Hideji Kura

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system

BackgroundThe aim of this study was to report the five scales comprising the rating system that the Japanese Society for Surgery of the Foot (JSSF) devised (JSSF standard rating system) and the newly offered interpretations and criteria for determinations of each assessment item.MethodsWe produced the new scales for the JSSF standard system by modifying the clinical rating systems established by the American Orthopaedic Foot and Ankle Society (AOFAS scales) and the Japanese Orthopaedic Association’s foot rating scale (JOA scale). We also provided interpretations of each assessment item and the criteria of determinations in the new standard system.ResultsWe improved the ambiguous expressions and content in the conventional standard rating systems so they would be easily understood by Japanese people. The result was five scales in total. Four were designed for use specifically for ankle-hindfoot, midfoot, hallux metatarsophalangeal-interphalangeal, and lesser metatarsophalangeal-ineterphalangeal sites; and the fifth was for the foot and ankle with rheumatoid arthritis. Furthermore, we described interpretations and criteria for determinations with regard to evaluation items in each scale.ConclusionsConventionally, the AOFAS scales or the JOA scale have been separately applied depending on the sites or disorders concerned, but it was often difficult to decide on scores during practical evaluations because of differing expressions in different languages and also because of ambiguity in the interpretation of each evaluation item and in scoring standards as well. JSSF improved these scales and added definite interpretations of evaluation items as well as criteria for the rating (to be reported here in part I). Because these steps were expected to improve the reliability of outcomes assessed by each scale, we examined the reliability in scores of the newly developed scales, which are reported in part II (in this issue).

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders II: interclinician and intraclinician reliability and validity of the newly established standard rating scales and Japanese Orthopaedic Association rating scale

BackgroundThis study evaluated the validity and inter- and intraclinician reliability of (1) the Japanese Society of Surgery of the Foot (JSSF) standard rating system for four sites [ankle-hindfoot (AH), midfoot (MF), hallux (HL), and lesser toe (LT)] and the rheumatoid arthritis (RA) foot and ankle scale and (2) the Japanese Orthopaedic Association’s foot rating scale (JOA scale).MethodsClinicians from the same institute independently evaluated participating patients from their institute by two evaluations at a 1- to 4-week interval. Statistical evaluation was as follows. (1) The intraclass correlation coefficient (ICC) was calculated from data collected from at least two examinations of each patient by at least two evaluating clinicians (Data A). (2) Total scores for the two evaluations were determined from the distribution of differences in data between the two evaluations (Data B); each item was evaluated by determining Cohen’s coefficient of agreement. (3) The relation between patient satisfaction and total score was investigated only for patients who underwent surgery (Data C). Spearman’s rank correlation coefficient was obtained.ResultsParticipants were 65 clinicians and 610 patients, including those with disorders of the AH (313), MF (47), HL (153), and LT (50) and those with RA (47). From Data A, the ICC was high for AH and HL by JSSF scales and for AH, MF, and LT by the JOA scale. From Data B, the coefficient showed high validity for both scales for AH, with almost no difference between the two scales; the validity for HL was higher with the JOA scale than with the JSSF scale. From Data C, correlations were significant between patient satisfaction and outcome for AH and HL by the JSSF scales and for AH, HL, and LT by the JOA scale.ConclusionsThe validity of both scales was high. Clinical evaluation of the therapeutic results using these scales would be highly reliable.

Three-dimensional corrective osteotomy for treatment of cubitus varus after supracondylar fracture of the humerus in children

Cubitus varus deformity after supracondylar fracture of the humerus in children generally includes deformities of varus, hyperextension, and internal rotation. Presently almost all corrective osteotomies for treatment of cubitus varus deformity have been limited to correction of only the varus or of the varus and hyperextension deformity. Electromyographic study and stick picture motion analysis have revealed unphysiological joint motion and muscle activity around the joint in elbows with cubitus varus, hyperextension, and internal rotation deformity. On this basis we have successfully attempted simultaneous correction of all three deformities. The end results in 41 elbows have been satisfactory. In conclusion, we recommend simultaneous correction of the three elements of cubitus varus deformity to restore anatomic alignment of the elbow joint.

