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Category: Trauma; Ankle Introduction/Purpose: Ankle fracture is one of the most common fractures over the age of 50 years. However, there is a lack of research on osteoporotic ankle fractures compared to other osteoporotic fractures. Recently, some studies have been published that Hounsfield Unit(HU) measuring bone attenuation from CT scan is used for assessing the bone density of not only the hip and spine but also extremities such as the distal radius and proximal humerus. This study aims to evaluate the correlation between HU of distal tibia without ankle fracture and DEXA-BMD and determine the cut-off value of HU for osteoporosis diagnosis. Additionally, this study determines whether the HU of the distal tibia obtained from the preoperative CT scan of ankle fractures helps evaluate patients with osteoporotic ankle fractures. Methods: From June 2016 to August 2020, We retrospectively studied foot and ankle traumatic patients who are postmenopausal women or men over 50 years. They conducted a foot or ankle CT scan containing the axial images of the distal tibia and DEXA- BMD within three months. Patients with open fractures with severe displacement or arthritic change were excluded. The mean HU was obtained from two sequential axial images of the distal tibial metaphysis's largest region of interest (ROI), more than 1cm proximal to the tibial plafond. We divided the patients into Group A without ankle fractures and Group B with distal tibia or fibula fractures in the ankle. The correlation analysis was done between the distal tibial HU and DEXA-BMD. We obtained the cut-off value of the distal tibial HU for osteoporosis using receiver operating characteristic(ROC) curves and compared the results between the two groups. Results: Group A was 38 cases(mean age 69.9), and Group B was 59 (mean age 71.0). There were no statistical differences in patients' characteristics, the mean distal tibial HU, bone density, T-score, and rate of osteoporosis in BMD. All HU values in both groups showed excellent inter- and intra-observer reliability(All intraclass coefficients>0.9). Both groups had significant correlations between the distal tibial HU and DEXA-BMD, especially in the femur neck and L3 spine(r=0.706, 0.622, p< 0.001 in Group A, r=0.625,0.499, p< 0.001 in Group B). The cut-off value for osteoporosis of the distal tibial HU was 153.15(sensitivity 73.9%, specificity 86.7%; area under the curve(AUC) 0.841, 95% CI 0.716-0.965, p< 0.001) in Group A. The cut-off value of Group B was 167.35(sensitivity 66.7%, specificity 75.9%; AUC 0.737, 95% CI 0.610-0.865, p=0.002). Conclusion: The distal tibial HU values on the axial images on the CT showed a significant correlation with the central bone of DEXA-BMD. The distal tibial HU value showed excellent reliability with or without fracture. HU value can be easily obtained using a preoperative ankle CT scan without additional cost & radiation exposure to patients with ankle fractures. Therefore, it can help treat osteoporotic ankle fractures by screening for osteoporosis and deciding the fixation method of surgery.

Category: Bunion Introduction/Purpose: The most frequent complication after hallux valgus corrective surgery is recurrence of deformity. Many factors have been identified previously as risk factors for recurrence. Especially, inadequate correction of the distal metatarsal articular angle (DMAA) has been reported one of the surgical risk factors for recurrence. This study aimed to investigate the recurrence rate after hallux valgus correction using Scarf and Akin osteotomy and to identify the significance of postoperative DMAA as a risk factor of recurrence. Methods: We reviewed 87 hallux valgus patients (122 feet) who received Scarf and Akin osteotomy from January 2007 to August 2015. Clinical outcomes were evaluated using VAS and the AOFAS score. Radiological outcome measures included hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) in serial weight bearing radiograph. Recurrence was defined as more than 20 degrees of HVA in final follow-up radiograph. Radiological factors associated with recurrence including high DMAA were evaluated and analyzed. Results: Mean follow-up duration was 20.6 months (range, 12.0-46.5 months) and mean age was 44 years (13-80 years). The VAS and AOFAS scores were significantly improved at the final follow-up (7.0 to 2.0, p

Category: Midfoot/Forefoot Introduction/Purpose: To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring Methods: Forty-four patients (mean age, 29.2 years; range, 13 to 54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided based on the osteosynthetic method: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography Results: The AOFAS midfoot and visual analog scale scores of both groups improved at the last postoperative follow-up. The times to return to social activities were 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p = 0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group Conclusion: The tension band wiring technique could be another osteosynthesis treatment choice for fixation of the accessory navicular bone

