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Category: Arthroscopy; Ankle Introduction/Purpose: Arthroscopic bone marrow stimulation (BMS) has been considered as the 1st-line treatment for osteochondral lesions of the talus (OLT) with its simplicity, cost-effectiveness, low complication rate and successful clinical results in numerous studies. However, there were few studies which had investigated long-term clinical outcomes about the arthroscopic BMS. The purpose of this study is to evaluate the long-term outcomes of arthroscopic BMS for OLT and to identify prognostic factors that affect the outcomes. Methods: A retrospective analysis was performed for 202 ankles (189 patients) who underwent arthroscopic BMS as a primary surgery for the OLT between January 2001 and December 2008 with more than 10 years of follow-up. Visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, Foot and Ankle Outcome Score (FAOS) were assessed as clinical outcomes and re-operation data were collected. The clinical scores were compared along the stream of time. Kaplan-Meier plot and log rank test showed survival outcomes of OLT in the long-term follow-up. Factors associated with revision surgery were evaluated with multivariate Cox proportional hazard regression model. Results: The VAS scales were improved from 7.11 +- 1.73 (preoperatively) to 1.51 +- 1.61 (3 to 6 years after BMS), and 2.00 +- 1.67 (over 10 years after BMS) (P < 0.001). Also the AOFAS ankle-hindfoot scale were also improved from 58.39 +- 13.7373 (preoperatively) to 85.85 +- 10.31 (3 to 6 years after BMS), and 82.56 +- 11.62 (over 10 years after BMS) (P < 0.001). FAOS at final follow-up was compatible with those of other literatures with short- and mid-term follow-up. Re-operation rate was 5.94 % (12 / 202 ankles). According to multivariate regression analysis, significant factors associated with the revision surgery were large- size (greater than 150mm2) OLT (P = 0.009) and body mass index greater than 25 kg/m2 (P = 0.014). Conclusion:: Arthroscopic bone marrow stimulation is an effective and reliable operative procedure for the primary treatment of osteochondral lesions of the talus with favorable long-term outcomes at a mean follow-up of 13.9 years. Therefore, we recommend this procedure for the 1st-line treatment of the OLT. Success of arthroscopic BMS depends on the size of the OLT and the body mass index of patients.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Periprosthetic osteolysis in total ankle arthroplasty (TAA) is a substantial problem. It may cause implant failure and has potential to affect long-term implant survival. To prevent major revisional arthroplasty, it is important to make an early diagnosis of osteolysis and decide an appropriate timing of surgical intervention such as bone graft. We report our updated result of bone graft for osteolysis after TAA associated with clinical and radiologic outcome. Methods: We retrospectively evaluated our consecutive series of 440 primary TAAs performed between May 2004 and August 2018 and identified those who had a subsequent bone graft procedure. A total of 38 bone graft procedures for periprosthetic osteolysis after TAA were performed. Mean time-interval between primary TAA and bone graft was 5.09 years (range 17.0 to 127.0 months). Location of osteolysis, bone grafting method and clinical outcome parameters using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score were recorded. Results: Radiographs revealed periprosthetic osteolysis in 51.8% (58/112) of distal tibial lesions and 41.1% (46/112) of talar lesions. Autogenous iliac bone graft was used in most of procedures. Both mean VAS and AOFAS scores improved significantly at the last follow-up (p

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: There are myriad procedures for hallux valgus deformity. Minimally invasive Surgery (MIS) using percutaneous technique has been recently introduced for the treatment of hallux valgus. The purpose of this study was to evaluate early radiological and clinical outcomes of MIS using percutaneous technique for hallux valgus deformity. Methods: This was a prospective cohort study of 19 feet (13 patients) undergoing operative correction of hallux valgus using MIFS technique with minimum 2-year of follow-up. Outcome measures include the visual analogue scale (VAS) for pain and the American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal (AOFAS-HMI) scale, Foot Function Index (FFI), hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Results: All patients were traced for a mean of 27.2 (range 24.7 - 30.4) months. The VAS, AOFAS-HMI scale and FFI were improved respectively with significance after operation (p

