Hyuk Jegal

Factors Associated With Recurrent Fifth Metatarsal Stress Fracture

Background: Many surgeons agree that fifth metatarsal stress fractures have a tendency toward delayed union, nonunion, and possibly refracture. Difficulty healing seems to be correlated with fracture classification. However, refracture sometimes occurs after low-grade fracture, even long after apparent resolution. Methods: The records of 168 consecutive cases of fifth metatarsal stress fracture (163 patients) treated by modified tension band wiring from March 2002 to June 2011 were evaluated retrospectively. Mean length of follow-up was 23.6 months (range, 10-112 months). Forty-nine cases classified as Torg III were bone grafted initially also. All enrolled patients were elite athletes. Eleven patients experienced nonunion and 18 refracture. The 11 nonunion cases were bone grafted. The 157 patients (excluding nonunion cases) were allocated to either a refracture group or a union group. Clinical features, such as age, weight, fracture classification, time to union, and reinjury history, were compared. Radiological parameters representing cavus deformity and fifth metatarsal head protrusion were compared to evaluate the influence of structural abnormalities. Results: Mean group weights were significantly different (P = .041), but mean ages (P = .879), fracture grades (P = .216, P = .962), and time from surgery to rehabilitation (P = .539) were similar. No significant intergroup differences were found for talocalcaneal (TC) angle (P = .470), calcaneal pitch (CP) angle (P = .847), or talo–first metatarsal (T-MT1) angle (P = .407) on lateral radiographs; for fifth metatarsal lateral deviation (MT5-LD) angle (P = .623) on anteroposterior (AP) radiographs; or for MT5-LD angle (P = .065) on the 30-degree medial oblique radiographs. However, the mean fourth-fifth intermetatarsal (IMA4-5) angle on AP radiographs was significantly greater in the refracture group, and for Torg II cases, mean weight (P = .042), IMA4-5 angle on AP radiographs (P = .014), and MT5-LD angle (P = .043) on 30-degree medial oblique radiographs were significantly greater in the refracture group. For B2 cases (incomplete fracture and a plantar gap of 1 mm or larger), mean weight (P = .046), IMA4-5 angle on AP radiographs (P = .019), and MT5-LD angle (P = .045) on 30-degree medial oblique radiographs were significantly greater in the refracture group. All cases of refracture had a traumatic history after bone union. Refracture developed within 6 months of starting rehabilitation in 13 cases and within 3 months in 8 cases. Conclusion: The development of refracture after the surgical treatment of fifth metatarsal stress fractures was found to be associated with higher body mass index (BMI) and with radiological parameters (IMA4-5 on AP radiographs, MT5-LD on oblique radiographs) associated with protrusion of the fifth metatarsal head. The study indicates that patients with a protruding fifth metatarsal head and a high BMI should approach rehabilitation with care before considering a return to previous sporting activity levels. Level of Evidence: Level III, retrospective comparative series.

Deceptions in Hallux Valgus: What to Look for to Limit Failures

The treatment of hallux valgus depends on multiple factors, including clinical examination, patient considerations, clinical findings, radiographic assessment, and surgeon preference. Appropriate procedure selection and proper technique will usually result in good-to-excellent outcomes. Complications following hallux valgus correction include recurrence, transfer metatarsalgia, avascular necrosis, hallux varus, and nonunion and malunion of metatarsal osteotomies. In order to decrease the risks of complication, a precise and meticulous physical examination should be conducted preoperatively. In addition, a surgeon should select appropriate osteotomies to correct complex hallux valgus deformities. As a general principle, the severity of deformity dictates treatment options.

Long-Term Results of Neurectomy in the Treatment of Morton’s Neuroma More Than 10 Years’ Follow-up

Purpose. The objective of this retrospective study was to evaluate the long-term follow-up results of neurectomy clinical outcomes and complications in the treatment of Morton’s neuroma. Materials and methods. A total of 19 patients (19 different feet) were treated for Morton’s neuroma by excision of the interdigital nerve at our institute between May 1997 and May 1999. Thirteen (13 feet) of them were followed up. The 13 patients were female and had an average age of 43 years (range 34-54 years) at the time of the operation. The patients were followed-up for a mean of 10.5 years (range 10.0-12.2 years) and scored using the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot scoring system and Visual Analogue Scale (VAS) score. Subjective satisfaction was evaluated at the final follow-up. Results. Eight patients scored more than 90 on the AOFAS forefoot scoring system. The VAS score was improved in all patients. The mean preoperative VAS score was 8.6 ± 0.8 cm (7-10) and the mean follow-up VAS score was 2.4 ± 1.8cm (0-6), which indicated no significant difference (P > .05). The final follow-up satisfaction results indicated that 4 patients were completely satisfied with the operation, 4 were satisfied with minor reservations, 5 were satisfied with major reservations, and no patient was unsatisfied. Neurectomy to treat Morton’s neuroma had a good satisfaction rate (61%). Eleven of the patients complained of numbness on the plantar aspect of the foot adjacent to the interspace, and 2 of these 11 patients complained of disability induced by severe numbness. There was a complaint of residual pain by 1 patient. There were no skin problems on the operation lesions. Conclusion. The long-term results of neurectomy clinical outcomes in Morton’s neuroma are slightly worse than the short- and mid-term results. Levels of Evidence: Therapeutic, Level IV, Retrospective case series

Prognostic classification of fifth metatarsal stress fracture using plantar gap.

