Byung-Ki Cho

Comparison between Suture Anchor and Transosseous Suture for the Modified-Broström Procedure

Background: This prospective, randomized study was conducted to compare clinical outcomes of the modified Broström procedure using suture anchor or transosseous suture technique for chronic ankle instability. Methods: Forty patients were followed for more than 2 years after modified Broström procedure. Twenty procedures using a suture anchor and 20 procedures using a transosseous suture were performed by one surgeon. The clinical evaluation consisted of the Karlsson scale and the Sefton grading system. Talar tilt and anterior talar translation were measured on anterior and varus stress radiographs. Results: The Karlsson scale had improved significantly to 90.8 points in the suture anchor group, and to 89.2 points in the transosseous suture group. According to Sefton grading system, 18 patients (90%) in suture anchor group and 17 patients (85%) in transosseous suture group achieved satisfactory results. The talar tilt angle and anterior talar translation improved significantly to 5.9 degrees and 4.2 mm in suture anchor group, and to 5.4 degrees and 4.1 mm in transosseous suture group, respectively. Conclusion: No significant differences existed in clinical and functional outcomes between the two techniques for ligament reattachment. Both modified Broström procedures using the suture anchor and transosseous suture seem to be effective treatment methods for chronic lateral ankle instability. Level of Evidence: I, Prospective Randomized Trial

Nonfusion method in thoracolumbar and lumbar spinal fractures.

Study Design. A retrospective study of surgically managed patients. Objective. To evaluate the results of posterior stabilization of thoracolumbar fracture using nonfusion method followed by the removal of metal implants within an appropriate period. Changes in the sagittal alignment and the restoration of segmental motion were also investigated. Summary of Background Data. Posterior fusion using a transpedicular screw system remains the treatment of choice for the management of thoracolumbar and lumbar fractures. However, fusion methods result in the permanent loss of segmental motion. If both stability and motion could be achieved, functional results would improve considerably. Methods. Twenty-three patients under 40 years of age (mean, 28.0 years) with thoracolumbar or lumbar spine fractures were managed by this nonfusion method. Implants were removed at a mean 9.7 months after initial fracture fixation, and patients were observed for more than 18 months. Sagittal alignments of metal fixed segments, heights of vertebral bodies, recovered motion ranges in flexion/extension, right-left bending view were measured radiologically. Clinical aspects, such as gross deformities and functional abilities, were also investigated. Results. Heights of fractured bodies were well maintained at final follow-up. Initial mean sagittal angle was 17.2° kyphosis, which became 2.8° lordosis after fixation of fractures. This angle was 1.7° kyphosis just before implant removal, 2.4° kyphosis just after implant removal, and showed 5.9° kyphosis at final follow-up. Mean segmental motion was 14.2° in the sagittal plane and 13.1° in the coronal plane at final follow-up. Most patients were satisfied with final gross appearance and functional outcome. Conclusion. The described nonfusion method appears to be effective in achieving favorable sagittal alignment and regaining motions of fixed segments. The present study suggests that the nonfusion method is one of the most effective methods for managing thoracolumbar fractures, especially in young active people.

Mini-open Muscle Resection Procedure under Local Anesthesia for Lateral and Medial Epicondylitis

Background This study examined the clinical results of surgical treatment using a mini-open muscle resection procedure under local anesthesia for intractable lateral or medial epicondylitis. Methods Forty two elbows (41 patients) were treated surgically for lateral or medial epicondylitis. The indication for surgery was refractory pain after six months of conservative treatment, or a history of more than three local injections of steroid, or severe functional impairment in the occupational activities. The treatment results were assessed in terms of the pain using the visual analogue scale (VAS), Roles & Maudsley score, and Nirschl & Pettrone grade. Results The preoperative VAS scores of pain were an average of 5.36 at rest, 6.44 at daily activities, and 8.2 at sports or occupational activities. After surgery, the VAS scores improved significantly (p < 0.01): 0.3 at rest, 1.46 at daily activities, and 2.21 at sports or occupational activities. The preoperative Roles & Maudsley score was acceptable in 6 cases, and poor in 36 cases, which was changed to excellent in 23 cases, good in 16 cases, acceptable in 3 cases after surgery. According to the grading system by Nirschl & Pettrone, 23 cases were excellent, 18 cases were good, and the remaining 1 case was fair. Overall, 41 cases (97.6%) achieved satisfactory results. Postoperative complications were encountered in three cases. Subcutaneous seroma due to the leakage of joint fluid in two patients was managed by additional surgery and suction drainage, and resulted in a satisfactory outcome. One patient complained of continuous pain on occupational activity, but her pain at rest was improved greatly. Conclusions The mini-open muscle resection procedure under local anesthesia appears to be one of effective methods for intractable lateral or medial epicondylitis.

