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Background: During the modified Broström procedure for chronic ankle instability, surgeons often experience cases with insufficiently restored mechanical stability even after anatomical ligament repair. In these cases, longer postoperative immobilization and delayed rehabilitation can be required, and a risk for recurrence of instability may persist. This study aimed to evaluate the clinical usefulness of suture-tape augmentation based on intraoperative stress radiographs during anatomical ligament repair for chronic ankle instability., Methods: Twenty-four patients who underwent additional suture-tape reinforcement because of residual mechanical instability on intraoperative stress radiographs were followed up ≥3 years. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Changes in mechanical stability were analyzed through periodic stress radiographs, and postural control ability was evaluated with the modified Romberg test., Results: FAOS and FAAM scores improved significantly from preoperative mean 55.1 and 52.4 points to 92.3 and 90.2 points at final follow-up, respectively ( P  < .001). Talar tilt angle and anterior talar translation improved significantly from preoperative mean 15.8 degrees and 13.6 mm to 2.9 degrees and 4.2 mm, respectively ( P  < .001). Balance retention time improved significantly from preoperative mean 3.6 to 6.4 seconds ( P  < .001). Although 9 patients experienced sprain injury after surgery, no patient showed recurrence of mechanical and subjective instability, and 21 patients (87.5%) were able to return to preinjury level of sports activity., Conclusion: Evaluation of residual mechanical instability through intraoperative stress view and additional suture-tape augmentation showed satisfactory clinical outcomes at midterm follow-up. Suture-tape augmentation based on intraoperative stress radiographs seems to be a useful surgical option for patients with insufficiently restored mechanical stability even after anatomical ligament repair. This combined procedure can provide a reliable mechanical stability that can be performed after recognition of residual instability during the index surgery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: Tibiofibula fractures occur across all age groups, and postoperative complications are frequent. An accurate and rapid classification methodology for these fractures could significantly assist physicians. Clinically, tibiofibula fractures occur at various locations, and the fracture types are not evenly distributed., Methods: This paper presents a deep learning model for the interpretable multi-label classification of tibiofibula fractures in two-dimensional (2D) CT scan images, addressing the challenges posed by a limited sample size and an uneven distribution of fracture types. We retrospectively collected 2494 2D CT images from 168 patients with tibia or fibula fractures. The types of fractures identified in the CT scan images were classified according to the AO/OTA fracture classification. A deep learning model was developed to classify composite fractures in 2D CT images, providing visual interpretation for each identified class. The visual interpretation was given with the saliency maps constructed by the Grad-CAM++ method. The deep learning model was trained using data augmentation techniques to address class imbalance and the limited dataset size., Results: Our experiments demonstrated that the proposed model achieved a mean average precision (mAP) of 95.71%., Conclusions: The saliency map-based visual interpretation enables the verification of whether the model provides reliable decision-making for classification.

Background: The conventional operative method to treat an osteochondral lesion of the talus (OLT) is through bone marrow stimulation (BMS). Autologous osteochondral transplantation (AOT) is being used as an alternative option in cases with a large OLT, accompanying subchondral cyst, and/or failed BMS. We aimed to compare the intermediate-term clinical and radiologic results between medial and lateral OLTs after an AOT procedure., Methods: Among the patients who underwent AOT, 45 cases with at least 3 years' follow-up were included in this retrospective study. We had 15 cases of lateral lesions and selected 30 cases of medial lesions matched for age and gender. Lateral lesions were resurfaced without an osteotomy; medial lesion resurfacing was combined with a medial malleolar osteotomy. Clinical assessment was performed using the Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM). Radiographic assessment included the irregularity of articular surface (subchondral plate), the progression of degenerative arthritis, and the change of the talar tilt., Results: The mean FAOS and FAAM scores significantly improved after surgery in both groups. Up to 1 year postoperatively, there was significant difference in FAAM scores between the both groups (mean 75.3 points in medial group and 87.2 points in lateral group, P  < .001). Delayed union or malunion of the malleolar osteotomy was found in 4 cases (13%) in the medial group. In addition, the progression of joint degeneration was observed in 3 cases (10%) in the medial group. There were no significant differences in the irregularity of articular surface and the change of talar tilt between both groups., Conclusion: A comparison between medial and lateral OLTs treated with AOT demonstrated comparable intermediate-term clinical outcomes. However, patients with medial OLT required a longer period to restore ability for daily and sport activities. In addition, we found more complications and higher rate of progression in the radiologic arthritis grade after medial malleolar osteotomy., Level of Evidence: Level IV, retrospective comparative study.

