Gi Won Choi

Prognostic Significance of the Containment and Location of Osteochondral Lesions of the Talus Independent Adverse Outcomes Associated With Uncontained Lesions of the Talar Shoulder

Background: Uncontained osteochondral lesions of the talar shoulder are associated with an increased risk of clinical failure in patients treated with current cylindrical osteochondral autograft techniques. Whether the same holds true in patients undergoing arthroscopic treatment is unknown. Purpose: To determine the relative prognostic significance of the containment (shoulder vs nonshoulder type) and location (medial vs lateral) of an osteochondral lesion of the talus (OLT). Hypothesis: Arthroscopic treatment may not be ideal for uncontained lesions of the talar shoulder due to a lack of structural support. Study Design: Cohort study; Level of evidence, 3. Methods: Arthroscopic treatment for OLT was performed on the ankles of 399 patients between 2001 and 2009. Analyses were performed by grouping the patients according to type of containment (shoulder, n = 181; nonshoulder, n = 218), location (medial, n = 274; lateral, n = 125), and both type of containment and location (medial shoulder, n = 129; medial nonshoulder, n = 145; lateral shoulder, n = 52; lateral nonshoulder, n = 73). To evaluate the role of containment and location independently of OLT size, patients were grouped according to quartile of defect size, and outcomes were analyzed within each group. Results: Patients with shoulder-type OLT had a substantially worse clinical outcome than did those with nonshoulder-type OLT, even after adjustment for OLT size (P < .05). However, there was no significant difference in clinical outcome between patients with medial OLT and those with lateral OLT, and the clinical failure rates of the 2 groups were similar (P > .05). A Cox proportional hazards regression model demonstrated that OLT containment, but not location, exerted an independent prognostic effect. Conclusion: Patients with uncontained OLT of the talar shoulder experienced a more complicated clinical outcome than did those with contained, nonshoulder-type OLT even after adjustment for OLT size and regardless of location.

Osteochondral Lesions of the Talus: Are There Any Differences Between Osteochondral and Chondral Types?

Background: Among the types of osteochondral lesions of the talus (OLTs), the osteochondral and chondral types make up the majority of OLTs. There is a possibility that between these two types of lesions, the clinical outcomes and characteristics may differ. Purpose: This study was designed to compare the clinical outcomes, demographics, and characteristics of osteochondral- and chondral-type lesions of OLTs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed 298 ankles that underwent arthroscopic marrow-stimulating procedures for OLTs between 2001 and 2009 that had been arthroscopically determined as either chondral type (210 ankles) or osteochondral type (88 ankles). Clinical outcomes, demographics, and characteristics of the lesions were compared. Results: The age distribution showed that the chondral type reached its peak in patients in their 50s, whereas the osteochondral type had a peak distribution for those in their 20s. The average duration of symptoms was greater in the chondral type (28.3 months; range, 7-240 months) than in the osteochondral type (14.4 months; range, 8-120 months) (P < .001). With regard to the characteristics of the lesions, differences only existed in the combined intra-articular lesions between the two types. Subchondral cysts (odds ratio [OR], 3.71; 95% CI, 1.61-8.55; P = .001) and soft tissue impingement (OR, 1.82; 95% CI, 1.10-3.03; P = .021) were more frequently present in the chondral type. The American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) for pain showed significant improvement from preoperative to postoperative scores in both groups. However, the preoperative and postoperative VAS and AOFAS scores did not differ significantly between the groups. Conclusion: Differences were found with age distribution, duration of symptoms, and combined intra-articular lesions between the osteochondral- and chondral-type lesions of OLTs. We achieved similar successful clinical outcomes in both types of lesions using arthroscopic marrow stimulating procedures, such as microfracture or abrasion arthroplasty.

Total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis: a meta-analysis of comparative studies

PurposeTotal ankle arthroplasty (TAA) and ankle arthrodesis (AA) are the main surgical treatment options for end-stage ankle arthritis. Although the superiority of each modality remains debated, there remains a lack of high-quality evidence-based studies, such as randomized controlled clinical trials, and meta-analyses of comparative studies. We performed a meta-analysis of comparative studies to determine whether there is a significant difference between these two procedures in terms of (i) clinical scores and patient satisfaction, (ii) re-operations, and (iii) complications.MethodsWe conducted a comprehensive search in the MEDLINE, EMBASE, and Cochrane library databases. Only retrospective or prospective comparative studies were included in this meta-analysis. The literature search, data extraction, and quality assessment were conducted by two independent reviewers. The primary outcomes were clinical scores and patient satisfaction. We also investigated the prevalence of complications and the re-operation rate.ResultsTen comparative studies were included (four prospective and six retrospective studies). There were no significant differences between the two procedures in the American Orthopaedic Foot and Ankle Society ankle–hindfoot score, Short Form-36 physical component summary and mental component summary scores, visual analogue scale for pain, and patient satisfaction rate. The risk of re-operation and major surgical complications were significantly increased in the TAA group.ConclusionsThe meta-analysis revealed that TAA and AA could achieve similar clinical outcomes, whereas the incidence of re-operation and major surgical complication was significantly increased in TAA. Further studies of high methodological quality with long-term follow-up are required to confirm our conclusions.

