Corrigendum to "The Association of Body Mass Index and Waist Circumference with the Risk of Achilles Tendon Problems: A Nationwide Population-Based Longitudinal Cohort Study"

[This corrects the article on p. 488 in vol. 15, PMID: 37274500.].

Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair

INTRODUCTION

Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5-12 weeks following primary Achilles tendon repair has not been established. We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase.

MATERIALS AND METHODS

We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12 months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°-30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event.

RESULTS

After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6 months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6 months (P < 0.05). After 12 months, there were no significant differences in these scores between the two groups (both P > 0.05).

CONCLUSION

Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient's natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.

The association between refractory plantar fasciitis and insertional Achilles tendinopathy and peripheral spondyloarthritis: a report of human leukocyte antigen B-27 investigation and treatment outcome

PURPOSE

This study aimed to determine the presence of peripheral spondyloarthritis and investigate the clinical characteristics of patients with concurrent peripheral spondyloarthritis in those presenting with refractory plantar fasciitis and Achilles tendinopathy by conducting human leukocyte antigen B-27 (HLA-B27) testing.

METHODS

This retrospective study aimed to investigate patients who complained of persistent pain and significant limitations in daily activities due to their respective foot pain, despite receiving conservative treatment for over one year under the diagnosis of plantar fasciitis or insertional Achilles tendinopathy. The study included 63 patients who underwent HLA-B27 testing. The patients were classified into two groups based on the presence or absence of HLA-B27 positivity. The Mann-Whitney U test assessed significant relationships between continuous variables, and the chi-square test was used to compare categorical variables.

RESULTS

Among the 63 included patients, HLA-B27 positivity was confirmed in 11 patients (17.5%), which was significantly associated with a lower average age (22.8 years versus 31.7 years, P = 0.01) and a substantially lower proportion of females compared to HLA-B27-negative patients (9.1% vs. 25.0%, P = 0.001). Ten of the 11 patients initiated treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) combined with oral steroids as the first-line medication after being diagnosed as HLA-B27 positive. Six patients experienced pain relief with the first-line medication (60%). Four patients who did not achieve pain control with the first-line medication received tumour necrosis factor-alpha inhibitors as the second-line medication. Two patients experienced pain relief, while two experienced reduced but persistent pain.

CONCLUSIONS

Among the patients with "refractory" plantar fasciitis and insertional Achilles tendinopathy, 17.5% were diagnosed with peripheral spondyloarthritis. Patients diagnosed with peripheral spondyloarthritis had a higher proportion of men and relatively younger mean age compared to those without the diagnosis. Approximately 70% of these patients achieved symptom improvement in foot and ankle joints by taking conventional synthetic DMARDs, TNF-α inhibitors, or both appropriate for spondyloarthritis.

A Novel Technique of Medial Displacement Calcaneal Osteotomy Using the Intramedullary Fixation of a Conventional Low-Profile Locking Wedge Plate

BACKGROUND

Postoperative heel pain arising from prominent screw heads is a common complication following medial displacement calcaneal osteotomy (MDCO). This study aims to present the clinicoradiographic outcomes of a novel MDCO technique, wherein intramedullary fixation of a conventional low-profile locking wedge plate is employed.

METHODS

A retrospective analysis, involving a comparison of clinical and radiographic parameters among consecutive patients who underwent MDCO was conducted. The patients were subjected to either intramedullary wedge plate fixation through the osteotomy site (IWPF group, n = 45 cases) or conventional cannulated screw fixation from the heel (CCSF group, n = 51 cases). Radiographic evaluation included measurement of hindfoot alignment angle, alignment ratio, and moment arm. Clinical outcomes were measured with the American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Ability Measure (FAAM) activities of daily living and sports subscales, before and at 6, 12, and ≥24 months postoperatively. The presence of heel pain was evaluated at the postoperative 6 and 12 months in both groups.

RESULTS

For both groups, a marked enhancement in all 3 radiographic parameters was observed. The extent of correction for all clinicoradiographic parameters demonstrated no statistically significant divergence between the 2 groups. However, the FAAM-Sports scores at the 6-month postoperative juncture exhibited a significant elevation in the IWPF group relative to the CCSF group. Importantly, no patient reported heel pain at postoperative 6 and 12 months in the IWPF group whereas the rates of patients having heel pain at postoperative 6 and 12 months were 56.8% (29 cases) and 33.3% (17 cases), respectively, in the CCSF group.

CONCLUSIONS

Both techniques yield analogous postoperative clinical and radiographic enhancements. However, the utilization of IWPF promotes a swifter clinical improvement with respect to sports activities when juxtaposed with the CCSF from the calcaneal tuberosity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of supramalleolar and inframalleolar correction for Takakura stage IIIB ankle arthritis in a single patient

A man in his early 60s with bilateral Takakura stage IIIB varus ankle arthritis underwent calcaneal osteotomy on the right side and supramalleolar osteotomy (SMO) with fibular osteotomy on the left side. Both sides underwent identical procedures, including multiple drilling of the denuded talar dome and gutter, deltoid ligament release, anterior talofibular ligament (ATFL) reconstruction and posterior tibial tendon (PTT) lengthening. This aimed to minimise patient-related factors when assessing correction efficacy. Both procedures demonstrated a similar degree of improvement in talar tilt. Supramalleolar correction contributed more significantly to lateralising the talar centre, while greater improvement in preoperative hindfoot varus was achieved through inframalleolar correction.

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients

INTRODUCTION

Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients.

MATERIALS AND METHODS

This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position.

RESULTS

The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively.

CONCLUSION

We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

The Association of Body Mass Index and Waist Circumference with the Risk of Achilles Tendon Problems: A Nationwide Population-Based Longitudinal Cohort Study

Background

The purpose of this study was to evaluate the association of body mass index (BMI) and waist circumference (WC) with the risk of Achilles tendinopathy (AT) or Achilles tendon rupture (ATR), using data from a nationwide population-based cohort. We hypothesized that higher BMI and WC would be independently associated with the increased risk of AT or ATR. In addition, a higher WC may potentiate the association between BMI and the risk of Achilles tendon problems.

Methods

We used the National Health Insurance database that covers the entire South Korean population to follow up subjects who participated in the National Health Screening Program (NHSP) from January 2009 to December 2010. The NHSP data include subjects' BMI, WC, blood test results, blood pressure, and information about lifestyle. Among the subjects, those who were newly diagnosed as having AT or ATR before December 31, 2017, were selected. To examine the association of the variables with the risk of AT or ATR and determine whether the effect of higher BMI varied according to WC, multivariate Cox proportional hazards regression was used.

