Eui Dong Yeo

Comparison of All-Inside Arthroscopic and Open Techniques for the Modified Broström Procedure for Ankle Instability:

Background: No reported study has compared clinical and radiologic outcomes between an all-inside arthroscopic modified Broström operation (MBO) and an open MBO. The purpose of this study was to compare clinical and radiologic outcomes of all-inside arthroscopic and open MBOs. Methods: From August 2012 to July 2014, 48 patients were included. They were divided into 2 groups: all-inside arthroscopic MBO (25 patients) and open MBO (23 patients). The American Orthopaedic Foot & Ankle Society (AOFAS) ankle–hindfoot score, visual analog scale (VAS) score, and Karlsson score were used to evaluate clinical outcomes. Anterior talar translation and talar tilt were used to evaluate radiologic outcomes. All patients had lateral ankle instability. MBO was performed in 87 patients. Of these, 50 patients met the inclusion criteria. All patients had giving way, persistent pain, and an inability to resume their preinjury activity level for more than 6 months. Patients were randomized into 2 groups, all-inside arthroscopic MBO and open MBO, using a permuted block randomization method. Clinical outcome evaluations were performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up at a minimum of 12 months postoperatively using the Karlsson score, the AOFAS ankle-hindfoot score, and pain VAS scores. Radiologic outcome evaluations were performed preoperatively and at 1 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle. Results: After randomization, 25 ankles were allocated to the all-inside arthroscopic MBO group and 25 to the open MBO group. Two ankles in the open MBO group were excluded from the analysis because they were lost to follow-up. Thus, evaluations were performed for 25 ankles in the all-inside arthroscopic MBO group and 23 in the open MBO group. There was no difference in age, gender, symptom duration, preoperative AOFAS, VAS, Karlsson scores, anterior talar translation, or talar tilt between the 2 groups (all P > .05). At the final follow-up, the AOFAS, VAS, and the Karlsson scores had improved significantly in both groups (P < .001). There was no difference in the Karlsson, AOFAS, or VAS scores, anterior talar translation, or talar tilt between the 2 groups at final follow-up (all P > .05). Conclusions: There was no difference in the clinical or radiologic outcome between the all-inside arthroscopic MBO and open MBO for the treatment of lateral ankle instability at up to 1 year after surgery. An all-inside arthroscopic MBO should be considered carefully in patients who have lateral ankle instability. Level of Evidence: Level I, randomized controlled trial.

Safe Zone for Medial Open-Wedge Supramalleolar Osteotomy of the Ankle A Cadaveric Study

Background: The purpose of this present study was to determine the incidence of lateral cortical fracture depending on the plane of osteotomy in medial open-wedge supramalleolar osteotomy (SMO) and to define a safe zone through which a medial open-wedge SMO could be performed with minimal risk of lateral cortical fracture. Materials and Methods: Matched pairs of fresh-frozen human cadaver lower leg specimens were obtained from 7 males and 3 females (average age = 63.9 [range 49–75] years). In group A, a safe zone-level medial open-wedge SMO (plane of osteotomy oriented to the proximal one-third of the intrasyndesmosis) was performed, and in group B, a higher-level medial open-wedge SMO (plane of osteotomy oriented to the suprasyndesmosis) was performed. Results: In group A, 7 of the 10 limbs had no lateral cortical fracture, and 3 had lateral cortical fracture, but all of the fractured limbs were stable during the medial open-wedge SMO procedure. In group B, 2 of 10 limbs had no lateral cortical fracture and 8 had lateral cortical fracture. Three of the 8 fractured limbs were stable, but 5 were unstable during the medial open-wedge SMO procedure. The incidence of lateral cortical fracture in group B was significantly higher compared to group A (P = .04). Conclusions: According to the present findings, lateral cortical fracture was less likely to occur when open-wedge SMO was at the plane of the proximal one-third of the intrasyndesmosis, the so-called “safe zone,” than at the plane of the suprasyndesmosis. Clinical Relevance: A safe zone for medial open-wedge SMO to prevent lateral cortical fracture during the medial open-wedge SMO procedure was identified.

Comparison of sagittal subluxation in two different three-component total ankle replacement systems.