Arthroscopic Synovectomy of the Ankle in Rheumatoid Arthritis

PURPOSE To evaluate the outcome of arthroscopic synovectomy of the ankle joint in patients with early-stage rheumatoid arthritis (RA). METHODS Between 2005 and 2009, 18 consecutive patients with RA involving the ankle underwent arthroscopic synovectomy. Pain was measured using a visual analog scale (VAS), and clinical outcome was determined by calculating the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score with a mean follow-up of 5 years (60 months). Assessments were performed preoperatively, at 6 and 12 months postoperatively, and then yearly thereafter. Clinical success was defined as the absence of synovitis symptoms or when patients demonstrated good or excellent outcomes (AOFAS Ankle-Hindfoot Scale score ≥80) with >50% improvement in VAS score for pain. Demographic, laboratory, and radiological variables were evaluated to determine possible factors predicting clinical outcome. RESULTS VAS and AOFAS scores were significantly improved at the final follow-up (60 months; P < .0001). The greatest improvements in clinical scores were observed after 12 months; thereafter, they steadily declined. Of the 18 patients examined, 14 (77.8%) were considered to have had clinical success with no reintervention. Variables predictive of clinical success were short duration of symptoms (P = .042) and minimal radiographic changes based on the Larsen grading system (P = .030). CONCLUSIONS Arthroscopic synovectomy is a safe and successful procedure in ankle joints affected by RA. The best clinical outcomes are achieved when the procedure is performed early in the disease course and when there is no evidence of cartilage degeneration. LEVEL OF EVIDENCE Level IV, prognostic case series.

Imageless Navigation Versus Conventional Open Wedge High Tibial Osteotomy: A Meta-Analysis of Comparative Studies

Purpose To summarize and compare radiological and clinical outcomes of open wedge high tibial osteotomy (HTO) using imageless computer-assisted navigation with conventional HTO. Methods A literature search of online register databases was conducted. The risk ratio (RR) of radiological outliers and mean differences in clinical outcomes were compared between navigated and conventional HTOs. Radiological results were evaluated by subgroup analyses according to the study period (concurrent/consecutive) and the use of locking fixation device. Results Seven comparative studies with a total sample size of 406 knees were included in this review. Radiographically, the mechanical axis [MA] was within the acceptable range (0°–6°) in 83.7% of the navigation HTO group, showing significant difference from 62.1% of the conventional HTO group. Clinically, despite the forest plot demonstrating a general trend of favoring the navigation system, there were not sufficient studies to determine statistical significance in the meta-analysis. None of the subgroup analyses demonstrated significant differences in the RR of MA outliers. Conclusions The present meta-analysis indicates that the use of navigation in open wedge HTO improves the precision of mechanical alignment by decreasing the incidence of outliers; however, the clinical benefit is not conclusive. Additionally, none of the subgroup analyses demonstrated significant difference in the RR of MA outliers.

Additional surgical factors affecting the recurrence of hallux valgus after Ludloff osteotomy

We reviewed 91 patients (103 feet) who underwent a Ludloff osteotomy combined with additional procedures. According to the combined procedures performed, patients were divided into Group I (31 feet; first web space release), Group II (35 feet; Akin osteotomy and trans-articular release), or Group III (37 feet; Akin osteotomy, supplementary axial Kirschner (K-) wire fixation, and trans-articular release). Each group was then further subdivided into severe and moderate deformities. The mean hallux valgus angle correction of Group II was significantly greater than that of Group I (p = 0.001). The mean intermetatarsal angle correction of Group III was significantly greater than that of Group II (p < 0.001). In severe deformities, post-operative incongruity of the first metatarsophalangeal joint was least common in Group I (p = 0.026). Akin osteotomy significantly increased correction of the hallux valgus angle, while a supplementary K-wire significantly reduced the later loss of intermetatarsal angle correction. First web space release can be recommended for severe deformity. Additionally, K-wire fixation (odds ratio (OR) 5.05 (95% confidence interval (CI) 1.21 to 24.39); p = 0.032) and the pre-operative hallux valgus angle (OR 2.20 (95% CI 1.11 to 4.73); p = 0.001) were shown to be factors affecting recurrence of hallux valgus after Ludloff osteotomy.

