Tsukasa Kumai

Reconstruction of the Lateral Ankle Ligaments with Bone-Patellar Tendon Graft in Patients with Chronic Ankle Instability A Preliminary Report

Background Unsatisfactory long-term results have been reported after use of a Broström repair for patients with chronic ankle ligament insufficiency. Hypothesis Repair or reconstruction of both the anterior talofibular and calcaneofibular ligaments is essential for normal kinematics of the ankle-hindfoot. Study Design Case series. Methods Thirteen patients with chronic instability of the ankle were found at operation to have injuries of both the anterior talofibular and calcaneofibular ligaments, with a lack of healthy ligament margins suitable for suturing. Reconstruction of the ligaments was performed with bone-patellar tendon graft. The score devised by Good et al. was used to assess the patients’ clinical condition before the operation and at final follow-up. Results Before the operation, six patients had a grade 3 clinical condition and seven had a grade 4 condition. At a mean follow-up of 26.5 months, all patients had a grade 1 condition. The average talar tilt of the patients was improved from 18.4° ± 5.5° to 4.9° ± 2.6°, and the average anterior drawer sign was improved from 9.1 ± 2.6 mm to 5.8 ± 1.6 mm. Conclusion In cases of combined injuries, short-term results of reconstruction of the anterior talofibular and calcaneofibular ligaments using bone-split patellar tendon graft were good, with a low frequency of complications.

Correlation of Compensatory Alignment of the Subtalar Joint to the Progression of Primary Osteoarthritis of the Ankle

Background The etiology of primary osteoarthritis of the ankle is not well understood. The varus deformity of the ankle and the compensatory function of the subtalar joint are expected to be important factors in the progression of osteoarthritis. The purpose of this study was to document joint inclination at the various stages and to try to deduce the mechanism of primary, varus osteoarthritis of the ankle. Materials and Methods Weightbearing ankle anteroposterior (AP) views, lateral views and subtalar views were taken for 133 ankles in 80 patients (OA group) and 62 ankles in 50 subjects (control group). The OA group was divided into 5 radiographic stages. The inclination of the articular surface of the tibial plafond, the talar dome and the posterior facet of the calcaneus were measured from the radiographs. The inclination of the subtalar joint against the ankle was also calculated. At each stage, each value of the OA group was compared with the control group. Results The varus inclination of the articular surface of the tibial plafond progressed by stages; however, anterior opening was not significant at all stages. The valgus inclination of the subtalar joint progressed until the intermediate stage and converted to varus position at the later stage. Conclusion The compensatory function of the subtalar joint was most pronounced at the intermediate ankle arthritis stage.

Follow-up study of MRI for osteochondral lesion of the talus.

Characteristic MRI findings of osteochondral lesions of the talus have been reported. We examined how they change before and after treatment and discussed their significance. Twenty two ankles in 21 patients had MRI examination before and after treatment of the talar lesion. We evaluated the changes in the low intensity areas in T1-weighted image and the signal rims behind osteochondral fragment in T2-weighted image which have been reported as characteristic findings. Clinical symptoms were improved postoperatively in all subjects. The low intensity areas in T1-weighted image seen before the surgical treatment tended to decrease in size postoperatively. The low intensity area in T1-weighted image was reduced in 15 of the 22 ankles (68.2%). Low signal rim in T2-weighted image was seen in three cases before the treatment. All disappeared completely after arthroscopic drilling. Similarly, high signal rim in T2-weighted image seen in 13 cases before the treatment disappeared in 10 postoperatively. These findings were considered indicative that surgical treatments reduced abnormal stress of the underlying bone element due to unstable osteochondral fragment, leading to reduction of the low intensity area. The disappearance of signal rims in T2-weighted images was considered to indicate obliteration of the interface between the osteochondral fragment and the talar bed with bone union. We believe that MRI of the osteochondral lesion of the talus will be useful for postoperative evaluation allowing assessment of the need for further treatment. The decreasing size of low intensity areas in T1-weighted images and disappearance of signal rims behind the osteochondral fragment in T2-weighted images suggested healing of the osteochondral lesions.

Vascularized bone graft from the medial calcaneus for treatment of large osteochondral lesions of the medial talus

Background: Operative treatment of large osteochondral lesions of the talus is difficult because the blood supply is poor in the talar dome. The purpose of this study was to evaluate the results of a vascularized bone graft transfer from the medial calcaneus to the large osteochondral lesion. Methods: Four ankles in four patients with medial osteochondral lesions were treated through a medial transmalleolar approach. Vascularized bone graft was harvested from the medial calcaneus using the calcaneal branch of the posterior tibial artery and was placed through a fenestration of the medial aspect of the talar dome. The mean duration of postoperative followup was 34 (range 24 to 48) months. Clinical and radiographic evaluations were made before surgery and at final followup. Results: According to the AOFAS ankle-hindfoot scale, mean pain and function scores improved from 20 to 33 points and 30 to 43 points, respectively. The mean total score improved from 60 to 83 points. Plain radiography at followup showed slight osteosclerosis in all patients, but joint space narrowing was not seen in any patient. Cysts seen preoperatively on MRI or CT resolved after 12 months postoperatively, and MRI or CT did not reveal any findings indicative of osteonecrosis. Conclusions: Clinical and radiographic results were satisfactory. Vascularized bone grafts harvested from the calcaneus were successful for the treatment of large osteochondral lesions of the medial talus.

