So Minokawa

Preservation technique of the piriformis tendon is superior to reattachment technique in terms of contiguity and muscle atrophy: using magnetic resonance imaging:

Purpose: The preservation technique of the piriformis tendon during the posterolateral approach in total hip arthroplasty (THA) is reportedly superior to the reattachment technique in terms of dislocation. However, the long-term effects of preservation of the piriformis tendon during THA remain unknown. In this study, we evaluated the contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle during a long-term postoperative follow-up using magnetic resonance imaging (MRI). Methods: We retrospectively evaluated 48 patients with available MRI. The 48 patients were classified into a P group (n = 29), in which the piriformis tendon was preserved, and an R group (n = 19), in which the piriformis was reattached after sectioning. The mean follow-up duration was 45.9 months. The contiguity of the piriformis/conjoined tendon and atrophy of the piriformis/internal obturator muscle were evaluated in all patients. Results: The piriformis tendon remained attached to the greater trochanter in all P-group patients and 68.4% of R-group patients. The mean piriformis muscle atrophy ratios were 15.9% ± 21.1% in the P group and 41.6% ± 19.1% in the R group (p < 0.001). The conjoined tendon repair remained intact in 72.4% of P-group patients and 36.8% of R-group patients (p < 0.05). The mean internal obturator muscle atrophy ratio was 31.4% ± 26.2% in the P group and 50.4% ± 19.1% in the R group (p < 0.05). No postoperative pulmonary embolism, wound infection, deep infection, or hip dislocation occurred. Conclusions: In our study, we suggest that the preservation technique of the piriformis tendon is superior to the reattachment technique in terms of contiguity and muscle atrophy.

Effect of the adjacent-joint osteoarthritis after arthroscopic ankle arthrodesis

Category: Ankle Arthritis Introduction/Purpose: Arthroscopic ankle arthrodesis (AAA) is a good clinical outcome, because the arthroscopic method has been deemed to have shorter union time, less blood loss, less morbidity, shorter hospital stays, and more rapid mobilization. However, it is unclear about the relationship between progression of adjacent-joint arthritis and clinical outcome at long-term follow-up. The purpose of this study was to investigate the relationship between AAA and adjacent-joint arthritis at 2 years postoperatively. Methods: We evaluated 17 feet of 17 patients at a minimum of two years after surgery that were able to be followed, from among 59 feet in 55 patients with ankle osteoarthritis who underwent AAA between January 2006 and April 2015. The mean age was 66.1 ± 8.1 (range, 57-79) years, and postoperative follow-up was performed at a mean of 4.5 ± 2.3 (range, 2-10) years after surgery. The radiographic evaluation examined a union rate of the ankle, and a progression of adjacent-joint osteoarthritis (OA) change. We examined the relationship between the presence of adjacent-joint OA and Japanese Society for Surgery of the Foot (JSSF) score before surgery and last follow up. Additionally, we examined the relationship between the presence of adjacent-joint OA and Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at last follow up. Results: JSSF score was improved to 56.9 points before surgery and 89.2 points last follow up, and the union rates was 17 feet of 17 feet (100%). At the last follow-up, radiographic signs of developed or progressing arthritis were observed in ten feet at subtalar joint (58.8%) and in three patients at talonavicular joint (17.6%). The postoperative JSSF scale regarding the presence or absence of the adjacent joint OA, there were no significant differences (89.3 ± 6.0 points in the absence group and 89.2 ± 6.1 points in the presence group). Postoperative SAFE-Q was not significantly different, pain and pain-related physical functioning and daily living, social functioning, shoe-related, and general health and well-being. Conclusion: There was no significant difference in the JSSF score of presence or absence of the adjacent-joint OA before surgery and at the final follow-up. Additionally, there was no significant difference in the SAFE-Q of presence or absence of the adjacent-joint OA at the final follow-up. The adjacent-joint OA was progressed after AAA, however clinical outcome was relatively maintained.

