Bavornrit Chuckpaiwong

Microfracture for osteochondral lesions of the ankle: outcome analysis and outcome predictors of 105 cases.

PURPOSEnThe purpose of this study was to identify outcomes and outcome predictors of arthroscopic debridement with osteochondral bone stimulation (microfracture) for osteochondral lesions of the ankle.nnnMETHODSnOne hundred five consecutive patients with osteochondral lesions of the ankle who underwent ankle arthroscopy with microfracture were prospectively followed up for a mean of 31.6 +/- 12.1 months. Study patients were evaluated at 6 weeks, 3 months, 6 months, 12 months, and annually after surgery. Assessments via a visual analog scale for pain during daily activities and sport activity, the Roles and Maudsley score, and the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system were obtained at each visit. Outcome predictors were analyzed by logistic regression model.nnnRESULTSnThere were no failures of treatment with lesions smaller than 15 mm. In contrast, only 1 patient met the criteria for success in the group of lesions greater than 15 mm. Statistical analysis revealed that increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affected outcome. The presence of instability and the presence of anterolateral soft-tissue scar were correlated with a successful outcome.nnnCONCLUSIONSnThis study found a strong correlation between lesion size and success across its entire population. For lesions smaller than 15 mm, regardless of location, excellent results were obtained. In addition, increasing age, higher body mass index, history of trauma, and presence of osteophytes negatively affect outcome. The presence of instability and anterolateral soft-tissue scar correlated with a successful outcome.nnnLEVEL OF EVIDENCEnLevel IV, prognostic case series, prognostic study.

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors.

UNLABELLEDnPlantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome.nnnLEVEL OF CLINICAL EVIDENCEn2.

Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus

PurposeThis study compared results of distal and proximal metatarsal osteotomy for moderate to severe hallux valgus in terms of radiographic correction and functional outcome.MethodsWe analyzed 125 moderate to severe hallux valgus surgeries. Patients were divided into two groups. Group 1 underwent distal metatarsal osteotomy, and group 2 underwent proximal metatarsal osteotomy. Patients were interviewed for functional scores before and onexa0year after surgery. The anteroposterior (AP) weight-bearing radiography of the foot was taken before and onexa0year after surgery.ResultsThere were no significant differences in pain and function after onexa0year in either group. Both groups experienced significant pain reduction and increase in all functional scores. There was significant improvement of hallux valgus and intermetatarsal angle corrections in group 2. There was less improvement in radiographic correction in group 1.ConclusionEither distal or proximal metatarsal osteotomy is an appropriate pain-relieving procedure and can increase functional outcome in moderate to severe hallux valgus. However, distal metatarsal osteotomy provides lower correction power.

Roof-arc angle and weight-bearing area of the acetabulum

BACKGROUNDnUnreduced fracture crossing the weight-bearing dome of the acetabulum leads to arthritis. Thus the integrity of the weight-bearing dome is considered to be an important prognostic indicator for acetabular fracture. The decision of whether or not to operate is based on the location of the fracture relative to the weight-bearing dome. A displaced fracture crossing the weight-bearing dome is an indication for surgery.nnnOBJECTIVEnTo measure the medial, anterior, and posterior roof-arc angles that cross the weight-bearing dome.nnnMETHODSnTwenty cadeveric hip joints were dissected and simulated transverse fractures of acetabuli through the transtectal area were made. The radiographic examinations were taken in three views: AP, obturator oblique, and iliac oblique. Roof-arc angle was measured in all three views (medial, anterior, and posterior).nnnRESULTSnThe medial roof-arc angle was 46+/-6.3 degrees , anterior roof-arc angle was 52+/-7.0 degrees , and posterior roof-arc angle was 62 degrees +/-8.5 degrees .nnnCONCLUSIONSnIn acetabular fracture, a medial roof-arc angle less than 46 degrees , an anterior roof-arc angle less than 52 degrees , or posterior roof-arc angle less than 61 degrees is considered to be involved in a weight-bearing area.nnnCLINICAL RELEVANCEnThese roof-arc angle values may be used as a surgical guideline for an acetabular fracture around the weight-bearing area.

