Suguru Inokuchi

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders I: development of standard rating system

BackgroundThe aim of this study was to report the five scales comprising the rating system that the Japanese Society for Surgery of the Foot (JSSF) devised (JSSF standard rating system) and the newly offered interpretations and criteria for determinations of each assessment item.MethodsWe produced the new scales for the JSSF standard system by modifying the clinical rating systems established by the American Orthopaedic Foot and Ankle Society (AOFAS scales) and the Japanese Orthopaedic Association’s foot rating scale (JOA scale). We also provided interpretations of each assessment item and the criteria of determinations in the new standard system.ResultsWe improved the ambiguous expressions and content in the conventional standard rating systems so they would be easily understood by Japanese people. The result was five scales in total. Four were designed for use specifically for ankle-hindfoot, midfoot, hallux metatarsophalangeal-interphalangeal, and lesser metatarsophalangeal-ineterphalangeal sites; and the fifth was for the foot and ankle with rheumatoid arthritis. Furthermore, we described interpretations and criteria for determinations with regard to evaluation items in each scale.ConclusionsConventionally, the AOFAS scales or the JOA scale have been separately applied depending on the sites or disorders concerned, but it was often difficult to decide on scores during practical evaluations because of differing expressions in different languages and also because of ambiguity in the interpretation of each evaluation item and in scoring standards as well. JSSF improved these scales and added definite interpretations of evaluation items as well as criteria for the rating (to be reported here in part I). Because these steps were expected to improve the reliability of outcomes assessed by each scale, we examined the reliability in scores of the newly developed scales, which are reported in part II (in this issue).

Classification of Fractures of the Talus: Clear Differentiation Between Neck and Body Fractures

The treatment and prognosis of neck fractures (extra-articular) and body fractures (intra-articular) of the talus are different. Ratios between neck fractures and body fractures reported by different investigators vary widely (from 6:1 to 1:1), because it is difficult to differentiate fractures crossing the anteromedial aspect of the trochlea. We examined 215 fractures of the talus. By examining the inferior surface fracture line, we found that the 61 fractures crossing the anteromedial aspect of the trochlea could be differentiated into 28 neck fractures and 33 body fractures. We suggest classifying fractures of the talus based on the inferior, not superior, surface fracture line.

Development and reliability of a standard rating system for outcome measurement of foot and ankle disorders II: interclinician and intraclinician reliability and validity of the newly established standard rating scales and Japanese Orthopaedic Association rating scale

BackgroundThis study evaluated the validity and inter- and intraclinician reliability of (1) the Japanese Society of Surgery of the Foot (JSSF) standard rating system for four sites [ankle-hindfoot (AH), midfoot (MF), hallux (HL), and lesser toe (LT)] and the rheumatoid arthritis (RA) foot and ankle scale and (2) the Japanese Orthopaedic Association’s foot rating scale (JOA scale).MethodsClinicians from the same institute independently evaluated participating patients from their institute by two evaluations at a 1- to 4-week interval. Statistical evaluation was as follows. (1) The intraclass correlation coefficient (ICC) was calculated from data collected from at least two examinations of each patient by at least two evaluating clinicians (Data A). (2) Total scores for the two evaluations were determined from the distribution of differences in data between the two evaluations (Data B); each item was evaluated by determining Cohen’s coefficient of agreement. (3) The relation between patient satisfaction and total score was investigated only for patients who underwent surgery (Data C). Spearman’s rank correlation coefficient was obtained.ResultsParticipants were 65 clinicians and 610 patients, including those with disorders of the AH (313), MF (47), HL (153), and LT (50) and those with RA (47). From Data A, the ICC was high for AH and HL by JSSF scales and for AH, MF, and LT by the JOA scale. From Data B, the coefficient showed high validity for both scales for AH, with almost no difference between the two scales; the validity for HL was higher with the JOA scale than with the JSSF scale. From Data C, correlations were significant between patient satisfaction and outcome for AH and HL by the JSSF scales and for AH, HL, and LT by the JOA scale.ConclusionsThe validity of both scales was high. Clinical evaluation of the therapeutic results using these scales would be highly reliable.

Long-term follow up of talus fractures

Eighty-six patients who had experienced a fracture of the talus more than 10 years previously were assessed. The fracture had occurred in the neck of the talus in 52 feet and in the body of the talus in 27 feet. The fracture was complicated by dislocation in 47 feet, and aseptic necrosis had developed in 33 feet. The outcome was rated as excellent in 20 feet, good in 43, fair in 18, and poor in 7. The cause of poor outcome in the late stage was posttraumatic osteoarthritis secondary to avascular necrosis and incongruity of the joint surface. Early active exercise without weight bearing is recommended to prevent contracture and bone atrophy due to disuse, which may promote osteoarthrosis. Arthrodesis is recommended in patients with pain because the outcome is greatly improved by arthrodesis, even when performed more than 10 years after the injury.