Nonunion is known to be a relatively common complication following ankle arthrodesis. Various fixation techniques have been introduced to enhance the stability and to improve fusion rate. With the use of anterior plate supplementation, postoperative wound problems have been frequently reported despite better fusion rate. This study was performed to determine the effects of tibialis anterior (TA) tenotomy on wound complications and functional outcomes after anterior fusion plating for severe ankle arthritis. Forty-six patients who underwent ankle arthrodesis using anterior fusion plate were followed for more than 2 years. TA tenotomy was performed prior to wound closure in all patients. As a control group, 38 patients who underwent arthrodesis without TA tenotomy were analyzed. Functional outcomes were evaluated with Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure. Wound complication rate, time to fusion, fusion rate, time to pain relief were evaluated. Mean Ankle Osteoarthritis Scale and Foot and Ankle Ability Measure scores significantly improved to 32.6 and 69.4 points at final follow-up, respectively. As compared to control group (33.8 and 67.7 points), there were no significant differences in functional outcomes. As postoperative wound complications, there were 1 case of wound dehiscence and 1 case of superficial wound infection. TA tenotomy group showed a significantly lower wound complication rate (4.3%) than control group (23.7%) (p < .001). While there were no significant differences in fusion rate, time to fusion, and time to pain relief between both groups, control group needed higher rate of implant removal. Ankle arthrodesis using anterior fusion plate in conjunction with TA tenotomy appears to be an effective surgical option for end-stage ankle arthritis, with excellent fusion rate and less wound complication rate. Although there were no specific functional deficits related to absence of TA tendon, further studies are needed to determine long-term effects of TA tenotomy in patients with a fused ankle., (Copyright © 2022 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population., Methods: We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures., Results: Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074)., Conclusion: Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

While the effectiveness of suture-tape augmentation for chronic ankle instability has been supported biomechanically and clinically, little information is available regarding biological changes of the lateral ligaments postoperatively. This study aims to quantitatively evaluate ligament regeneration with MRI after suture-tape augmentation. Forty-six patients underwent MRI scan at follow-up of a minimum of 1 year after lateral ligaments augmentation using suture-tape. The signal-to-noise ratio (SNR) and width of anterior talofibular ligament (ATFL) were measured on preoperative and postoperative MRI by 3 researchers. The degree of biological healing of ATFL was analyzed based on the change of SNR and comparison with normal contralateral ankle. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Mean Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved significantly from 63.1 to 92.7, and 59.6 to 91.5 points at final follow-up, respectively (p < .001). Mean SNR and width of ATFL were changed insignificantly from 8.24 to 7.96, and 1.88 mm to 2.05 mm at final follow-up, respectively (p = .391, .509). As compared to contralateral side, there were significant differences in both mean SNR and width of the ATFL, respectively (p < .001, p = .0012). Spearman's correlation analysis revealed no significant association between clinical outcomes and degree of biological healing of ATFL based on MRI. Despite significant improvement in patient-reported clinical outcomes, the influence on ligament regeneration of suture-tape augmentation for chronic ankle instability was insignificant. In addition, there was no significant correlation between clinical outcomes and degree of biological healing of the ATFL., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Because modified Broström procedure provides a restoration of mechanical stability by reinforcing attenuated host tissue, poor quality of remnant ligamentous tissue is considered as a prognostic factor for ligament repair surgery. The purpose of this study was to assess the intermediate-term clinical results after anatomic anterior talofibular ligament repair augmented with suture-tape for chronic lateral ankle instability (CLAI) with poor quality of ligament remnants., Methods: 64 patients with the insufficient anterior talofibular ligament confirmed by preoperative magnetic resonance image and intraoperative inspection were followed for ≥3 years after the augmented anterior talofibular ligament repair. The clinical outcomes were assessed with the Foot and Ankle Outcome Score, Foot and Ankle Ability Measure. Measurements on stress radiographs were performed to assess the changes of mechanical instability. To identify the changes of functional ankle instability, postural control ability was analysed with single leg stance test., Result: Foot and Ankle Outcome Score and Foot and Ankle Ability Measure scores improved from preoperative mean 58.3 and 53.6 points to 90.2 and 88.7 points at final followup, respectively ( p < 0.001). Talar tilt angle and anterior talar translation improved from preoperative mean 16.5° and 13.4 mm to 3.2° and 4.4 mm at final followup, respectively ( p < .001). Two patients (3.1%) showed a recurrence of instability. Although balance retention time improved from preoperative mean 3.9-6.2 seconds at final followup ( p < .001), a significant side-to-side difference was found., Conclusion: Anatomic anterior talofibular ligament repair augmented with suture-tape appears to be a useful surgical option for CLAI with poor quality of ligament remnants at intermediate-term followup. Through anatomic repair of attenuated ligaments and suture-tape augmentation, this combined procedure can provide the reliable restoration of mechanical stability and advantages of the anatomic ligament repair. Postural control deficit compared to the uninjured ankle supports a necessity of continuous proprioceptive-oriented rehabilitation.