Results

Among a total of 16,830,532 subjects, 125,814 and 31,424 developed AT and ATR, respectively. A higher BMI showed a greater association with the increased risk of ATR than AT (adjusted hazard ratio [HR], 3.49 vs. 1.96). A higher WC was associated with the increased risk of AT (adjusted HR, 1.22), but not ATR. In a separate analysis, the association between BMI and the risk of AT was higher when subjects had higher WC as compared to those with lower WC, being most significant in individuals with both higher BMI and higher WC.

Conclusions

Higher BMI was more associated with the increased risk of ATR than AT. Moreover, a high central fat distribution played an independent and potentiating role in the development of AT. This implies the greater importance of a high central fat distribution contributing to the development of AT in obese people.

Operative outcome of mucous cyst of lesser toes: A comparison between cyst excision with osteophytectomy and distal interphalangeal fusion

BACKGROUND

To date, the optimal operative treatment for mucous cysts of the lesser toes (MCLT) has not been discussed in detail, although many previous studies have focused on treating finger lesions. Therefore, we evaluated the operative outcomes of two different procedures for MCLT: cyst excision with osteophytectomy and cyst excision with distal interphalangeal (DIP) fusion.

METHODS

We retrospectively reviewed and compared the clinico-radiographic outcomes of patients who underwent cyst excision with osteophytectomy (group 1, 22 cases) or cyst excision with DIP fusion (group 2, 16 cases) for MCLT between January 2010 and August 2021. The minimum follow-up duration for inclusion in the study was 12 months. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) lesser toes metatarsophalangeal-interphalangeal scale and the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale. We also collected information on postoperative recurrence and operation-related complications.

RESULTS

The preoperative and postoperative AOFAS and FAAM-ADL scores were not significantly different between the two groups (P > 0.05, each). However, the postoperative recurrence rate was 31.8 % in group 1 (7 of 22 cases), whereas no recurrence was observed in group 2. Every recurrence occurred within 8 postoperative weeks (mean, 4.8 weeks; range, 3-8 weeks). Nonunion of the fusion site was observed in one patient (6.3 %).

CONCLUSION

We confirmed that postoperative recurrence was significantly lower in the case of cyst excision with DIP fusion than in cyst excision with osteophytectomy for the treatment of MCLT. Clinical outcomes were not significantly different between the two procedures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Operative outcomes of a high-grade talar neck fracture - Lessons from 20 years' clinical experience in a single, tertiary hospital

BACKGROUND

The operative treatment of high-grade talar neck fractures remains challenging, despite numerous previous reports. Our goal was to determine long-term outcomes and to establish a plan for management of postoperative complications (especially, avascular necrosis [AVN] of talar body) after high-grade talar neck fractures. We hypothesized that not every case with AVN of talar body require secondary surgical interventions.

METHODS

We retrospectively reviewed the radiographic and clinical findings of 14 patients who underwent operative treatment for high-grade talar neck fractures (modified Hawkins type III and IV) between January 2000 and December 2017. The minimum follow-up duration for inclusion was 3 years. Using radiographs during follow-up, we assessed the development of AVN of the talar body, malunion, nonunion, and posttraumatic osteoarthritis. Information about the secondary operations and their outcomes were also investigated using visual analogue scale (VAS) and American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot scale at the final follow-up.

RESULTS

In 10 of 14 patients (71.4 %), talar body AVN developed during follow-up. However, secondary operation was required in only 30.0 % (3 of 10 patients). In the remaining 7 patients who did not undergo secondary operation, the symptoms were tolerable with a maximum of 89 months follow-up; although the talar body presented sclerotic changes, but without talar dome collapse. The rates of malunion and post-traumatic subtalar osteoarthritis were 21.4 % and 14.3 %, respectively. No patients presented with fracture site nonunion. After a mean of 55.86 ± 14.45 months (range, 37-89) follow-up, the final mean VAS and AOFAS scores were 3.07 ± 0.73 (range, 2-4) and 80.43 ± 3.11 (range, 75-85), respectively.

CONCLUSION

We recommend leaving talar body AVN untouched, unless the patient's symptoms become intolerable. In our clinical practice, postoperative AVN could be stably maintained without talar dome collapse for more than 7 years, although the sclerotic change persisted. Despite the small number of patients, our clinical experience may benefit patients with high-grade talar neck fractures and surgeons who treat such rare, serious, and challenging foot injuries.

LEVEL OF EVIDENCE

Level IV, Case series.

Does ankle arthrodesis induce satisfactory changes in the medial longitudinal arch height of the foot for severe varus ankle arthritis?

PURPOSE

We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA).

METHODS

We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2 mm or < 2 mm).

RESULTS

A post-operative MCH decrease of ≥ 2 mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2 mm than in those with < 2 mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172).

CONCLUSION

Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.

Operative strategy for tri-malleolar ankle fractures with posteromedial plafond involvement: a review of sixty six cases

PURPOSE

We aimed to summarize the radiographic and clinical outcomes in various conditions of tri-malleolar ankle fractures (TMFs) with posteromedial (PM) plafond involvement (TMF + PM) and determine the factors affecting their subjective clinical outcomes.

METHODS

Radiographic and clinical findings of 66 patients who underwent operative treatment for TMF + PM were retrospectively reviewed. The patients were classified into three groups according to the PM fracture line location. Type I fractures were defined when the PM fracture line extended medially beyond the PM corner of the distal tibia while type II fractures were those in which the PM fracture line was located laterally to the PM corner. Type III fractures were defined as medial malleolar avulsion fractures when the PM fracture integrated into the medial malleolus. Clinical outcomes were evaluated using a subjective rating scale (excellent, good, fair, poor, and bad). Satisfactory results were defined as excellent, good, and fair. Factors affecting satisfactory clinical outcomes were assessed using a binary logistic regression analysis. Independent variables included demographic, fracture-related, and operation-related factors and radiographic measurements at the final follow-up.

RESULTS

Satisfactory clinical outcomes were observed in 74.2% of the total patients; of these patients, 75.7% (28/37), 76.5% (13/17), and 66.7% (8/12) had type I, type II, and type III fractures, respectively. The binary logistic regression analysis revealed that age at the time of operation, number of incarcerated fragments (IFs), type of IFs, and postoperative articular step-offs (mm) were related to subjective clinical outcomes (all P < 0.05). A positive value for post-operative articular step-offs represented distal migration of the posterior malleolar fragments. The odds ratios for older age, increased numbers of IFs, rotated IFs, and positive articular step-offs were 0.936, 0.116, 0.020, and 0.295, respectively.

CONCLUSION

Because TMF + PM is highly unstable, a delicate approach is needed according to each patient's fracture condition. Although it is best to reduce the fractured articular surface, a negative step-off, rather than a positive step-off, would be more likely recommended if accurate reduction is impossible. This could be applied to manage IFs, especially when the IFs are rotated. Dimpling of the articular surface induced by the removal of a small IF was not related to unsatisfactory clinical outcomes.

