Young Yi

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.

The relationships between empathy, stress and social support among medical students

Objectives To examine the relationship between stress, social support, and empathy among medical students. Methods We evaluated the relationships between stress and empathy, and social support and empathy among medical students. The respondents completed a question-naire including demographic information, the Jefferson Scale of Empathy, the Perceived Stress Scale, and the Multidimensional Scale of Perceived Social Support. Corre-lation and linear regression analyses were conducted, along with sub-analyses according to gender, admission system, and study year. Results In total, 2,692 questionnaires were analysed. Empathy and social support positively correlated, and empathy and stress negatively correlated. Similar correla-tion patterns were detected in the sub-analyses; the correla-tion between empathy and stress among female students was negligible. In the regression model, stress and social support predicted empathy among all the samples. In the sub-analysis, stress was not a significant predictor among female and first-year students. Conclusions Stress and social support were significant predictors of empathy among all the students. Medical educators should provide means to foster resilience against stress or stress alleviation, and to ameliorate social support, so as to increase or maintain empathy in the long term. Furthermore, stress management should be emphasised, particularly among female and first-year students.

Arthroscopic Lateral Collateral Ligament Repair

BACKGROUND Lateral ulnar collateral ligament injury following unstable elbow dislocation can induce posterolateral rotatory instability that requires surgery. The aim of this study was to determine the effectiveness of arthroscopic repair of the lateral collateral ligament (LCL) complex in an unstable elbow joint. METHODS The study group consisted of 13 patients who experienced posterolateral rotatory instability after an unstable elbow dislocation with an injury to the lateral ulnar collateral ligament. The diagnosis was confirmed with computed tomography (CT), magnetic resonance imaging (MRI), and physical examination. The patients underwent arthroscopically assisted surgery between May 2011 and January 2013 and were followed for a minimum of 18 months postoperatively. Coronoid and/or radial head fractures combined with the ligament injury were treated through an arthroscopic technique. Range of motion, pain, outcomes according to the Mayo Elbow Performance Score (MEPS) and Nestor grading system, and surgical complications were evaluated. CT and MRI were performed at 3 months postoperatively, and isometric muscle strength was measured at the time of final follow-up. RESULTS At the time of final follow-up, at a minimum of 18 months, all 13 patients reported complete resolution of the instability and average (and standard deviation) extension of 3° ± 1°, flexion of 138° ± 6°, supination of 88° ± 5°, and pronation of 87° ± 6. The mean MEPS was 92 points and, according to this validated outcome score, the results were rated as excellent in 12 patients and good in 1 patient. According to the Nestor grading system, the results were rated as excellent in 11 patients and good in 2. Complete healing was seen on the 3-month follow-up MRI in 12 patients; however, 1 patient had mild widening of the radiocapitellar joint space with incomplete healing but no instability symptoms. All patients demonstrated normal strength on elbow flexion, extension, pronation, and supination at the final follow-up visit. CONCLUSIONS Arthroscopic repair of the LCL complex in patients with posterolateral rotatory instability after an unstable elbow dislocation, with or without an intra-articular fracture, is an alternative treatment option for restoring elbow stability and achieving satisfactory clinical and radiographic results. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Peri-talar re-alignment osteotomy for joint preservation in asymmetrical ankle osteoarthritis

Various types of re-alignment surgery are used to preserve the ankle joint in cases of intermediate ankle arthritis with partial joint space narrowing. The short-term and mid-term results after re-alignment surgery are promising, with substantial post-operative pain relief and functional improvement that is reflected by high rates of patient satisfaction. In this context, re-alignment surgery can preserve the joint and reduce the pathological load that acts on the affected area. Good clinical and radiological outcomes can be achieved in asymmetrical ankle osteoarthritis by understanding the specific deformities and appropriate indications for different surgical techniques. Cite this article: EFORT Open Rev 2017;2:324-331. DOI: 10.1302/2058-5241.2.160021

Is Antegrade Transmalleolar Drilling Method for Osteochondral Lesion of Talus Necessary? Iatrogenic Cystic Formation at the Tibia: A Report of Five Cases

Antegrade transmalleolar drilling method is one of the options for the treatment of osteochondral lesion of talus (OLT). We present five patients who underwent tibial drilling for treatment of OLT and later developed distal tibial cystic formation induced by cartilage opening or heat necrosis during drilling. Antegrade transmalleolar drilling can be a possible option for the treatment of OLT if the lesion is not easily reachable; however, other viable treatment should be considered due to its possibility of distal tibial pathologic change.

Comparison of Three-Dimensional Displacement Among Different Metatarsal Osteotomies

Hallux valgus is a slowly progressing complex 3-dimensional biomechanical process. Therefore, precise understanding of 3-dimensional deformity is essential for satisfactory clinical result. Uniplanar correction on anteroposterior view of foot would be insufficient, and rotation on frontal plane as well as sagittal alignment should also be well corrected. This article will review the 3-dimensional components of bony displacement in different surgical methods for hallux valgus correction.