Background: We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients., Methods: In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)-reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications., Results: At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group ( P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures ( P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024)., Conclusion: Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures., Level of Evidence: Level III, retrospective comparative study.

Purpose : Residual functional ankle instability regardless of the restoration of mechanical stability after the lateral ligament repair or reconstruction can cause recurrent sprain. The purpose of this study was to identify the sequential changes of joint-position sense, peroneal strength, postural control, and functional performance ability after the modified Broström procedure (MBP) for chronic ankle instability. Methods : A total of 46 patients (46 ankles) who underwent the MBP for chronic ankle instability were eligible for this study and were followed up for 1 year postoperatively. The changes of joint-position sense and peroneal strength were periodically evaluated with an isokinetic dynamometer. Postural control ability was evaluated using a one-leg stance test with eyes closed. The functional performance ability examination comprised a one-leg hop test, a six-meter hop test, and a cross three-meter hop test. Results : The error in joint-position sense significantly improved from a mean 4.3° to 2.8° ( p < 0.001). Peak torque for eversion significantly improved from a mean 18.2 Nm to 21.2 Nm ( p = 0.024). Balance retention time significantly improved from a mean 4.7 s to 6.4 s ( p < 0.001). Among the functional performance tests, only the one-leg hop test showed a significant improvement postoperatively ( p = 0.031). At 1 year postoperatively, the recovery ratios compared to the unaffected ankle were 67.9% in joint-position sense ( p < 0.001), 86.9% in peroneal strength ( p = 0.012), and 74.4% in postural control ( p < 0.001), with significant side-to-side differences. Conclusion : Although joint-position sense, peroneal strength, postural control, and functional performance ability were significantly improved after the MBP, recovery ratios compared to the unaffected ankle were insufficient up to 1 year postoperatively. Level of Evidence : Level IV (prospective case series).

Background: This study aimed to compare clinical and radiographic outcomes and recurrence rates after reverse proximal chevron metatarsal osteotomy (PCMO) for patients with hallux valgus (HV) with or without metatarsus adductus (MA). We hypothesized that patients with MA would have poorer outcomes and a higher radiographic recurrence rate than those without MA., Methods: This retrospective single-surgeon series comprised 144 patients (173 feet) with moderate to severe HV, treated with PCMO and Akin osteotomy without lesser metatarsal procedures, who were grouped according to the presence (MA group) or absence of MA (non-MA group). Clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score, pain visual analog scale (VAS), and patient satisfaction rating. Radiographic assessments included metatarsus adductus angle (MAA), HV angle (HVA), and intermetatarsal angle (IMA)., Results: The prevalence of the MA was 24.2%. The mean MAA was 23.1 ± 3.3 degrees in the MA group. There were no differences in the mean AOFAS score and pain VAS score at the final follow-up between the 2 groups (all P > .05). The patient satisfaction rate was 73.8% in the MA group vs 90.1% in the non-MA group ( P = .017). The mean postoperative HVA and IMA significantly improved at the final follow-up in both groups, respectively (all P < .001). Preoperative and postoperative HVA were larger in the MA group vs non-MA group. However, no significant difference was found in the improvement of HVA and IMA after surgery between the 2 groups (all P > .05). The recurrence rate was 28.6% in the MA group and 6.1% in the non-MA group ( P < .001)., Conclusion: HV patients associated with the MA had a higher degree of preoperative HV, lower correction of the HVA, higher radiographic recurrence rate, and poorer patient satisfaction than those without MA post-PCMO without lesser metatarsal procedures. Therefore, a more extensive HV correction procedure or the addition of a lesser metatarsal realignment procedure may need to be considered., Level of Evidence: Level III, retrospective comparative series.

