J-Young Kim

Biomechanical evaluation against calcaneofibular ligament repair in the Brostrom procedure: a cadaveric study.

The modified Brostrom procedure is commonly recommended for reconstruction of the anterior talofibular ligament (ATF) and calcaneofibular ligament (CF) with an advancement of the inferior retinaculum. However, some surgeons perform the modified Bostrom procedure with an semi-single ATF ligament reconstruction and advancement of the inferior retinaculum for simplicity. This study evaluated the initial stability of the modified Brostrom procedure and compared a two ligaments (ATF + CF) reconstruction group with a semi-single ligament (ATF) reconstruction group. Sixteen paired fresh frozen cadaveric ankle joints were used in this study. The ankle joint laxity was measured on the plane radiographs with 150 N anterior drawer force and 150 N varus stress force. The anterior displacement distances and varus tilt angles were measured before and after cutting the ATF and CF ligaments. A two ligaments (ATF + CF) reconstruction with an advancement of the inferior retinaculum was performed on eight left cadaveric ankles, and an semi-single ligament (ATF) reconstruction with an advancement of the inferior retinaculum was performed on eight right cadaveric ankles. The ankle instability was rechecked after surgery. The decreases in instability of the ankle after surgery were measured and the difference in the decrease was compared using a Mann–Whitney U test. The mean decreases in anterior displacement were 3.4 and 4.0 mm in the two ligaments reconstruction and semi-single ligament reconstruction groups, respectively. There was no significant difference between the two groups (P = 0.489). The mean decreases in the varus tilt angle in the two ligaments reconstruction and semi-single ligament reconstruction groups were 12.6° and 12.2°, respectively. There was no significant difference between the two groups (P = 0.399). In this cadaveric study, a substantial level of initial stability can be obtained using an anatomical reconstruction of the anterior talofibular ligament only and reinforcement with the inferior retinaculum. The modified Brostrom procedure with a semi-single ligament (Anterior talofibular ligament) reconstruction with an advancement of the inferior retinaculum can provide as much initial stability as the two ligaments (Anterior talofibular ligament and calcaneofibular ligament) reconstruction procedure.

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.

Factors influencing result of autologous chondrocyte implantation in osteochondral lesion of the talus using second look arthroscopy

This study is to know the factors that may affect cartilage repair after autologous chondrocyte implantation (ACI) for the treatment of an osteochondral lesion of the talus (OLT) as seen through a second look arthroscopy. A total of 38 patients who had ACI treatment for OLT underwent a second look arthroscopy 1 year after the ACI operation. A modified magnetic resonance observation of cartilage repair tissue (MOCART) scoring system was used to assess the outcome of the repaired cartilage. Influencing factors were sex, accompanied procedure, location, site, depth, pre‐operative AOFAS score, size and age. Factors that may affect cartilage repair after ACI treatment for OLT were evaluated. Of the different factors assessed, sex (P=0.75), accompanied procedure (P=0.50), depth (P=0.08), location (P=0.54), site (P=0.50) and pre‐operative AOFAS score (P=0.42) were found not to affect cartilage repair after ACI treatment for OLT. The size of the lesion (P=0.0021) and patients age (P=0.01) were the influential factors. As a result, factors affecting repaired cartilage formation after ACI of OLT were found through the second look arthroscopy. It was determined that not all of the factors affecting the clinical outcome after ACI for the repair of an OLT affected cartilage repair after ACI.

An Anatomical Study of Morton's Interdigital Neuroma: The Relationship Between the Occurring Site and the Deep Transverse Metatarsal Ligament (DTML)