Are Portable Imaging Intraoperative Radiographs Helpful for Assessing Adequate Acetabular Cup Positioning in Total Hip Arthroplasty

Despite advances in surgical techniques and instrumentation, current intra-operative estimations of acetabular version in total hip arthroplasty are of limited accuracy. In the present study, two experienced orthopedic surgeons compared intra-operatively measured (using portable imaging) anteversions and vertical inclinations of acetabular components with those measured using standardized radiographs post-operatively in 40 patients. Of the all vertical inclinations measured from intra-operative radiographs, 72.5% (n=29) were within ±2°, and 97.5% (n=39) were within ±5° of those determined using post-operative radiographs, and for anteversion, 52.5% (n=21) were within ±2°, and 97.5% (n=39) were within ±5°. Post-operative radiographs demonstrated that 90.0% (n=36) of vertical inclinations and anteversions were within the adequate zone. Obviously, our method has its limitations, but the authors conclude that the method described in this article better allows surgeons to verify acetabular version intra-operatively. In particular, the described method is suitable in cases with a deformed acetabular anatomy and difficult revision surgery.

How early must an acute Achilles tendon rupture be repaired

An acute Achilles tendon rupture is the most common tendon rupture of the lower extremities, yet the optimal timing for an early surgical repair is unclear. To identify the optimal time for an early surgical repair with favorable results, we evaluated the isokinetic muscle strength and clinical outcomes of early surgical repairs of acute Achilles tendon ruptures performed at different time points after injury. Between January 2011 and July 2015, a total of 65 patients underwent an acute Achilles tendon rupture repair within 1 week after injury. To compare the outcomes at different time points post-injury, we divided patients into 3 groups: group 1, surgical treatment at ≤24h; group 2, surgery at ≥24h and ≤48h; and group 3, surgery at ≥48 hours and ≤1 week. The isokinetic muscle strength in both ankles were measured using a Cybex dynamometer, and the Achilles tendon total rupture score, the modified Tegner scoring system, the visual analog scale was used to assess clinical outcomes. Kruskal-Wallis and Fishers exact tests were used to compare multiple results in the 3 groups. No significant differences were found among the groups in terms of ankle isokinetic muscle strength or clinical outcome scores (P>0.05). The complication rate was low in all groups. There were no significant differences in isokinetic muscle strength or clinical outcomes following acute Achilles tendon rupture repairs performed within 1 week after injury.

Arthroscopic Versus Open Ankle Arthrodesis: A Systematic Review

PURPOSE To perform a systematic review comparing the clinical scores, union rate, complications, reoperations, hospital stay, and operation time between open ankle arthrodesis (OAA) and arthroscopic ankle arthrodesis (AAA). METHODS We conducted a comprehensive search in the MEDLINE, Embase, and Cochrane Library databases. Only comparative studies were included in this meta-analysis. The literature search, data extraction, and quality assessment were conducted by 2 independent reviewers. The outcomes analyzed included clinical scores, union rate, complications, reoperations, hospital stay, operation time, and intraoperative blood loss. RESULTS A total of 7 retrospective comparative studies were included in this systematic review. Clinical scores were noted in 3 studies. The American Orthopaedic Foot & Ankle Society ankle-hindfoot score and the Ankle Osteoarthritis Scale score were better in the AAA group than in the OAA group. The union rate was similar between the OAA (70%-100%) and AAA (76.2%-100%) groups. The complication rate was higher in the OAA group (6.7%-47.1%) than in the AAA group (0%-23.8%) in 6 studies. The reoperation rate was similar between the OAA (0%-26.5%) and AAA (0%-27.6%) groups. The hospital stay was shorter in the AAA group in 6 studies. Among the 5 studies that reported operation time, 4 reported no significant difference. Two studies showed that intraoperative blood loss was significantly less in the AAA group. CONCLUSIONS AAA was shown to offer the advantages of better clinical scores, fewer complications, a shorter hospital stay, and less blood loss compared with OAA. However, the union rate, reoperation rate, and operation time were similar overall between the 2 groups. LEVEL OF EVIDENCE Level III, systematic review of Level III studies.

Sex-related differences in outcomes after hallux valgus surgery.

Purpose With differences between the sexes in foot bone anatomy and ligamentous laxity, there is the possibility that the results of hallux valgus surgery may also differ between the sexes. We aimed to compare the results of hallux valgus surgery between the sexes. Materials and Methods The authors retrospectively reviewed 60 males (66 feet) and 70 females (82 feet) who underwent distal or proximal chevron osteotomy for the treatment of hallux valgus deformity between June 2005 and December 2011. We compared the clinical and radiologic outcomes between the sexes. Results There were no statistically significant differences in demographics between the sexes. The mean American Orthopedic Foot and Ankle Society score, visual analogue scale for pain, and patient satisfaction at the last follow-up did not differ significantly between the sexes. The mean preoperative hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were not significantly different between the sexes. At the last follow-up, the mean HVA was significantly greater in females (p=0.003) than in males; mean IMA was not significantly different between the sexes. The mean correction of HVA in males was significantly greater than that in females (p=0.014). Conclusion There were no significant differences between the sexes regarding clinical outcomes after distal and proximal chevron osteotomy. However, male patients achieved greater correction of HVA than female patients. There is a possibility that sexual dimorphism of the foot may affect postoperative HVA.