Objectives This study aimed to investigate the epidemiology of intravenous midazolam-induced postoperative expressive aphasia (EA). Methods The incidence rate, risk ratio, and contributing factors to intravenous midazolam-induced postoperative EA were analyzed retrospectively in 6756 orthopedic patients. A telephone interview was conducted with patients with EA after surgery. Results Patients were allocated to either the midazolam group (n = 6178) or no-midazolam group (n = 578). Twelve patients developed EA in the midazolam group, with an incidence of 0.19%, and no patient developed EA in the no-midazolam group. The mean age of EA patients was 70 years, and 92% were women. Among them, 75% received general anesthesia, and the mean dose of midazolam was 1.8 mg. EA was reversed in nine of 12 (75%) patients within 4 minutes of flumazenil administration, and >60 minutes were required to reverse EA in the other three patients (25%). Conclusion Intravenous midazolam administration for preoperative sedation caused transient EA in 0.19% of patients, especially elderly women who received general anesthesia, and EA could be reversed by flumazenil.

A median nerve injury in the forearm may lead to devastating sequelae if left untreated. Even with appropriate treatments involving microsurgical techniques and postoperative care, patients may still experience lasting neuropathic pain that significantly reduces their quality of life. Pulsed radiofrequency (PRF) is widely performed to alleviate such neuropathic pain caused by trauma. A 47-year-old man visited our pain clinic with allodynia, hyperalgesia, paresthesia, skin color changes, and atrophy in the right forearm. In the orthopedic department, the patient was treated by neurectomy of the median nerve to manage the intractable pain. However, the effect was unsatisfactory. The fourth median nerve block performed in our pain clinic after neurectomy produced good results, and ultrasound-guided PRF of the median nerve was performed. The patient showed 80% relief of symptoms within 5 hours after the procedure. The visual analog scale score for the forearm decreased from 8/10 to 1/10. This case suggests that ultrasound-guided PRF can be a therapeutic option for the management of refractory neuropathic pain after neurectomy in patients with a median nerve injury.

Category: Trauma Introduction/Purpose: Posterior malleolus fractures occur most commonly in the setting of a rotational ankle fracture. In the treatment of posterior malleolus fractures, the indications for the surgical procedure are determined by the size of the fragment and the articular congruity of the tibiotalar joint. In general, the size of the bone fragment is known to be an indication of surgery if it involves more than 25% of the joint surface, and if it is less than that, anatomical reduction and fixation of only lateral or medial malleolus was suggested. We evaluate the clinical and radiological results of fixation and early range of motion exercise using a single cannulated screw when the fragment of the posterior malleolus fracture is less than 25%. Methods: Among 60 patients with SER stage 3 or 4 who had undergone surgery from March 2010 to March 2014, percutaneous cannulated screw fixation was performed for posterior malleolus in 30 cases (Group 1). In the other 30 cases (Group 2), we did not perform the fixation for posterior malleolus fracture and only cast immobilization was done after fixation for lateral or medial malleolus. Mean follow-up period was 14.8 weeks(12~18) for the Group 1, 12.9 weeks(12~18) for Group 2. Mean age of patients was 46.6(19~78) for Group 1, 50.2(19~74) for Group 2. The range of motion was checked at week 2, 4, 12, and at last follow-up. Results: There was no significant difference of time to union and union rate between two groups, and AOFAS score between two groups also showed no significant difference(91.94(83~100) vs 90.8(85~100), p = 0.45). The range of motion of ankle joint at the final follow-up showed significant difference (Ankle ROM 52.7’ (45’~65’) vs 45.3’(35’~65’), (p