Background: Proximal femoral fracture (PFF), such as intertrochanteric femoral fracture or femur neck fracture, and its management are crucial issues to surgeons. PFF has been dramatically is becoming exponentially prevalent, and it is at high risk of complication and mortality because it is frequently associated with serious trauma and advanced age, especially in patients treated with anticoagulants or antiplatelet agents. Surgical management is essential for the treatment of PFF. Unfortunately, current surgical procedures have been related to accompanied by vascular complications, including laceration, hemorrhage, thrombosis, embolism, intimal flap tear and pseudoaneurysm. Furthermore, these vascular injuries following surgical management of PFF are potentially limb- and life-threatening. Of the complications after operation of PFF, femoral arteriovenous fistula (AVF) is rare, but remains a challenging problem because it is frequently associated with significantly high mortality and morbidity and is very difficult to treat., Methods: A systematic literature review was conducted using the PRISMA guidelines with no language restriction. We searched scientific publications via PubMed, Embase, Cochrane central register of controlled trial, Google Scholar, the KoreaMed and the Research Information Sharing Service database. The goal of this study was to report on the incidence, clinical presentation, diagnosis, treatment, associated complications, morbidity and mortality of femoral AVF caused by PFF and to draw special attention to its prevention and management., Results: A total of 7 case reports on femoral AVF associated with operation of PFF were identified, and one our case was added to the systematic analysis. Of the 8 cases, 4 were male and 4 were female under the age of 67.87±18.44; 6 (75.0%) survived without any events, 1 (12.5%) survived with a sequela of peroneal nerve impairment, and 1 (12.5%) died of multi-organ failure and hypovolemia., Conclusions: The incidence of femoral AVF associated with PFF is extremely low, though it appears to increase with the rising frequency of PFF. With a very few exceptions, complications following internal fixation are potentially limb- and life-threatening. There is still no definite consensus on the standardized diagnostic or therapeutic modalities. Therefore, surgeons should keep in mind that this serious complication requires early diagnosis and prompt treatment, which should not be underestimated. Femoral AVF following operation of PFF should be meticulously managed, because untreated fistulae result in serious unexpected complications including renin-mediated hypertension, high-output heart failure and venous and/or arterial insufficiency. Surgical treatment is still the gold standard for such cases, but in limited cases endovascular procedures using embolization and closure device can be a good treatment option., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 Annals of Translational Medicine. All rights reserved.)

Background: We examined whether the intramedullary nailing (IMN) can be used as an alternative modality to the plate fixation (PF) in patients with distal fibular fracture with displaced fragments., Patients and Methods: The eligible patients of two treatment arms (IMN group: n=30 and the group: n=31) were evaluated at 3, 6, 9 and 12 months postoperatively, for which functional outcome measures include differences in the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and the Olerud Molander Ankle Scores (OMAS) between the two groups. In addition, radiological outcome measures include differences in radiological outcome scores at 12 months between the two groups. Differences in the percentage of frequency of postoperative complications between the two groups served as safety outcome measures., Results: At 3 months, the AOFAS and OMAS were significantly higher in the IMN group as compared with the PF group (p<0.0001 and p=0.0177, respectively). At 6 months, the AOFAS were significantly higher in the IMN group as compared with the PF group (p=0.0255). But there were no significant differences in the OMAS between the two groups (p=0.1077). At 9 and 12 months, there were no significant differences in the AOFAS and OMAS between the two groups (p=0.4334 and 0.3227, respectively at 9 months and p=0.8731 and 0.7610, respectively, at 12 months). These results indicate that the IMN group achieved a faster recovery as compared with the PF group. At 12 months, the radiological outcome scores were 3.67±0.60 in the IMN group and 3.71±0.52 in the PF group (p=0.7816). All the patients of each group achieved a bony union at 12 months. At 12 months, the percentage of frequency of postoperative complications was significantly lower in the IMN group as compared with the PF group (p=0.0227)., Conclusions: The IMN might be considered as an alternative surgical modality to the PF in patients with distal fibular fracture with displaced fragments. But further large-scale, multi-center studies are warranted to establish our results., (Copyright © 2019. Published by Elsevier Masson SAS.)

