Kyung Tai Lee

Arthroscopic Anterior Talofibular Ligament Repair for Chronic Ankle Instability With a Suture Anchor Technique

The goal of this study was to retrospectively evaluate the clinical outcomes of arthroscopic repair for chronic ankle instability using a bioabsorbable anchor with 2 sutures. We evaluated the results of 28 ankles treated with arthroscopic anterior talofibular ligament repair using bioabsorbable anchors with a FiberWire and TigerWire suture (Arthrex, Inc, Naples, Florida) placed on the fibula from March 2008 to January 2009. Average follow-up was 15.9 months (range, 13-25 months). Patients were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot ankle score and stress radiographs. Mean AOFAS hindfoot ankle score was 92.48 ± 6.14 at last follow-up compared to the mean preoperative score of 60.78 ± 16.38 (P=.041). Mean postoperative anterior draw test score difference between 2 ankles was 0.61 ± 0.75 compared to the mean preoperative score difference of 3.59 ± 0.68 (P=.00). There was a 14% complication rate, including 3 cases of portal site irritation and 1 case of superficial infection. Stress radiographs revealed 3 cases of anterior displacement >3 mm compared to the other side. All patients returned to their previous activity level.Arthroscopic ligament reconstruction for chronic lateral ankle instability using suture anchors is effective in returning patients to their preinjury function levels. Good clinical results were obtained with some minor complications. This minimally invasive technique is a reasonable alternative to other open surgical procedures for chronic ankle instability.

Long-Term Results After Modified Brostrom Procedure Without Calcaneo- fibular Ligament Reconstruction

Background: The short-term results of modified Brostrom procedures (MBP) have been satisfactory. However, the long-term results of anatomical reconstruction have been less frequently reported. We report on our long-term results in our patient group. Materials and Methods: Thirty patients with chronic ankle instability who were treated using the MBP without CFL reconstruction from March 1997 to June 1999 were evaluated retrospectively. This consecutive series of patients was comprised of 26 males and four females. The mean age of the patients at the time of operation was 23 years. The mean followup period was 10.6 years. Twenty-four of the 30 were high-level amateur or professional athletes. The operation procedure involved only ATFL imbrication with inferior extensor retinaculum (IER) reinforcement. Clinical outcomes were evaluated by reviewing clinical charts, retrospectively. Functional outcome scores were obtained using the Hamilton scale, a VAS, and AOFAS score at final followup visit, when each patient underwent a physical examination and stress radiography. Results: Mean AOFAS score was 91 and the mean VAS at final followup was 87. According to the Hamilton classification, 12 achieved an excellent result, 16 a good result, and two a fair result. Mean anterior translation values at final followup were 6.9 and 6.1 mm on ipsilateral and contralateral sides. Furthermore, mean talar tilt angles were 3.0 and 2.5 degrees for ipsilateral and contralateral sides. Twenty-eight of the 30 patients Level of Evidence: IV, Retrospective Case Series

Measurement of first-ray mobility in normal vs. hallux valgus patients

Hypermobility of the first ray is one causative factor in development of hallux valgus and an important factor in the treatment of hallux valgus, but measuring first-ray motion is difficult. There are two known ways of measuring first-ray motion. One is measuring the bony angle on the lateral foot X-ray using a modified Coleman block. The other is using devices. However, neither is suitable for clinical application. We introduce a simple, fast and easy way of measuring first-ray range of motion. Using this method, we compared the first-ray motion between a normal group and a hallux valgus group. Forty normal and 60 hallux valgus patients were included in the measurement. We measured the first-ray range of motion in the following way: with one hand we held the 2nd, 3rd, 4th, and 5th rays at the metatarsal head level with a simple right-angled indicator. With the other hand, we held the first ray at the metatarsal head level using a simple right-angled device, such as a scale. Keeping the other rays fixed, we moved the first ray up and down and recorded the average distance (d) 10 times to reduce intra-measurement differences. We also measured and recorded the first metatarsal length (L) on the anteroposterior foot X-ray film. Finally, we calculated the first-ray range of motion (a) using the above data. We also measured the hallux valgus angle and intermetatarsal angle in the hallux valgus patient group. With this method, the average first-ray motion was 10.3° in the normal group and 12.9° in the hallux valgus patient group. If we define 14°, (that is, above the 95th percentile in the normal group) as having hypermobility, 38% of hallux valgus patients had first ray hypermobility. There was no correlation between first-ray hypermobility and either hallux valgus angle or intermetatarsal angle.