Category: Bunion Introduction/Purpose: Minimally invasive surgical techniques have challenged objectives in hallux valgus surgery, attempting to obtain good clinical outcomes with the least damage to anatomic structures, low complication rates, short time of surgery, cosmetic advantages and an earlier recovery. However, because patients with generalized ligamentous laxity have a major risk for recurrence, arthrodesis of the first tarsometatarsal (TMT) joint is an established method for the surgical treatment of the patients with generalized ligamentous laxity. This study aims to investigate the clinical and radiographic outcomes of joint-preserving minimally invasive distal metatarsal osteotomy in moderate hallux valgus patients with generalized ligamentous laxity. Methods: Thirty-two feet from 29 patients were involved prospectively with mean follow-up of 16.8 (range, 10 – 26) months. Generalized ligamentous laxity was assessed in all patients and the patients were divided into two groups (16: 16) with the result. Clinical outcomes were assessed using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Outcome Score (FAOS). Radiographic parameters were evaluated by preoperative and postoperative weight bearing radiographs. Results: Mean tourniquet time was 30.4 (range, 19 – 44) minute and additional procedures were required in 6 cases in each group. The mean VAS (p

Category: Ankle, Arthroscopy Introduction/Purpose: The gold standard for the surgical treatment of chronic lateral ankle instability is the modified Brostrom procedure. Surgery aims to re-establish ankle stability and function, without compromising ankle motion. Recently introduced all inside arthroscopic modified Brostrom procedure coincide with the goal on that aspect. The purpose of this study was to investigate the early outcomes of all inside arthroscopic modified Brostrom operation for chronic ankle instability. Methods: From January 2015 to August 2016, 30 patients were included. The visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle–hindfoot score, Foot and Ankle Outcome Score (FAOS), and Karlsson score were used to evaluate clinical outcomes. Anterior talar translation and talar tilt were used to evaluate radiologic outcomes. All patients had lateral ankle instability. All patients had giving way, persistent pain, and an inability to resume their preinjury activity level for more than 6 months. Clinical outcome evaluations were performed preoperatively, at 3 months and 6 months postoperatively, and at a final follow-up using the VAS score, the AOFAS ankle-hindfoot score, FAOS, and Karlsson score. Radiologic outcome evaluations were performed preoperatively and at 1 year postoperatively at final follow-up using anterior talar translation, and talar tilt angle. Results: Thirty patients (19 males and 11 females) were followed up for a mean of 11.0 (range 4 – 23) months. The VAS, AOFAS, 1 FAOS subscale (Quality-of-life) and the Karlsson scores were improved significantly at the each follow-up period of 3 month, 6 month and 1 year postoperatively. Other 4 subscales of FAOS showed no significant outcomes (Table 1). The mean anterior talar translation and talar tilt showed significant improvements from 5.8 mm (SD = 0.4) and 7.9° (SD = 1.0) to 5.3 mm (SD = 0.3) and 5.7° (SD = 0.6) at the final follow-up each (p = 0.034, p=0.034). Conclusion: The arthroscopic modified Brostrom technique could be a viable alternative to the gold-standard open modified Brostrom procedure for anatomic repair of chronic lateral ankle instability. It can yield outstanding functional and clinical outcomes without adverse effects in terms of pain.

Category: Ankle, Tumor Introduction/Purpose: Tumors arising in the foot and ankle are often need surgical treatment. However, there is hesitation about the surgical treatment of anxiety about general anesthesia in some patients. Ultrasound-guided nerve block can be a useful method of anesthesia for tumor surgery in the foot and ankle.This study was performed to compare general anesthesia and ultrasound (US)-guided nerve block for tumor surgery in the foot and ankle. Also, whether US-guided nerve block is a useful method of anesthesia for tumor surgery was investigated. Methods: In this prospective, randomized study, 50 patients who underwent tumor surgery between February 2013 and February 2016 were allocated to two groups: general anesthesia (n = 25, or US-guided nerve block (n = 25). All patients completed a questionnaire with three questions 2 weeks after surgery. For the nerve block group, the procedure duration, interval between the procedure and onset of the anesthetic effect, the point of loss of the anesthetic effect, intraoperative, postoperative visual analog scale (VAS) pain score, and discomfort during surgery were assessed. Results: There was no patient in which the anesthetic was changed to another method during the operation. VAS pain score of postoperative 1 and 6 h was significantly different between the nerve block group (2.2 ± 1.5 and 3.0 ± 1.8, respectively) and general anesthesia group (5.2 ± 3.9 and 5.4 ± 4.5, respectively) Twenty three US-guided nerve block (92%) and 17 general anesthesia patients (68%) reported that they would prefer the same type of anesthesia if they were to undergo tumor surgery in the foot and ankle again; these differences were significant (P < 0.05). There were no long-term complications, such as neurological deficits or infection, after the procedure in all patients. Conclusion: Tumor surgery, such as tumor excision or biopsy, amputation, and other procedures, was performed safely and effectively under US-guided nerve block. These results indicated that US-guided nerve block for tumor surgery is a highly satisfactory and safe procedure without complications and is available for use by any orthopedist.

