Joon-Sang Eom

Anatomical Reconstruction of Lateral Ankle Ligaments Using Free Tendon Allografts and Biotenodesis Screws

Background: Lateral ankle instability is one of the most common musculoskeletal disorders and can result in ankle damage. This study reports on the results of the anatomical reconstruction of ligaments using semitendinosus tendon allograft and bioabsorbable tenodesis screws for chronic lateral ankle instability, as well as the functional and radiological results of this procedure. Methods: From February 2007 to January 2013, 70 patients (72 ankles) underwent this procedure. Six patients were lost to follow-up, and ultimately 64 patients (66 ankles) were evaluated. Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, Karlsson-Peterson ankle scores, and patient satisfaction were evaluated at a mean of 22.1 months (range, 12-68 months) postoperatively. The talar tilt angle and anterior translation were assessed radiographically in pre- and postoperative ankle stress views. The mean patient age at surgery was 30.1 years (range, 16-59 years). Results: The mean VAS pain score decreased from 5.5 to 1.3 (P < .05), and the mean AOFAS improved from 71.0 to 90.9 (P < .05). The mean Karlsson-Peterson score improved from 55.1 to 90.3, whereas talar tilt decreased from 14.8 degrees to 3.9 degrees. There was no significant difference in clinical outcomes between the pretensioned and nonpretensioned groups. Conclusion: This procedure yielded successful results, including satisfactory ankle stability and clinical outcomes, in ankles with poor lateral ligament tissues. Level of Evidence: Level IV, case series.

Anterior Heterotopic Ossification at the Talar Neck After Total Ankle Arthroplasty

Background: Recently, as total ankle arthroplasty (TAA) has been widely performed, its outcomes and complications have been reported. Heterotopic ossification (HO) after TAA has been reported in the posterior compartment of the ankle. We report on a series of HOs that developed in the anterior compartment of the ankle at the talar neck region after TAA. Methods: TAA was performed using the Hintegra and the Mobility in 54 ankles (Hintegra, 21 ankles; Mobility, 33 ankles) from 2004 to 2012. The outcome was assessed by visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, patient satisfaction, and radiographic evaluation. The HO was confirmed on the lateral ankle view. HO in the anterior compartment of the ankle was classified based on a modification of the Brooker classification. Results: After TAA, 13 HOs developed in 12 of the 54 ankles. Six HOs developed in the anterior compartment, and 7 HOs developed in the posterior compartment. The majority of the anterior compartment HO (5/6) was observed in the Mobility group. There was no significant relationship between HO and the clinical outcomes (VAS score, P = .62; AOFAS score, P = .31; ankle range of motion, P = .31). Conclusions: Besides the posterior ankle, the anterior compartment of the ankle in the talar neck region was demonstrated to be another potential area for HO after TAA. The development of anterior HO was strongly related to the wide exposure of the cancellous bony surface at the talar neck and therefore occurred more often with the Mobility than with the Hintegra prosthesis. Level of Evidence: Level III, retrospective comparative case series.

Comparison of the outcomes between two 3-component total ankle implants.

Background: Total ankle arthroplasty (TAA) with the use of third generation implants has demonstrated favorable clinical results and improved survival. However, few studies have compared the different types of implants. The purpose of this study was to perform a retrospective evaluation of patient outcomes and complications by comparing TAA procedures performed with HINTEGRA versus MOBILITY systems. Methods: Fifty-two consecutively enrolled patients (28 men and 24 women; mean age 64.8 years) underwent TAA using HINTEGRA (21 ankles) or MOBILITY (33 ankles) between September 2004 and July 2012. Visual analog scale (VAS) pain scores and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were determined at each follow-up visit. The radiographs were reviewed to assess component positioning, radiolucency, heterotopic ossification, and other factors. The mean follow-up period was 28.3 months in the HINTEGRA group and 32.5 months in the MOBILITY group. Results: VAS decreased from 8.3 to 2.0 for the HINTEGRA group and from 7.9 to 2.7 for the MOBILITY group. The AOFAS score increased from 43.8 to 87.3 for the HINTEGRA group and from 46.6 to 83.7 for the MOBILITY group. Intra- and postoperative malleolar fractures were not noted in the HINTEGRA group, whereas 5 ankles (15.2%) in the MOBILITY group sustained this injury (P = .144). Ankle impingement syndrome was noted in 8 ankles (38.1%) in the HINTEGRA group and 3 (9.1%) in the MOBILITY group (P = .015). However, no significant differences in postoperative osteolysis and neuralgia were noted between the groups. Conclusions: Both implants exhibited favorable clinical outcome without significant differences. However, in terms of complications, ankle impingement syndrome was significantly more common in the HINTEGRA group, while intraoperative malleolar fracture was observed only in the MOBILITY group. Level of Evidence: Level III, comparative series.