Perioperative complications of the MOBILITY total ankle system: comparison with the HINTEGRA total ankle system

BackgroundThe perioperative complications associated with MOBILITY total ankle replacement arthroplasty have not yet been reported.MethodsDuring the research period from May 2008 to June 2009, a total of 30 consecutive cases of ankle arthritis were treated with surgery. An investigation into the perioperative complications for these cases was conducted. Comparison with the previously reported perioperative complications for the HINTEGRA model was made. The 30 cases were divided into two groups wherein the first group underwent surgery during the early half of the study period and the second group underwent surgery during the later half. The incidences of complications between the two groups were then compared.ResultsThere was no difference in the incidence of perioperative complications between the use of the HINTEGRA model and the MOBILITY model for total ankle replacement arthroplasty, although medial malleolar fracture was statistically increased with the use of MOBILITY.ConclusionsThe study implies that a new learning curve may affect the outcome of surgery when a newly designed implant is used for total ankle replacement arthroplasty and that long tibial procedure time and long distraction time played a critical role in the incidence of malleolar fracture.

Comparison of MRI and Arthroscopy in Modified MOCART Scoring System After Autologous Chondrocyte Implantation for Osteochondral Lesion of the Talus

Magnetic resonance imaging (MRI) and arthroscopy have frequently been used to evaluate articular cartilage. Many studies have compared the accuracy of MRI to that of arthroscopy. However, there have been no previous comparison studies between MRI and arthroscopy in the evaluation of repaired cartilage after autologous chondrocyte implantation using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system. The purpose of this study was to compare the results between MRI and arthroscopy after autologous chondrocyte implantation of an osteochondral lesion of the talus using a modified MOCART scoring system. Our study investigated 27 consecutive cases in 26 patients who underwent follow-up MRI and second-look arthroscopy 1 year following autologous chondrocyte implantation based on their osteochondral lesion of the talus diagnosis. According to the comparison results of those 5 categories, the agreement between MRI and arthroscopy evaluation results was statistically significant with good reliability in the categories of the degree of defect repair and defect filling, the quality of repaired tissue surface, and synovitis. However, the integration with the border zone and the adhesion category showed poor to moderate reliability. There has been no well-established correlation method between arthroscopy and MRI after autologous chondrocyte implantation of an osteochondral lesion of the talus.

Radiographic Evaluation of Foot Structure following Fifth Metatarsal Stress Fracture

Background: Correlation between foot structure and stress fracture risk has not been adequately evaluated or proven. The purpose of this study was to compare foot structure in fracture cases versus control with respect to radiological parameters in stress fractures of the fifth metatarsal. Materials and Methods: The study group consisted of 50 consecutive athletes with a diagnosis of fifth metatarsal stress fracture and a control group matched for sport type and age. Fifth metatarsopha-langeal (MTP-5) angle, fourth-fifth intermetatarsal (IMA4–5) angle, fifth metatarsal lateral deviation (MT5-LD) angle were measured on standing antero-posterior (AP) radiographs. Talo first metatarsal (T-MT1) angle, talo-calcaneal (TC) angle, and calcaneal pitch (CP) angle were measured on a standing lateral view, and MT5-LD angle was measured on a 30-degree medial oblique view. Results: Significant inter-group differences were found for TC angle (p < 0.001) and calcaneal pitch angle (p < 0.001) on lateral radiographs, and for IMA4–5 angle (p = 0.003), MT5-LD angle (p = 0.002) on AP radiographs, and for MT5-LD angle (p < 0.001) on the 30-degree medial oblique radiographs. Conclusion: Fifth metatarsal stress fractures were found to be associated with elevated T-MT1 angle and CP angle representing a cavus foot and the increased curvature of fifth metatarsal. In addition, the extent of fifth metatarsal curvature on a 30-degree medial oblique view was found to be more related to the risk of fracture than on the AP view. Level of Evidence: IV, Retrospective Case Series

Medial approaches to osteochondral lesion of the talus without medial malleolar osteotomy

The purpose of this study was to determine the area of the talus that can be reached through combined anterior and posterior arthrotomy without medial malleolar osteotomy. Five fresh-frozen cadaver foot-ankle specimens were examined using posteromedial approach and anteromedial approach. We calculated the size of the marked area beginning from the posteromedial corner of the talus in the posteromedial approach and beginning from the anteromedial corner in the anteromedial approach. From the posteromedial talus, we can access 33% of the talus’ AP length and 30% of its medial to lateral length through a posteromedial approach. From the anteromedial arthrotomy, 50% of the AP length and 31% of the medial to lateral length can be reached. This leaves approximately 20% that is not accessible. If the osteochondral lesion is within the accessible area through either a posteromedial or anteromedial approach as viewed on MRI/CT, it can be safely reached without a medial malleolar osteotomy.