Category: Trauma Introduction/Purpose: To introduce reliable and newly developed radiographic measures based on a lateral ankle radiograph to assess a syndesmotic reduction after screw fixation and to compare with the radiographic measures based on the anteroposterior (AP) and mortise radiographs. Methods: The postoperative ankle radiographs of 34 ankle fracture cases after screw fixation for concurrent syndesmosis injury were reviewed. Two radiographic parameters were measured on each AP and mortise radiograph; tibiofibular clear space (TFCS) and tibiofibular overlap (TFO). Five radiographic parameters were measured on the true lateral radiographs; the anteroposterior tibiofibular (APTF) ratio, anterior tibiofibular ratio (ATFR), posterior tibiofibular ratio (PTFR), distances of intersection of the anterior fibular border and the tibial plafond to anterior cortex of the tibia (AA’), and the intersection of posterior fibular border and tibial plafond to the tip of the posterior malleolus (BB’). In addition, the distance (XP) between the fibular posterior margin (X) crossing tibial plafond or the posterior malleolus and posterior articular margin (P) of the tibial plafond was measured on the lateral view. Results: Using TFCS and TFO in the AP and mortise radiographs, malreductions of syndesmosis were estimated in 17 of 34 cases (50.0%). Using the introduced and developed radiographic measures in the lateral radiographs, syndesmotic malreductions were estimated in 16 out of 34 cases (47.1%). Seventeen cases (50.0%) showed no evidence of postoperative diastasis using the radiographic criteria on the AP and mortise view, 10 cases (58.8%) of whom showed evidence of a malreduction on the lateral radiograph. The newly developed measurements, XP, were measured 0 in 11 out of 34 cases (32.4%). Conclusion: The reduction of syndemosis after screw fixation can be accurately assessed intraoperatively with a combination of several reliable radiographic measurements of lateral radiograph and traditional radiographic measurements of AP and mortise radiograph. Using various radiographic parameters selectively, malreduction could be prevented even when some parameters are difficult to measure because of implants or when posterior malleolar fracture is accompanied.

Category: Midfoot/Forefoot Introduction/Purpose: To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring. Methods: Forty-four patients (mean age, 29.2 years; range, 13–54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided into two groups by the method of osteosynthesis: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot & Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography. Results: The AOFAS midfoot and visual analog scale scores of both groups were improved at the last postoperative follow-up. The time to return to social activities was 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p = 0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group. Conclusion: The tension band wiring technique could be another treatment choice of osteosynthesis for fixation of the accessory navicular bone.

Category: Bunion Introduction/Purpose: The scarf osteotomy has gained in popularity for the treatment of a symptomatic hallux valgus deformity due to its inherent stability, versatility of correction and early mobilization. We have reported parallel-shaped modified scarf osteotomy(PSMSO) with good functional outcomes and no complication as stress fracture or troughing. However, we encountered second transfer metatarsalgia after the osteotomy. The scarf osteotomy can be shortened, but there was no specific amount of shortening that will produce transfer metatarsalgia in limitation of our literature review. In this study, we measured the shortening of first metatarsal length and investigated the relation of first metatarsal length and second transfer metatarsalgia after PSMSO for hallux valgus deformity. Methods: We retrospectively reviewed 168 consecutive PSMSOs performed in 124 patients with hallux valgus deformity between March 2009 and August 2015. Concomitant other pathologies of foot or previous second metatarsalgia were excluded. After excluding 45 cases, 123 cases in 88 patients were included. For clinical assessment, VAS, the AOFAS Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP) Scale were obtained. The hallux valgus angle (HVA), the intermetatarsal angle (IMA), the distal metatarsal articular angle (DMAA), the first metatarsal length measured by a modified Davies and Saxby’s method and the protrusion of second metatarsal relative to first metatarsal using the Maestro’s method were assessed on standard weight bearing radiographs of the foot. For evaluation of the development of second transfer metatarsalgia, callosity or tenderness beneath the second metatarsal head was investigated. After identifying the lesion, we divided two groups with and without second transfer metatarsalgia and compared the variables after propensity score matching. Results: Mean follow-up period was 20.6±7.8 (12-66) months. The mean VAS and AOFAS Hallux MTP-IP score improved significantly (p