of this study was to characterize and visualize the three-dimensional shape variations of the calcaneus in relation to sex and age using geometric morphometrics. Computed tomography images of 56 feet without subtalar injuries or disorders were used in this study. Thirty-seven anatomical landmarks were identified on the bone model of the calcaneus to calculate principal components (PCs) of shape variations among specimens. The PC scores were compared between males and females, and their correlations with age were also analyzed. The female calcaneus was longer in length and shorter in height than that of males. The medial process of the calcaneal tuberosity in females was more inferiorly projected and the tuberosity was shifted more laterally. Also, the calcaneus was wider and the sustentaculum tali thickened with aging. Female structural features of the calcaneus alter the kinematics of the foot during walking and could be a structural factor in foot and knee disorders. This study contributes to a comprehensive understanding of shape variations in the human calcaneus. Clin. Anat., 33:751-758, 2020. © 2019 Wiley Periodicals, Inc.

Can an insole for obese individuals maintain the arch of the foot against repeated hyper loading?

BACKGROUND

Insoles are often applied as preventive therapy of flatfoot deformity, but the therapeutic effects on obese individuals are still controversial. We aimed to investigate the effect of insole use on time-dependent changes in the foot arch during a repeated-loading simulation designed to represent 20,000 contiguous steps in individuals with a BMI value in the range of 30-40 kg/m2.

METHODS

Eighteen cadaveric feet were randomly divided into the following three groups: normal, obese, and insole. Ten thousand cyclic loadings of 500 N (normal group) or 1000 N (obese and insole groups) were applied to the feet. We measured time-dependent change in arch height and calculated the bony arch index (BAI), arch flexibility, and energy absorption.

RESULTS

The normal group maintained more than 0.21 BAI, which is the diagnostic criterion for a normal arch, throughout the 10,000 cycles; however, BAI was less than 0.21 at 1000 cycles in the obese group (mean, 0.203; 95% confidence interval [CI] 0.196-0.209) and at 6000 cycles in the insole group (mean, 0.200; 95% CI, 0.191-0.209). Although there was a significant time-dependent decrease in flexibility and energy absorption in both the obese and insole groups (P < 0.001), the difference between 1 and 10,000 cycles were significantly smaller in the insole group than in the obese group (P = 0.024).

CONCLUSIONS

Use of insoles for obese individuals may help to slow time-dependent foot structural changes. However, the effect was not enough to maintain the foot structure against repeated hyper loadings.

Kinematics and Laxity of the Ankle Joint in Anatomic and Nonanatomic Anterior Talofibular Ligament Repair: A Biomechanical Cadaveric Study

BACKGROUND

Although it is crucial to accurately identify the anterior talofibular ligament (ATFL) attachment site, it may not be feasible to fully observe the ATFL attachment site during arthroscopic surgery. As a result, the repair position might often be an unintentionally nonanatomic ATFL attachment site.

HYPOTHESIS

Anatomic ATFL repair restores kinematics and laxity to the ankle joint, while nonanatomic ATFL repair does not.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven normal fresh-frozen human cadaveric ankles were used. The ankles were tested with a 6 degrees of freedom robotic system. The following ankle states were evaluated: intact, ATFL injured, ATFL anatomic repair, and ATFL nonanatomic repair. The ATFL nonanatomic repair position was set 8 mm proximal from the center of the ATFL attachment site of the fibula. For each state, a passive plantarflexion (PF)-dorsiflexion (DF) kinematics test and a multidirectional loading test (anterior forces, inversion moment, and internal rotation moment) were performed.

RESULTS

The kinematics and laxity of the anatomic repair were not significantly different from those of the intact state. In nonanatomic repair, the inversion-eversion angle showed significant inversion (3.0°-3.4°) from 5° to 15° of DF, and the internal rotation-external rotation angle showed significant internal rotation (2.0°) at neutral PF-DF versus the intact state. In addition, internal rotation laxity was significantly increased (5.5°-5.8°) relative to the intact state in the nonanatomic repair at 30° and 15° of PF. There were no significant differences in anterior-posterior translation between the repairs.

CONCLUSION

Although the anatomic ATFL repair state did not show significant differences in kinematics and laxity relative to the intact state, the nonanatomic ATFL repair state demonstrated significant inversion and internal rotation kinematics and internal rotation laxity when compared with the intact state.

CLINICAL RELEVANCE

Nonanatomic repair alters kinematics and laxity from the intact condition.

