Woo-Chun Lee

Indications for Supramalleolar Osteotomy in Patients with Ankle Osteoarthritis and Varus Deformity

BACKGROUND Osteotomies are reported to be effective for the treatment of most cases of primary and traumatic moderate osteoarthritis of the ankle joint. Because of unsatisfactory results following supramalleolar tibial osteotomy in several of our patients, we investigated the cause of the unsatisfactory results and the indications for this surgical procedure. METHODS Supramalleolar tibial osteotomy combined with fibular osteotomy was performed in sixteen ankles (sixteen patients) to treat moderate medial ankle osteoarthritis. The median duration of follow-up was 2.3 years (range, one to 6.5 years). Clinical assessment was performed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and the osteoarthritis stage was determined radiographically with use of the modified Takakura classification system. Clinical and radiographic results were compared among groups defined by high (≥9.5°) or low (≤4°) postoperative talar tilt and by the presence or absence of postoperative lateral subfibular pain. The optimal threshold of preoperative talar tilt for predicting high postoperative talar tilt was determined with use of receiver operating characteristic curve analysis. RESULTS The mean AOFAS score, mean Takakura stage, and mean values of all radiographic parameters were improved significantly after surgery. The preoperative talar tilt was correlated with the postoperative talar tilt (Spearman rho = 0.75, p < 0.01). The mean AOFAS score was higher (p = 0.02) and the mean radiographic stage was lower (p = 0.03) in the group with low postoperative talar tilt than in the group with high talar tilt. The optimal threshold for predicting high postoperative talar tilt was 7.3° of preoperative talar tilt, with a sensitivity of 100% and a specificity of 91.7%. The patients with lateral subfibular pain had a lower mean AOFAS score, a greater angle between the tibia and the ankle surface postoperatively, and greater postoperative heel valgus than those without lateral subfibular pain. CONCLUSIONS Supramalleolar osteotomy is indicated for the treatment of ankle osteoarthritis in patients with minimal talar tilt and neutral or varus heel alignment.

Alignment of Ankle and Hindfoot in Early Stage Ankle Osteoarthritis

Background: Supramalleolar osteotomy has been recommended to correct varus deformity of the tibial plafond; however, we have seen only a few ankles with significant deviation of alignment in early stage osteoarthritis, in which realignment treatments might be necessary to modify the course of the disease. Our hypothesis was that there are diverse radiographic features of the tibial plafond and hindfoot in varus ankle osteoarthritis. Materials and Methods: The study included 154 ankles of 98 patients with medial osteoarthritis, and 80 ankles of 80 normal subjects. On weightbearing AP radiographs, the tibial anterior surface angle (TAS), tibial axis-medial malleolus angle (TMM) and talar tilt angle was measured. On weightbearing lateral radiographs, tibial lateral surface angle (TLS) was measured. On the hindfoot alignment view, the heel alignment angle and heel alignment ratio were obtained. Inter- and intraobserver reliabilities were obtained for all radiographic parameters. The radiographic parameters were compared among the normal ankles and the ankles in different stages of ankle arthritis by the Takakura classification. Results: Inter- and intraobserver reliability were very high for all radiographic parameters except TLS. There was no statistically significant difference in TAS among Stages 2, 3a, and 3b. TAS was 86.9 ± 2.4 degrees, 86.2 ± 3.3 degrees, and 85.4 ± 3.1 degrees in Stages 2, 3a, and 3b, respectively. There was no significant difference in hindfoot alignment among normal, Stage 2, Stage 3a. The hindfoot alignment angle was 0.5 ± 8.1 degrees, 0.5 ± 6.8 degrees, and 9.6 ± 9.1 degrees in Stages 2, 3a, and 3b, respectively. Conclusion: Alignment of the tibial plafond and hindfoot was variable in early stage ankle osteoarthritis. Level of Evidence: III, Retrospective Case Control Study

A comparison of proximal and distal chevron osteotomy for the correction of moderate hallux valgus deformity

The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001). We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis.

Radiographic predictability of cartilage damage in medial ankle osteoarthritis.

