Seung-Myung Choi

Minimal Invasive Suture-Tape Augmentation for Chronic Ankle Instability

Background: Although the modified Brostrom procedure has had excellent clinical results, postoperative complications such as skin irritation by suture material and problematic scar formation occur. This prospective study was performed to evaluate the clinical outcomes of mini-open ligament augmentation (internal brace technique) using suture tape for chronic ankle instability in a select cohort of patients. Methods: Thirty-four young female patients with less than 70 kg of body weight were followed for more than 2 years after suture tape augmentation for lateral ankle instability. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) score, Sefton grading system, and the period to return to various activities. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate the longevity of mechanical ankle stability. Results: FAOS and FAAM scores had significantly improved to 92.5 points at final follow-up (P < .001). According to the Sefton grading, 31 cases (91.2%) achieved satisfactory functional results. The period to return to exercise was on average 10.2 weeks for jogging and 9.6 weeks for walking on uneven ground. The average subjective satisfaction score of patients was 93.8 points, and satisfaction with the scar was 98.5 points. Talar tilt angle and anterior talar translation had significantly improved to an average of 4.5 degrees and 4.1 mm, respectively, at final follow-up (P < .001). There were no complications such as skin irritation and wound infection, except for 1 case of chronic inflammation. Conclusions: Minimally invasive suture tape augmentation seems to be an effective alternative for young women with chronic ankle instability. Because there is a possibility of progressive elongation over time, the longevity of mechanical ankle stability and the proper indication for using the internal brace technique should be addressed in future studies. Level of Evidence: Level IV, case series study.

Percutaneous Deltoid Ligament Augmentation Using Suture Tape for Medial Ankle Instability

Compared with lateral ankle instability, medial ankle instability has many fewer treatment strategies and fewer reconstructive options available. The best method for deltoid ligament reconstruction remains unclear. Percutaneous deltoid ligament augmentation using suture tape represents a novel alternative technique for chronic medial ankle instability.

Functional Outcomes Following Anterior Transfer of the Tibialis Posterior Tendon for Foot Drop Secondary to Peroneal Nerve Palsy

Background: This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Methods: Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height. Results: Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group (P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group (P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity. Conclusions: Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up. Level of Evidence: Level IV, retrospective case series.

The Effect of Peroneal Muscle Strength on Functional Outcomes After the Modified Broström Procedure for Chronic Ankle Instability

Background: Although the peroneal muscles are known to be the major dynamic lateral stabilizers of the ankle, little information is available regarding the change in muscle strength and relation with the outcomes after lateral ligament repair surgery. The purpose of this study was to identify the effects of peroneal strength on the validated functional outcome measures after the modified Broström procedure (MBP) for chronic ankle instability. Methods: Forty-one patients (41 ankles) who underwent MBP using suture anchors were eligible and followed up to 2 years postoperatively. Functional evaluation consisted of the Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). The changes of peroneal strength were evaluated using an isokinetic dynamometer. Differences in the functional outcomes between the 3 groups divided according to the recovery rate of peroneal strength were analyzed. Results: Peak torque and total work for eversion in 60 degrees/s angular velocity significantly improved from a mean 8.1 and 5.2 Nm preoperatively to 11.4 and 6.9 Nm at postoperative 2 years, respectively (P < .001, P = .038). The deficit ratio of peak torque for eversion significantly improved from a mean 38.6% to 17.4%, and a significant side-to-side difference was found (P = .011). There were no significant differences in FAOS, FAAM, and measurements of stress radiograph between the 3 groups. Conclusions: Although restoration of peroneal strength postoperatively was about 82.6% of the unaffected ankle, patient-reported function in daily and sport activities were satisfactorily improved. Postoperative isokinetic strength of the peroneals demonstrated no statistically significant effects on the functional outcomes after MBP. Level of Evidence: Level III, prospective comparative case series.