Randomized clinical trial of single skin sterilization with a povidone-iodine applicator versus conventional skin sterilization in abdominal surgery

Background

The efficacy of widely used povidone–iodine applicators for skin sterilization in abdominal surgery is unclear. The aim of this trial was to evaluate whether sterilization with a povidone–iodine applicator was not inferior to a conventional sterilization method.

Methods

Patients undergoing elective abdominal surgery were assigned randomly to receive single sterilization with the applicator or conventional sterilization. The primary endpoint was wound infection rate. Secondary endpoints were rate of organ/space surgical‐site infection (SSI), adverse effects of povidone–iodine, amount of povidone–iodine used and total cost of sterilization.

Results

Of 498 patients eligible for the study between April 2015 and September 2017, 240 were assigned and analysed in the applicator group and 246 in the conventional group. Wound infection was detected in 16 patients (6·7 per cent) in the applicator group and 16 (6·5 per cent) in the conventional group (absolute difference 0·0016 (90 per cent c.i. −0·037 to 0·040) per cent; P = 0·014 for non‐inferiority). There was no difference between the groups in the organ/space SSI rate (11 patients (4·6 per cent) in the applicator group and 16 (6·5 per cent) in the conventional group. Both the amount of povidone–iodine used and the total cost of sterilization were higher in the conventional group than in the applicator group (median 76·7 versus 25 ml respectively, P < 0·001; median €7·0 versus €6·4, P < 0·001). Skin irritation was detected in three patients in the conventional group.

Conclusion

In abdominal surgery, this povidone–iodine applicator was not inferior to conventional sterilization in terms of the wound infection rate, and it is cheaper. Registration number: UMIN000018231 (http://www.umin.ac.jp/ctr/).

Talbot interferometry for imaging two-dimensional electron density distribution over discharge plasma with higher sensitivity

The basic properties of a Talbot interferometer implementing pinhole arrays were experimentally and numerically investigated for the improvement of measurement sensitivity of laser wavefront sensors utilized for electron density imaging over discharge plasmas. A numerical simulation using a plane wave decomposition method indicated that the pinhole arrays with a pitch of 300 μm and a pinhole diameter of 150 μm were most suitable for the measurement of the millimetre-scale discharge plasmas, in consideration of the spatial resolution and measurement accuracy. The plane wave decomposition simulation expected that the measurement sensitivity of the 8th-Talbot-length interferometer could be improved by a factor of 4 compared with the previously developed Shack-Hartmann type laser wavefront sensors, which was experimentally verified by the self-image behavior of the pinhole arrays. The Talbot interferometric system was successfully used for electron density imaging over the vacuum arcs generated between a 3-mm gap. The electron density image observed by the Talbot interferometers was in excellent agreement with that visualized by the previously developed Shack-Hartmann sensors. The practical notification for the pinhole array fabrication was also presented.

Investigation of factors related to the occurrence of osteochondral lesions of the talus by 3D bone morphology of the ankle

Aims

The aims of this study were to evaluate the morphology of the ankle in patients with an osteochondral lesion of the talus using 3D CT, and to investigate factors that predispose to this condition.

Patients and Methods

The study involved 19 patients (19 ankles) who underwent surgery for a medial osteochondral lesion (OLT group) and a control group of 19 healthy patients (19 ankles) without ankle pathology. The mean age was significantly lower in the OLT group than in the control group (27.0 vs 38.9 years; p = 0.02). There were 13 men and six women in each group. 3D CT models of the ankle were made based on Digital Imaging and Communications in Medicine (DICOM) data. The medial malleolar articular and tibial plafond surface, and the medial and lateral surface area of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolar surface area and volume (MMA and MMV) and the anterior opening angle of the talus were measured.

Results

The mean TMM angle was significantly larger in the OLT group (34.2°, sd 4.4°) than in the control group (29.2°, sd 4.8°; p = 0.002). The mean MMA and MMV were significantly smaller in the OLT group than in the control group (219.8 mm2, sd 42.4) vs (280.5 mm2, sd 38.2), and (2119.9 mm3, sd 562.5) vs (2646.4 mm3, sd 631.4; p < 0.01 and p = 0.01, respectively). The mean anterior opening angle of the talus was significantly larger in the OLT group than in the control group (15.4°, sd 3.9°) vs (10.2°, sd 3.6°; p < 0.001).