Three-Dimensional Analysis of Ankle Instability After Tibiofibular Syndesmosis Injuries: A Biomechanical Experimental Study

Background Rupture of the distal tibiofibular syndesmosis commonly occurs with extreme external rotation. Most studies of syndesmosis injuries have concentrated only on external rotation instability of the ankle joint and have not examined other defects. Hypothesis Syndesmosis injuries cause multidirectional ankle instability. Study Design Controlled laboratory study. Methods Ankle instability caused by distal tibiofibular syndesmosis injuries was examined using 7 normal fresh-frozen cadaveric legs. The anterior tibiofibular ligament, interosseous membrane, and posterior tibiofibular ligament, which compose the distal tibiofibular syndesmosis, were sequentially cut. Anterior, posterior, medial, and lateral traction forces, as well as internal and external rotation torque, were applied to the tibia; the diastasis between the tibia and fibula and the angular motion among the tibia, fibula, and talus were measured using a magnetic tracking system. Results A medial traction force with a cut anterior tibiofibular ligament significantly increased the diastasis from 1.1 to 2.0 mm (P = .001) and talar tilt angles from 9.6° to 15.2° (P < .001). External rotation torque significantly increased the diastasis from 0.5 to 1.8 mm (P= .009) with a complete cut; external rotation torque also significantly increased rotational angles from 7.1° to 9.4° (P = .05) with an anterior tibiofibular ligament cut. Conclusion Syndesmosis injuries caused ankle instability with medial traction force and external rotation torque to the tibia. Clinical Relevance Both physicians and athletes should be aware of inversion instability of the ankle joint caused by tibiofibular syndesmosis injuries.

Skewed X-chromosome inactivation causes intra-familial phenotypic variation of an EBP mutation in a family with X-linked dominant chondrodysplasia punctata

Abstract. X-linked dominant chondrodysplasia punctata (CDPX2) is a skeletal dysplasia characterized by stippled epiphyses, cataracts, alopecia and skin lesions, including ichthyosis. CDPX2 exhibits a number of perplexing clinical features, such as intra- and inter-familial variation, anticipation, incomplete penetrance and possible gonadal and somatic mosaicism. Recently, mutations in the gene encoding Δ8,Δ7 sterol isomerase/emopamil-binding protein (EBP) have been identified in CDPX2. To better understand the genetics of CDPX2, we examined the entire EBP gene by direct sequencing in four CDPX2 patients. We found EBP mutations in all four patients, including three novel mutations: IVS3+1G>A, Y165C and W82C. Surprisingly, a known mutation (R147H) was identified in a patient and her clinically unaffected mother. Expression analysis revealed the mutant allele was predominantly expressed in the patient, while both alleles were expressed in the mother. Methylation analysis revealed that the wild-type allele was predominantly inactivated in the patient, while the mutated allele was predominantly inactivated in her mother. Thus, differences in expression of the mutated allele caused by skewed X-chromosome inactivation produced the diverse phenotypes within the family. Our findings could explain some of the perplexing features of CDPX2. The possibility that an apparently normal parent is a carrier should be considered when examining seemingly sporadic cases and providing genetic counseling to CDPX2 families.

Pathomechanics of Hallux Valgus: Biomechanical and Immunohistochemical Study

Background: One factor believed to contribute to the development of hallux valgus is an abnormality in collagen structure and makeup of the medial collateral ligament (MCL) of the first metatarsophalangeal joint (MTPJ). We hypothesized that the mechanical properties of the MCL in feet with hallux valgus are significantly different from those in normal feet and that these differences may be related to alterations in the type or distribution of collagen fibers at the interface between the MCL and the bone. Materials and Methods: Seven normal fresh-frozen cadaver feet were compared to four cadaver feet that had hallux valgus deformities. The MCL mechanical properties, structure of collagen fibers, and content proportion of type I and type III collagen were determined. Results: The load-deformation and stress-strain curves were curvilinear with three regions: laxity, toe, and linear regions. Laxity of the MCL in feet with hallux valgus was significantly larger than that of normal feet (p = 0.022). Stiffness and tensile modulus in the toe region in feet with hallux valgus were significantly smaller than those in normal feet (p = 0.004); however, stiffness and tensile modulus in the linear region were not significantly different. The MCL collagen fibrils in the feet with hallux valgus had a more wavy distribution than the fibrils in the normal feet. Conclusions: In general, strong staining for collagen III and to a lesser extent, collagen I was observed at the interface between the MCL and bone in the feet with hallux valgus but not in the normal feet. These results indicate that the abnormal mechanical properties of the MCL in feet with hallux valgus may be related to differences in the organization of collagen I and collagen III fibrils.