Reattachment using the suture bridge augmentation for Achilles tendon avulsion fracture with osteoporotic bony fragment

Although avulsion fractures of the calcaneal tuberosity are rare injuries, these can be a challenging problem with frequent complications, such as loss of reduction and soft tissue problem. Anatomical reduction and internal fixation are indicated to avoid these pitfalls and to restore function of the triceps surae. However, the best fixation device and operative technique are still controversial. A case that achieved satisfactory clinical outcome through a reattachment technique using the suture bridge augmentation for Achilles tendon avulsion fracture with osteoporotic bony fragment is presented.

The peroneal strength deficits in patients with chronic ankle instability compared to ankle sprain copers and normal individuals

BACKGROUND Despite a consensus regarding the correlation of peroneal strength deficit with chronic ankle instability (CAI), there are conflicting reports in regards to peroneal strength as assessed by isokinetic dynamometer in patients with CAI. The purpose of this study was to evaluate the changes of isokinetic strength in patients with CAI compared to ankle sprain copers and normal individuals. METHODS Forty-two patients (CAI group) with chronic ankle instability who were scheduled for the modified Broström procedure met inclusion criteria. Thirty-one ankle sprain copers (ASC group) who were eligible at 6 months after acute injury and 30 controls were recruited. The muscle strength associated with four motions of the ankle were evaluated using isokinetic dynamometer. RESULTS Peak torque for inversion and eversion at 60°/s angular velocity were significantly lower in the CAI group compared to the ASC and control group (P=.004, P<.001, respectively). Deficit ratio of peak torque for eversion at 60°/s and 120°/s in the CAI group were 33.8% and 19.8%, respectively, which indicated significant side to side differences (both P<.001). The evertor/invertor strength ratio (0.59) for eversion at 60°/s was significantly lower in the CAI group (P<.001). CONCLUSION As compared to the ankle sprain copers and normal individuals, patients with chronic ankle instability who were scheduled for modified Broström procedure demonstrated a significant weakness of isokinetic peroneal strength. Isokinetic muscular assessment can provide the useful preoperative informations regarding functional ankle instability focusing on peroneal weakness.

Ankle Fusion Combined With Calcaneal Sliding Osteotomy for Severe Arthritic Ball and Socket Ankle Deformity

Background: Although a ball and socket ankle deformity is usually congenital and asymptomatic, abnormal inversion and eversion mobility can result in recurrent ankle sprain and osteoarthritis. This retrospective study was performed to evaluate the clinical and radiologic outcomes of ankle fusion combined with calcaneal sliding osteotomy for severe arthritic ball and socket ankle deformity. Methods: Fourteen patients with severe arthritic ball and socket ankle deformity were followed for more than 3 years after operation. The clinical evaluation consisted of American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS) for pain, and subjective satisfaction score. The period to fusion and union of osteotomy, the change of hindfoot alignment angle, and complications were evaluated radiologically. Results: AOFAS and FAAM scores were significantly improved from an average of 37.4 and 34.5 points to 74.6 and 78.5 points, respectively. VAS for pain with walking over 20 minutes was significantly improved from an average of 8.4 points to 1.9 points. The average satisfaction score of patients was 88.9 points. The difference in heel alignment angle (compared to contralateral side) was significantly improved from an average of 34.8 to 5.4 degrees. There were 2 cases of progressive arthritis in an adjacent joint and 1 case of failed fusion. Conclusions: Ankle fusion combined with calcaneal sliding osteotomy can be an effective operative option for ball and socket ankle deformity with advanced arthritis. In spite of increased complication rate, reliable pain relief, and restoration of gait ability through correcting hindfoot malalignment could improve the quality of life. Level of Evidence: Level IV, retrospective case series.

Prognostic Factors for Intermediate-term Clinical Outcomes Following Bosworth Fractures of the Ankle Joint

BACKGROUND This retrospective comparative study was performed to evaluate the clinical outcomes after surgical treatment for Bosworth fracture-dislocation, and to analyse the prognostic factors related to postoperative outcomes. METHODS Fifteen patients were followed for ≥2 years after Bosworth fracture-dislocation. Twenty-five ankle fracture-dislocations as control group were enrolled to compare clinical outcomes. Clinical evaluation consisted of the AOFAS and Olerud-Molander scores. Patient and injury factors were analysed to identify the outcome predictors. RESULTS There were no significant differences in either clinical evaluation score as compared to control group (P=0.245, .302, respectively). The time interval to operation and number of manual reduction attempts were found to be predictive factors for poor outcomes (P=0.004, .038, respectively). CONCLUSION As compared to more common patterns of ankle fracture-dislocations, intermediate-term clinical outcomes after Bosworth fracture-dislocations were statistically comparable. Delayed surgical reduction and repeated attempts at closed reduction appear to be negative outcome predictors.