Category: Ankle Arthritis Introduction/Purpose: Periprosthetic osteolysis in total ankle arthroplasty (TAA) is a substantial problem. It may cause implant failure and has potential to affect long-term implant survival. To prevent major revisional arthroplasty, it is important to make an early diagnosis of osteolysis and decide an appropriate timing of surgical intervention such as bone graft. We report our experience of bone graft for osteolysis after TAA associated with clinical and radiologic outcome. Methods: Between May 2004 and Oct. 2013, 238 primary TAA were performed on 219 patients. We excluded 37 ankles with follow-up less than 24 months; thus, 201 ankles in 185 patients with mean follow-up of 61.9 (range, 24-130) months were included in the study. Nineteen patients were treated with a total of 21 bone graft procedures for periprosthetic osteolysis after TAA. Of these patients, 12 (57.1%) were males with mean follow-up length after bone graft 35.0 months. Location of osteolysis, bone grafting method and clinical outcome parameters using visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score were recorded. Results: Radiographs revealed total of 62 osteolysis lesions in 19 patients; 35 (56.5%) distal tibial lesions, 23 (37.0%) talar lesions. Autogenous iliac bone graft was used in 18 procedures (85.7%). The mean scores (and standard deviation) improved for the VAS from 4.8 ± 1.23 points before bone graft to 3.0 ± 0.94 points at the last follow-up (p

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Osteochondral autograft transplantation (OAT) for large sized osteochondral lesions of the talus (OLT) has presented promising clinical results in recent studies. However, there was no study which has compared clinical outcomes between primary OAT and secondary OAT in the large sized OLT. The purpose of this study is to compare clinical outcomes between patients receiving primary transplantation and patients receiving secondary transplantation after failure of previous marrow stimulation for large sized OLT and investigate prognostic factor affecting clinical failures. Methods: Between 2005 and 2014, 18 patients with large sized OLT (=150 mm2) underwent primary OAT as a primary surgery (primary group) and 28 patients with large sized OLT underwent secondary OAT after a failure of arthroscopic marrow stimulation (secondary group). After arthroscopic inspection and debridement for concomitant soft tissue pathologies, conventional OAT procedures were performed. Clinical outcomes were assessed using visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS) and re-operation rate. Factors associated with clinical failure were evaluated using bivariate analysis and logistic regression analysis. Survival outcomes were compared using Kaplan-Meier analysis. Results: The mean follow-up time was 6.0 years (range 2.0-10.8) and the mean size of the lesion was 194.9 mm2 (range 151.7- 296.3). There was no significant difference in patients` demographics, and preoperative findings between primary and secondary groups. Postoperative VAS, AOFAS score, FAOS, and re-operation rate had no significant difference between primary and secondary groups at the last follow-up. According to bivariate analysis, significant factor associated with clinical failure was not prior marrow stimulation but more than 225 mm2 of lesion size in preoperative MRI. Logistic regression analysis revealed that preoperative AOFAS score was significant predictor of clinical failure after the OAT in this study. The survival probabilities were not significantly different between primary and secondary groups in Kaplan-Meier plots (P = .947). Conclusion: Outcomes of secondary OAT were comparable to those of primary OAT in the large sized OLT. Therefore, we suggested that symptomatic patients with large sized OLT could be initially treated by either arthroscopic marrow stimulation or OAT and if failed with marrow stimulation, secondary OAT could be considered.