Purpose: Iatrogenic radial nerve injury caused by surgical exposure of the humerus is a serious complication. We aimed to describe the course of the radial nerve at the posterior humeral shaft using a three-dimensional (3D) reconstruction technique by utilizing computed tomography (CT) images of living subjects. We hypothesized that the course of the radial nerve in the posterior aspect of the humeral shaft would be reliably established using this technique and the measurements would have satisfactory intraobserver/interobserver reliabilities., Methods: This in vivo anatomical study utilized 652 upper extremity CT angiography images from 326 patients. A 3D modeling of the humerus and radial nerve was performed. We evaluated the segment of the radial nerve that lays directly on the posterior aspect of the humeral shaft and measured its proximal point, mid, and distal points. The shortest distances from the olecranon fossa to these points were defined as R1, R2, and R3, respectively. The relationships between these parameters and humeral length (HL) and transcondylar length (TL) were evaluated, and the intraobserver/interobserver reliabilities of these parameters were measured., Results: The HL was 293.6 mm, and TL was 58.64 mm on average. The R1 measured 159.2 (range 127.1-198.2) mm, R2 was 136.6 (105.7-182.5), and R3 was 112.8 (76.8-150.0) mm on average ( p < .001). The intraobserver/interobserver reliabilities ranged from 0.90 to 0.98., Conclusion: The course of the radial nerve at the posterior aspect of the humeral shaft can be reliably established using the 3D reconstruction technique, and all measurements had excellent intraobserver/interobserver reliability.