Conclusion

3D CT measurements showed that, in patients with a medial osteochondral lesion of the talus, the medial malleolus opens distally, the MMA and MMV are small, and the anterior opening angle of the talus is large. This suggests that abnormal morphology of the ankle predisposes to the development of osteochondral lesions of the talus. Cite this article: Bone Joint J 2018;100-B:1487–90.

Investigation of the Effect of Initial Graft Tension During Anterior Talofibular Ligament Reconstruction on Ankle Kinematics, Laxity, and In-situ Force

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Ankle sprains are the most common sports injuries, and anterior talofibular ligament (ATFL) injury comprised 85% of all ankle sprains. Most patients recover with conservative treatment, but 20% of them progress to chronic ankle instability. Some studies have reported that anatomic reconstruction using a tendon graft is one of the best procedures to restore the ankle to its condition before symptom development. However, the effect of initial graft tension during ATFL reconstruction is still unclear. Therefore, the objective of this study was to investigate the effect of the initial graft tension during ATFL reconstruction.

Methods:

Eight fresh-frozen cadaveric ankle specimens were subjected to passive plantarflexion (PF)-dorsiflexion (DF) movement from 15° DF to 30° PF using the 6-degree-freedom robotic system. In addition, 60 N of anterior-posterior load, 1.7 Nm of inversion-eversion (IV-EV) torque, and 1.7 Nm of internal-external rotation (IR-ER) torque were applied to the ankle. During testing, 3-dimensional paths of the ankle were recorded simultaneously. Furthermore, in-situ forces of the ATFL and reconstructed graft were calculated using the principle of superposition. A repeated experiment was designed with the intact condition (intact), ATFL transection, and ATFL reconstruction with four different initial graft tensions (10 N, 30 N, 50 N, and 70 N).

Results:

AP laxity, IV-EV laxity and IR-ER laxity with ATFL transection was significantly greater than those with intact. In ATFL transection, the talus was significantly translated anteriorly with inversion and internal rotations under passive PF-DF motion compared with intact. Kinematic patterns and laxity in ATFL reconstruction with initial tension of 10 N and 30 N almost imitated intact, but in ATFL reconstruction with initial tension 70 N, the talus was significantly translated with external rotation compared with intact. As the initial graft tension during ATFL reconstruction increased, in-situ force of the reconstructed graft tended to increase during PF-DF motion. In-situ force of the reconstructed graft tension was significantly greater with initial tensions of 50 N, and 70 N than with intact during PF-DF motion (Figure 1).

Conclusion:

ATFL deficiency altered ankle kinematics and laxity. Although the optimal initial graft tension during ATFL reconstruction might restore ankle kinematics and laxity, excessive initial graft tension caused abnormal kinematics and laxity. Furthermore, the reconstructed graft tension increased as the initial tension increased. Initial tension during ATFL reconstruction has the important effect of imitating the normal ankle condition. We suggest that over-tensioning during ATFL reconstruction should be avoided in order to imitate the conditions of a normal ankle.

Factors Related to the Occurrence of Osteochondral Lesions of the Talus by 3-dimensional Bone Morphology of the Ankle

Category:

Ankle

Introduction/Purpose:

Repeated microtrauma is thought to play a major role in the occurrence of osteochondral lesions of the talus (OLTs), but much remains unknown. Two-dimensional assessments of the relationship between ankle bone morphology and OLTs are occasionally seen. The purpose of this study was to evaluate the bone morphology of the ankle in OLT 3-dimensionally using three-dimensional computed tomography (3DCT), and to investigate the factors related to the occurrence of OLTs.

Methods:

The subjects were 19 patients (19 ankles) who underwent surgery for medial OLTs (OLT group). They included 13 men and 6 women. A healthy group without ankle disease served as a control group with the same number of 19 ankles. Three-dimensional ankle joint models were made based on DICOM data obtained with CT images. In the 3D model, the medial malleolus articular surface and the tibial plafond surface, the medial surface of the trochlea of the talus, and the lateral surface of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolus surface area (MMA), the medial malleolus volume (MMV), and the anterior opening angle of the talus were measured 3-dimensionally and compared in the OLT and control groups.

Results:

The mean TMM angle was significantly larger in the OLT group (34.2 ± 4.4°) than in the control group (29.2 ± 4.8°; p = 0.002). The mean MMA was significantly smaller in the OLT group (219.8 ± 42.4 mm2) than in the control group (280.5 ± 38.2 mm2; p < 0.001). The mean MMV was significantly smaller in the OLT group (2119.9 ± 562.5 mm3) than in the control group (2646.4 ± 631.4 mm3; p = 0.01). The mean anterior opening angle of the talus was significantly larger in the OLT group (15.4 ± 3.9°) than in the control group (10.2 ± 3.6°; p < 0.001).