Background: There have been diverse results even in same Torg type of fifth metatarsal stress fractures. Methods: Eighty-six cases with a fifth metatarsal stress fracture that were treated with modified tension band wiring from January 2003 to May 2009 were evaluated retrospectively. Each case was classified according to Torg’s classification and a new classification. Using the new proposed classification, cases were subdivided into complete fracture and incomplete fracture. The cases of incomplete fracture were subdivided based on presence or absence of plantar gap more than 1 mm. After surgery, bone union was determined by CT. Statistical analysis of the Torg classification and time for bone union as well as the proposed new classification and time for bone union was performed. Results: There was a significant difference in the time for bone union among the three Torg types (P = 0.004). The mean time for bone union in group A (complete fracture, n = 32) was 67.5 ± 28.8, and it was 103.2 ± 47.7 for group B (incomplete fracture, n = 54). There was a significant difference in time for bone union between them (P < 0.001). The mean time for bone union in group B1 (incomplete fracture, plantar gap less than 1 mm, n = 16) was 73.9 ± 26.7, and it was 115.5 ± 45.4 for group B2 (incomplete fracture, plantar gap 1 mm or more, n = 38). There was a significant difference in time for bone union between them (P < 0.001). Conclusion: The results of this study suggest that the classification incorporating the plantar gap might be used for classification of fifth metatarsal stress fractures. Level of Evidence: Level III, retrospective comparative series.

Unilateral Hallux Valgus Is It True Unilaterality, or Does It Progress to Bilateral Deformity?

Background: This study was undertaken to determine whether unilateral hallux valgus progresses unilaterally and to evaluate the demographics, etiologies, and radiographic findings associated with symptomatic unilateral hallux valgus deformities. Methods: Patients treated for hallux valgus between January 2004 and December 2008 were identified, and of these, 33 patients with unilateral deformities were enrolled. Progression of deformities in normal feet were evaluated at last follow-up visit, and the clinical information and radiographic measurements of those with a deformed normal foot or an unchanged normal foot were compared. Results: Thirty-three patients (3.4%) had a unilateral hallux valgus deformity on preoperative radiographs. The mean length of follow up was 4.7 years (range, 2.4-11). Twenty-four cases had no deformity of the normal foot at last follow-up (the unchanged group), but 15 cases had developed hallux valgus deformity (the deformed group). No significant intergroup differences were found in terms of metatarsus adductus angle (P = .412), Meary angle (P = .771), talocalcaneal angle (P = 1.000), or calcaneal pitch angle (P = .267). However, members of the deformed group were significantly younger at disease onset (P = .045), exhibited a curved first metatarsal head (P = .046), and had a larger initial hallux valgus angle (P < .001). Conclusions: The frequency of bilateral symptomatic hallux valgus was found to be over 97.3%, and significant differences were found between the deformed and unchanged groups in terms of age of onset, metatarsal head shape, and hallux valgus angle. Level of Evidence: Level III, case-control study.

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.

Accessory Navicular Syndrome in Athlete vs General Population

Background: Symptomatic accessory navicular syndrome (ANS) typically develops in young athletes. The symptoms are exacerbated during exercise or while walking, affecting the sports performance of athletes. The purpose of this study was to evaluate the radiologic findings and clinical course in athletes with accessory navicular syndrome (ANS) in comparison with a nonathletic population. Methods: Seventy-nine patients with ANS between August 2012 and August 2013 were included. Overall, 29 were athletes and 50 were not athletes, and 19 (2 athletes and 17 nonathletes) of them improved after at least 6 months of conservative treatment. The records of 60 patients (64 consecutive feet) of ANS treated by modified Kidner operation were evaluated retrospectively. The study population included 27 athletes (31 feet) and 33 nonathletes (33 feet). Clinical features and radiologic findings were compared between them. Results: Overall, 34% of the nonathletes improved after conservative treatment, but only 6.9% of athletes improved (P < .001). Mean age at surgery in the athlete group was 16.1 years (range, 12-26), and 24.3 years (range, 12-52) in the nonathlete group (P < .001). There was a history of trauma in 23 feet (74%) of the athlete group and in 13 feet (39%) of the nonathlete group (P = .006). Eighteen feet (58%) in the athlete group and 11 feet (32%) in the nonathlete group showed movement between the 2 bones (P = .047). Bone marrow edema was observed in both navicular and accessory navicular in all of the athletes (27/27, 100%). But it was only present in 80% (16/20) for nonathletes (P = .012). Conclusion: The radiologic findings and clinical course of athletes were different from that of the general population. Their symptoms were more refractory to conservative treatment than the nonathletes group. Therefore, early operative treatment could be considered in cases of symptomatic ANS especially for athletes. Level of Evidence: Level III, retrospective comparative case series.