Background: This retrospective comparative study was performed to evaluate the clinical outcomes after surgical treatment for Bosworth fracture-dislocation, and to analyse the prognostic factors related to postoperative outcomes., Methods: Fifteen patients were followed for ≥2 years after Bosworth fracture-dislocation. Twenty-five ankle fracture-dislocations as control group were enrolled to compare clinical outcomes. Clinical evaluation consisted of the AOFAS and Olerud-Molander scores. Patient and injury factors were analysed to identify the outcome predictors., Results: There were no significant differences in either clinical evaluation score as compared to control group (P=0.245, .302, respectively). The time interval to operation and number of manual reduction attempts were found to be predictive factors for poor outcomes (P=0.004, .038, respectively)., Conclusion: As compared to more common patterns of ankle fracture-dislocations, intermediate-term clinical outcomes after Bosworth fracture-dislocations were statistically comparable. Delayed surgical reduction and repeated attempts at closed reduction appear to be negative outcome predictors., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Despite a consensus regarding the correlation of peroneal strength deficit with chronic ankle instability (CAI), there are conflicting reports in regards to peroneal strength as assessed by isokinetic dynamometer in patients with CAI. The purpose of this study was to evaluate the changes of isokinetic strength in patients with CAI compared to ankle sprain copers and normal individuals., Methods: Forty-two patients (CAI group) with chronic ankle instability who were scheduled for the modified Broström procedure met inclusion criteria. Thirty-one ankle sprain copers (ASC group) who were eligible at 6 months after acute injury and 30 controls were recruited. The muscle strength associated with four motions of the ankle were evaluated using isokinetic dynamometer., Results: Peak torque for inversion and eversion at 60°/s angular velocity were significantly lower in the CAI group compared to the ASC and control group (P=.004, P<.001, respectively). Deficit ratio of peak torque for eversion at 60°/s and 120°/s in the CAI group were 33.8% and 19.8%, respectively, which indicated significant side to side differences (both P<.001). The evertor/invertor strength ratio (0.59) for eversion at 60°/s was significantly lower in the CAI group (P<.001)., Conclusion: As compared to the ankle sprain copers and normal individuals, patients with chronic ankle instability who were scheduled for modified Broström procedure demonstrated a significant weakness of isokinetic peroneal strength. Isokinetic muscular assessment can provide the useful preoperative informations regarding functional ankle instability focusing on peroneal weakness., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: This study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity., Methods: There were 23 cases in laxity group (Beighton score ≥5 points) and 175 in non-laxity group with a mean followup of 46.3 months. Clinical evaluation consisted of the AOFAS score, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis., Results: Recurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (P=.218). There were no significant differences in clinical and radiographic measurements at final followup between the 2 groups. Preoperative HVA and IMA were found to be predictive factors of recurrence (OR=6.3, 4.2; P=.001, .018, respectively)., Conclusion: There were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Although various minimally invasive procedures for chronic ankle instability are increasingly being used, a question regarding whether these procedures can be a viable alternative of the modified Broström procedure remains controversial. This study was conducted to compare the intermediate-term clinical outcomes between lateral ligaments augmentation using suture-tape and modified Broström repair in a selected cohort of patients., Methods: Sixty female patients with chronic lateral ankle instability were randomly assigned and underwent surgical treatments by one surgeon. Twenty-eight patients with suture-tape augmentation and 27 modified Broström procedures were followed ≥2 years and analysed in this comparative study. The clinical evaluation included the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and stress radiographs. Medical expense related with operation was analysed to evaluate the cost-effectiveness., Results: There were no statistically significant differences in the clinical outcomes between two procedures based on FAOS, FAAM, recurrence rate of instability, and stress radiographs. Total medical expense was approximately 1.3 times more in the suture-tape group (P<0.001), despite shorter operation time., Conclusions: Lateral ankle ligaments augmentation using suture-tape showed the similar clinical outcomes but low cost-effectiveness, as compared to modified Broström repair for young female patients with chronic ankle instability., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Objective: Radiologic parameters are important factors for planning the treatment for thoracolumbar fracture. However, we noted that measurements of the degree of kyphosis by lateral decubitus plain radiography were greater than supine CT. The cause of this discrepancy is unclear., Methods: We retrospectively reviewed the plain radiographs and CT scans of 90 patients with thoracolumbar fractures (fracture group). We measured the segmental sagittal angle (SSA) on lateral decubitus plain radiographs and in the median sagittal plane on CT scans obtained in the supine position. The method agreement (plain radiography versus CT) was determined by utilizing Bland-Altman plots. For the purpose of comparison, the same analyses were performed in a group of age and sex-matched controls (normal group). After establishing the method disagreement in the fracture group, the factors that contributed to the difference in the SSA between plain radiography and CT, as well as their threshold values, were determined., Results: On Bland-Altman plots for the fracture group, the mean difference was 4.53° [95% confidence interval (CI) - 4.87° to 13.93°]. For the normal group, the mean difference was - 0.64° (95% CI - 5.87° to 4.58°). On univariate analysis, male sex, thoracolumbar level, and SSA(X) were significant factors associated with ∆SSA (P = 0.03, 0.002, and 0.000, respectively). Multivariable regression analysis showed that SSA(X) was the only significant factor. Receiver operating characteristic curve analysis indicated that the optimal threshold of SSA(X) was 17° with a sensitivity of 78% and a specificity of 75% (area under curve: 0.752)., Conclusions: The mean SSA determined on lateral decubitus plain radiographs indicated significantly more kyphosis than that determined on CT images obtained in supine position. When the SSA on plain radiography is more than 17°, there might be a significant discrepancy between the two imaging modalities. This discrepancy seems to be mainly attributable to the difference in patient positioning (lateral decubitus position for plain radiography versus supine position for CT imaging).

Background: Although the peroneal muscles are known to be the major dynamic lateral stabilizers of the ankle, little information is available regarding the change in muscle strength and relation with the outcomes after lateral ligament repair surgery. The purpose of this study was to identify the effects of peroneal strength on the validated functional outcome measures after the modified Broström procedure (MBP) for chronic ankle instability., Methods: Forty-one patients (41 ankles) who underwent MBP using suture anchors were eligible and followed up to 2 years postoperatively. Functional evaluation consisted of the Foot and Ankle Outcome Score (FAOS), and Foot and Ankle Ability Measure (FAAM). The changes of peroneal strength were evaluated using an isokinetic dynamometer. Differences in the functional outcomes between the 3 groups divided according to the recovery rate of peroneal strength were analyzed., Results: Peak torque and total work for eversion in 60 degrees/s angular velocity significantly improved from a mean 8.1 and 5.2 Nm preoperatively to 11.4 and 6.9 Nm at postoperative 2 years, respectively ( P < .001, P = .038). The deficit ratio of peak torque for eversion significantly improved from a mean 38.6% to 17.4%, and a significant side-to-side difference was found ( P = .011). There were no significant differences in FAOS, FAAM, and measurements of stress radiograph between the 3 groups., Conclusions: Although restoration of peroneal strength postoperatively was about 82.6% of the unaffected ankle, patient-reported function in daily and sport activities were satisfactorily improved. Postoperative isokinetic strength of the peroneals demonstrated no statistically significant effects on the functional outcomes after MBP., Level of Evidence: Level III, prospective comparative case series.