Safety Area for Proximal Metatarsal Procedures

Background: Forefoot and tarsometatarsal surgery may be performed on the first and second metatarsal through the intermetatarsal space. However, no study has identified the safety area of the proximal metatarsal bone to avoid vascular injury. Methods: One hundred and twenty-two uninjured embalmed feet of 31 female and 33 male cadavers aged 15 to 91 years (mean, 69.9 years) were studied. The dorsalis pedis artery was identified and dissected from its origin to the deep plantar artery. The distances from the artery to the dorsomedial aspect of first metatarsal bone, from the artery to the first tarsometatarsal joint, and from dorsalis pedis artery to the most plantar surface of second metatarsal bone were measured. Results: The distance from the artery to the first tarsometatarsal joint averaged 23.1 mm (range, 12-31 mm) and the distance from the artery to the most plantar surface of the second metatarsal bone averaged 6.3 mm (range, 3-13 mm). Conclusions: The safety area for proximal metatarsal procedure is about a 69-mm2 triangular area (23 mm from first tarsometatarsal joint and 6 mm from the most plantar surface of the second metatarsal bone). Clinical Relevance: The study provides information of normal location and variation of deep plantar artery is which related to medial midfoot complex. This information may be used during proximal metatarsal procedures.

Is the Arthroscopic Transillumination Test Effective in Localizing the Superficial Peroneal Nerve

PURPOSEnTo evaluate the transillumination test in showing the position of the superficial peroneal nerve (SPN) to quantify the effectiveness of this test.nnnMETHODSnProspectively, we selected 53 ankle arthroscopy patients (71 patients were excluded because of the invisible SPN). Demographic data including gender, weight, height, and body mass index were recorded. The intraoperative transillumination test was performed during portal establishment and recorded as positive if the SPN was visible via transillumination. The data were analyzed as mean, standard deviation, and percentage. Wilsons method was used as 95% confidence interval for proportion of the positive transillumination test.nnnRESULTSnThe intraoperative transillumination test was positive in 0 of 53 patients (0%) with 95% confidence interval ranging from 0% to 6.7%.nnnCONCLUSIONSnThe transillumination test has no value for showing the SPN.nnnLEVEL OF EVIDENCEnLevel II, prospective diagnostic study.

Müller-Weiss Disease: Three- to Eight-Year Follow-Up Outcomes of Isolated Talonavicular Arthrodesis

Abstract Numerous surgical techniques for the treatment of Müller‐Weiss disease (MWD) have been reported. However, no extensive clinical and radiographic studies of isolated talonavicular arthrodesis and MWD have been reported. The present retrospective cohort study examined the outcomes of isolated talonavicular arthrodesis at 3 to 8 years of follow‐up in 16 MWD patients with a collapsed longitudinal arch and at least Maceira stage III. Demographic data, pre‐ and postoperative visual analog scale (VAS) scores for pain on walking and walking disability, foot and ankle outcome scores (FAOSs), and radiographic parameters were analyzed, with statistical significance at p < .05. A survival analysis was used to determine the median time to union. The mean ± standard deviation pre‐ and postoperative VAS scores for pain on walking were 7.69 ± 1.62 and 2.19 ± 1.52 and the walking disability scores were 7.06 ± 2.11 and 2.31 ± 1.92, respectively. The pre‐ and postoperative FAOSs were 48.07 ± 21.50 and 82.27 ± 13.86 for activities of daily living, 30.86 ± 19.70 and 76.17 ± 22.39 for quality of life, and 20.93 ± 22.89 and 51.88 ± 23.66 for sports/recreation, respectively. The median pre‐ and postoperative FAOSs for the symptoms subscale were 73.22 (range 42.88 to 100.00) and 87.50 (35.71 to 100.00) and for pain were 34.72 (range 8.33 to 72.22) and 88.89 (54.41 to 100.00), respectively. Significant improvements occurred from preoperatively to postoperatively for VAS scores and FAOSs (p < .05). The mean pre‐ and postoperative calcaneal pitch angles were 11.31° ± 4.35° and 13.81o ± 5.60o, significant improvement (p = .016). Improvement was also seen midfoot abduction, with a mean pre‐ and postoperative anteroposterior Mearys angle of 14.38° ± 10.07° and 9.38° ± 12.21°. The survival analysis showed union was achieved in all patients, with a median time to union of 2 (95% confidence interval 1.03 to 3.00) months. Our data indicate that talonavicular arthrodesis provides satisfactory functional outcomes for MWD patients with a collapsed longitudinal arch. &NA; Level of Clinical Evidence: 4

Appropriate Area for Operative Procedures Near Tibialis Anterior Tendon Insertion: A Cadaveric Study