The Mobility Total Ankle Replacement:Techniques and Pitfalls

The Mobility total ankle replacement (DePuy, Leeds, United Kingdom) is an uncemented, 3-component, mobile-bearing design. This article highlights the design rationale and explains the surgical technique with the Mobility implant, as well as offering technical tips and pitfalls gained through personal experiences and literature review. The tibial component has a flat articular surface and a conical intramedullary stem on the tibial side.

Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

Category: Ankle, Trauma Introduction/Purpose: Isolated Lateral malleolus fracture, like any other fractures can be treated by operative or conservative treatment. Stability of ankle joint is the most important factor in deciding the type of treatment. Unstable ankle joints present superior clinical outcomes with surgical management. There are many methods to assess the stability of ankle joint such as plain x- ray films, stress radiographies and physical examination. Many studies have suggested the usage of ultrasound for diagnosis of ankle ligament injury. But, there are no reports about its use for stability assessment of isolated lateral malleolar ankle fracture. Therefore, the purpose of this study is to evaluate the value of ultrasound for stability assessment of isolated lateral malleolar fractures, compared to simple x-ray, stress radiography and arthroscopy. Methods: We have conducted a prospective study which included 13 consecutive patients who underwent arthroscopic exam and subsequent open reduction and internal fixation for isolated lateral malleolar ankle fracture. Before operation simple x-ray, external rotation stress radiographs were done. Stress ultrasound was performed to assess the anterior inferior tibiofibular ligament (AITFL) and medial deltoid ligament prior to operation. The arthroscopic findings were used as the reference standard. A standardized physical examination (tenderness and ecchymosis, external rotation stress test), simple radiography, stress radiography and ultrasound images were compared to assess the stability. Results: Deltoid ligament injury and or syndesmosis injury were verified arthroscopically in 12 cases with a clinical diagnosis (92.3%). There were 9 cases who showed unstable ankle fracture on the simple radiography. (69.2%). There were all cases who showed unstable ankle fracture on the external rotation stress radiography. (100%) In addition, for 12/13, there were acute tear of the deltoid ligament or AITFL injury on the ultrasound (92.3%). Conclusion: The results suggest that ultrasound could be used for the assessment of the instability of isolated lateral malleolar fracture.

Osteoarthritis of the second metatarsophalangeal joint associated with hallux valgus deformity.

Background: Hallux valgus is speculated to increase the load on the second metatarsophalangeal (MTP) joint, possibly inducing degenerative osteoarthritis. In addition, the severity of arthritis may be correlated with the severity of hallux valgus. This study evaluated the association of arthritis of the second MTP joint in hallux valgus patients and the relationship between arthritis of the second MTP joint and hallux valgus deformity. Methods: A total of 382 patients (509 feet) underwent surgery for symptomatic hallux valgus deformities by the 2 senior authors (KTL, YUP) from November 2011 to December 2012. A total of 54 patients (61 feet), all female, were included in the osteoarthritis (OA) group. The rest were assigned to the nonosteoarthritis (NOA) group. There were 328 patients (448 feet) consisting of 16 men and 432 women. Osteoarthritis patients were then evaluated and classified according to joint space narrowing (JSN) and osteophyte (OP) formation. A statistical analysis was conducted to compare the 2 groups in terms of their hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), hypermobility of the first metatarsal ray, the length of the second metatarsal bone, and the length ratio of the first and second metatarsal bones. Correlation coefficients were calculated to compare the severity of hallux valgus and the degree of osteoarthritis of the second MTP joint. Results: The IMA of the OA group was 16.2 ± 2.9 degrees, and that of the NOA group was 15.4 ± 3.3 degrees (P = .034, Mann-Whitney U test). The DMAA of the OA group was 18.2 ± 8.3 degrees, and that of the NOA group was 16.1 ± 8.0 degrees (P = .029, Mann-Whitney U test). There were no significant differences between the 2 groups in terms of the HVA, hypermobility, the length of the second metatarsal bone, and the length ratio of the second and first metatarsal bones. In the OA group, there was a positive correlation between the HVA and the degree of osteoarthritis (osteophyte formation) (ɣ = 0.278, P = .030). In addition, there was a positive correlation between the IMA and the degree of osteoarthritis (ɣ = 0.284 [JSN], 0.327 [OP] for the HVA, P = .026 [JSN], .010 [OP]). However, there was no significant difference between hypermobility and the degree of osteoarthritis (P = .356 [JSN], .635 [OP], Mann-Whitney U test). Furthermore, there were no positive correlations between the DMAA, the length of the second metatarsal bone, and the metatarsal length ratio. Conclusion: Our study demonstrated a positive correlation between HVA, IMA, and osteoarthritis of the second MTP joint. Other studies will be needed to determine the factors that are responsible for this correlation. Level of Evidence: Level III, retrospective comparative series.