Hyong Nyun Kim

Modified Broström Procedure for Chronic Ankle Instability With Generalized Joint Hypermobility.

Background: Chronic ankle instability with generalized joint hypermobility (GJH) is considered a contraindication for the modified Broström procedure. The most widely accepted definition of GJH is a Beighton score of ≥4 on a 9-point scale. However, it is not clear whether this criterion can be applied to determine the GJH that would lead to a poor outcome after a modified Broström procedure. Some of the previous studies that report unfavorable outcomes do not specify the tests or cutoff scores used to determine the GJH, and, in fact, some of the patients with GJH in these studies had good outcomes. Hypothesis: The modified Broström procedure results in satisfactory outcomes in patients who have chronic ankle instability with GJH if the contralateral uninjured ankle shows a normal varus talar tilt and anterior talar translation during stress tests. Study Design: Case series; Level of evidence, 4. Methods: Modified Broström procedure was performed in 32 patients with chronic ankle instability with GJH if the contralateral uninjured ankle showed a normal varus talar tilt and anterior talar translation on stress tests. The mean patient age at surgery was 21.7 years, and the mean follow-up duration was 27.4 months. Results: The Karlsson-Peterson ankle score significantly improved from a mean ± SD of 63.6 ± 7.1 preoperatively to 90.4 ± 6.7 at the final postoperative follow-up (P < .001). Sixteen patients were very satisfied with the results, 10 patients were satisfied, 3 patients rated their satisfaction as fair, and 1 patient was dissatisfied with the results. Nine patients sustained ankle sprains after the surgery, 6 of which were mild sprains. Although 3 of these 9 patients had a mechanically unstable ankle on stress radiographs, they were satisfied with the postoperative results. None of the patients required a reoperation. Conclusion: GJH was not a contraindication for the modified Broström procedure if the contralateral uninjured ankle showed a normal varus talar tilt and a normal anterior talar translation on stress tests. Further studies are needed to better define GJH affecting the ankle.

Use of a real-size 3D-printed model as a preoperative and intraoperative tool for minimally invasive plating of comminuted midshaft clavicle fractures

AbstractBackgroundOpen reduction and plate fixation is the standard operative treatment for displaced midshaft clavicle fracture. However, sometimes it is difficult to achieve anatomic reduction by open reduction technique in cases with comminution.MethodsWe describe a novel technique using a real-size three dimensionally (3D)-printed clavicle model as a preoperative and intraoperative tool for minimally invasive plating of displaced comminuted midshaft clavicle fractures. A computed tomography (CT) scan is taken of both clavicles in patients with a unilateral displaced comminuted midshaft clavicle fracture. Both clavicles are 3D printed into a real-size clavicle model. Using the mirror imaging technique, the uninjured side clavicle is 3D printed into the opposite side model to produce a suitable replica of the fractured side clavicle pre-injury.ResultsThe 3D-printed fractured clavicle model allows the surgeon to observe and manipulate accurate anatomical replicas of the fractured bone to assist in fracture reduction prior to surgery. The 3D-printed uninjured clavicle model can be utilized as a template to select the anatomically precontoured locking plate which best fits the model. The plate can be inserted through a small incision and fixed with locking screws without exposing the fracture site. Seven comminuted clavicle fractures treated with this technique achieved good bone union.ConclusionsThis technique can be used for a unilateral displaced comminuted midshaft clavicle fracture when it is difficult to achieve anatomic reduction by open reduction technique. Level of evidence V.

Percutaneous lateral ankle ligament reconstruction using a split peroneus longus tendon free graft: technical tip.

Several percutaneous lateral ankle ligament reconstruction techniques have been introduced for the treatment of chronic lateral ankle instability with local ligamentous tissue so severely attenuated or deficient that direct repair would be expected to have a poor outcome. Percutaneous Chrisman-Snook lateral ankle ligament reconstruction using half of the peroneus brevis tendon has been introduced. However, disturbing the peroneus brevis, the primary evertor and dynamic lateral ankle stabilizer, can be a drawback. An allograft tendon can be used in percutaneous reconstruction. However, the associated high cost and possibility of an immunogenic response is a concern. A minimally invasive lateral ankle ligament reconstruction technique using a semitendinosus autograft was recently introduced. However, harvesting the semitendinosus tendon may not be easy for foot and ankle surgeons who are not familiar with the knee anatomy. Precutting of the tendon can occur because of the juncturae connected to the tendon. Inadvertent saphenous nerve injury during the harvesting procedures may result in numbness around the harvest site. We developed a technique using a split half of the peroneus longus tendon as a free autograft for the percutaneous lateral ankle ligament reconstruction. The free graft can be easily harvested from 1 of the percutaneous incisions for reconstruction in the same position as that of the ligament reconstruction. The percutaneous technique offers better cosmesis with less scarring than a standard open procedure.