Change in Talar Translation in the Coronal Plane After Mobile-Bearing Total Ankle Replacement and Its Association with Lower-Limb and Hindfoot Alignment

Background: Mobile-bearing total ankle replacement (TAR) enables motion at the tibial implant-polyethylene insert interface. This motion could lead to coronal translation of the talus relative to the tibia and may affect radiographic outcome. We aimed to assess the translation of the talus before and after mobile-bearing TAR to determine whether translation of the talus after TAR is associated with coronal plane alignment of the lower limb and hindfoot as well as to investigate the complications associated with talar translation. Methods: In this retrospective cohort study, we enrolled 153 patients (159 ankles) with a minimum follow-up of 3 years who underwent mobile-bearing TAR. The location of the talus in the coronal plane was quantified with use of talar center migration (TCM) on anteroposterior radiographs both preoperatively and at postoperative intervals, and the relationship between them was investigated. Radiographic parameters in the coronal plane—including mechanical axis deviation (MAD), lateral distal tibial angle (LDTA), hindfoot alignment angle, and hindfoot moment arm—were measured. The relationship between TCM and radiographic parameters in the coronal plane was assessed in each group. The complications associated with talar translation were examined during the same period. Results: During the 36-month follow-up period, the postoperative TCM showed a strong relationship with the preoperative TCM. Moreover, MAD, LDTA, and hindfoot alignment were significantly related to talar translation (p < 0.01). Complications included medial malleolar impingement in 5 cases (including delayed medial malleolar fracture due to medial impingement in 2 cases), insert dislocation in 1 case, and edge-loading in 2 cases; all of the cases with complications demonstrated implant overhang with talar translation. Conclusions: Talar translation in the coronal plane after mobile-bearing TAR correlates with the preoperative talar translation. Talar translation arises from deformities of MAD, LDTA, and hindfoot alignment, and it may be accompanied by various complications, as observed on coronal radiography. Therefore, additional realignment procedures for coronal malalignment should be considered to prevent talar translation after mobile-bearing TAR. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Joint space widening may be a paradoxical pathologic feature of early ankle arthritis

Category: Ankle, Ankle Arthritis Introduction/Purpose: Joint space narrowing and bony spur are typical pathologic feature of early ankle osteoarthritis. The meaning of joint space widening has never been discussed in previous literature. However, we found some osteoarthritic ankles which showed joint widening with diffuse spur change.(Fig.1) We hypothesized that joint space widening may be caused by malpositioning of the talus which may lead to degenerative arthritis. The purpose of this study were to investigate the radiological abnormalities in ankles with joint space widening. Methods: In order to define joint space widening and anterior subluxation of the talus, we included 72 ankles (66 people) with no abnormalities on plain radiographs into control group. We measured joint space and lateral talar station(LTS) on plain weight- bearing radiographs.(Fig.2) The 95% prediction interval of joint space (2.4 mm to 4.2 mm) and the LTS (-0.9 mm to 3.8 mm) in the control group were regarded as a normal range. The joint space widening was defined when the joint space was wider than 4.2 mm, and the anterior subluxation of talus was defined when the LTS was larger than 3.8 mm. Thirty-two ankles (29 people) with the joint space widening which underwent operation in our clinic between 2009 and 2014 were included in patient group. Ankle instability was determined on stress radiographs (Fig.2). In the patient group, we investigated the anterior subluxation of talus and the ankle instability, and the sites of spur in conventional CT. Results: The average age was 26 years (range:18 - 35) in the control group and 33 years (range:16 - 71) in the patient group. The mean joint space of the patient group was 4.7 mm (range: 4.3 mm to 6.0 mm). In the patient group, the LTS showed a mean of 6.4 mm (range 3.9 mm -10.7 mm). Because all the LTS in the patient group was over the 3.8 mm, the anterior subluxation of talus was showed in all ankles of the patient group. In the patient group, 31 ankles (97%) showed instability on anterior stress radiograph and 24 ankles (75%) showed instability on varus stress radiograph. All ankles in the patient group showed spurs on 4 sides of ankle, anterior, posterior, medial and lateral side. Conclusion: This study showed that paradoxical joint space widening may be a pathologic feature of early ankle arthritis which had diffuse spur change, anterior displacement of the talus and ankle instability.