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

Category:

Ankle Arthritis; Ankle

Introduction/Purpose:

We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy.

Methods:

We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into two groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the two groups.

Results:

There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the two groups (all, P>.05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P<.05). Among patients with TT >=8 degrees, a greater decrease in TT (+1.0 degrees vs. -2.8 degrees) and TCA was observed in the DS group, while the PS group demonstrated greater increases in TCA and intermalleolar distance (all, P<.01).

Conclusion:

In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.

A Novel Technique of Minimally Invasive Calcaneal Osteotomy for Intractable Insertional Achilles Tendinopathy Associated with Haglund Deformity

Category:

Hindfoot

Introduction/Purpose:

To date, minimally invasive surgery (MIS) involving calcaneal osteotomy for Haglund deformity associated with intractable insertional Achilles tendinopathy has not been reported. This study presents the radiographic and clinical outcomes of our novel MIS-dorsal closing wedge calcaneal osteotomy (DCWCO) technique compared to open Haglund resection. We hypothesized that earlier clinical improvement after MIS-DCWCO could be achieved by leaving the Achilles tendon insertion site untouched.

Methods:

We retrospectively reviewed and compared the clinical and radiographic parameters of patients who underwent MIS- DCWCO (11 cases) or open Haglund resection (14 cases) between January 2012 and June 2019. The minimum duration of follow-up for inclusion was 18 months. We measured the calcaneal pitch, Meary's, Fowler-Philip, and Böhler's angles. Clinical outcomes were evaluated using the visual analogue scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores measured preoperatively and at 3, 6, 9, 12, and >=18 months, postoperatively.

Results:

In both groups, the Meary's and calcaneal pitch angles did not change significantly, whereas the Fowler-Philip and Böhler's angles were significantly changed postoperatively. Significant improvements in VAS and VISA-A scores were observed in both groups (P < .001). The extent of correction of the four radiographic and two clinical parameters were not significantly different between the two groups. However, VAS and VISA-A scores at postoperative 6 months were significantly different, whereas these parameters were not significantly different at all other time points.

Conclusion:

Both techniques provided similar postoperative clinical and radiographic improvement. However, MIS-DCWCO achieved earlier clinical improvement than open Haglund resection.

Factors influencing postoperative residual diastasis after the operative treatment of acute Lisfranc fracture dislocation

INTRODUCTION

Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3-dimensional computed tomography (3D-CT).

MATERIALS AND METHODS

Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t test was used to compare continuous numeric parameters, while a Chi-square test was used for the proportional parameters. Statistical significance was set at P value less than 0.05 for all analyses.

RESULTS

The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P > 0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (> 25% of 2nd tarsometatarsal joint involvement), displaced (> 2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P = 0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P = 0.001).

CONCLUSIONS

While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Factors Influencing Postoperative Residual Diastasis after the Operative Treatment of Acute Lisfranc Fracture-Dislocation

Category:

Trauma; Midfoot/Forefoot

Introduction/Purpose:

Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture-dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3- dimensional computed tomography (3D-CT).

Methods:

Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture- dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t-test was used to compare continuous numeric parameters, while a chi-square test was used for the proportional parameters. Statistical significance was set at P-value less than 0.05 for all analyses.

Results:

The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P>0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (>25% of 2nd tarsometatarsal joint involvement), displaced (>2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P=0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P=0.001).

Conclusion:

While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Operative treatment options for Morton's neuroma other than neurectomy - a systematic review

BACKGROUND

The effectiveness of operative treatments other than neurectomy for Morton's neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton's neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies.

METHODS

Several electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton's neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type.

RESULTS

After reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy.

CONCLUSION

Whether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable.

LEVEL OF EVIDENCE

Level III, systematic review.

Effect of four combined procedures to achieve inframalleolar correction for advanced varus ankle arthritis

A man in his early 60s with Takakura stage IIIB varus ankle arthritis underwent four combined procedures (Dwyer’s osteotomy with lateral displacement, superficial/deep deltoid ligament release, anterior talofibular ligament/calcaneofibular ligament reconstruction with suture tape augmentation and posterior tibial tendon lengthening). Decreased talar tilt and talar centre lateral shifting and improved hindfoot varus were observed 2 years postoperatively. Also, excellent clinical outcome could be achieved.

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

BACKGROUND

We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy.

METHODS

We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups.

RESULTS

There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P > .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs -2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01).

CONCLUSION

In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Low tibial valgization osteotomy for varus ankle arthritis - does age effect the outcome?

BACKGROUND

Evidence-based literature identifying the age limit for low tibial valgization osteotomy (LTO) is lacking to date. We addressed the following research questions: (1) is LTO effective for ankle arthritis in patients over 65 years?; (2) does patients' age alter the effectiveness of LTO?; and (3) does preoperative Takakura stage affect the degree of correction in patients over 65 years?

METHODS

We retrospectively reviewed the radiographic and clinical findings of 49 cases which underwent LTO. Patients were divided into two groups according to age at operation (19 cases in group 1 aged ≥65 years and 30 cases in group 2 aged <65). Patients in a single group were regrouped into two subgroups according to preoperative Takakura stage (stage II + IIIA versus IIIB) to determine if the degree of correction varied in Takakura stage IIIB.

RESULTS

Significant changes in radiographic parameters were observed with no significant differences in the amounts of correction between groups 1 and 2. Comparison of Takakura stage II + IIIA in group 1 to that in group 2 and stage IIIB in group 1 to that in group 2 revealed no significant differences in the amounts of correction.

CONCLUSION

LTO could be indicated for patients over 65 years if patient selection was appropriate. LTO in patients over 65 years showed similar radiographic improvements to those in younger patients, and the correction was successfully maintained during the follow-up period. The correctional power of all radiographic parameters did not vary by preoperative Takakura stage.

LEVEL OF EVIDENCE

Level III, comparative series.

Dyslipidemia Is Associated With Increased Risk of Achilles Tendon Disorders in Underweight Individuals to a Greater Extent Than Obese Individuals: A Nationwide, Population-Based, Longitudinal Cohort Study

Background:

The association between dyslipidemia and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) remains controversial, although some studies have examined this topic.

Purpose:

To evaluate the correlation of dyslipidemia and the risk of AT or ATR, and its association with body mass index (BMI), by assessing data from a nationwide population-based cohort.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We used the National Health Insurance database, which includes the entire population of the Republic of Korea, to evaluate participants in the National Health Screening Program between January 2009 and December 2010. Participants diagnosed with AT or ATR before December 31, 2017, were selected. The variables assessed were age, sex, frequency of high-intensity exercise per week, BMI, waist circumference, systolic blood pressure, and levels of low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and fasting blood glucose. Multivariate Cox proportional hazards regression was used for data analysis.