Chronic varus instability or recurrent subluxation following isolated interphalangeal dislocation of the hallux is a rare injury. No consensus has been reached regarding the best joint-salvage procedure for patients with the failed collateral ligament reconstruction using tendon graft. We report a case who achieved satisfactory clinical outcome through a modified surgical procedure (revision collateral ligament reconstruction augmented with suture-tape)., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Although avulsion fractures of the calcaneal tuberosity are rare injuries, these can be a challenging problem with frequent complications, such as loss of reduction and soft tissue problem. Anatomical reduction and internal fixation are indicated to avoid these pitfalls and to restore function of the triceps surae. However, the best fixation device and operative technique are still controversial. A case that achieved satisfactory clinical outcome through a reattachment technique using the suture bridge augmentation for Achilles tendon avulsion fracture with osteoporotic bony fragment is presented., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy., Methods: Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height., Results: Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group ( P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group ( P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity., Conclusions: Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up., Level of Evidence: Level IV, retrospective case series.

Purpose: To investigate which method can predict tibiofibular diastasis more accurately among the tibiofibular interval at the ankle joint level or previous parameters taken 1 cm above the joint line., Methods: An arthroscopic examination was performed in 78 consecutive patients with anterolateral ankle pain. Four different methods were performed to take measurements of the tibiofibular interval using an axial computed tomography (CT) scan under existing arthroscopic diagnosis. Three previously reported parameters were assessed at 1 cm above the joint level. In the first method, 2 measurements were obtained. The anterior measurement was the closest distance between the anterior border of the fibula and anterior tibial tubercle. The posterior measurement was the closest distance between the medial border of the fibula and posterior tibial tubercle. In the second method, an angle between the fibular axis and the line connecting the anterior and posterior tibial tubercle was measured. In the third method, the nearest distance between the line perpendicular to the line connecting the tubercles at the anterior tubercle of the distal tibia and the anterior-most margin of the fibula was measured. The fourth method, which was developed in this study, measured the narrowest tibiofibular distance at the joint level. Data were analyzed using Student's t-test and the receiver operating characteristic curve to make comparisons among 4 CT-based parameters., Results: In the comparison between the patients with arthroscopic diastasis and without diastasis, the posterior parameter in the first method and the narrowest tibiofibular distance at the joint level in the fourth method showed a significant difference (P < .05) The areas under the receiver operating characteristic curve (AUCs) of the anterior and posterior parameter of the first method were 0.58 (95% confidence interval [CI], 0.43-0.73; P = .167) of anterior measurement and 0.6 (95% CI, 0.45-0.75; P = .029) of posterior measurement, respectively. The second and third methods presented AUCs of 0.59 (95% CI, 0.44-0.74; P = .458) and 0.48 (95% CI, 0.33-0.64; P = .987), respectively. The fourth method presented an AUC of 0.86 (95% CI, 0.75-0.94; P = .000). When the syndesmosis was measured at the joint level, 2 mm of syndesmosis interval as a cutoff value showed 76% of sensitivity and 81% of specificity., Conclusions: Syndesmosis assessment using an axial CT scan at the joint level best correlated with the arthroscopic examination. When there is more than 2 mm of widening in syndesmosis on the axial CT scan at the joint level, there is a high likelihood of diastasis of the distal tibiofibular syndesmosis in patients who are suspicious clinically to have acute or chronic syndesmosis lesion., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Although a ball and socket ankle deformity is usually congenital and asymptomatic, abnormal inversion and eversion mobility can result in recurrent ankle sprain and osteoarthritis. This retrospective study was performed to evaluate the clinical and radiologic outcomes of ankle fusion combined with calcaneal sliding osteotomy for severe arthritic ball and socket ankle deformity., Methods: Fourteen patients with severe arthritic ball and socket ankle deformity were followed for more than 3 years after operation. The clinical evaluation consisted of American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS) for pain, and subjective satisfaction score. The period to fusion and union of osteotomy, the change of hindfoot alignment angle, and complications were evaluated radiologically., Results: AOFAS and FAAM scores were significantly improved from an average of 37.4 and 34.5 points to 74.6 and 78.5 points, respectively. VAS for pain with walking over 20 minutes was significantly improved from an average of 8.4 points to 1.9 points. The average satisfaction score of patients was 88.9 points. The difference in heel alignment angle (compared to contralateral side) was significantly improved from an average of 34.8 to 5.4 degrees. There were 2 cases of progressive arthritis in an adjacent joint and 1 case of failed fusion., Conclusions: Ankle fusion combined with calcaneal sliding osteotomy can be an effective operative option for ball and socket ankle deformity with advanced arthritis. In spite of increased complication rate, reliable pain relief, and restoration of gait ability through correcting hindfoot malalignment could improve the quality of life., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2016.)