BackgroundRadiographic grading has been used to assess and select between treatment options for ankle osteoarthritis. To use radiographic grading systems in clinical practice and scientific studies one must have reliable systems that predict the fate of the cartilage.Questions/purposesWe therefore asked whether (1) radiographic grading of ankle osteoarthritis is reliable and (2) grading reflects cartilage damage observed during arthroscopy. We then (3) determined the sensitivity, specificity, and predictive values of the radiographic findings.Patients and MethodsWe examined 74 ankles with medial osteoarthritis and 24 with normal articular cartilage based on arthroscopy. Arthroscopic findings were graded according to the modified Outerbridge grades and all radiographs were graded using the modified Kellgren-Lawrence, Takakura et al., and van Dijk et al. grading systems. The reliability of each radiographic grading system was evaluated. We correlated the radiographic grades and severity of cartilage damage for each radiographic grading system. Sensitivity, specificity, and predictive values of spurs and joint space narrowing with or without talar tilting then were determined.ResultsThe interobserver weighted kappa ranged from 0.58 to 0.89 and the intraobserver weighted kappa from 0.51 to 0.85. The correlation coefficients for the Kellgren-Lawrence, Takakura et al., and van Dijk et al. grades were 0.53, 0.42, and 0.42, respectively. Ankles with medial joint space narrowing (Stage 2 of Takakura et al. and van Dijk et al. grades) showed varying severity of cartilage damage. The positive predictive value of cartilage damage increased from 77% for medial joint space narrowing regardless of the presence of talar tilting to 98% for medial joint space narrowing with talar tilting.ConclusionsOur observations suggest the inclusion of talar tilting in grading schemes enhances the assessment of cartilage damage.Level of EvidenceLevel II, diagnostic study. See the Guidelines for Authors for a complete description of level of evidence.

Lengthening of fourth brachymetatarsia by three different surgical techniques

We carried out a retrospective study to assess the clinical results of lengthening the fourth metatarsal in brachymetatarsia in 153 feet of 106 patients (100 female, six males) using three different surgical techniques. In one group lengthening was performed by one-stage intercalary bone grafting secured by an intramedullary Kirschner-wire (45 feet, 35 patients). In the second group lengthening was obtained gradually using a mini-external fixator after performing an osteotomy with a saw (59 feet, 39 patients) and in the third group lengthening was achieved in a gradual manner using a mini-external fixator after undertaking an osteotomy using osteotome through pre-drilled holes (49 feet, 32 patients). The mean age of the patients was 26.3 years (13 to 48). Pre-operatively, the fourth ray of the bone-graft group was longer than that of other two groups (p < 0.000). The clinical outcome was compared in the three groups. The mean follow-up was 22 months (7 to 55). At final follow-up, the mean lengthening in the bone-graft group was 13.9 mm (3.5 to 23.0, 27.1%) which was less than that obtained in the saw group with a mean of 17.8 mm (7.0 to 33.0, 29.9%) and in the pre-drilled osteotome group with a mean of 16.8 mm (6.5 to 28.0, 29.4%, p = 0.001). However, the mean time required for retention of the fixation in the bone-graft group was the shortest of the three groups. Patients were dissatisfied with the result for five feet (11.1%) in the bone-graft group, eight (13.6%) in the saw group and none in the pre-drilled osteotomy group (p < 0.000). The saw group included eight feet with failure of bone formation after surgery. Additional operations were performed in 20 feet because of stiffness (n = 7, all groups), failure of bone formation (n = 4, saw group), skin maceration (n = 4, bone-graft group), malunion (n = 4, bone-graft and saw groups) and breakage of the external fixator (n = 1, saw group). We conclude that the gradual lengthening by distraction osteogenesis after osteotomy using an osteotome produces the most reliable results for the treatment of fourth brachymetatarsia.

A cohort study of patients undergoing distal tibial osteotomy without fibular osteotomy for medial ankle arthritis with mortise widening.