Results:

A total of 16,830,532 participants were included. Of these, 125,814 and 31,424 participants developed AT and ATR, respectively. A higher level of LDL-C was associated with an increased risk of AT (adjusted hazard ratio [HR], 1.16) and ATR (adjusted HR, 1.18). A slightly increased risk of AT was observed in participants with higher TG levels (adjusted HR, 1.03), whereas higher HDL-C level was associated with a slight risk reduction for AT (adjusted HR, 0.95). However, no significant association was observed between higher TG or HDL-C levels and ATR. In the underweight group (BMI <18.5 kg/m²), a higher LDL-C level was associated with an increased risk of AT and ATR by 37% and 116%, respectively, compared with lower LDL-C. Higher LDL-C level was associated with an increased risk of AT and ATR by 10% and 16%, respectively, in the obese group (BMI ≥25 kg/m²).

Conclusion:

Dyslipidemia was related to the development of AT and ATR. The association of higher LDL-C levels with AT and ATR risk was more pronounced in underweight than in overweight and obese individuals.

Outcome of proximal triple derotational metatarsal osteotomy for three-dimensional correction of hallux valgus deformity

PURPOSE

To correct hallux valgus deformities in patients with a greater pronation of the first metatarsal, we designed a novel proximal triple derotational metatarsal osteotomy (PTDMO), which could be used to achieve three-dimensional correction of hallux valgus deformities at the proximal metatarsal level.

METHODS

We prospectively evaluated the radiographic and clinical outcomes of 13 consecutive cases underwent PTDMO between November 2018 and May 2020. The minimum follow-up for inclusion was 12 months. The hallux valgus angle (HVA), first-to-second intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), relative length of the second metatarsal, and medial sesamoid position on the weight bearing foot anteroposterior radiographs, and the degree of the first metatarsal pronation on forefoot axial radiographs were measured pre-operatively, at six weeks post-operatively, and at the final follow-up. The American Orthopaedic Foot and Ankle Society (AOFAS) score and Foot Ankle Outcome Scores (FAOS) were measured.

RESULTS

In the comparison of pre-operative and final follow-up parameters, HVA, IMA, and DMAA were significantly improved post-operatively (all, P < 0.001). The relative length of the second metatarsal did not differ significantly post-operatively (P = 0.724). The medial sesamoid was significantly reduced (P = 0.01), and the first metatarsal pronation decreased by 10.16° (P = 0.034). Regarding clinical parameters, the AOFAS score and FAOS in all categories significantly improved post-operatively (all, P < 0.001).

CONCLUSION

PTDMO resulted in satisfactory radiographic and clinical outcomes with respect to deformity correction and pain relief, with significant post-operative reduced pronation of the first metatarsal.

Clear Cell Sarcoma of the Achilles Tendon: A Case Report

Clear cell sarcoma of the Achilles tendon is an extremely rare condition, with a handful of cases reported in the literature over the past 3 decades. Patients usually present late because of the slow progress of the disease and seemingly benign nature of its presentation. Clinical and radiological findings are not enough to make a diagnosis; hence, a high index of suspicion is required. A firm diagnosis is made only after histopathologic studies. We present a rare case of this tumor in a young female, the management plan, and prognostic outlook, with subsequent review of the literature.

Radiographic measurements on hindfoot alignment view in 1128 asymptomatic subjects

BACKGROUND

The primary aim of this study was to determine the mean values for three of the most common parameters measured to assess hindfoot alignment in asymptomatic subjects: hindfoot alignment angle (HAA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA). The secondary aim was to evaluate the mean value of each parameter according to age and sex.

METHODS

We assessed 1128 asymptomatic subjects from January 2014 to June 2019. HAA, HAR and HMA were measured to evaluate the degree of hindfoot varus or valgus deviation on the hindfoot alignment view, described by Saltzman and el-Khoury. All subjects were divided into subgroups according to sex and age (<45 years versus ≥45 years).

RESULTS

The overall mean HAA, HAR, and HMA were -4.07 ± 3.48°, 0.21 ± 0.15, and -6.12 ± 5.22 mm, respectively. Female subjects ≥45 years old had the largest valgus deviation (HAA, -7.08 ± 6.34°; HAR 0.09 ± 0.25; HMA, -10.58 ± 11.46 mm).

CONCLUSIONS

HAA, HAR, and HMA evaluation revealed that asymptomatic subjects had a hindfoot alignment with valgus deviation. Furthermore, the degree of valgus deviation was the largest in female subjects aged ≥45 years. We hope that the results of our study will be helpful to inform other researchers about the usefulness of these parameters as references.

Corticosteroid Injection for Morton's Interdigital Neuroma: A Systematic Review

Backgroud

This review aimed to evaluate the effects of corticosteroid injections on Morton's neuroma using an algorithmic approach to assess the methodological quality of reported studies using a structured critical framework.

Methods

Several electronic databases were searched for articles published until April 2020 that evaluated the outcomes of corticosteroid injections in patients diagnosed with Morton's neuroma. Data search, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). guidelines, and clinical outcomes were evaluated using various outcome measures.

Results

With 3–12 months of follow-up, corticosteroid injections provided satisfactory outcomes according to Johnson satisfaction scores except in two studies. Visual analog scale scores showed maximal pain reduction between 1 week and 3 months after injection. We found that 140 subjects out of 469 (29.85%) eventually underwent surgery after receiving corticosteroid injections due to persistent pain.

Conclusions

Corticosteroid injections showed a satisfactory clinical outcome in patients with Morton's interdigital neuroma although almost 30% of the included subjects eventually underwent operative treatment. Our recommendation for future research includes using more objective outcome parameters, such as foot and ankle outcome scores or foot and ankle ability measures. Moreover, studies on the safety and effectiveness of multiple injections at the same site are highly necessary.

Enhanced wound healing using a 3D printed VEGF-mimicking peptide incorporated hydrogel patch in a pig model

There is a need for effective wound healing through rapid wound closure, reduction of scar formation, and acceleration of angiogenesis. Hydrogel is widely used in tissue engineering, but it is not an ideal solution because of its low vascularization capability and poor mechanical properties. In this study, gelatin methacrylate (GelMA) was tested as a viable option with tunable physical properties. GelMA hydrogel incorporating a vascular endothelial growth factor (VEGF) mimicking peptide was successfully printed using a three-dimensional (3D) bio-printer owing to the shear-thinning properties of hydrogel inks. The 3D structure of the hydrogel patch had high porosity and water absorption properties. Furthermore, the bioactive characterization was confirmed by cell culture with mouse fibroblasts cell lines (NIH 3T3) and human umbilical vein endothelial cells. VEGF peptide, which is slowly released from hydrogel patches, can promote cell viability, proliferation, and tubular structure formation. In addition, a pig skin wound model was used to evaluate the wound-healing efficacy of GelMA-VEGF hydrogel patches; the results suggest that the GelMA-VEGF hydrogel patch can be used for wound dressing.

