Il Hoon Sung

Mobility changes of the first ray after hallux valgus surgery: clinical results after proximal metatarsal chevron osteotomy and distal soft tissue procedure.

Background: The purpose of this study was to evaluate the change of the first ray mobility after PMCO and DSTP in hallux valgus patients. Materials and Methods: From May 2004 to December 2005, 82 PMCO with DSTP surgeries were performed for the management of hallux valgus deformity. The dorsiflexion mobility of the first ray of the foot was measured both preoperatively and 1 year after surgery using a modified Klaue device. The data were statistically analyzed with a paired t-test. An American Orthopedic Foot and Ankle Society (AOFAS) forefoot hallux score and patient satisfaction were also evaluated. Results: Subjects consisted of 9 male and 73 female patients with an average age of 47.7 years (range, 19 to 74 years). The mean preoperative dorsiflexion mobility was 6.8 (range, 2.32 to 15.02) mm and the mean dorsiflexion mobility at one year after operation was 3.2 (range, from 1.7 to 5.4) mm. This decrease was statistically significant (p < 0.01). The mean preoperative AOFAS forefoot hallux score was 66.2 (range, 44 to 90) and improved to 89.1 (range, 72 to 100) by the 1-year followup (p < 0.01). Conclusion: Clinically, the dorsiflexion mobility of the first ray was significantly reduced after correction of hallux valgus with PMCO with DSTP. Because the stability of the first ray can be improved with PMCO with DSTP, the surgical indication for this procedure could include some patients showing hypermobility of the first ray.

1,25-Dihydroxyvitamin D3 inhibits directly human osteoclastogenesis by down-regulation of the c-Fms and RANK expression.

OBJECTIVE 1,25-Dihydroxyvitamin D3 (1,25(OH)2D3) is a key molecule to maintain calcium homeostasis and bone metabolism. It was recently reported that 1,25(OH)2D3 directly inhibited osteoclast differentiation in mouse bone marrow cells and human bone marrow-derived colony-forming unit granulocyte macrophage (CFU-GM) cells. However, the direct effects of 1,25(OH)2D3 and its affecting mechanisms on the osteoclast differentiation of human osteoclast precursors remain largely unknown. In this study, we examined the direct effects of 1,25(OH)2D3 on the osteoclastogenesis of human peripheral blood (PB) osteoclast precursors. METHODS In vitro osteoclastogenesis assays were performed using osteoclast precursors from normal PB. The gene expressions were analyzed using real-time PCR. The cell surface proteins, including c-Fms and RANK, were measured by flow cytometry. RESULTS 1,25(OH)2D3 strongly inhibited osteoclast differentiation and it suppressed the expression of RANK in the human PB osteoclast precursors. One mechanism of RANK inhibition by 1,25(OH)2D3 is down-regulation of the M-CSF receptor c-Fms, which is required for the expression of RANK. In contrast to the previous reports on mouse osteoclast precursors, 1,25(OH)2D3 did not affect the expression of c-Fos. Parallel to the inhibition of osteoclastogenesis, 1,25(OH)2D3 increased the expression and phosphorylation of CCAAT enhancer-binding protein β (C/EBPβ), which is a recently discovered inhibitor of osteoclastogenesis. CONCLUSIONS Our results show that 1,25(OH)2D3 inhibits human osteoclastogenesis by decreasing the RANK+ osteoclast precursors, and we suggest that 1,25(OH)2D3 may be a powerful therapeutic agent for treating inflammation-induced bone disease that shows excessive osteoclast activation.

Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps.

Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm2 to 12 × 16 cm2, and the flaps from 3 × 5 cm2 to 10 × 15 cm2. Two cases were reconstructed using chimeric‐pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow‐up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super‐thin, allowing patients to wear shoes, and it can be harvested in a chimeric‐pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.

Is delayed reconstruction using the latissimus dorsi free flap a worthy option in the management of open IIIB tibial fractures

Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty‐three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7–22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3–12) months. Mean follow‐up period was 16.34 (range, 12–26) months. During follow‐up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage.

Effects of Beraprost Sodium on Subjective Symptoms in Diabetic Patients with Peripheral Arterial Disease

Background This study evaluated the effects of Beraprost sodium (Berasil) on subjective leg symptoms in patients with peripheral arterial disease caused by diabetes mellitus. Methods Ninety-four diabetic patients with peripheral arterial disease were treated with Beraprost in a fixed-dose, prospective, multicenter, cohort study. Beraprost (40 µg) was administered orally 3 times daily (120 µg/day) for 12 weeks. We developed a new disease-specific symptom questionnaire, which evaluated the effect of peripheral arterial disease on leg discomfort in daily life and assessed therapeutic responses to treatment. Patients were asked for their subjective assessment of symptoms on a written questionnaire before treatment and after 12 weeks of therapy. Results There was significant improvement in all estimated subjective symptoms (burning, coldness, edema, exertional pain, stabbing, and paresthesias) in the lower extremities at 12 weeks (p < 0.001). There were 18 patients with neuropathy in whom significant improvement was noted for 6 subjective symptoms at 12 weeks (p < 0.05). Adverse events considered to be drug-related were observed in 4 patients (4.3%), all of which were mild and resolved with discontinuation of the medication. Conclusions Beraprost is effective as a treatment for improving various subjective symptoms in the lower extremities, such as burning, coldness, edema, exertional pain, stabbing, and paresthesias, in diabetic patients with peripheral arterial disease.

Latissimus dorsi flap coverage of soft tissue defect following below-knee amputation: emphasis on flap design and recipient vessels

High-energy trauma to the lower extremity often results in amputation of the limb. For maximal preservation of limb length during amputation, free tissue transfer is often necessary. In this study, we report our experience of stump coverage using latissimus dorsi musculocutaneous flaps with an emphasis on flap design and recipient vessels. Between January 2005 and September 2010, twelve patients with severe traumatic injuries to the lower leg underwent below-knee amputations with stump coverage using latissimus dorsi free flaps. The primary and secondary cases were approached differently regarding the flap design and recipient vessels. All flaps survived completely. There were 8 primary cases and 4 secondary cases. In the primary cases, the anterior tibial artery was used as the recipient vessel in 6 cases, and in 2 cases, the descending geniculate artery was used. In the secondary cases, the descending geniculate artery was used in all cases. There were two cases of ulceration on the grafted non-weight-bearing site, but after the usage of collagen–elastin artificial dermis, no ulcerations were seen. The latissimus dorsi musculocutaneous flap is the most feasible option for coverage of amputation stumps. In flap design, the width of the skin paddle must match the anteroposterior diameter of the defect at the stump. The latissimus dorsi muscle must sufficiently wrap the bony stump for padding. We recommend using the anterior tibial artery as a recipient vessel in primary cases, and the descending geniculate artery in secondary cases.

Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps

Reconstruction of complicated diabetic lower leg and foot defects involving multiple tissue components remains a challenge. The purpose of this report is to introduce thoracodorsal artery perforator (TDAP) chimeric flaps for reconstructing diabetic lower leg and foot soft tissue defects.

Reconstruction of severe atherosclerotic and obstructive diabetic feet using thoracodorsal artery perforator flaps with long vascular pedicles

Foot ulcers in diabetic patients often require free flaps. A long vascular pedicle is mandatory so that more proximal vessels can be used as recipient vessels, especially when the flap is used to reconstruct distal foot defects. We evaluated the outcome of diabetic foot defect that were reconstructed using thoracodorsal artery perforator (TDAP) flaps with long vascular pedicles.

Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene

Symmetrical peripheral gangrene (SPG) is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP) free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44–69) years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC) level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6–54) months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.