Background: Using clinical and cadaver studies, we examined the relationship between the location of Morton interdigital neuromas and the surrounding structures, including the deep transverse metatarsal ligament (DTML), which has been suspected as a major causative factor in neuroma formation. Methods: Seventeen fresh-frozen cadavers were evaluated to determine the relationship between the location of Morton interdigital neuromas and the DTML at two phases of the gait cycle with 60 degrees of metatarsophalangeal dorsiflexion and with 15 degrees of ankle dorsiflexion. We measured the distance from the bifurcation of the common digital nerve in the foot to the anterior margin of the DTML and also measured the length of the DTML itself. Clinically, we checked the location of the Morton interdigital neuroma and its length during surgery in 32 feet. Results: In the second and third webspace, the mean distance from the bifurcation of the common digital nerve of the foot to the anterior margin of the DTML was 16.7 mm, 15.1 mm in the mid-stance position, and 15.9 mm and 14.6 mm in the heel-off position. The length of the second and third DTML averaged 12.8 mm and 10.6 mm. Clinically, all of the cases of Morton interdigital neuroma started at the bifurcation area of the common digital nerve, and the mean neuroma length was 7.5 mm (6 to 11). Conclusions: Morton interdigital neuromas were located more distally than the DTML in both the mid-stance and the heel-off stage during walking. The main lesion was located between the metatarsal head and the metatarsophalangeal joint and more distal than the DTML, questioning previous studies suggesting that the DTML is the major causative factor in development of Morton interdigital neuroma.

Modified Resection Arthroplasty for Infected Non-healing Ulcers with Toe Deformity in Diabetic Patients:

Background: Diabetic motor neuropathy is expressed as the loss of function and the contracture of the intrinsic muscles of the foot, leading to the classic claw toe deformity. This deformity predisposes the foot to ulcerations on the dorsum or tip of the toes or an interdigital ulcer over a condyle between the toes. We present our results of a modified resection arthroplasty for the treatment of this difficult problem. Materials and Methods: In this study, 72 toes (57 feet) with a deformity in the second to fifth toe accompanied by chronically infected ulcers were involved. All patients underwent modified resection arthroplasty of the PIP or DIP joint depending on the ulcer location. The second toe was involved in 27 cases (38%), the third toe in 11 cases (15%), the fourth toe in 19 cases (26%), and the fifth toe in 15 cases (21%). With the exception of 4 patients, all had a positive culture, including 7 cases of MRSA. The mean followup was 28.7 ± 8.1 months. Results: The mean wound healing time was 25.6 ± 6.2 days. Three cases eventually required toe amputation but there was no proximal spread of infection. No recurrence of a claw toe or ulcer occurred in the remaining toes. Conclusion: We believe that modified resection arthroplasty for toe deformities with chronic infected ulcers in diabetic patients is a good treatment alternative to toe amputation.

A Simpler Device for Measuring the Mobility of the First Ray of the Foot

Background: Since some devices can be cumbersome to use, we evaluated the validity and reliability of a specially designed device for easily checking the mobility of the first ray of the foot. Materials and Methods: To analyze the validity of the device, the dorsal mobility of the first ray of the foot was measured with the modified Coleman block test developed by Fritz et al., the Klaue device, and the custom device. Two-tailed Students paired t-test and Pearson correlation were used to compare the values of the two tests. For evaluation of inter- and intra observer reliability of the EMC device, 3 independent observers measured the dorsal mobility of the first ray of the foot twice. The results were analyzed with two-tailed Students paired t-test and ANOVA to evaluate intraobserver and interobserver reliability, respectively. Results: For both the first and second examinations of reliability, the difference between the two values was significant (p < 0.05) for the Coleman block test but not significant (p = 0.118) in comparison with the Klaue device. The measurements from both examinations showed good correlation (Pearson correlation coefficient: comparison with the Coleman block test = 0.84 (p < 0.05), with the Klaue device = 0.92 (p < 0.05)). The paired t-test for intraobserver validity showed no statistically significant difference among observers (p = 0.52, 0.58, 0.96, Pearson correlation coefficient = 0.76, 0.79, 0.80), and ANOVA testing for interobserver reliability showed no significant difference either (p = 0. 96, Pearson correlation coefficients = 0.83, 0.84, and 0.86, respectively). Conclusion: This study demonstrated that the EMC device is both reliable and valid for measuring the mobility of the first ray of the foot.