Minimally invasive correction for symptomatic, fixed curly toe deformity

BACKGROUND

Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity.

METHODS

Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up.

RESULTS

The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury.

CONCLUSIONS

Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.

Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis

BACKGROUND

Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operation-related factors influencing postoperative TT decrease.

METHODS

We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis (≥8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.

RESULTS

Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P = .052), clinical parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was more corrected (3.9 vs 1.8 degrees, P = .023) with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration (P = .016), hindfoot alignment angle (P = .033), hindfoot moment arm (P = .041), and hindfoot alignment ratio (P = .016).

CONCLUSION

LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant varus ankle arthritis.

LEVEL OF EVIDENCE

Level III, comparative series.

Categorization of single cuneiform fractures and investigation of related injuries: A 10-year retrospective study

PURPOSE

The purpose of this study was to define the fracture type and investigate the injuries related to single medial, intermediate, or lateral cuneiform fracture.

METHODS

From January 2008 to December 2018, 30 consecutive patients (30 cases) who were treated in the single institution for the single cuneiform fractures were reviewed retrospectively. Each fracture was categorized by location and type (intra- or extra-articular avulsion, axial compression, and direct blow). We also investigated the related foot bone fractures or dislocations on the affected side.

RESULTS

Twenty-one, one, and eight cases with single medial, intermediate, and lateral cuneiform bone fractures, respectively, were identified. More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. The single medial cuneiform fracture was associated with various types of foot injuries including Lisfranc injury, naviculo-cuneiform joint dislocation, or calcaneo-cuboidal dislocation. Single lateral cuneiform fractures were more frequently observed than single intermediate cuneiform fractures.

CONCLUSION

More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. Most intra-articular avulsion fractures were associated with high-energy trauma.

LEVEL OF EVIDENCE

4.

Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot? - A prospective comparative study

BACKGROUND

Several conservative treatment methods, from intrinsic muscle exercises to orthoses, including insoles or specially designed shoes, have been introduced for pediatric flexible flat foot (PFFF). However, the structural effects of a long-term use of medial arch support insole remain unclear because the normal physiological maturation of the medial longitudinal arch cannot be ruled out.

METHODS

From January 2005 to June 2015, 18 patients (34 feet) in group 1 (continuously insole applied group) and 13 patients (26 feet) in group 2 (untreated group) were enrolled. Medial arch support insole was applied from the age 10-11years to radiographic physeal closure.

RESULTS

In group 1, talonavicular coverage angle, lateral talo-1st metatarsal angle, calcaneal pitch angle and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Further, no significant differences were found in any of the increments of the radiographic parameters between group 1 and 2.

CONCLUSIONS

Radiographic improvements were found in both of medial arch support insole treated or untreated group despite all radiographic values were still within the abnormal range. It was meaningful that the PFFF could be improved somewhat until the physes were closed. And the hindfoot alignment remained unchanged regardless of medial arch support insole application.

Determining the factors influencing the symptoms related to naviculo-medial cuneiform coalition

PURPOSE

We aimed to determine the factors that influence the symptoms of naviculo-cuneiform (NC) coalition using radiography and computed tomography (CT).

METHODS

We retrospectively reviewed the radiographic and CT findings of 37 NC coalition cases. The existence of a large pit (depth >3 mm), irregular articular surface, joint space narrowing, dorsal bony spur, subchondral sclerosis, multiple subchondral bony cysts, and intra-articular loose body were evaluated on radiographs or CT. The size of the largest subchondral bony cyst was also measured using CT. All cases were divided into two subgroups according to the symptoms. Fisher's exact test was used to distinguish the factors influencing the symptoms.

RESULTS

Twenty-three and fourteen feet were enrolled into the symptomatic and asymptomatic groups, respectively. The rates of the large pit on either radiograph (47.83 vs. 21.43%) or CT (65.22 vs. 28.57%) were significantly different between both groups ( p = 0.001). The mean size of the largest subchondral bony cyst on CT was also significantly greater in the symptomatic group (4.25 vs. 1.53 mm, p = 0.005).

CONCLUSION

A large deep pit and huge subchondral bony cyst on the radiograph or CT can be related to symptoms for the patient with NC coalition. A CT is highly recommended for a more accurate evaluation in patients with NC coalition.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity: Magnetic resonance imaging evaluation

BACKGROUND

The importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints.

METHODS

We reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes.

RESULTS

The binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P<0.001, 0.001. 0.006, respectively).

CONCLUSIONS

Medial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.

LEVEL OF EVIDENCE

III, observational study.

Minimally invasive surgery for young female patients with mild-to-moderate juvenile hallux valgus deformity

BACKGROUND

We aimed to compare the clinical and radiographic outcomes of minimally invasive surgery (MIS) and distal chevron metatarsal osteotomy (DCMO) for young female patients with mild-to-moderate juvenile hallux valgus deformity.

METHODS

We retrospectively reviewed the radiographs and clinical findings of young female patients with mild-to-moderate juvenile hallux valgus who underwent MIS (25 feet) or DCMO (30 feet). In 12 of 25 MIS feet, 2.0-mm bio-absorbable pins were used as an additional fixation device crossing the osteotomy site, and 1.4-mm Kirschner wires were used in the remaining 13 feet.

RESULTS

Radiographic and clinical parameters preoperatively and at the final follow-up were not significantly different between the 2 groups. There were no significant differences in the increments of hallux valgus angle (HVA), distal metatarsal articular angle, medial sesamoid position, first metatarsal length, metatarsal length index, or relative second metatarsal length. Two MIS subgroups according to the additional fixation device showed no significant differences in HVA, the first to second intermetatarsal angle lateral translation ratio, or plantar offset at the final follow-up.

CONCLUSIONS

MIS for young female patients with mild-to-moderate juvenile hallux valgus deformity had similar radiographic and clinical outcomes compared to DCMO. Regarding additional fixation crossing the osteotomy site, both temporary Kirschner wires and absorbable pins showed no radiographic differences in terms of correction maintenance.

LEVEL OF EVIDENCE

3.

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients' mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p = .179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p = .215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.

Changes in Hindfoot Alignment After High or Low Tibial Osteotomy

BACKGROUND

We aimed to determine the change in hindfoot alignment after high (HTO) or low tibial osteotomy (LTO), which is commonly performed to prevent the progression of arthritis of the knee or ankle.