Background: Malalignment following total ankle arthroplasty (TAA) has been reported in 4% to 45% of patients. However, all reports to date have been related to coronal deformity. This study compared sagittal malalignment between the Mobility and Hintegra total ankle systems and assessed the positional stability of the implant components over time. Methods: The study included 50 cases each of total ankle replacement arthroplasty with the Hintegra and Mobility total ankle systems performed between May 2008 and June 2010. The Mobility group included 24 men and 25 women, and the mean age was 60.3 years (range, 50.7-70.0 years). The Hintegra group included 25 men and 25 women, and the mean age was 59.8 years (range, 50.8-68.7 years). The 2 groups did not differ in terms of gender (P = .76) or age (P = .77). Three independent observers with different levels of training evaluated the radiographs and performed the measurements independently. Each observer evaluated the radiographs twice at a 6-week interval to determine the intraobserver reliability, and the anteroposterior offset ratio was evaluated. Results: The anteroposterior offset ratio intra- and interobserver reliabilities all showed good or excellent levels of agreement in the Hintegra total ankle system and the Mobility total ankle system. With respect to the stability of sagittal translation of the talus, the Mobility system (0.08 ± 0.07 immediately, 0.0 ± 0.07 at 6 weeks postoperatively, and 0.01 ± 0.07 at 1 year postoperatively) was better than the Hintegra system (0.20 ± 0.08 immediately, 0.18 ± 0.11 at 6 weeks postoperatively, and 0.15 ± 0.10 at 1 year postoperatively) (P < .0001). Conclusions: The Mobility system had less sagittal malalignment of the talus than the Hintegra system. Consequently, when treating ankles in patients with osteoarthritis using the Hintegra system, one must pay careful attention to sagittal malalignment during surgery. Level of Evidence: Level III, retrospective comparative series.

Can Bassett’s ligament be removed?

PurposeTo investigate the functional characteristics of Bassett’s ligament in the ankle, focusing on mechanoreceptors and potential problems following resection of Bassett’s ligament.MethodsBassett’s ligament, the anterior talofibular ligament (ATFL), and synovium were obtained from 20 ankles of 10 fresh-frozen cadavers. Histologically, mechanoreceptors were identified and classified as Ruffini (type I), Vater–Pacini (type II), Golgi–Mazzoni (type III) corpuscles, and free nerve endings (type IV). Differences in receptor densities were compared.ResultsType I clusters were observed with three to six ramifications; type II mechanoreceptors were encapsulated in clusters of two to four with ovoid or cylindrical shape; type III were amorphous, long and wide, and fusiform- or spindle-shaped; and type IV were long and fine without a defined shape. Differences in the densities of the mechanoreceptors inside three soft tissues (Bassett’s ligament, ATFL, and synovium) were not significant.ConclusionThere were no significant differences in the densities of the four types of mechanoreceptors among the soft tissues studied. In Bassett’s ligament, type I mechanoreceptors were present at significantly higher densities than the other receptors.

Arthroscopic syndesmotic repair: technical tip.

Syndesmotic diastasis is a common form of ankle injury. Several approaches to the treatment of syndesmotic injury exist, but there is no “gold standard” technique, and the optimal method of syndesmotic fixation remains a topic of ongoing debate. Arthroscopy is a useful diagnostic and therapeutic tool to identify and confirm the presence of syndesmotic injury. Brown et al reported a high incidence of associated injuries, including a 28% incidence of osteochondral lesions of the talus, in cases of syndesmotic injury. Osteochondral lesions of the talus can be treated at the time of surgery. Their size can be confirmed by visualizing it while fixing the syndesmosis. Arthroscopy has proven more accurate in detecting syndesmotic injury compared with radiological methods. Furthermore, any dynamic instabilities can be addressed during the diagnostic arthroscopy. The purpose of the present report is to describe an arthroscopic syndesmotic repair technique for syndesmotic injury to the ankle.

Comparison of Outcomes in Patients With Generalized Ligamentous Laxity and Without Generalized Laxity in the Arthroscopic Modified Broström Operation for Chronic Lateral Ankle Instability

Background: The arthroscopic modified Broström operation (MBO) has been frequently used to treat chronic lateral ankle instability (CLAI). However, no reports comparing the clinical outcomes between patients with or without generalized ligamentous laxity (laxity or no laxity, respectively) currently exist. The purpose of this study was to compare the clinical outcomes of the 2 groups with CLAI. Methods: Between January 2013 and November 2015, arthroscopic MBO was performed on 99 patients with CLAI. Patients were divided into 2 groups: the laxity group (24 ankles) and no laxity group (75 ankles). Generalized ligamentous laxity was defined as a Beighton score of 4 or more points. Evaluation tools included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot ankle score, a pain visual analog scale (VAS), and talar tilt angle. Results: The change in talar tilt angle from preoperative to 12 months postoperative was significantly greater in the laxity group (–6.9 ± 5.2) compared with the no-laxity group (–4.2 ± 4.2) (P = .03). The final follow-up AOFAS hindfoot ankle score and pain VAS in both groups showed improvement compared with the preoperative values. Conclusion: All groups achieved successful clinical and radiological final follow-up outcomes. Arthroscopic MBO should be considered a reasonable method in patients who have chronic lateral ankle instability, regardless of generalized ligamentous laxity. Level of Evidence: III, comparative study.