Second-Look Arthroscopic Evaluation and Clinical Outcome After Supramalleolar Osteotomy for Medial Compartment Ankle Osteoarthritis

Background: The aim of this study was to evaluate the clinical and radiologic outcomes of medial compartment ankle osteoarthritis after supramalleolar osteotomy (SMO) without the bone marrow stimulation procedure and confirm cartilage recovery by second-look arthroscopy. Methods: Twenty-two ankles that were followed for more than 1 year after SMO were retrospectively reviewed. Visual analog scale pain scores and American Orthopaedic Foot & Ankle Society ankle-hindfoot scores were used for functional evaluations. The tibial anterior surface angle and tibial lateral surface angle were measured on radiographs, and ankle osteoarthritis was classified by Takakura stage. Among the 22 patients, 21 underwent ankle arthroscopy prior to SMO, and second-look arthroscopy was performed in 16 patients 1 year postoperatively. Tibiotalar cartilage regeneration was evaluated according to the modified Outerbridge classification for the 14 patients who had undergone SMO without the bone marrow stimulation procedure. Results: The mean visual analog scale and American Orthopaedic Foot & Ankle Society scores significantly improved from 6.5 preoperatively to 1.1 postoperatively and from 60.7 preoperatively to 87.1 postoperatively, respectively (P < .05). The mean tibial anterior surface and tibial lateral surface angles significantly improved from 83.5° and 76.9° preoperatively to 93.8° and 80.2° postoperatively, respectively (P < .05). All preoperative Takakura stage IIIa cases and IIIb case improved to postoperative stage II. On second-look arthroscopy, cartilage regeneration of the medial compartment of the tibiotalar joint was observed in 12 of 14 patients (85%), whereas cartilage deterioration was not observed in any patient. Conclusions: SMO without the bone marrow stimulation procedure for medial ankle osteoarthritis demonstrated cartilage regeneration in the medial tibiotalar joint in most patients by second-look arthroscopy, as well as satisfactory clinical and radiologic outcomes. Level of Evidence: Level IV, case series.

Magnetic Resonance Imaging and Stress Radiography in Chronic Lateral Ankle Instability.

Background: Studies regarding magnetic resonance imaging (MRI) findings of the lateral ankle ligaments in chronic lateral ankle instability and their clinical relevance for surgery are lacking. This study classified the lateral ankle ligament MRI findings of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) in chronic lateral ankle instability (CLAI) and correlated these findings with ankle stress radiographs. Methods: We included 132 ankles with CLAI that underwent ligament reconstructions from 2006 to 2013. The distributions of the ATFL and CFL morphologies were evaluated using the following categories: (1) the amount of thickness: normal/thickened/attenuated/non-visualized, (2) the presence of discontinuity, (3) wavy or irregular contour, and (4) increased signal intensity on T2-weighted images. The relationships between the ligament morphologies and stress radiographs were analyzed. Results: The ATFL was normal in 5 (4%) ankles, thickened in 35 (27%), attenuated in 76 (58%), and non-visualized in 16 (12%), while the CFL was normal in 39 (30%) ankles, thickened in 42 (32%), attenuated in 44 (33%), and non-visualized in 7 (5%). Discontinuity of the ATFL or CFL was observed in 46 (35%) ankles. Wavy or irregular contours were observed in 55 (42%) ATFLs and 37 (28%) CFLs, and signal intensity of both ligaments was increased in 19 (14%) ankles. ATFL (P < .001) and CFL thickness (P = .007) correlated with the talar tilt angle. Conclusions: The MRI findings of CLAI showed several morphologies and specific incidences for each morphology. Attenuated, wavy appearance was the most frequent MRI pattern. Thickness was related to the degree of instability. Level of Evidence: Level IV, retrospective case series.

Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability: A technical report

BACKGROUND Deltoid ligament insufficiency can cause arthritic changes with various symptoms in the ankle joint. However, reconstruction procedures of the medial collateral and deltoid ligaments have drawn less attention than those of the lateral ankle ligaments. Few techniques for reconstructing deltoid ligaments are available, and those that are can be complex. OBJECTIVE We introduce a new surgical method for reconstructing superficial deltoid ligaments that is simple and straightforward. CONCLUSION With this method, the tibionavicular and tibiocalcaneal ligaments can be reconstructed efficiently and easily.

Hallux Valgus and Bunionette

1. Hallux valgus is associated with multiple factors, such as genetic and anatomical abnormality and other disease entities such as rheumatoid arthritis, pes planus, generalized neuromuscular disease, etc. 2. As for the hallux valgus with incongruent MTP joint, the surgical options according to the severity of the HVA and the IMA of the patient are classified. 3. Although there are three approaches for the lateral soft tissue release, we prefer the single medial incision approach, because of avoidance of dorsal web operation scar, and the wide exposure. 4. According to the severity of the hallux valgus especially by IMA, distal chevron osteotomy, scarf osteotomy, Ludloff osteotomy, proximal chevron osteotomy, and modified Lapidus procedure are the main surgical options that are commonly performed. 5. Bunionette is classified into three types according to the morphologic structures and the surgical options such as lateral osteotomy and various osteotomies are performed.

Incomplete differentiation of the hypoplastic long head of the biceps tendon from the joint capsule

Anatomic variations of the biceps brachii muscle are often observed [1]. Among these variations, anomalies of the intra-articular segment of the long head biceps tendon (LHB) are rarely encountered in daily practice. Intracapsular origin of the LHB has been reported; this mimics tears of the superior labrum and LHB at its site of origin [2–4]. Yeh et al. [2] suggested ‘‘differentiation’’ theory to explain the origin of the intra-articular segment of the LHB, which was contrary to the original migration concept. The LHB is believed to develop outside the joint capsule and then migrate through the capsule to its final intra-articular location later in fetal life [3, 5]. According to Yeh’s [2] assumption, the intraarticular segment of the LHB is differentiated from the joint capsule during development. The process of natural development is difficult to classify because of the lack of clinical cases. We report a case in whom the hypoplastic LHB merged into cord-like capsular thickening and was anchored to the supraglenoid tubercle after separating from the joint capsule. The patient was informed that details of the case would be submitted for publication.