Modified Broström Procedure for Chronic Ankle Instability with Generalized Joint Hypermobility

Category: Sports Introduction/Purpose: Chronic ankle instability with generalized joint hypermobility (GJH) is considered a contraindication for the modified Broström procedure. The most widely accepted definition of GJH is a Beighton-Horan score of ≥4 on a 9-point scale. However, it is not clear if this criterion can be applied to determine the GJH that would lead to a poor outcome after the modified Broström procedure. Methods: The modified Broström procedure was performed in 32 patients with chronic ankle instability with GJH, if the contralateral uninjured ankle showed a normal varus talar tilt and anterior talar translation during the stress tests. We hypothesized that when the contralateral uninjured ankle shows a normal varus talar tilt and anterior talar translation during stress tests in patients with GJH, GJH may have a smaller effect on the ankle ligaments, and the modified Broström procedure in these cases may have satisfactory outcomes. The mean patient age at surgery was 21.7 years. The mean follow-up duration was 27.4 months. Results: The Karlsson-Peterson ankle score significantly improved from 63.6 ± 7.1 points (p< 0.001; 95% CI, 22.1 – 29.7) preoperatively to 90.4 ± 6.7 points at the final postoperative follow-up. Sixteen patients were very satisfied with the results, 10 patients were satisfied, 3 patients rated their satisfaction as fair, and 1 patient was dissatisfied with the results. We stratified the clinical outcomes according to the Beighton scores. There was no correlation between the Beighton scores and the Karlsson- Peterson ankle scores at the last follow-up (Spearman’s correlation coefficient, -0.11; p= 0.591). However, 1 patient with a Beighton score of 8 points and 1 patient with a score of 9 points had lower Karlsson-Peterson ankle scores (82 and 85, respectively) compared to the average scores at the last follow-up. Conclusion: The modified Broström procedure was successful in patients with chronic ankle instability with GJH, if the contralateral uninjured ankle showed a normal varustalar tilt and anterior talar translation during the stress tests. The repaired ligaments may eventually stretch out in patients with GJH secondary to connective tissue disorders such as Marfan syndrome as these patients have been found to have inherent connective tissue extensibility. However, GJH includes mild joint hypermobility without any symptoms or problems except increased joint range of motion. When the contralateral normal ankle shows negative stress tests that the modified Broström procedure may be successful.

Fixation of a Posteromedial Osteochondral Lesion of the Talus Using a Three-Portal Posterior Arthroscopic Technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.

Subtalar Arthroscopy with Calcaneal Skeletal Traction in a Hanging Position

Several arthroscopic approaches to the subtalar joint have been developed in the supine, lateral, or prone position. However, it is difficult to use the posteromedial portal with the patient in the supine or lateral position and the anterolateral portal with the patient prone. Furthermore, obtaining joint distraction in the lateral or prone position is difficult. We present a technique that enables the combination of 2 posterior portals and lateral portals to the subtalar joint with calcaneal skeletal traction in a hanging position for better visualization and instrumentation of the joint.

Arthroscopic Ankle Arthrodesis with Intra-articular Distraction

Arthroscopic ankle arthrodesis has shown high rates of union comparable to those with open arthrodesis but with substantially less postoperative morbidity, shorter operative times, less blood loss, and shorter hospital stays. To easily perform arthroscopic resection of the articular cartilage, sufficient distraction of the joint is necessary to insert the arthroscope and instruments. However, sometimes, standard noninvasive ankle distraction will not be sufficient in post-traumatic ankle arthritis, with the development of arthrofibrosis and joint contracture after severe ankle trauma. In the present report, we describe a technique to distract the ankle joint by inserting a 4.6-mm stainless steel cannula with a blunt trocar inside the joint. The cannula allowed sufficient intra-articular distraction, and, at the same time, a 4.0-mm arthroscope can be inserted through the cannula to view the joint. Screws can be inserted to fix the joint under fluoroscopic guidance without changing the patients position or removing the noninvasive distraction device and leg holder, which are often necessary during standard arthroscopic arthrodesis with noninvasive distraction.