Calcaneal fractures in children.

Calcaneal fractures are rare in children but frequent in adults. We report 18 cases (20 feet) of pediatric calcaneal fractures before the distal tibial growth line closed to assess the characteristics of pediatric calcaneal fractures and reveal differences in treatment and prognosis between children and adults. Twelve (60%) of the fractures were extraarticular, a higher percentage than in adults, and only four (20%) were intraarticular fractures associated with displacement. One case of avulsion fracture of the portion of the calcaneus where the Achilles tendon inserts, in which there was large displacement, and one intraarticular fracture were treated surgically. The outcome was good, including the surgical cases. One of the reasons that calcaneal fractures are considered rare in children is that they are missed, and thus care is required in making the diagnosis.

Closed complete rupture of the flexor hallucis longus tendon at the groove of the talus.

A rare case of closed complete rupture of the flexor hallucis longus tendon at its groove in the posterior process of the talus is reported in a soccer player who developed pseudarthrosis of the posterolateral tubercle of the talus after a Shepherds fracture. Partial rupture or tenosynovitis of the flexor hallucis longus tendon at this level is well known in classical ballet dancers and soccer players. Three cases of complete rupture of the flexor hallucis longus tendon near the metatarsophalangeal joint and three under the sustentaculum tali have been reported, but there have been no reports at the groove of the talus. Repair was accomplished by tendon graft, and active flexion of the interphalangeal joint is now possible.

Anterior Subtalar Dislocation: Case Report

Anterior subtalar dislocations are extremely rare. To our knowledge, only four cases have been reported in detail in the literature. A diagnosis of anterior subtalar dislocation should be confirmed by an anteroposterior view radiograph because lateral subtalar dislocation always includes some anterior displacement of the mid-foot. We report a case of anterior subtalar dislocation confirmed by both lateral and anteroposterior view radiographs and discuss its pathomechanism, diagnosis, and treatment.

A Kinematic Study of Ankle Joint Instability Due to Rupture of the Lateral Ligaments

Kinematic analysis of patients who have ruptured the ligaments of the ankle joint was performed to evaluate the function of those ligaments. Ten patients with ruptured lateral collateral ligaments and 10 normal volunteers were examined. Patients’ ages ranged from 17 to 29, averaging 20.9 years old. We performed kinematic evaluation by a three-dimensional optical analytic technique using surface markers. According to our results, the ankles with lateral ligament injury abnormally pronated and rotated externally at the time of heel strike and abnormally supinated and rotated internally during the acceleration phase.

The effects of tensile load on the metabolism of cultured chondrocytes.

The effect of cyclic tensile load on articular cartilage metabolism was investigated experimentally using 12 Japanese White rabbits. Chondrocytes obtained from the knee joints were cultured on plates with flexible silicone rubber bases. They were subjected to a cyclic (3 seconds on and 3 seconds off) tensile load for 24 hours with a maximum increase in area of 17%. Proteoglycan synthesis, collagen synthesis, and tissue inhibitors of metalloproteinases production by the chondrocytes under the load were quantified and compared with those produced by the control cells in an unloaded condition. The cultured chondrocytes under the cyclic tensile load perpendicularly aligned to the direction of the tensile load. Collagen synthesis and tissue inhibitors of metalloproteinases production increased significantly under the cyclic tensile load, although no significant change in proteoglycan synthesis was observed. These results suggested that the cyclic tensile load on the chondrocytes contribute to the regulation of articular cartilage metabolism in part.

Standard growth of the foot arch in childhood and adolescence--derived from the measurement results of 10,155 children.

BACKGROUND The definition of flatfoot remains analytically vague. Toward the purpose of establishing the standard values of the foot length and arch height in childhood and adolescence, large-scale measurement and investigation of the foot arch were conducted using a three-dimensional foot-measuring device. METHODS Measurements of foot structure were performed on 5311 boys and 4844 girls, for a total of 20,310 ft. of 10,155 children aged from 6 to 18 years during the 2006-2008 year period. The foot length (FL) and the navicular height (NH) were measured, and the arch height ratio (AHR (%)=NH×100/FL) was calculated. RESULTS The FL in boys showed an extension from the age of 6 to 14 and nearly reached a plateau at 14 years old. In girls, the extension was observed from the age of 6 to 13, and the FL came to a plateau at 13 years old. The NH in boys increased from the age of 6 to 13. In girls, the NH increased from the age of 8 to 13. The AHR, presented a normal distribution, and no differences were observed in the distribution for all ages in boys and girls. In boys, the AHR was almost flat until 11 years old, but elevated in the 11-13 year age period. In girls, the AHR was almost flat until 10 years old, but elevated in the 10-12 year age period. CONCLUSIONS We are certain that the data demonstrating the normal growth of the foot contribute to the diagnosis and treatment of the failure of the foot to thrive.