Category: Ankle, Pain Introduction/Purpose: We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery of the foot and ankle. Methods: Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound- guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25 mg) was applied in group A (30 patients), diluted anesthetic (0.2% ropivacaine, 30 ml) was injected into the sciatic nerve once, about 12 hours after the pre-operative nerve block in group B (27 patients), and periodic analgesic intramuscular injection (ketorolac (Tarasyn? R), 30 mg) was performed in group C (27 patients). Visual analog scale (VAS) pain scores at 6, 12, 18, 24, and 48 hours after surgery were checked, and complications of all methods were surveyed. Results: The mean VAS pain score was lower in group B, with a statistically significantly difference (p < .05) between groups A, B, and C at 12 and 18 hours after surgery. Four patients in group A suffered from nausea and vomiting, whereas no other patients complained of any complications or side effects. Conclusion: The ultrasound-guided injection of diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase following foot and ankle bone surgery. By injecting the diluted anesthetic once on the evening of the day of surgery, patients suffered less postoperative pain.

Category: Lesser Toes, Trauma Introduction/Purpose: The standard treatment of 5th metatarsal shaft fracture is still not determined yet. Conservative treatment using cast immobilization can be applied for shaft fractures without displacement, but there are reports that open reduction is indicated for displacement more than 3 mm, rotational displacement, and angular displacement more than 30 degrees. In this study, we report the result of 5th metatarsal shaft fracture using MIPO technique, which can shorten recovery period by reducing soft tissue damage with minimal incision. Methods: This study consists of 25 patients who had undergone surgery for displaced 5th metatarsal shaft fracture from March 2013 to December 2015; 8 males and 17 females. Mean age at the time of surgery was 47.4(29~69) and mean follow period was 15.0(8~25) months. 11 cases were simple oblique fracture and 14 cases were comminuted fracture with fracture fragments. Mean fracture gap was 4.4(3.1~7.6)mm. MIPO technique with LCP Compact Hand Locking Condylar Plate 2.0(Depuy-Synthes, Zuchwil, Switzerland) was used for all cases. Partial weight bearing was allowed until 4th week post-op, then full weight bearing was allowed until 6th week post-op. Clinical and radiological follow-up was made at post-op week 2, 6, 12, 24. Clinical results were obtained using Visual Analogue Scale(VAS) and American Orthopedic Foot and Ankle Society(AOFAS) score. Results: VAS of 24 weeks post-op was decreased from 5.6 ± 0.8 (4~7) preoperatively to 1.2 ± 1.3 (0~4), and AOFAS score of 24 weeks post-op was increased from 42.0 ± 12.8 (24~54) preoperatively to 86.4 ± 7.7 (74~95), both showed significant difference. Anatomic reduction and complete bone union was noted in all cases. Mean union period obtained from follow-up radiograph was 6.0 week post-op. For 15 cases, plate removal was performed at 9.5(7~25) months post-op. Conclusion: Plate fixation can be the preferred option for 5th metatarsal shaft fracture, because 5th metatarsal shaft is surgically easily accessible and more stable fixation can be applied. Since it results complete bone union without any complications and enables early weight bearing, MIPO techinque for displaced 5th metatarsal shaft fracture can be considered as useful surgery technique.