Comparison of Weil Osteotomy and Cheilectomy for Second Metatarsophalangeal Joint Osteoarthritis

Category: Midfoot/Forefoot Introduction/Purpose: Second metatarsophalangeal (MTP) joint osteoarthritis (OA) was newly introduced at 2013. However, treatment of second MTP joint OA was not reported yet. The purpose of this study was to investigate the difference in clinical and radiographic outcomes between a chilectomy and an Weil osteotomy for treatment of second MTP joint OA. Methods: From August 2007 to January 2015, 61 feet of 51 patients who had been operated for second MTP joint OA by were retrospectively reviewed. The cheilectomy involved removal of bone spur on the second MTP joint. And the Weil osteotomy involved shortening of second metatarsal bone and removal of the bone spur (Fig.1). The average age was 60 years (95% CI: 57-62 years), the mean duration of follow up was 15 months (95% CI: 12-17months). The 61 feet were divided into two groups, the cheilectomy-group (36 feet) and the Weil-osteotomy-group(25 feet). The preoperative and the last follow-up radiological values and clinical values were measured. Length of the second metatarsal relative to the fourth (2-4 MT length ratio), second MTP joint OA grade, and Visual Analogue Scale (VAS) of pain were measured to evaluate clinical and radiological outcomes. Further, prevalence of second MTP joint disturbance at the time of last follow-up was measured. Results: There were no significant differences of age (P=0.83), gender (P=0.08), BMI (P=0.09), the preoperative 2-4 MT length ratio (P=0.68) and the second MTP joint OA grade (P=0.21) between the chilectomy-group and the Weil-osteotomy-group. In the cheilectomy-group, the last follow-up 2-4 MT length ratio and second MTP joint OA grade were not statistically different from the preoperative values. In the Weil-osteotomy-group, there was a significant decreasing of the 2-4 MT length ratio and a significant improvement of the second MTP joint OA grade between the preoperative values and the last follow-up values. For both the cheilectomy-group and the Weil-osteotomy-group, there was a significant improvement of the VAS of pain after treatment. However, the cheilectomy-group showed the statistically higher prevalence of second MTP joint disturbance than the Weil- osteotomy-group (Table.1). Conclusion: The Weil-osteotomy group showed superior result than the cheilectomy group clinically and radiologically in this study. Because shortening of second metatarsal bone could reduce a pressure of second MTP joint, joint space widening and joint disturbance decreasing could be achieved after the Weil osteotomy. We therefore recommend the Weil osteotomy as a treatment of second MTP joint OA.

Comparison of Radiographic Outcomes Between Dynamic Medial Column Stabilization and Lateral Column Lengthening

Category: Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening (LCL) has been recognized as a most effective surgical treatment for flexible flatfoot. But the LCL is known to be associated with many complications, which are lateral foot pain or calcaneocuboid arthrosis. In order to correct flexible flatfoot without these complications, we have developed a novel technique-dynamic medial column stabilization (dynamic-MCS). The dynamic-MCS consists of flexor hallucis longus transfer to the medial cuneiform, arthrodesis of first tarsometatarsal joint and medial displacement calcaneal osteotomy. The dynamic-MCS had different mechanism from the LCL. The dynamic-MCS directly restores longitudinal arch of flexible flatfoot, while the LCL indirectly restores the longitudinal arch. The purpose of this study is to investigate difference of radiographic outcomes between the dynamic-MCS and the LCL. Methods: Dynamic-MCS group included 16 flexible flatfeet of 16 patients which were treated with the dynamic-MCS from January 2014 to February 2015. The LCL group included 23 flexible flatfeet of 21 patients which were treated with the LCL from January 2011 to January 2014. A single surgeon performed the dynamic-MCS and the LCL in our clinic. We retrospectively evaluated radiological outcomes of the dynamic-MCS group and the LCL group. The preoperative and postoperative radiographic parameters were measured. Talonavicular coverage angle was measured on plain weight-bearing anteroposterior radiograph. Calcaneal pitch, talocalcaneal angle, talar angle, meary angle and 1st metatarsal declination angle were measured on plain weight- bearing lateral radiograph. Hindfoot alignment angle was measured on hindfoot alignment view. We compared postoperative improvements of the dynamic-MCS group with those of the LCL group in each radiographic parameters. All the postoperative values were obtained at the last follow-up. Results: The average age in the dynamic-MCS group was 41 years (95% CI: 33.5-47.9) and mean follow-up period was 12.9 months (minimum 10months). The average age in the LCL group was 36 years (95% CI: 27.9-43.1) and mean follow-up period was 22.2 months (minimum 12 months). The talonavicular coverage angle (P=0.002) and calcaneal pitch (P=0.002) of the LCL group showed significant higher improvement than that of the dynamic-MCS group. The talocalcaneal angle (P=0.030) and hindfoot alignment angle (P=0.005) of the dynamic-MCS group showed significant higher improvement than that of the LCL group. The improvement of the other radiographic parameters showed no significant difference between the dynamic-MCS group and the LCL group (Fig 1-B). Conclusion: Radiographic outcomes between the dynamic-MCS and the LCL were different for flatfoot correction in this study. The LCL showed higher correction of forefoot abduction than the dynamic-MCS. The dynamic-MCS showed higher correction of heel valgus than the LCL. Correction of flat longitudinal arch was not different between the dynamic-MCS and the LCL. To restore the flat longitudinal arch,the dynamic-MCS corrected the plantar-flexed talus and the LCL corrected the low calcaneal pitch. Lateral plantar pain and calcaneocuboid arthrosis did not occurred after the dynamic-MCS in our experience. We concluded that the dynamic-MCS could be a good treatment option for flexible flatfoot.