Background: The tibialis anterior tendon has its insertion sites on both the medial and plantar surfaces of the medial cuneiform and the base of the first metatarsal. Operative procedures near those areas, especially at the first metatarsocuneiform joint, may disturb tendon insertions and cause irritation or functional impairment of the tendon. Methods: Tibialis anterior tendons and their insertion sites were dissected and examined from 46 cadaveric feet (19 female and 27 male cadavers, aged between 33 and 86 years, with a mean of 68.5 ± 14.3 years). The greatest lengths and widths of the tendon attachments on the bony surface of the medial cuneiform and base of the first metatarsal, on both the medial and plantar surfaces, were measured and analyzed. The measurement reliability was evaluated by using the intraclass correlation coefficient. Results: Most of the tibialis anterior tendon insertions were found to be longer at the medial cuneiform than at the base of the first metatarsal (mean, 8.3 and 5.4 mm; P < .001), but the widths were almost similar (mean, 11.0 and 10.4 mm; P = .079). When focusing on each bone, the widths of the tendon attachments on the medial and plantar surfaces of the medial cuneiform were equivalent (mean, 5.4 and 5.6 mm; P = .584). At the base of the first metatarsal, the tendon attachment on the plantar surface was found to be wider than on the medial surface (mean, 7.0 and 3.4 mm; P < .001). Conclusion: The widths of the tibialis anterior tendon insertions on the medial and plantar surfaces of the medial cuneiform were equal, as were the total widths of insertions on the medial cuneiform and on the base of the first metatarsal. However, the width of insertions on the medial surface of the first metatarsal was significantly smaller than on the plantar surface, and the total length of insertions at the medial cuneiform was longer than at the first metatarsal. Clinical Relevance: This study provides information about characteristics of the tibialis anterior tendon insertions, particularly details of the dimensions on each surface of the bones. This knowledge enables surgeons to minimize the risk of irritation or tendon injuries during operations near the base of the first metatarsal and medial cuneiform area.

Benefit of Adding Fibular Osteotomy to Open-Wedge, Valgus, Distal Tibial Osteotomy for Correcting Varus Ankle Arthritis: An In Vitro Study

Abstract Early‐stage varus ankle arthritis can usually be treated with a medial, open‐wedge, valgus, distal tibial osteotomy; however, the value of adding a fibular osteotomy has been debated. We sought to determine the increase in the maximum medial osteotomy gap and correction angle provided by fibular osteotomy. In 3 sequential experiments on 12 fresh cadaveric legs, we first performed a medial open‐wedge, valgus, distal tibial osteotomy alone. Second, we added a transverse fibular osteotomy. Finally, we added a blocked fibular osteotomy. In each experiment, we measured the maximum corrected osteotomy gap and the maximum correction angle. Correction was defined as the absence of lateral cortex diastasis and talocrural joint incongruity. The mean ± standard deviation maximum osteotomy gaps and correction angles were 8.40 ± 1.6 mm and 10.70° ± 3.3° for the tibial osteotomy alone, 15.70 ± 4.6 mm and 20.20° ± 5.6° for the tibial plus transverse fibular osteotomy, and 16.67 ± 3.7 mm and 20.56° ± 4.6° for the tibial plus transverse plus blocked fibular osteotomies, respectively. The corresponding median maximum correction angles were 10° (range 8° to 18°), 19.5° (range 14° to 30°), and 20° (range 14° to 28°). The osteotomy gap and correction angle in the distal tibial and transverse fibular osteotomy were significantly greater than those in the distal tibial osteotomy alone (p < .001 for both) but not in the distal tibial and blocked fibular osteotomy (p = .62 for the gap and p = .88 for the correction angle). Our data support the clinical use of adjunct transverse fibular osteotomies. The blocked fibular osteotomy provided no additional benefit. &NA; Level of Clinical Evidence: 5

How to harvest the greatest length of tibialis posterior tendon for tendon transfer: A cadaveric study: How to Harvest the Greatest Length

In anterior transfer of the tibialis posterior tendon, the tendon was harvested using two incisions, the first at its attachment point on the navicular bone and second on the medial side of the leg above the medial malleolus. To provide the maximum tendon length, the second incision needs to be as proximal as possible but injury to the muscle origin must be avoided. The purpose of this study is to establish the location of the second incision that yields the greatest tendon length. Forty‐five unpaired embalmed cadaveric legs were dissected. Demographic data, gender, age, and side of specimen were recorded. The distance between the tip of the medial malleolus and the muscle origin was measured. Mobile tendon length, muscle origin, foot length, tibial length, and position of ankle were also noted. The mean mobile tendon length was 11.1 (range 10.7–11.4) cm and the distance between the tip of the medial malleolus and the muscle origin was 6.8 (range 6.5–7.0) cm. The mean foot length was 22.2 cm (range 21.7–22.7), tibial length was 31.5 cm (range 30.8–32.2), and muscle origin was 23.7 cm (range 21.0–26.3). The mean angle position was 46 degrees plantar flexion (range 43–49). In subgroup analysis by gender, the mobile tendon length, distance between the tip of the medial malleolus and the muscle origin, and tibial length, were significantly greater in males than females. In conclusion, for anterior transfer of the tibialis posterior tendon, an incision 7.1 cm above the medial malleolus in the male and 6.4 cm above it in the female provides the longest mobile tendon without injury to its origin. Clin. Anat. 30:1083–1086, 2017.