Prognosis of Medial Gutter Osteoarthritis Combined with Chronic Ankle Instability: Clinical and Radiological Evaluations Following Modified-Broström Procedure and Arthroscopic Debridement

Category: Ankle Arthritis Introduction/Purpose: Although the frequent intraarticular pathologies associated with recurrent ankle sprains are well known, informations regarding treatment method for arthritic changes in the medial gutter are still insufficient. This study was performed to evaluate the intermediate-term clinical and radiological outcomes following modified Broström procedure and arthroscopic debridement in the middle-aged patients. Methods: Twenty-two patients with medial gutter osteoarthritis related to chronic lateral ankle instability were followed for more than 3 years after surgical treatment. All patients showed medial joint space narrowing of Takakura stage 2. The clinical evaluation consisted of the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) for medial ankle pain during walking, and Foot and Ankle Ability Measure (FAAM). Results: Mean AOFAS and FAAM scores significantly improved from 51.2 and 45.7 points preoperatively to 80.3 and 78.4 points at final followup, respectively (P < .001). Although mean pain-VAS significantly improved from 6.8 points to 3.5 points (P < .001), 8 patients (36.4%) complained of discomfort at gait with considerable pain ≥ 4 points. There was only 1 patient (4.5%) with recurrent ankle instability, while 6 patients (27.3%) showed a progression in arthritis stage. Conclusion: Modified Broström procedure concomitant with arthroscopic debridement for medial gutter osteoarthritis secondary to chronic ankle instability is not effective enough to treat the medial ankle pain and functional impairment. Alternative treatment strategies for middle-aged cohort with arthritic changes are needed to improve the clinical outcomes and to prevent a progressive osteoarthritis.

Comparison of sagittal values between lateral decubitus plain radiography and supine computed tomography in thoracolumbar fractures: a greater degree of kyphosis is observed in plain radiography than CT

ObjectiveRadiologic parameters are important factors for planning the treatment for thoracolumbar fracture. However, we noted that measurements of the degree of kyphosis by lateral decubitus plain radiography were greater than supine CT. The cause of this discrepancy is unclear.MethodsWe retrospectively reviewed the plain radiographs and CT scans of 90 patients with thoracolumbar fractures (fracture group). We measured the segmental sagittal angle (SSA) on lateral decubitus plain radiographs and in the median sagittal plane on CT scans obtained in the supine position. The method agreement (plain radiography versus CT) was determined by utilizing Bland–Altman plots. For the purpose of comparison, the same analyses were performed in a group of age and sex-matched controls (normal group). After establishing the method disagreement in the fracture group, the factors that contributed to the difference in the SSA between plain radiography and CT, as well as their threshold values, were determined.ResultsOn Bland–Altman plots for the fracture group, the mean difference was 4.53° [95% confidence interval (CI) − 4.87° to 13.93°]. For the normal group, the mean difference was − 0.64° (95% CI − 5.87° to 4.58°). On univariate analysis, male sex, thoracolumbar level, and SSA(X) were significant factors associated with ∆SSA (P = 0.03, 0.002, and 0.000, respectively). Multivariable regression analysis showed that SSA(X) was the only significant factor. Receiver operating characteristic curve analysis indicated that the optimal threshold of SSA(X) was 17° with a sensitivity of 78% and a specificity of 75% (area under curve: 0.752).ConclusionsThe mean SSA determined on lateral decubitus plain radiographs indicated significantly more kyphosis than that determined on CT images obtained in supine position. When the SSA on plain radiography is more than 17°, there might be a significant discrepancy between the two imaging modalities. This discrepancy seems to be mainly attributable to the difference in patient positioning (lateral decubitus position for plain radiography versus supine position for CT imaging).