Distal Fibular Length Needed for Ankle Stability

Background: The fibula is commonly used for bone grafts. Previous clinical and biomechanical studies have suggested that the length of the residual portion of the distal part of the fibula has an important effect on the long-term stability of the ankle joint. However, we cannot find clear-cut guidelines for the amount of bone that can be harvested safely. Methods: Using six normal fresh-frozen cadaver legs, motions of the tibia, talus and calcaneus were measured. The fibula was cut sequentially 3 cm from the proximal tip of the fibula and distally 10 cm, 6 cm, and 4 cm from the distal tip of the lateral malleolus. The angular motion of each bone was measured while a medial and lateral traction force of 19.6 N was applied to the proximal tibia. Angles of the tibia, talus, and calcaneus were measured. Results: Sequential resection of the fibula increased the inversion angles of the ankle joint. The proximal 3-cm cut increased the inversion angle from 42.1 ± 6.2 degrees to 49.6 ± 3.6 degrees, and the distal 4-cm cut increased the angle from 57.6 ± 6.6 degrees to 67.4 ± 5.9 degrees. The rotational angles were almost constant with sequential resections of the fibula; however, the distal 4-cm cut increased the rotational angle from 11.3 ± 25.1 degrees to 78.7 ± 37.5 degrees. Conclusions: The whole fibula including the head is essential for the stability of the ankle joint complex, and the distal fibula is responsible for stabilizing the ankle mortise during external rotation and inversion. We recommend fixation of the syndesmosis or bracing to prevent ankle joint instability with rotation of the talus in the mortise, especially when the distal fibula is shortened 6 cm or more.

Role of medial capsule and transverse metatarsal ligament in hallux valgus deformity

The role of the medial capsule and transverse metatarsal ligament in hallux valgus deformity including stability of the first metatarsophalangeal and adjacent joints was investigated in vitro. The three-dimensional positions of the proximal phalanx, first metatarsal, and second metatarsal before and after sectioning the medial capsule and metatarsal ligament were measured using a magnetic tracking system. Valgus deformity of the hallux increased with medial capsule sectioning an average of 22.3 degrees +/- 6 degrees. Valgus deformity of the hallux increased with medial capsule and metatarsal ligament sectioning an average of 27.4 degrees +/- 9.1 degrees. Valgus deformity of the hallux did not change significantly after sectioning the metatarsal ligament only. No significant changes were found in varus and eversion of the first metatarsal, in valgus of the second metatarsal, in the distance between first and second metatarsal heads after sectioning the medial capsule, or in the metatarsal ligament. This study shows the importance of the medial capsule in hallux valgus deformity. The transverse ligament did not contribute substantially to cause the deformity.

Analysis of ankle-hindfoot stability in multiple planes : An in vitro study

Background: It is necessary to have an understanding of ankle and hindfoot motion and stability to accurately diagnosis and treat ankle-hindfoot disorders. Methods: We devised an ankle ligament testing apparatus to more critically determine ankle stability in all planes with a constant rotational force applied (inversion, eversion, internal rotation, external rotation) throughout the range of sagittal plane motion in 13 cadaver specimens. Three-dimensional kinematics were determined with a magnetic tracking device. Results: With inversion force applied, calcanealtibial inversion was greatest in maximal plantarflexion (mean 22.1 ± 6.0 degrees) and gradually decreased with dorsiflexion, which indicated that the ankle had the most inversion instability in plantarflexion. With eversion force applied, calcaneal-tibial eversion gradually increased with increasing dorsiflexion to 12.7 ± 7.4 degrees indicating that the most eversion instability was in dorsiflexion. With internal rotation force applied, calcaneal-tibial internal rotation from plantarflexion to neutral ankle position increased. With external rotation force application, external rotation from neutral to maximal dorsiflexion increased. Conclusions: Ankle laxity was not constant but varied depending on the plantarflexion-dorsiflexion position and the direction of the applied force. The degree of ankle laxity was greater with inversion and internal rotation torque. Variation in laxity between specimens was observed, consistent with previous reports. These data indicate that the ankle is less stable in plantarflexion when inversion and internal rotation forces are applied. This may explain why the lateral ankle ligaments are most prone to injury in this position. The ankle was less stable in dorsiflexion when eversion and external rotation forces were applied. This is consistent with the observation that deltoid ligament injuries occur in the neutral to dorsiflexion position. The study demonstrates the importance of examining patients with suspected ankle ligament injuries in several ankle positions. The ankle testing device has potential application for in vivo testing of patients with suspected ankle ligament instability.

Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: A report of two cases

Two cases of insufficiency fracture of the body of the calcaneus are presented to show its clinical presentation and diagnosis. It often is overlooked as a cause of pain in the ankle region. Both patients were elderly women with pain developing at the lateral aspect of the hindfoot in the absence of significant trauma. Physical examination was significant for marked tenderness at the superolateral aspect of the calcaneus. These clinical features suggested the diagnosis, which was confirmed by radionuclide bone scan and magnetic resonance imaging. Magnetic resonance imaging was the diagnostic tool in both cases, after abnormal bone scans and normal plain radiographs. Radiologic alterations were not seen for up to 2 months after the onset of pain. Treatment consisted of rest and protected weightbearing for 8 weeks, with complete resolution of symptoms in both patients. An insufficiency fracture of the body of the calcaneus should be considered in a differential diagnosis of elderly patients with osteoporosis with spontaneous pain in the ankle region.