BACKGROUND Although the supramalleolar osteotomy can shift the weight-bearing axis laterally, it cannot reconstruct a widened ankle mortise caused by progression of medial ankle osteoarthritis. The aim of this study was to evaluate radiographic and clinical outcomes of distal tibial osteotomy without fibular osteotomy in patients with medial ankle osteoarthritis and mortise widening. METHODS Distal tibial osteotomy without fibular osteotomy was performed in eighteen patients to treat medial ankle osteoarthritis with mortise widening. Fifteen women and three men with a mean age of fifty-seven years (range, forty-nine to sixty-four years) were followed for a mean of thirty-four months (range, twenty-four to sixty-six months). Mortise widening was diagnosed using valgus stress radiographs and intraoperative examination. The clinical outcome was assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) score, visual analog scale (VAS) score for pain, and the ankle osteoarthritis scale (AOS) score. The translation of the talus within the ankle mortise, talar tilt, medial distal tibial angle, and anterior distal tibial angle were evaluated on weight-bearing radiographs made preoperatively and postoperatively. RESULTS The AOFAS score improved significantly from 78.4 points (95% confidence interval [CI], 74.6 to 80.5 points) to 89 points (95% CI, 86.5 to 90.5 points) (p < 0.001). The VAS score for pain also decreased significantly from 6.7 points (95% CI, 6 to 7.5 points) to 2.7 points (95% CI, 2.3 to 3.3 points) (p < 0.001). The mean AOS score was 29.8 points (95% CI, 22 to 38.2 points) at the latest follow-up. The center of the talus moved laterally within the ankle mortise after the distal tibial osteotomy. The mean medial distal tibial angle changed from 86.6° (95% CI, 85.7° to 87.6°) to 92.9° (95% CI, 91.6° to 94.3°) (p < 0.001), and the mean anterior distal tibial angle changed from 81.1° (95% CI, 78.6° to 83.6°) to 84.3° (95% CI, 81.9° to 86.4°) (p < 0.001). However, talar tilt was not corrected significantly (p = 0.916). CONCLUSIONS Distal tibial osteotomy without fibular osteotomy reduces pain in the short term in patients with ankle arthritis, a widened mortise, and minimal talar tilt.

Comparison of Outcome After Retinaculum Repair With and Without Fibular Groove Deepening for Recurrent Dislocation of the Peroneal Tendons.

Background: This study compared the operative outcome between retinaculum repair with and without fibular groove deepening for the treatment of recurrent traumatic peroneal tendon dislocation in young, active patients. Methods: A consecutive series of 29 patients who underwent operative treatment of recurrent peroneal tendon dislocation were evaluated. Thirteen patients were treated by the superior peroneal retinaculum repair with fibular groove deepening (group A) and 16 patients by superior peroneal retinaculum repair alone (group B). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS) score for pain, and overall patient satisfaction were used to evaluate the clinical outcome after a minimum follow-up period of 12 months postoperatively. In addition, mean time to return to sports activity and tourniquet time were compared between groups. Results: Mean AOFAS score improved significantly from 59.3 points preoperatively to 92.2 points at the final follow-up in group A and from 58.5 points preoperatively to 91.3 points at the final follow-up in group B. Mean VAS score also improved significantly from 5.0 points preoperatively to 1.0 points at the final follow-up in group A and from 4.9 points preoperatively to 1.2 points at the final follow-up in group B. Improvements in AOFAS and VAS scores at the final follow-up were not significantly different between the 2 groups. Mean time to return to sports activity was approximately 3 months in both groups. Mean tourniquet time in group B was significantly shorter than that in group A (42.2 vs 29.5 min). Conclusions: Isolated retinaculum repair compared to retinaculum repair with fibular groove deepening was a faster and simpler technique, but both techniques had good outcomes for the treatment of recurrent traumatic peroneal tendon dislocation. Level of Evidence: Level II, prospective, nonrandomized, comparative study.