Talocalcaneal coalition: A focus on radiographic findings and sites of bridging

Background: Verifying the exact location of talocalcaneal (TC) coalition is important for surgery, but the complicated anatomy of the subtalar joint makes it difficult to visualize on radiographs. No study has used computed tomography (CT) or magnetic resonance imaging (MRI) to verify the radiological characteristics of TC coalition or those of different facet coalitions. Therefore, this study verified the radiological findings used to identify TC coalitions and those of different facet coalitions using CT and MRI. Materials and Methods: Plain with/without weight bearing anteroposterior and lateral radiographs, CT, and MRI of 43 feet in 39 patients with TC coalitions were reviewed retrospectively. CT or MRI was used to verify the location of the TC coalition. Secondary signs for the presence of a coalition in the anteroposterior and lateral plain radiographs, including talar beak, humpback sign, duck-face sign, and typical or deformed C-sign, were evaluated. Three independent observers evaluated the radiographs twice at 6-week intervals to determine intraobserver reliability. They examined the radiographs for the secondary signs, listed above, and coalition involved facets. Results: The average rates from both assessments were as follows: Middle facet 5%, middle and posterior facets 27%, and posterior facet 68%. The deformed C-sign is more prevalent in posterior facet coalitions. The posterior facet has the highest prevalence of involvement in TC coalitions, and the deformed C-sign and duck-face sign have high correlations with TC coalitions in the posterior subtalar facet. Conclusion: A posterior facet is the most prevalent for TC coalition, and the C-sign is useful for determining all types of TC coalition.

2016 Roger A. Mann Award - Comparison of All-Inside Arthroscopic and Open Techniques in Treatment for Chronic Lateral Ankle Instability A Prospective Randomized Trial

Category: Sports. Introduction/Purpose: The modified Broström operation (MBO) is frequently used to treat chronic lateral ankle instability. The open MBO is currently the gold standard procedure for treatment of chronic lateral ankle instability. The all-inside arthroscopic MBO has been developed for chronic lateral ankle instability. Clinical outcome of all-inside arthroscopic MBO was reported as good or excellent. Biomechanically, the stiffness, torque to failure, and degree to failure of all-inside arthroscopic MBO and open MBO have the same results. But there were no report about comparison of clinical outcome between all-inside arthroscopic MBO and open MBO for chronic lateral ankle instability. The purpose of this study is to compare the clinical outcomes of the all- inside arthroscopic MBO and open MBO for chronic lateral ankle instability. Methods: From September 2013 to August 2014, MBO was performed in 87 patients. Of these, 50 consecutive patients were included in terms of inclusion criteria. All patients had giving way, persistent pain and an inability to resume one’s preinjury activity level for more than 6 months. Patients were randomized into 2 groups: all-inside arthroscopic MBO and open MBO using permuted block randomization method. Evaluation was performed preoperatively, at 6 weeks and 6 months postoperatively, and at a final follow-up a minimum of 12 months postoperatively using the Karlsson score, the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot ankle score, pain Visual Analogue Scale (VAS), anterior talar translation, and talar tilt angle. Results: After randomization, 25 ankles were allocated in the all-inside arthroscopic MBO group, and 25 ankles were placed in the open MBO group. Two ankles in the open MBO group were excluded from analysis due to loss of follow-up. Therefore the evaluation was performed for 25 ankles in the all-inside arthroscopic MBO group and 23 ankles in the open MBO group. There were no differences in age, sex, symptom duration, preoperative Karlsson, AOFAS, and VAS scores between the 2 groups (P >.05). At final follow-up, the Karlsson, AOFAS, and VAS scores were significantly improved in both groups (P < .001). There were no differences in the Karlsson, AOFAS, VAS scores, anterior talar translation and talar tilt angle between the 2 groups at final follow-up (P >.05). Conclusion: There was no difference in the clinical evaluation and radiologic evaluation between all-inside arthroscopic MBO group and open MBO group at a minimum 12 months follow-up. All-inside arthroscopic MBO should be carefully considered as a reasonable alternative method in patients who have chronic lateral ankle instability.

Relationship of Sesamoid Position and Other Radiographic Measurements in Hallux Valgus

Category: Midfoot/Forefoot Introduction/Purpose: Many radiographic measurements have been developed and used for evaluating hallux valgus, but their relationships have not been clearly established. The purpose of the present study was to investigate the relationship and reliability of sesamoid position and other radiographic measurements in hallux valgus. Methods: We included 180 patients(mean age 52 years; 18 males and 162 females) with weightbearing plain radiograph. In anteroposterior view, hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, proximal phalangeal articular angle, hallux interphalangeal angle, sesamoid subluxation and metatarsophalangeal congruency were measured. In lateral view, Meary angle(tarso-1st metatarsal angle) was measured. 3 trained observers measured. Correlations among the radiographic measurements were analyzed. Relationship of sesamoid position and other radiographic measurements were evaluated using ANOVA or Fisher’s exact test. Results: The sesamoid subluxation had the correlation with the hallux valgus angle (p < 0.001), intermetatarsal angle (p < 0.001) and metatarso-phalangeal joint congruency (p < 0.001). As the sesamoid subluxation grade increased, the metatarso-phalangeal joint congruency was non-congruent joint. In intraobserver reliability, the hallux valgus angle showed the highest ICC value (0.989; 95% CI, 0.984–0.992) Conclusion: we suggest that the measurements of sesamoid subluxation in assessments of hallux valgus deformity may be helpful for operation and degree of metatarsophalangeal congruency.