METHODS

We retrospectively reviewed the radiographic findings of patients who underwent HTO or LTO for arthritis with varus deformity of the knee or ankle joint. The hindfoot alignment view angle (HAVA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA) were measured using the hindfoot alignment radiographs. All radiographic parameters were measured at 3, 6, and 12 months postoperatively to assess serial changes.

RESULTS

In the HTO group, the HAVA and HMA were significantly increased at 12 months postoperatively compared to preoperatively ( P = .03 and .001, respectively). Similarly, the HAR increased from 0.23 preoperatively to 0.44 at 12 months postoperatively, which was a statistically significant change ( P = .001). In the LTO group, the 12-month postoperative HAVA, HAR, and HMA were significantly decreased ( P = .001 for each), which represented a hindfoot alignment change to the valgus position.

CONCLUSIONS

After HTO, preoperative hindfoot valgus deviation was significantly decreased at 12 months and approached normal values, while the preoperative mild hindfoot varus alignment was changed to valgus deviation after LTO.

LEVEL OF EVIDENCE

Level III, comparative series.

Changes of hindfoot alignment after high or low tibial osteotomy

Category:

Hindfoot

Introduction/Purpose:

We aimed to determine the change in hindfoot alignment after high (HTO) or low tibial osteotomy (LTO), which is commonly performed to prevent the progression of arthritis of the knee or ankle.

Methods:

We retrospectively reviewed the radiographic findings of patients who underwent HTO or LTO for arthritis with varus deformity of the knee or ankle joint. The hindfoot alignment view angle (HAVA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA) were measured using the hindfoot alignment radiographs. All radiographic parameters were measured at 3, 6, and 12 months postoperatively to assess serial changes.

Results:

In the HTO group, the HAVA and HMA were significantly increased at 12 months postoperatively compared to preoperatively (P=0.03 and 0.001, respectively). Similarly, the HAR increased from 0.23 preoperatively to 0.44 at 12 months postoperatively, which was a statistically significant change (P=0.001). In the LTO group, the 12-month postoperative HAVA, HAR, and HMA were significantly decreased (P=0.001 for each), which represented a hindfoot alignment change to the valgus position.

Conclusion:

After HTO, preoperative hindfoot valgus deviation was significantly decreased at 12 months and approached normal values, while the preoperative mild hindfoot varus alignment was changed to valgus deviation after LTO.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity

Category:

Midfoot/Forefoot

Introduction/Purpose:

The importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints.

Methods:

We reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes.

Results:

The binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P <0.001, 0.001. 0.006, respectively).

Conclusion:

Medial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.

CT Features of Naviculocuneiform Coalitions

Category:

Midfoot/Forefoot

Introduction/Purpose:

The purpose of our study was to evaluate and compare the CT features in patients with symptomatic and asymptomatic naviculocuneiform coalition

Methods:

We retrospectively reviewed the CT images of 37 naviculocuneiform coalitions in 26 patients (mean age 30 years). The 26 patients were 12 males and 14 females, with 19 right and 18 left feet, including 11 patients with bilateral coalition. The CT images were analyzed with regard to irregular articular surface, subchondral sclerosis, subchondral cyst, bone spur, joint space distance, loose body and bony fusion. The size of subchondral cyst was measured. The location and extent of joint involvement was also evaluated. CT features were compared between symptomatic and asymptomatic feet.

Results:

There were 20 feet (54%) in symptomatic group and 17 feet (46%) in asymptomatic group. The mean size of the subchondral cyst was 6.3 mm in the symptomatic group and 2.5 mm in the asymptomatic group (statistically significant). Bone spurs were significantly more common in the symptomatic group (11 of 20 feet) than in the asymptomatic group (2 of 17 feet) (p < 0.01). All 8 feet received operative treatment had subchondral cysts (mean size 6.7 mm) or bone spurs. Irregular articular surfaces were seen in all feet. Subchondral sclerosis, joint space distance, loose body, location and extent of joint involvement did not differ statistically significantly between two groups.

Conclusion:

Because of a statistically significant overlap of CT features, only large subchondral cysts and bone spurs can be more commonly detected with CT in the symptomatic feet compared to the asymptomatic feet, and may indicate aggressive treatment in patients with naviculocuneiform coalition.

Candida catenulata Candidaemia and Possible Endocarditis in a Cirrhotic Patient Successfully De-escalated to Oral Fluconazole

WHAT IS KNOWN AND OBJECTIVE

Candida catenulata is a fungus commonly found in Australian cheeses. C. catenulata has been identified as the causative pathogen for one report of onychomycosis and one report of candidaemia.

CASE DESCRIPTION

A 37-year-old male underwent surgery for an incarcerated umbilical hernia repair and bowel obstruction and presented with severe abdominal pain and ascitic fluid draining from the surgical site. C. catenulata was isolated in blood cultures. The patient was treated with antifungal therapy for approximately 6 weeks.

WHAT IS NEW AND CONCLUSION

To our knowledge, this is the first case describing successful treatment of possible fungal endocarditis caused by C. catenulata.

Stress Radiographs Under Anesthesia for Painful Chronic Lateral Ankle Instability

Category:

Ankle

Introduction/Purpose:

Anterior drawer and varus stress radiographs are commonly used for chronic lateral ankle instability. We compared pre-operative stress radiographs to intra-operative ones under anesthesia to figure out the accuracy and efficacy of stress radiographs at outpatient clinic.

Methods:

Data was collected from the patients underwent Modified Broström operation for painful chronic unilateral lateral ankle instability from January, 2014 to June, 2016. Subjects were divided by three groups (complete tear, partial tear and instability without rupture) according to the status of preoperative MRI findings of anterior talofibular ligament.

Results:

Ninety six patients were enrolled with a mean age of 29.63±12.04 (male: female=65: 31). Complete, partial tear and instability without rupture were 39, 46 and 11 respectively. On anterior drawer and varus stress radiographs on the affected limb, talar translation and tilting were increased significantly (2.57 mm and 2.01o). The differences between the unaffected limbs were increased by 2.47 mm and 1.32 o. Despite the stress radiographs were performed under anesthesia, the results often showed relatively small value which was not matched to the diagnostic value, even for complete tear group.

Conclusion:

Stress radiographs for chronic painful unilateral lateral ankle instability performed at outpatient clinic would be inaccurate. Therefore, additional diagnostic tools such as, ultrasonography or MRI are highly necessary.