Conclusion:

It was shown with 3DCT measurements that, in medial OLT patients, the medial malleolus opens distally, the MMA and MMV are small, and the talus anterior opening angle was significantly larger than in controls. This study suggests the possibility that the 3D bone morphology of both the mortise and tenon of the ankle joint are closely related to the occurrence of OLTs.

Stability of the ankle joint in anatomical or non-anatomical anterior talofibular ligament repair

Category:

Ankle

Introduction/Purpose:

Chronic ankle instability (CAI) often needs surgical treatment if conservative treatment is ineffective. Recently, arthroscopic surgeries have become widely used to treat CAI. Although it is crucial to accurately ascertain the anterior talofibular ligament (ATFL) attachment site under arthroscopy, previous study showed that it might not be feasible to thoroughly observe the ATFL attachment site, and repair or reconstruction position were often unintentionally carried out proximal to the ATFL attachment site at the fibula as a result. Currently, there are few reports about stability of the ankle joint by different repair position of ATFL. The aim of this study was to evaluate the stability of the ankle joint by different repair position of ATFL.

Methods:

Six fresh-frozen human cadaveric ankles with the mean age of 83.5 ± 7.3 years were used. The ankles were tested using a six-degrees of freedom robotic system. The following ankle states were evaluated: intact, ATFL transection, ATFL anatomical repair, and ATFL non-anatomical repair. ATFL was transected at fibular attachment. Anatomical repair was performed at the center of original ATFL attachment of the fibula. Non-anatomical repair was set 8mm proximal from anatomical ATFL attachment of the fibula. At each state, laxity of anterior translation under 60 N load, inversion under 1.7 Nm load, and internal rotation under 1.7 Nm load were evaluated. Each test was performed at 30 degrees plantarflexion (PF), 15 degrees PF, 0 degree, and 15 degrees dorsiflexion (DF). The one-way repeated measures analysis of variance (ANOVA) with post hoc pairwise comparisons with Dunnett’s test was adopted. A P value of 0.05 was chosen as the level of significance.

Results:

Anterior translation under 60 N load was significantly increased in transection condition at 30 degrees PF compared with the intact condition (P=0.005). Anatomical repair and Non-anatomical repair did not show significant differences. Inversion under 1.7 Nm load was significantly increased in transection condition at 30 and 15 degrees PF compared with the intact condition (P=0.004, =0.049). Anatomical repair and Non-anatomical repair did not show significant differences. Internal rotation under 1.7 Nm load was significantly increased in transection condition at 30, 15 degrees PF and 0 degree compared with the intact condition (P<0.001, <0.001, and <0.001). Although anatomical repair did not show significant differences, non-anatomical repair showed significant increase at 30 and 15 degrees compared with the intact condition (P=0.006, =0.026). (Fig. 1).

Conclusion:

Anatomical repair did not show significant difference in all three loads with the intact condition. In non-anatomical repair, anterior translation and inversion did not show significant difference, but internal rotation significantly increased at 30 and 15 degrees PF compared with the intact condition. Compared with anatomical repair, non-anatomical repair might become more vertical ligament running because its attachment site of the fibula was more proximal. This difference might affect stability of the ankle joint. Anatomical repair of the ATFL might be essential to obtain the stability of the ankle joint like the intact condition.

Congenital Combined Deficiency of Factor V and Factor VIII

A case of congenital combined deficiency of factor V and factor VIII was reported. The patient, a 9 year old boy, gave a history of epistaxis, hematomas, and of hemorrhages following dental extraction since the age of 2 ; plasma levels of factor V and factor VIII were found to be 16% and 8% of normal, respectively. No one in his family had a deficiency of either factor. The effects of transfusion of normal fresh plasma and whole blood from a patient with hemophilia A were studied. While the former were similar to the pattern as seen in classical hemophilia, the latter consisted of an immediate increase of factor V activity and a delayed increase of factor VIII activity, despite the fact that factor VIII activity was almost absent from the donor’s blood.