Cartilage Lesions in Anterior Bony Impingement of the Ankle

PURPOSE The aim of this study was to investigate the correlations between spur severity, clinical characteristics, and articular cartilage lesions in patients with anterior bony impingement. METHODS The study included 57 ankles in 57 patients (48 male and 9 female patients; age range, 15 to 59 years) who had undergone a spur resection for anterior impingement. We excluded spurs in patients with osteoarthritis with joint space narrowing. Spur severity was classified by use of the McDermott scale. The correlations between spur severity, clinical characteristics, and articular cartilage lesions were evaluated. Differences in the mean lengths of the tibial spurs were examined according to the presence or absence of tram-track lesions, spur fragmentation, and loose bodies. RESULTS The duration of pain, degree of sports activity, and presence of mechanical instability showed no relation to spur severity. Of the ankles, 28 (49.1%) were grade 1, 1 (1.8%) was grade 2, and 28 (49.1%) were grade 3. Cartilage lesions were present in 46 ankles (80.7%). Spur severity was correlated with the degree of cartilage lesions (Spearman rho = 0.30, P = .02). Grade 3 ankles had more spur fragmentation than grade 1 or 2 ankles. The mean length of the tibial spurs with tram-track lesions or spur fragmentation was longer than that without these lesions. CONCLUSIONS The results suggest that cartilage lesions are present even in ankles with small spurs and that the degree of cartilage lesions increases as spurs become larger. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Treatment of brachymetatarsia of the first and fourth ray in adults.

Background: The purpose of this study was to review our results of treatment for brachymetatarsia involving the first and fourth ray. Materials and Methods: This study includes 47 feet of 30 patients who have been treated for brachymetatarsia of the first and fourth rays. The average age of patients was 26.4 (range, 20 to 36) years. The second and third metatarsals were shortened in 44 feet. In 41 feet, the fourth metatarsals were lengthened at one stage with resected bones from the second and third metatarsals. The lengthening or shortening of each metatarsal was recorded. American Orthopaedic Foot and Ankle Society score and subjective satisfaction were obtained for the clinical evaluation. Results: The average amount of shortening in the second and third metatarsal was 8.9 ± 2.8 mm and 7.2 ± 2.6 mm respectively. The average amount of lengthening in the fourth metatarsal was 10.3 ± 4.1 mm. Postoperative AOFAS score was 83.2 ± 7.6. Stiffness of the fourth metatarsophalangeal joint was the most common cause of functional deficit. All except three patients were satisfied with some reservation. Additional operations were performed on eleven feet. Conclusion: Most adult patients with the first and fourth ray brachymetatarsia have been subjectively satisfied with the treatment with some loss of function mostly due to stiffness of the metatarsophalangeal joints. Level of Evidence: IV, Retrospective Case Series

Simultaneous reconstruction of the medial and lateral ligament complexes of the ankle joint with semitendinosus tendon allograft. A case report.

Ankle ligament injuries occur frequently during recreational activities as well as competitive sports1. Although most heal with little medical intervention, recurrent instability can occur in 15% to 48% of patients2-6 and long-term sequelae can occur in up to 50% of patients7. Even following nonoperative treatment such as physiotherapy, bracing, or medication, continued problems may require surgical intervention, and the normal stability and biomechanics of the ankle joint should be reestablished to prevent the development of arthritis8,9. Several procedures for the reconstruction of the lateral ankle ligaments have been proposed, and the overall success rates of these operations have been reported to be >80%6,9-15. However, reconstruction of the deltoid ligament has received relatively little attention16-20. Moreover, operative management of chronic global ankle instability, including an incompetent deep deltoid ligament, has rarely been described, to the best of our knowledge18,21. We present a case of combined insufficiency of the medial and lateral ankle ligaments that was treated successfully with simultaneous reconstruction of those ligaments with a semitendinosus tendon allograft. The patient was informed that data concerning the case would be submitted for publication, and he consented. A thirty-six-year-old man presented with discomfort in the left ankle. He had sustained an ankle injury seven years earlier during a soccer game, after which recurrent sprains had often occurred with only minor exertion. He did not participate in sports activity as much as he wanted to because of a feeling of the ankle giving way. He was seen at our clinic with symptoms of instability and a clunking sensation in the ankle joint two months after sustaining another, severe ankle injury. On physical examination, there was no effusion or swelling …