Factors Affecting Early Single Heel Raise after Repair of Achilles Tendon Rupture

Category:

Sports

Introduction/Purpose:

No physical exam or clinical test can clearly predict a final course of acute Achilles tendon rupture after surgical treatment. But, in recent studies, ability to perform single-heel-raise during the early postoperative period was considered as a significant prognostic factor. Therefore, analysis of the relationship between preoperative factors and timing of the single heel raise might help to predict the prognosis and aid to establish an individualized rehabilitation plan. The purpose of this study was to analyze the factors affecting early single heel raise after surgical treatment of acute Achilles tendon rupture.

Methods:

From January 2012 to August 2015, a retrospective analysis was performed for 68 patients who met the inclusion criteria among 98 cases of surgically treated acute Achilles tendon rupture. Operative technique and rehabilitation protocol were same in all cases. The patients who were able to perform a single heel raise within 3 months postoperatively were classified into the study group and the rest was determined as the control group. During periodic outpatient observation, we evaluated Achilles tendon total rupture score (ATRS), Visual Analog Scale (VAS), and timing capable of a single heel raise. We also preoperatively measured defect size and distance between calcaneal osteotendinous junction and rupture site by ultrasound image in all cases.

Results:

No difference was found in demographic factors between the study group (23 cases) and the control group (45 cases) who performed a single heel raise later than 3 months postoperatively. There were no significant difference in defect size and distance between calcaneal osteotendinous junction to the rupture site (P=0.38, P=0.63). However, when the rupture site was divided into hyporvascular zone (from calcaneal osteotendinous junction to the rupture site: 4~7 cm) and hypervascular zone, the study group showed a significantly low hyporvascular zone rupture rate. (14/23, 41/45, P=0.003). Also, in the logistic regression analysis that included age, BMI, smoking, hyporvascular zone rupture, defect size, and operation delay, patients with hypervascular region rupture showed odds ratio of 5.3 (P=0.017) in performing a single heel raise within postoperative 3 month. ATRS score at postoperative 3 months and last f/u were significantly higher in the study group. (p<0.01)

Conclusion:

Achilles tendon rupture at hypovascular zone is a poor prognostic factor for the early single heel raise and might significantly affect the prognosis after acute Achilles tendon rupture operation.

Effects of wearing shoes on the feet

Category:

Midfoot/Forefoot

Introduction/Purpose:

Maasai tribe members either walk barefoot or wearing traditional shoes made from recycled car tires. Despite walking long distances (up to 60 km) daily, they do not generally experience foot ailments. We compared parameters associated with the feet, ankles, and gait of middle-aged partially and regularly shod Maasai women and Koreans.

Methods:

Foot length, calf circumference, hindfoot alignment, step length, cadence, and walking velocity were compared among 20 middle-aged bush-living partially shod (PS) Maasai women, urban-living regularly shod (RS) Maasai women and Korean. Static and dynamic Harris mat footprints were taken to determine forefoot pressure distribution during walking. We also compared standing foot and ankle radiographic parameters.

Results:

The mean ratios of foot length to the width were not significantly different among three groups. Claw toe deformity was showed highly in PS (80%) and RS (95%) Maasai women. There were no significant differences in walking velocity and Harris mat findings among the three groups. On comparing PS and RS Maasai groups radiographically, talonavicular coverage angle, talo-first metatarsal angle and naviculo-cuboidal overlap were significantly greater in the PS Maasai group, whereas hallux valgus angle, the first and second intermetatarsal angle Meary angle and the medial cuneiform height were greater in the RS Maasai group.

Conclusion:

Regularly wearing shoes can protect the feet from fallen medial longitudinal arches with everted hindfeet and abducted midfeet. It could also cause hallux valgus deformity. Claw toe deformity was seen frequently in the Maasai tribe regardless of shoe wearing habits.

Effect of the additional first ray osteotomy on hindfoot alignment after calcaneal osteotomy for the correction of mild-to-moderate adult type pes plano-valgus

PURPOSE

To determine the effect of the additional first ray osteotomy on hindfoot alignment for the correction of pes plano-valgus.

METHODS

Data obtained from 37 consecutive patients recruited from 2006 to 2014 who underwent medial displacement calcaneal osteotomy (MDCO) alone (group H) or MDCO followed by medial cuneiform opening wedge osteotomy (MCOWO) (group HF) with a minimum 1-year follow-up were reviewed retrospectively. The mean follow-up periods were 34 and 32 months.

RESULTS

Degree of decrease of Talonavicular coverage angle (TNCA) via surgery or postoperative TNCA on standing foot AP radiographs were not significantly different between group H and HF ( p = 0.287). The calcaneal pitch angle and medial cuneiform height on the standing foot lateral radiographs was significantly increased after operation in group HF ( p = 0.01), there was a significant difference with group H as well ( p = 0.033). In group HF, the Meary's angle was significantly decreased after operation, a significant difference compared to group H ( p = 0.009). Hindfoot alignment angle on the hindfoot alignment view was decreased after operation in both groups but was not significantly different between both groups ( p = 0.410). Hindfoot alignment ratio was also increased after the operation in both groups, but was not different between two groups ( p = 0.783).

CONCLUSION

The additional first ray osteotomy using MCOWO had no correctional power for hindfoot correction, although it caused improvement in some radiographic parameters.

Comparison of Postoperative Height Changes of the Second Metatarsal Among 3 Osteotomy Methods for Hallux Valgus Deformity Correction

BACKGROUND

We aimed to compare the postoperative height of the second metatarsal head relative to the first metatarsal head using axial radiographs among 3 different commonly used osteotomy techniques: proximal chevron metatarsal osteotomy (PCMO), scarf osteotomy, and distal chevron metatarsal osteotomy (DCMO).

METHODS

We retrospectively reviewed the radiographs and clinical findings of the patients with painful callosities under the second metatarsal head, complicated by hallux valgus, who underwent isolated PCMO, scarf osteotomy, or DCMO from February 2005 to January 2015. Each osteotomy was performed with 20 degrees of plantar ward obliquity. Along with lateral translation and rotation of the distal fragment to correct the deformity, lowering of the first metatarsal head was made by virtue of the oblique metatarsal osteotomy.

RESULTS

Significant postoperative change in the second metatarsal height was observed on axial radiographs in all groups; this value was greatest in the PCMO group (vs scarf: P = .013; vs DCMO: P = .008) but did not significantly differ between the scarf and DCMO groups ( P = .785). The power for second metatarsal height correction was significantly greater in the PCMO group (vs scarf: P = .0005; vs DCMO: P = .0005) but did not significantly differ between the scarf and DCMO groups ( P = .832).

CONCLUSIONS

Among the 3 osteotomy techniques commonly used to correct hallux valgus deformity, we observed that PCMO yielded the most effective height change of the second metatarsal head.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Surgical correction of hallux valgus complicated with adult-type pes plano-valgus

PURPOSE

To investigate the efficiency of simultaneous correction of moderate to severe hallux valgus deformity and adult-type pes planus.