Elastic Bandage Traction Technique for Reduction of Distal Tibial Fractures

In the present technique report, we describe a useful noninvasive traction technique that uses a 6-inch elastic bandage that can be obtained in every operating room and can be easily applied around the patients ankle and the surgeons waist to offer a stable traction force during minimally invasive plate fixation of distal tibial fractures. This technique frees the surgeons hands to focus on applying other forces, such as rotational, varus, or valgus forces, to reduce the fracture and stabilize the reduction and alignment during percutaneous insertion and fixation of the plate. This technique, although simplistic and old-fashioned, is also useful for the closed reduction of distal tibial physeal injuries in children, because it can provide a significant amount of traction force while allowing the surgeon to apply other forces for fracture reduction. This technique can be used in the emergency room, where an ankle distractor is not usually present, and in some cases could be useful during ankle arthroscopy.

Fibular Lengthening Using the Elongated Combi-hole of a Locking Compression Plate: Technical Tip.

Fibular shortening and rotational malunion may occur after the operative or nonoperative treatment of ankle fractures. A malunited fracture with fibular shortening and lateral talus shift portends a poor outcome, with pain, swelling, or stiffness often leading to degenerative arthritis. Biomechanical studies have shown that symptoms arise because of increased ankle joint contact pressure resulting from distal fibular displacement and shortening of 2 mm or external rotation of 5 degrees or more. Several techniques have been introduced for lateral malleolar reconstruction, including transverse, oblique, and Z-osteotomy. Transverse osteotomy with bone grafting and internal fixation has been shown to effectively treat fibular shortening. An AO distractor can be used to distract the osteotomy and thus achieve the correct fibular length. After fibular osteotomy, a plate is applied to the distal fibular fragment; one arm of the distractor hooks into the proximal end of the plate, and the other arm is applied to a temporary screw inserted proximal to the plate for distraction. However, this technique requires proximal extension of the incision and exposure for temporary screw placement. This technique requires a special device (AO distractor) that may not be available in some operation rooms. Although a laminar spreader can be used, it can only be used for a transverse osteotomy (not oblique or Z-osteotomy), and it may sometimes be difficult to impact a strut bone graft into the gap when the laminar spreader is positioned in the gap to maintain the distraction. Fibular plate application may not be straightforward when a laminar spreader is placed. Fibular lengthening with a uniplanar external fixator for distraction osteogenesis has been reported. However, the main disadvantage of this technique is the required lengthy external fixation period. Another surgery may be needed to apply a plate for additional stability after external fixator removal because the newly formed bone might fracture. In this article, we describe a novel technique that uses the oblong hole of a locking plate for fibular lengthening and does not require a special device. This technique is straightforward and allows easy control of osteotomy distraction and compression. This technique can also be used during minimally invasive plate osteosynthesis for a shortened and comminuted lateral malleolus fracture to restore the fibular length without opening the fracture site.

Prevention of cavus foot deformity following gradual distraction osteogenesis for first brachymetatarsia--technique tip.

Brachymetatarsia, a rare foot deformity, can be congential or acquired in origin and is defined as an abnormal shortening of the metatarsal bone. This shortening is caused by a premature fusion of the metatarsal epiphysis. Gradual distraction osteogenesis, which allows lengthening of the metatarsal while giving adequate time for the soft tissue to adapt to the lengthened bone, is most widely used for operative correction of brachymetatarsia. However, several complications have been reported following distraction osteogenesis for first brachymetatarsia. Oh et al reported cavus foot deformity as a major complication in 4 of 13 first metatarsal lengthenings. Normally, the first metatarsal has approximately 30 degrees of metatarsal inclination in the sagittal plane. However, the short first metatarsal in first brachymetatarsia usually has an increased inclination angle, and its head is situated at a similar level as that of the second metatarsal head in the sagittal plane, maintaining a plantigrade foot (Figure 1). Therefore, when the first metatarsal is lengthened along its longitudinal axis, the first metatarsal head will project downward under the plantar surface of the foot resulting in a cavus foot deformity. This may result in excessive load and pain in the plantar area of the first metatarsal head. Some authors have suggested the use of horizontal distraction in the anterior direction rather than lengthening through the anatomical axis. However, this requires insertion of external fixator pins into the first metatarsal parallel to the plantar surface of the foot, which is difficult in a short and inclined first metatarsal (Figure 1). The short first metatarsal with an increased inclination angle may not accept the most distal pin in a horizontal direction parallel to the plantar surface of the foot or the dorsal cortex of the metatarsal head may break during lengthening (Figure 1). In this article, we describe a technique that corrects the increased inclination angle of the short metatarsal before the lengthening. This allows insertion of 4 pins at the center of the first metatarsal and lengthening along the longitudinal axis without subsequent plantar projection of the first metatarsal head and subsequent development of cavus deformity of the foot.