MR Imaging Findings of Painful Type II Accessory Navicular Bone: Correlation with Surgical and Pathologic Studies

Objective To evaluate the MR imaging findings of painful type II accessory navicular bone and to correlate these with the surgical and pathologic findings. Materials and Methods The MR images of 17 patients with medial foot pain and surgically proven type II accessory navicular abnormalities were reviewed. The changes of signal intensity in the accessory navicular, synchondrosis and adjacent soft tissue, the presence of synchondrosis widening, and posterior tibial tendon (PTT) pathology on the T1-weighted and fat-suppressed T2-weighted images were analyzed. The MR imaging findings were compared with the surgical and pathologic findings. Results The fat-suppressed T2-weighted images showed high signal intensity in the accessory navicular bones and synchondroses in all patients, and in the soft tissue in 11 (64.7%) of the 17 patients, as well as synchondrosis widening in 3 (17.6%) of the 17 patients. The MR images showed tendon pathology in 12 (75%) of the 16 patients with PTT dysfunction at surgery. The pathologic findings of 16 surgical specimens included areas of osteonecrosis with granulomatous inflammation, fibrosis and destruction of the cartilage cap. Conclusion The MR imaging findings of painful type II accessory navicular bone are a persistent edema pattern in the accessory navicular bone and within the synchondrosis, indicating osteonecrosis, inflammation and destruction of the cartilage cap. Posterior tibial tendon dysfunction was clinically evident in most patients.

The Plantar Gap Another Prognostic Factor for Fifth Metatarsal Stress Fracture

Background: There have been diverse results, even in the same Torg type classification, in cases with fifth metatarsal stress fracture. Hypothesis: The “plantar gap” is correlated with the time for bone union and complications. It might be used for a prognostic factor. Study Design: Cohort study; Level of evidence, 3. Methods: Seventy-five cases with a fifth metatarsal stress fracture treated with modified tension band wiring from January 2003 to December 2008 were evaluated retrospectively. This consecutive series of patients included 71 male and 2 female patients with a mean of 19.8 years of age at the time of surgery. All of the enrolled patients were elite-level athletes. Each case was classified according to Torg classification and the degree of plantar gap was also measured. After the surgery, bone union was determined by computed tomography findings. Statistical analysis of the Torg classification and time for bone union, as well as plantar gap and time for bone union, was performed. Results: The mean time for bone union for each Torg type was 71.05 ± 21.77 days for type I, 104.48 ± 54.62 days for type II, and 122.92 ± 51.75 days for type III. There was a significant difference in the time for bone union among the 3 Torg types (P = .008). The mean time for bone union in group A (plantar gap <1 mm) was 71.21 ± 29.95 days and it was 126.4 ± 51.99 days for group B (plantar gap ≥1 mm) (significantly different; P < .001). In addition, there was a positive correlation of the time for bone union with the degree of plantar gap (ρ = .661, P < .001). In cases with Torg type II classification, there was a significant difference in the time for bone union between groups A and B (P < .001) In addition, there was a strong correlation between the time for bone union and the degree of plantar gap (ρ = .657, P < .001). There were 8 cases of nonunion in Torg type II, and 1 case in Torg III. With regard to the plantar gap, there was 1 case of nonunion in group A, and 8 cases in group B. Conclusion: The results of this study suggest that the plantar gap might be used for prognosis in cases with a fifth metatarsal stress fracture, even in patients with the same Torg classification.

Perioperative Complications and Learning Curve of the Mobility Total Ankle System

Background: Only 2 articles related to the recently developed Mobility Total Ankle System (Johnson & Johnson Medical/DePuy International, Leeds, UK) have been published to date. The purpose of this study was to determine the perioperative complications associated with the Mobility Total Ankle System and whether a learning curve exists for this system. Materials and Methods: We recruited 60 consecutive patients undergoing total ankle arthroplasty using the Mobility Total Ankle System for advanced osteoarthritis and rheumatoid arthritis between May 2008 and June 2010. Group A included the initial 30 patients who underwent surgery, and group B included the next 30 patients. Reporting of adverse perioperative events, including wound healing problems, fracture, aseptic loosening, tendinitis, component malposition, neuroma, and bony impingement, was limited to the first 3 months after the surgery. Results: Eleven of the 30 patients in group A developed complications (36.7%), and 1 died of an unknown cause 6 months after leaving the hospital. The complications in this group included medial malleolar fracture in 6 patients, lateral malleolar fracture in 1, wound healing problems in 2, and varus deformity in 2. Five of the 30 patients in group B developed complications (16.7%). The complications in this group included medial malleolar fracture in 1 patient, medial impingement in 2, Achilles tendon rupture in 1, and wound problems in 1. There was no statistically significant difference (P = .08) between the 2 groups in the incidence of complications after total ankle replacement arthroplasty. There was also no significant difference between the 2 groups in the types of complications seen. Conclusions: Perioperative complications associated with total ankle replacement arthroplasty using the Mobility Total Ankle System were seen in 16 of 60 patients. Group A had a higher incidence of perioperative complications than did group B. However, the difference was not statistically significant. Either the expertise of the surgeon or the simplicity of the total ankle system can affect the learning curve, although these things were not specifically quantified in this study. Level of Evidence: Level III, comparative case series.