New cross-table lateral radiography method for measuring acetabular component anteversion in total hip arthroplasty: a prospective study of 93 primary THA

Introduction Various methods have been described for measuring acetabular component anteversion. However, accurate measurement of anteversion is difficult. We herein propose a new method using cross-table lateral (CL) radiography performed with the contralateral hip flexed to 45° (45° flexed CL radiography). The main purpose of this study was to evaluate the reliability and validity of this new method. Methods The study group included 93 patients who underwent total hip arthroplasty (THA). All hips were evaluated with computed tomography (CT) and both standard and 45° flexed CL radiographs to measure acetabular component anteversion the week after THA. The intraobserver and interobserver reliability of each measurement was assessed. Plain radiography measurements were compared with reference CT measurements to evaluate their validity. Results All measurements had excellent intraobserver and interobserver reliability, and plain radiography measurements correlated well with CT measurements. The mean measurements were 21.9° (3°-39°) with CT, 24.9° (7°-47°; p<0.001) with standard CL radiographs, and 22.5° (7°-43°; p = 0.112) with 45° flexed CL radiographs. Discussion The anteversion values measured with our new method were closer to the CT values used as a reference standard than those with standard CL radiographs. Our new method appears to be reliable and valid for measuring acetabular component anteversion.

Neurectomy for Bilateral Morton's Neuroma A Case Report of a Male Patient.

Mortons neuroma is a common condition that mainly affects middle-aged women, and many articles have addressed the surgical treatment of this condition. Previous reports have described bilateral neuroma excision in women but not in men. We report a rare case of bilateral neuromas in a male patient treated with simultaneous neurectomy.

Effect of Blood Flow of the Metatarsal Head with Hallux Valgas after Minimally Invasive Distal Linear Metatarsal Osteotomy

Category: Hindfoot Introduction/Purpose: Distal first metatarsal osteotomies are recommended for surgical treatment of mild to severe hallux valgus (HV) deformities. Angthong et al. reported that minimally invasive distal linear metatarsal osteotomy (DLMO) exhibited good outcomes, with no major complications. However, avascular necrosis of the metatarsal head following a distal osteotomy has been reported, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. The purpose of this study was to evaluate the in vivo blood flow of the pre- and post-osterotomy metatarsal head in patients with HV using laser Doppler flowmetry (LDF). Methods: Between April and November 2015, DLMO was performed on seven patients with HV. The patients comprised one male and four females, with a mean age at surgery of 43.4 (21–62) years. The primary surgical indications for DLMO were all levels of severity of possible manual correction in patients with foot pain. The patients were placed in the supine position, and without a tourniquet, a 1.5-cm skin incision was centered over the medial aspect of the first metatarsal neck. A 2.0-mm Kirschner wire was inserted manually from the wound to the medial side of the hallux using a retrograde technique. Under direct vision, the Kirschner wire was introduced into the medullary canal of the first metatarsal shaft. Blood flow measurements of the pre- and post-osteotomy first metatarsal head in the seven patients were performed by LDF (ALF21 N; ADVANCE Co., Tokyo, Japan). The probe was touched to the first metatarsal head. The blood flow measurements were repeated three times, and the mean values were calculated. Results: On preoperative plain radiographs, the mean hallux valgus angle was 38.0° (range: 22.4–45.8°), and the mean intermetatarsal angle was 17.0° (range: 10.4–21.9°). The mean pre- and post-DLMO systolic blood pressure at the time of the measurements was 87.3±7.76 and 88.1±8.25 mmHg, respectively (P=0.85). The mean pre- and post-DLMO blood flow rate was 1.71±0.68 and 1.66±0.49 ml/min/100 g, respectively (P=0.90). Conclusion: Steven et al. reported that a distal osteotomy can lead to avascular necrosis of the metatarsal head, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. However, we found that blood flow of the pre- and post-osteotomy metatarsal head was present in all patients examined, with no significant difference in the blood flow rates of the metatarsal head before and after DLMO. Based on the present results, it is possible to avoid major complications, such as avascular necrosis of the metatarsal head, because DLMO is minimally invasive and involves less release of the soft tissue.