Proximal Spherical Metatarsal Osteotomy for the Foot with Severe Hallux Valgus

Background: A proximal spherical metatarsal osteotomy was devised to correct not only varus deviation of the first metatarsal, but also dorsiflexion. We expected to increase the medial longitudinal arch by adding plantar flexion at the osteotomy site. To investigate the limitations of this procedure for feet with severe hallux valgus, a followup study was performed on patients with preoperative hallux valgus angles greater than or equal to 40 degrees. Materials and Methods: Forty-eight feet in 37 patients (10 male, 27 female) (60 years; range, 20 to 84 years) were investigated. Mean followup was 4 years and 1 month, ranging from 2 to 8 years. The spherical osteotomy was performed using a curved chisel. A distal soft tissue procedure was done at the same time. Twenty feet received combined operations for their combined deformities. Results: While 81% of patients were satisfied with the results, 50% of those with preoperative hallux valgus angles greater than or equal to 50 degrees had postoperative hallux valgus angle greater than or equal to 20 degrees. In these patients, correction of metatarsus primus varus was good, but correction of valgus deviation of the hallux was fair. Mean correction toward plantar flexion was 1.5 degrees and no increase in arch height was achieved. Conclusion: The proximal spherical osteotomy could consistently achieve satisfactory results for the patients with hallux valgus angles less than 50 degrees. However, the corrections were worse in feet with more severe deformities. Furthermore, plantarflexion at the osteotomy site was offset by displacement at the first tarsometatarsal joint. If plantarflexion is indispensable, arthrodesis of the tarsometatarsal joint is recommended. Level of Evidence: IV, Retrospective Case Series

Ultrasound evaluation of cartilage damage in osteochondral lesions of the talar dome and correlation with clinical etiology: A preliminary report

Background: The current study aimed to determine whether the acoustic properties of living human cartilage during arthroscopy differ between damage from trauma and that from pigmented villonodular synovitis (PVNS). Methods: Nine patients were evaluated with ultrasound during arthroscopy. As a quantitative index of cartilage quality, the percentage maximal magnitude (maximal magnitude of the measurement area divided by that of the intact cartilage; %MM) was selected. After ultrasound evaluation, the measurement points were divided into two groups on the basis of the etiologic findings (group T: cartilage damage from trauma and group P: cartilage damage from PVNS) and analyzed for the presence of significant differences in ultrasound analysis. Results: In the ultrasound findings, the %MM values ranged from 34.4% to 92.3%. According to the etiologic differences, the mean %MM was 81.0% in group T and 39.3% in group P, and significantly higher in group T than in group P (p < 0.01). Conclusions: This study showed a correlation between the ultrasound results and the cartilage lesion etiology. Ultrasound evaluation may be useful for elucidating the process of articular cartilage degeneration with trauma and PVNS.

Sclerotherapy for Intractable Ganglion Cyst of the Hallux

BACKGROUND We devised a method of sclerotherapy using OK432. The present study comprised a retrospective followup of sclerotherapy outcomes. MATERIALS AND METHODS Eighteen feet in 18 consecutive patients (seven men, 11 women; mean age, 55 years) were treated with sclerotherapy. Previous surgery had been performed one to four times for seven feet. After aspirating the contents of the ganglion cysts, 0.2 to 0.3 ml of suspension of OK432 (lyophilized strep pyogenes) was injected. The volume of fluid aspirated was from 0.2 to 2.5 ml, with an average of 0.9 ml. Mean duration of followup was 3 years 6 months. Clinical evaluation was performed using the AOFAS hallux scale. RESULTS All ganglion cysts disappeared after sclerotherapy. However, recurrences were observed in eight feet. Mean duration until recurrence was 13 months. Sclerotherapy was again performed for all patients with recurrence. Re-recurrence occurred in three feet. A third sclerotherapy was performed for all three patients. All ganglion cysts had disappeared by final followup. Mean AOFAS score improved from 75 points before therapy to 95 points at followup. Six patients had complications with local redness and pain for 1 to 6 days after injection. CONCLUSION Sclerotherapy using OK432 is a minimally invasive treatment of symptomatic ganglion cysts of the hallux. Recurrence is common but complications are infrequent and self-limited.