Compared with lateral ankle instability, medial ankle instability has many fewer treatment strategies and fewer reconstructive options available. The best method for deltoid ligament reconstruction remains unclear. Percutaneous deltoid ligament augmentation using suture tape represents a novel alternative technique for chronic medial ankle instability., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Study Design: A single-institution, single-surgeon retrospective review., Objective: To assess the efficacy of posterior only approach with short instrumentation and prolonged suction drainage in managing lumbar pyogenic spondylitis., Summary of Background Data: Several methods of posterior surgical treatment for pyogenic spondylitis have been reported, there have been few reports regarding the efficacy of posterior only approach with short instrumentation including even inflamed segment., Methods: Thirty-three patients with lumbar pyogenic spondylitis who underwent posterior decompression and lumbar interbody fusion with short instrumentation including the inflamed segment and catheter drainage were enrolled. Clinically infection control (erythrocyte sedimentation rate and C-reactive protein normalization time) and onset of ambulation were reviewed. Moreover, achievement of fusion and changes of sagittal alignment were investigated radiologically., Results: In all 33 cases, infection was controlled successfully without any recurrence. There was no breakage of implant. Postoperative interval to normalization of erythrocyte sedimentation rate was average 69.4 days and C-reactive protein was 25.4 days, respectively. Ambulation was started at average 5.8 postoperative days. Successful interbody fusion was confirmed radiologically in all the cases at a mean of 5.4 months. Sagittal angle of fixed segment was average 6.9 degrees of lordosis before operation, which became more lordotic to 11.5 degrees just after operation, but decreased to 4.7 degrees of lordosis at the final follow up. Actually final sagittal alignment was almost same as preoperative status (P = 0.24)., Conclusion: By achieving favorable clinical and radiological results, short instrumentation and prolonged suction drainage with posterior only approach seemed to be an effective method in managing lumbar pyogenic spondylitis., Level of Evidence: 3.

Background: Although the modified Brostrom procedure has had excellent clinical results, postoperative complications such as skin irritation by suture material and problematic scar formation occur. This prospective study was performed to evaluate the clinical outcomes of mini-open ligament augmentation (internal brace technique) using suture tape for chronic ankle instability in a select cohort of patients., Methods: Thirty-four young female patients with less than 70 kg of body weight were followed for more than 2 years after suture tape augmentation for lateral ankle instability. The clinical evaluation consisted of the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) score, Sefton grading system, and the period to return to various activities. Measurement of talar tilt angle and anterior talar translation was obtained from stress radiographs to evaluate the longevity of mechanical ankle stability., Results: FAOS and FAAM scores had significantly improved to 92.5 points at final follow-up (P < .001). According to the Sefton grading, 31 cases (91.2%) achieved satisfactory functional results. The period to return to exercise was on average 10.2 weeks for jogging and 9.6 weeks for walking on uneven ground. The average subjective satisfaction score of patients was 93.8 points, and satisfaction with the scar was 98.5 points. Talar tilt angle and anterior talar translation had significantly improved to an average of 4.5 degrees and 4.1 mm, respectively, at final follow-up (P < .001). There were no complications such as skin irritation and wound infection, except for 1 case of chronic inflammation., Conclusions: Minimally invasive suture tape augmentation seems to be an effective alternative for young women with chronic ankle instability. Because there is a possibility of progressive elongation over time, the longevity of mechanical ankle stability and the proper indication for using the internal brace technique should be addressed in future studies., Level of Evidence: Level IV, case series study., (© The Author(s) 2015.)