Minimal Invasive Suture-Tape Augmentation for Chronic Ankle Instability

Background: Although the modified Brostrom procedure has had excellent clinical results, postoperative complications such as skin irritation by suture material and problematic scar formation occur. This prospective study was performed to evaluate the clinical outcomes of mini-open ligament augmentation (internal brace technique) using suture tape for chronic ankle instability in a select cohort of patients. Methods: Thirty-four young female patients with less than 70 kg of body weight were followed for more than 2 years after suture tape augmentation for lateral ankle instability. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) score, Sefton grading system, and the period to return to various activities. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate the longevity of mechanical ankle stability. Results: FAOS and FAAM scores had significantly improved to 92.5 points at final follow-up (P < .001). According to the Sefton grading, 31 cases (91.2%) achieved satisfactory functional results. The period to return to exercise was on average 10.2 weeks for jogging and 9.6 weeks for walking on uneven ground. The average subjective satisfaction score of patients was 93.8 points, and satisfaction with the scar was 98.5 points. Talar tilt angle and anterior talar translation had significantly improved to an average of 4.5 degrees and 4.1 mm, respectively, at final follow-up (P < .001). There were no complications such as skin irritation and wound infection, except for 1 case of chronic inflammation. Conclusions: Minimally invasive suture tape augmentation seems to be an effective alternative for young women with chronic ankle instability. Because there is a possibility of progressive elongation over time, the longevity of mechanical ankle stability and the proper indication for using the internal brace technique should be addressed in future studies. Level of Evidence: Level IV, case series study.

Outcomes of the Modified Brostrom Procedure Using Suture Anchors for Chronic Lateral Ankle Instability—A Prospective, Randomized Comparison between Single and Double Suture Anchors

The present prospective, randomized study was conducted to compare the clinical outcomes of the modified Brostrom procedure using single and double suture anchors for chronic lateral ankle instability. A total of 50 patients were followed up for more than 2 years after undergoing the modified Brostrom procedure. Of the 50 procedures, 25 each were performed using single and double suture anchors by 1 surgeon. The Karlsson scale had improved significantly to 89.8 points and 90.6 points in the single and double anchor groups, respectively. Using the Sefton grading system, 23 cases (92%) in the single anchor group and 22 (88%) in the double anchor group achieved satisfactory results. The talar tilt angle and anterior talar translation on stress radiographs using the Telos device had improved significantly to an average of 5.7° and 4.6 mm in the single anchor group and 4.5° and 4.3 mm in the double anchor group, respectively. The double anchor technique was superior with respect to the postoperative talar tilt. The single and double suture anchor techniques produced similar clinical and functional outcomes, with the exception of talar tilt as a reference of mechanical stability. The modified Brostrom procedure using both single and double suture anchors appears to be an effective treatment method for chronic lateral ankle instability.

A prospective outcome and cost-effectiveness comparison between two ligament reattachment techniques using suture anchors for chronic ankle instability.

Background: There are various ligament reattachment techniques for the modified Brostrom procedure. There have been few comparative studies on recently developed techniques. This prospective study was performed to compare the functional outcomes of 2 different ligament reattachment techniques using suture anchors. We furthermore evaluated the cost-effectiveness of the suture bridge technique. Methods: Forty-five amateur athletes under 30 years of age were followed for more than 2 years. Twenty-four procedures with the suture anchor technique and 21 procedures with the suture bridge technique were performed by one surgeon. The functional evaluation consisted of the American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), Karlsson score, Sefton grading system, and the period to return to various forms of exercise (jogging, spurt running, jumping, one leg standing for >1 minute, walking on uneven ground, and going down stairs). Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate mechanical stability. Results: There were no significant differences on AOFAS score, FAOS, Karlsson score, Sefton grade, and stress radiographs. There were no significant differences on the return to exercises, except for jumping. As the most common complication, there were 3 cases of skin irritation by suture materials in the suture anchor group and 2 cases of intraoperative breakage of the suture anchor in suture bridge group. Conclusions: Both ligament reattachment techniques using suture anchors showed similar functional outcomes. Considering the additional medical expenses incurred by more suture anchors, the modified Brostrom procedure using the suture bridge technique had low cost-effectiveness. Proper indication and clinical usefulness of suture bridge technique for chronic ankle instability will be addressed in further studies. Level of Evidence: Level II, prospective comparative study.