METHODS

Twenty cases of moderate to severe hallux valgus complicated with adult-type pes planus in 19 consecutive patients (15 (79%) women, 4 (11%) men; mean age: 44.50 ± 17.13 years, mean follow-up duration: 31.30 ± 17.02 months) were included. Medial calcaneal sliding osteotomy was performed to correct hindfoot valgus, whereas treatments of hallux valgus were case dependent.

RESULTS

The mean postoperative hallux valgus angle, intermetatarsal angle, hindfoot alignment angle, and hindfoot alignment ratio were 8.40 ± 5.29°, 4.20 ± 2.54°, 3.09 ± 2.92º and 0.41 ± 0.17, respectively. Although a hallux varus deformity occurred as a postoperative complication in one case (5%), there were no cases of postoperative recurrence.

CONCLUSION

Simultaneous correction of hallux valgus and pes plano-valgus using medial calcaneal sliding osteotomy is an effective technique that reduces recurrence of hallux valgus and increases satisfaction in patients with moderate to severe hallux valgus deformity complicated with adult-type pes planus accompanying hindfoot valgus.

The Effect on Radiographic Parameters of Dwyer’s Osteotomy and 1st Metatarsal Osteotomy for Pes Cavo-Varus Correction

Category:

Hindfoot

Introduction/Purpose:

Authors retrospectively reviewed and compared the data of patients who underwent 1st metatarsal osteotomy alone, Dwyer’s osteotomy alone and 1st metatarsal osteotomy combined with Dwyer’s osteotomy to figure out the effect on radiographic parameters for the correction of pes cavo-varus.

Methods:

Data on 28 cases in 27 consecutive patients recruited from 2006 to 2014 who underwent 1st metatarsal osteotomy alone (Group F), Dwyer’s osteotomy alone (Group H) or 1st metatarsal osteotomy followed by Dwyer’s osteotomy (Group HF) with a minimum 1-year follow-up were reviewed retrospectively.

Results:

Calcaneal pitch angle on the standing foot lateral radiographs was significantly decreased after operation in group H and HF whereas Meary angle was decreased in group F and HF. Hindfoot alignment angle and ratio on the hindfoot alignment view were improved in group H and HF. Maximal medial cuneiform height reduction was shown in group HF. 1st ray was significantly shortened in group F and HF.

Conclusion:

Combined forefoot and hindfoot operation took the largest correction power for all radiologic parameters.

A comparative study of the feet of middle-aged women in Korea and the Maasai tribe

Background

Members of the Maasai tribe spend their days either barefoot or wearing traditional shoes made from recycled car tires. Although they walk long distances (up to 60 km) daily, they do not generally experience foot ailments. Here, we compared parameters associated with the feet, ankles, and gait of middle-aged women in Korea and the Maasai tribe.

Methods

Foot length, calf circumference, hindfoot alignment, step length, cadence, and walking velocity were compared among 20 middle-aged Korean and bush-living Maasai women. Static and dynamic Harris mat footprints were taken to determine the distribution of forefoot pressure patterns during walking. We also compared several radiographic parameters with standing foot and ankle radiographs.

Results

The mean foot length and width were significantly longer in Maasai women. Interestingly, 38 ft (96 %) in the Maasai group showed a claw deformity of the toe (s). There were no statistically significant differences in gait-related indices and Harris mat findings between the two groups. On radiographic analysis, tibial anterior surface angle, tibial lateral surface angle, talonavicular coverage angle, talo-first metatarsal angle, Meary angle, and naviculo-cuboidal overlap were significantly greater in the Maasai group, whereas hallux valgus angle and the first and second intermetatarsal angle were greater in the Korean group.

Conclusions

Middle-aged women from the Maasai tribe showed a higher prevalence of abducted forefeet, everted hindfeet, and fallen medial longitudinal arches than did Korean women, while Korean women showed a higher prevalence of hallux valgus, a preserved medial longitudinal arch, and toes that are free from claw deformity.

Identification of a novel HLA-B*15 variant, B*15:367, using sequence-based typing in a Korean woman

New allele, B*15:367, differs from B*15:11:01 by a single nucleotide exchange at codon 222 (GAG→AAG).

Operative Treatment for Fourth Curly Toe Deformity in Adults

BACKGROUND

Curly toe deformity, a relatively common condition, occurs because of contracture of the flexor digitorum longus and flexor digitorum brevis. Numerous operative techniques have been introduced for treatment. However, there are no reports on fixed, longstanding deformity in adults.

METHODS

Data on 32 toes in 24 consecutive patients treated from 2003 to 2013 who underwent dorsolateral closing wedge-shaped resection arthroplasty for fourth curly toe deformity with a minimum 1-year follow-up were reviewed retrospectively. The mean follow-up period was 49 months. All patients presented preoperatively with a fixed deformity, underriding the adjacent toe. Combined surgeries were performed in 17 cases.

RESULTS

Of 32 toes, fixed deformity presented more frequently at the proximal interphalangeal (PIP) joint, and resection at the PIP joint level was performed in 19 cases as opposed to 13 at the distal interphalangeal joint. The mean corrections of varus inclination and shortening were 31 ± 16 degrees and 3.1 ± 2.1 mm, respectively. American Orthopaedic Foot & Ankle Society scores significantly improved from 50 ± 2 preoperatively to 89 ± 8 at the final follow-up. There was 1 case of recurrence, floating toe deformity following pin tract infection in 1 case, and floating toe deformity without infection in 1 case.

CONCLUSION

We introduced dorsolateral closing wedge-shaped resection arthroplasty as a simple, effective, and powerful option for treating fixed, longstanding fourth curly toe deformity in adults.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Late Onset Osteonecrosis of the Proximal Phalanx of the Great Toe in a Child

Osteonecrosis, also known as avascular necrosis or osteochondrosis, refers to the death of bone tissue resulting from a to lack of blood supply. Osteonecrosis of the foot is most commonly seen in the talus and metatarsals and not as frequently in other bones. We report an extremely rare case of late-onset osteonecrosis of the proximal phalangeal head of the great toe in a 9-year-old male. Plain radiographs and computed tomography did not show any findings of osteonecrosis initially. However, because of persistent pain at the interphalangeal joint of the first toe and a decrease in the range of movement at the interphalangeal joint at 7 months after injury, the patient underwent additional examination with repeated radiographs and magnetic resonance imaging. We diagnosed late-onset osteonecrosis as a result of a subtle traumatic type I dislocation. Conservative treatment led to spontaneous recovery, leaving a bony fragment in the interphalangeal joint. To our knowledge, this is the first report of late-onset proximal phalangeal osteonecrosis after trauma in the great toe.