Tibiotalocalcaneal Arthrodesis Using a Soft Tissue-Preserved Fibular Graft for Treatment of Large Bone Defects in the Ankle

BACKGROUND

Pathogenesis of ankle disorders with a large bone defect is varied and treatment for those problems is challenging for orthopaedic surgeons. The aims of this study were to present an operative technique of arthrodesis for the reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue-preserved fibular strut graft and to report outcomes of consecutively treated patients.

METHODS

Twelve feet from 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening, were treated. Bone defects were filled using iliac bone and/or resected fibula and tibiotalocalcaneal arthrodesis was performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint while preserving the lateral to posterior skin and soft tissues on the fibula. The periods of bony fusion and outcomes were radiographically and clinically evaluated. The mean follow-up period was 33.4 months.

RESULTS

Bony fusion was achieved within 3 months in all cases. Coronal and sagittal alignments were acceptable, and the mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded their results of treatment as "satisfied."

CONCLUSION

This procedure did not require special techniques and it should be applicable to complicated cases with large bone defects. High fusion rates that we believe are due to preserving blood supply to the fibular graft can be expected with preservation of the hindfoot height.

LEVEL OF EVIDENCE

Level IV, case series.

Repair of Acute Patellar Tendon Rupture Augmented with Strong Sutures

Rupture of the patellar tendon is an uncommon injury that requires acute surgical repair to restore the function of the knee. Multiple techniques for repair have been described in the literature. Complications with these repair techniques include rerupture and extensor lag caused by gap formation at the site of repair. Thus, many surgeons have suggested augmenting the standard repair. Several methods of augmentation have been described each with disadvantages. The purpose of this article was to present our case series of six patients with acute patella tendon ruptures treated by a novel procedure using strong sutures. In this method, eight strands of four-strong sutures run within the tendon. At the patellar site, a combination of suture button and figure eight pattern techniques is used, avoiding stress concentration. The optimal tension is applied to each suture, so as the patella might be positioned at the original placement. Then all sutures are secured onto the tibia. Postoperatively with a mean follow-up of 32.7 months (range: 25-48 months), all patients had a stable knee with mean flexion of 143.3 degrees (range: 140-150 degrees) and without any extension lag. With an improvement in the International Knee Documentation Committee score to 86.8 (range: 80-92), the excellent outcome was noted in all patients. The average postoperative Lysholm score was 98.8 (range: 97-100) and the average Kujala score was 95.2 (range: 92-97). All patients recovered to near-normal strength and stability of the patellar tendon as well as restoration of function after the operation. This augmentation technique offers a distinct advantage over previous augmentation methods and materials, and may be especially useful in managing patellar tendon rupture caused by rheumatoid arthritis or other systemic conditions. For these reasons, we recommend this procedure for acute patellar tendon ruptures.

Early results of multicenter phase II trial of perioperative oxaliplatin and capecitabine without radiotherapy for high-risk rectal cancer: CORONA I study

BACKGROUNDS

Perioperative introduction of developed chemotherapy into the treatment strategy for locally advanced rectal cancer (LARC) may be a promising option. However, the most prevalent treatment for high-risk LARC remains preoperative chemoradiotherapy (CRT) in Western countries.

PATIENTS AND METHODS

A phase II trial was undertaken to evaluate safety and efficacy of perioperative XELOX without radiotherapy (RT) for patients with high-risk LARC. Patients received 4 cycles of XELOX before and after surgery, respectively. Primary endpoint was disease-free survival.

RESULTS

We enrolled 41 patients between June 2012 and April 2014. The completion rate of the preoperative XELOX was 90.3%. Twenty-nine patients (70.7%) could start postoperative XELOX, 15 of these patients (51.7%) completed 4 cycles. Allergic reaction to oxaliplatin was experienced by 5 patients (17.2%) during postoperative XELOX. One patient received additional RT after preoperative XELOX. Consequently, the remaining 40 patients underwent primary resection. Major complications occurred in 6 of 40 patients (15.0%). Pathological complete response (pCR) rate was 12.2%, and good tumor regression was exhibited in 31.7%. N down-staging (cN+ to ypN0) and T down-staging were detected in 56.7% and 52.5%, respectively. Clinical T4 tumor was a predictor of poor pathological response (p < 0.001).

CONCLUSIONS

We could show the favorable pCR rate after preoperative XELOX alone. However, the T and N down-staging rate was likely to be insufficient. When tumor regression is essential for curative resection, the use of preoperative CRT is likely to be recommended. For patients with massive LN metastasis, the additional Bev to NAC might be a promising option.