Treatment of Symptomatic Incurved Toenail with A New Device

Background: The purpose of this study was to report our results treating symptomatic incurved toenail with a K-D® (S&C Biotech, Seoul, South Korea) device. Materials and Methods: Between October 2007 and March 2008, 19 patients (31 cases) underwent treatment of symptomatic incurved toenails with a K-D®. The mean age of the patients involved was 38.8 ± 12.4 years. The mean period of time at last followup was 13.3 ± 4.9 months. An American Orthopedic Foot and Ankle Society (AOFAS) forefoot hallux score was assigned, and patients were evaluated at pretreatment and the last followup period. Patient satisfaction and the recurrence rate of the deformity were evaluated. For evaluation of improvement in toenail shape, the center to edge angle of the toenail was measured at pretreatment and last followup. The complication rate was also evaluated. Results: All ingrown toenails healed and the nail deformity was corrected within 3 weeks after the procedure. Among the 31 cases, only two cases of incurved toenails recurred on last followup (6% recurrence rate). The mean pretreatment AOFAS forefoot hallux score was 71.1 ± 13.9 and improved to 100 by the last followup (p < 0.001). Every patient was very satisfied or satisfied with the results of treatment including the two cases of recurrence. The mean center to edge angle of the toenail improved from 51.1 ± 9.5 degrees to 18.4 ± 5.2 degrees by the last followup (p < 0.001). Minor paronychia, which were managed with local wound dressing and oral antibiotics, were identified in seven cases. No other complication associated with the K-D® were identified. Conclusion: The management of an incurved toenail with the K-D® was an effective and safe treatment method for patients having symptomatic incurved toenail deformity. Level of Evidence: IV, Case Series

FHL Tendon Transfer in Diabetics for Treatment of Non-Healing Plantar Heel Ulcers

Background: In diabetics, although heel ulcers occurring after Achilles tendon lengthening for managing forefoot ulcers are rare, they are a very troublesome complication. The purpose of this study was to evaluate the results of FHL tendon transfer for management of a plantar heel ulcer as a sequelae of insufficiency of the Achilles tendon in diabetic patients. Materials and Methods: Nine diabetic patients who underwent FHL tendon transfer for treatment of non-healing plantar heel ulcers due to insufficiency of the Achilles tendon for management of forefoot ulcers were treated between October 2005 and April 2007. All of the patients had undergone Achilles tendon lengthening with Hokes triple hemisection method. The mean age was 55.9 ± 9.7 years old. The average duration of a plantar heel ulcer was 11.9 ± 3.8 months. The mean period of followup was 23.9 ± 8.0 months. Between the occurrence of a heel ulcer and the FHL transfer, five of the patients underwent more than one attempt at direct Achilles tendon repair. The mean size of the wound was 1.2 ± 0.6 cm2. We assessed the healing time of the heel plantar ulcers and recurrence rates during followup periods. The complication rate and walking ability was also evaluated. Results: All of the plantar heel ulcers healed within 8 weeks after the operation and had not recurred as of the last followup. Two patients had recurrences of previous forefoot ulcers. One patient had a local infection in the FHL tendon transfer area. All of patients could walk without a brace or walking aid device after surgery. Conclusion: We believe that Achilles tendon reconstruction using an FHL transfer for non healing plantar heel ulcers resulting from a triple Hoke lengthening of the Achilles tendon is a good treatment option for diabetic patients. Level of Evidence: IV, Retrospective Case Series

Algorithm and Experimental Verification of Underwater Acoustic Communication Based on Passive Time-Reversal Mirror

The underwater acoustic communication is characterized by doubly spread channels, which are the delay spread due to multiple paths and the doppler spread due to environmental fluctuations or a moving platform. An equalizer is used to remove the inter-symbol interferences that the delay spread causes, but an equalizer doesn`t use an acoustic environment such as a multipath. However, a passive time-reversal mirror is simpler than an equalizer because a matched filter is implemented numerically at the receiver structure along with one-way propagation. In this paper, a passive time-reversal mirror is applied to remove interferences due to a multipath in sea-going experimental data in East Sea in Oct. 2010 and improved communication performance is confirmed. The performance is verified by comparing the signal-to-interference plus noise ratio before/after passive time-reversal mirror. It is also performed independently of the passive time-reversal mirror and adaptive equalizer and the bit error rate is compared to verify the performance of underwater acoustic communication.

A New Treatment for Severe Incurved Toenails : A Case Report

Level of Evidence: V, Case Report