A Ligament Reattachment Technique for High-Demand Athletes With Chronic Ankle Instability

The present prospective study was conducted to evaluate the clinical outcomes of the new ligament reattachment procedure for chronic lateral ankle instability in high-demand athletes. A total of 24 athletes <30 years old were followed for >2 years after undergoing the modified Brostrom procedure using the suture bridge technique. The clinical evaluation included the Karlsson score, the Sefton grading system, and the period to return to exercise. As an evaluation of mechanical stability, the talar tilt angle and anterior talar translation were measured on stress radiographs. The Karlsson score had improved significantly from a preoperative average of 43.5 points to 92.2 points. Using the Sefton grading system, 22 (91.7%) patients achieved satisfactory results. The period to return to exercise was as follows: a mean of 8.4 weeks for jogging, 12.5 weeks for spurt running, 10.5 weeks for jumping, 9.2 weeks for 1 leg standing for >1 minute, 10.6 weeks for walking on uneven ground, and 11.2 weeks for going downstairs. The talar tilt angle and anterior talar translation had improved significantly from the preoperative average of 15.4° and 13.3 mm to 3.8° and 4.2 mm at 2 months postoperatively and 4.9° and 4.8 mm at the final follow-up visit, respectively. The modified Brostrom procedure using the suture bridge technique resulted in satisfactory clinical outcomes comparable to those with conventional ligament reattachment techniques. The suture bridge technique appears to be an effective treatment option for chronic ankle instability in high-demand athletes.

Percutaneous Deltoid Ligament Augmentation Using Suture Tape for Medial Ankle Instability

Compared with lateral ankle instability, medial ankle instability has many fewer treatment strategies and fewer reconstructive options available. The best method for deltoid ligament reconstruction remains unclear. Percutaneous deltoid ligament augmentation using suture tape represents a novel alternative technique for chronic medial ankle instability.

Outcomes of the Modified Broström Procedure Augmented With Suture-Tape for Ankle Instability in Patients With Generalized Ligamentous Laxity.

Background: Although recent biomechanical studies have reported mechanical superiority of augmented anterior talofibular ligament reconstruction using suture-tape, clinical evidence regarding the efficacy of suture-tape augmentation is still insufficient. This prospective study was performed to evaluate the outcomes of the modified Broström procedure augmented with suture-tape for chronic ankle instability with generalized ligamentous laxity, which has been known to be a poor prognostic factor for anatomic ligament repair. Methods: Twenty-eight patients with generalized ligamentous laxity were followed for more than 2 years after the augmented modified Broström procedures for chronic ankle instability. Generalized ligamentous laxity was defined as a Beighton score ≥4 points. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) score. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate mechanical ankle stability. Results: FAOS and FAAM scores had significantly improved from preoperative average 63.2 and 54.3 points to 90.6 and 89.5 points at final follow-up, respectively (P < .001). Talar tilt angle and anterior talar translation had significantly improved from preoperative average 16.2° and 12.1 mm to 3.6° and 4.2 mm at final follow-up, respectively (P < .001). Preoperative side-to-side comparison with stress radiographs was significantly different, but this returned to within nonstatistical differences at final follow-up, respectively (P = .105, .532). Although 6 patients sustained an ankle sprain after operation, only 1 patient (3.6%) showed a recurrence of subjective and mechanical instability. Conclusions: Suture-tape augmentation for the modified Broström procedure appears to be an effective operative alternative for chronic ankle instability with generalized ligamentous laxity. As one of the methods to improve the clinical outcomes in patients with relative contraindications of the modified Broström repair, this procedure provided reliable stability with the advantages of anatomic ligament repair through the augmentation using suture-tape. Level of Evidence: Level IV, prospective case series.

Functional Outcomes Following Anterior Transfer of the Tibialis Posterior Tendon for Foot Drop Secondary to Peroneal Nerve Palsy

Background: This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Methods: Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height. Results: Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group (P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group (P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity. Conclusions: Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up. Level of Evidence: Level IV, retrospective case series.