Stress Distribution within the Osteochondral Lesions of the Talus with Nonshoulder-type and Shoulder-type

Category: Basic Sciences/Biologics Introduction/Purpose: Arthroscopic bone marrow stimulation techniques including excision with curettage and microfracture are recommended as initial treatments for osteochondral lesions of the talus (OLT). However, several reports have indicated that lesion size and location are important prognostic factors for the clinical outcomes. A cutoff point regarding the risk of clinical failure exists for a lesion size of approximately 15 mm diameter or 150 mm2 area. A recent study reported that shoulder-type lesions had significantly worse clinical outcomes than nonshoulder-type lesions. However, to the best of our knowledge, no previous reports have provided biomechanical data for how nonshoulder-type and shoulder-type OLT affect the clinical outcomes. The purpose of this study was to clarify the stress distribution in articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using finite element (FE) analysis. Methods: The healthy 33-year-old male and 29-year-old female volunteers participated in the present study. They underwent computed tomography (CT) scans, and three-dimensional FE models of his ankle joint were created from the CT data using Mechanical Finder software (version 7.0, extended edition; Research Center of Computational Mechanics, Tokyo, Japan). Six different sizes of nonshoulder-type and shoulder-type OLT were simulated in the present study. For the nonshoulder-type lesion models, circular cartilage defects with diameters of 5, 7, 9, 11, 13, and 15 mm were created on the medial half of the talar dome using a cutting tool. The shoulder-type lesion models were created in the medial half of the talar shoulder, also with cartilage defect diameters of 5, 7, 9, 11, 13, and 15 mm. We set the loading condition at 686 N on the upper part of the tibia from the tibial axis for body-weight loading. The peak and average articular cartilage stress and defect rim stress were compared between the two models and among the six different defect sizes. Results: In both lesion models, stress concentration was seen at the cartilage defect rim. The peak and average cartilage stress and defect rim stress increased with increasing defect size of the two models. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models. Conclusion: Lesion size of OLT was the most powerful predictor of the clinical outcome by arthroscopic bone marrow stimulation. The shoulder-type OLT experience a worse clinical outcome than the nonshoulder-type OLT, even after adjustment for OLT size and regardless of location. In the present study evaluated the stress distribution in the articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using FE analysis. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models.

Optimum Insertional Direction of the Suture Anchor in Arthroscopic Lateral Ankle Ligament Repair

Category: Arthroscopy Introduction/Purpose: The gold standard for chronic lateral ankle ligament injury is ligament repair via the modified Broström- Gould procedure. Recently, lateral ankle ligament repair has been performed arthroscopically. This requires the insertion of one to three suture anchors in the fibula from anterior to posterior via the accessory portal. It is important to insert the suture anchors completely into the fibula bone. Because the distal fibula is tapered and has a fossa on the posterior surface, unfavorable insertional direction of the suture anchor can lead to complications such as inadequate suture anchor stability or friction between the suture anchor and the peroneus tendons. This study aimed to investigate the distance between the insertion point of the suture anchors and the posterior surface of the fibula on computed tomography (CT) images. Methods: Twenty ankles from 16 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (10 male, 10 female; mean age, 32 years; age range, 12–78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of fossa/the top of the convex of fibula was measured on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. We also measured the distance from the insertion point of the suture anchor to the posterior surface of the fibula, in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. Results: The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in a parallel direction was 15.6 mm at 90°, 18.0 mm at 75°, 21.5 mm at 60°, and 24.8 mm at 45°. The posterior points in a parallel direction were located on the posterior fossa in 40% of cases at 90°, in 10% at 75°, and in 0% at 60° and 45°. Conclusion: We suggest that the suture anchor should be directed from anterior to posterior at an angle of less than 60° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, in order to avoid passing through the fibula.