Category: Ankle, Arthroscopy Introduction/Purpose: Non-operative treatment options with symptomatic OLT after failed primary arthroscopic treatment may be treated by various methods such as analgesics, anti-inflammatory drug, steroid injection, Platelet rich plasma (PRP) injection and hyaluronic acid (HA) injection. HA injection could be treated OLT besides osteoarthritis on knee or ankle joint. Effect of HA is viscoelastic and lubricating properties primarily, and other biomechanical effect can be considered. Purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection in the patients with recurrent pain after the arthroscopic microfracture for OLT Methods: This study included 20 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between June 2014 and August 2016. All patients had persistent pain for more than 3 months after the index surgery. The patients were followed for 16.7 months (range: 4.6-30.9). At each visit, the efficacy of HA injection in reducing pain was evaluated by a Visual Analog Scale (VAS). In addition, subjective satisfactions were assessed by the Alexander scale. Results: The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS scores decreased from 6.7 ± 1.1 at a pre-injection to 3.8 ± 2.3 at post-injection six months (p = 0.02). According to the Alexander scale, there were 65.0% (13/20) good, 25.0% (5/20) fair, and 10.0% (2/20) poor results at post-injection six months. There was no severe adverse effect. Conclusion: The HA injection may be a useful treatment option after failed arthroscopic microfracture in OLT. Further studies will be needed to evaluate long-term results.

Category: Ankle, Arthroscopy Introduction/Purpose: Tram track lesion in the ankle joint has been occasionally found during the ankle arthroscopy and there has been few studies relating the pathophysiology, diagnostic method and treatment of the lesion. This study aimed to show the effectiveness of magnetic resonance imaging (MRI) for detection of tram track lesion in the ankle joint comparing with ankle arthroscopy. Methods: We retrospectively assessed 175 ankles in 170 patients with anterior bony impingement syndrome in the ankle who underwent arthroscopic surgery between January 2013 and July 2015. Anterior ankle bony spurs were scored in preoperative weight-bearing radiographs using the impingement classification. MRIs were reviewed for the detection of tram track lesions according to our definition (focal high signal intensity along the talar dome cartilage surface on coronal view), which were then compared with arthroscopic findings. The grade of cartilage defect was stratified according to international cartilage repair society (ICRS) grading system by arthroscopic finding. Results: Fourteen (8.0%) ankles were identified with tram track lesion on MRI and 16 (9.1%) ankles were identified with tram track lesion at ankle arthroscopy. Overall sensitivity of MRI for detection of tram track lesion was 87.5% and specificity was 100%. On plane weight-bearing radiographs, 4 patients had grade 1, 2 patients had grade 2 and 10 patients had grade 3 impingement spurs. Under the ICRS grading system, 4 cases were grade 2, 4 cases were grade 3, and 8 cases were grade 4 at arthroscopy. Comparing with MRI, 2 cases of grade 2, 4 cases of grade 3 and 8 cases of grade 4 were detected (Table). Impingement spur grade showed no significant correlation with arthroscopic ICRS grade of tram track lesion (p = 0.609). Conclusion: Tram track lesions in the ankle joint can be confidently detected on MRI with high sensitivity and specificity. Early detection and following treatment of the lesion can maximize the clinical outcome that eliminates the possibility for further damage to the cartilage and consequent osteoarthritic change.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has become an increasingly attractive option for advanced tibiotalar arthritis treatment. The Salto prosthesis (Tornier SA, Saint Ismier, France) was reported to have midterm and long term promising outcomes. However, to date, the clinical reports of this prosthesis are few and most of the papers were published by the inventors and disclosed consultants. The published areas are also limited to Europe, and no results were documented from other region. Methods: We retrospectively reviewed 62 patients in total. All of underwent unilateral Salto TAA. The average clinical follow-up was 34.3 months. Clinical and radiologic results were evaluated and enrolled. Clinical follow-up included medical records review, visual analogue scale (VAS) pain score, American Orthopeadic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS) pain and disability score and range of motion (ROM). Apart from these, subsequent surgeries and perioperative events that occurred at the first 3 months after the operation were recorded simultaneously. In the radiographic evaluation, we measured the tibial angle (TA), talar angle (TAL), tibial slope, and talocalcaneal angle (TCA) described by Bonnin. Distributive regions of osteolysis and radiolucency were reviewed. In addition, heterotopic ossification also be observed and graded. Endpoint of the follow-up was either any component removal or reoperation for any reason. Results: Date to last follow-up, the survival rate with any reoperation as the endpoint was 88.7% (7/62). Using any component removal as the endpoint of followup, the survival rate was 95.2% (3/62). The mean VAS score, AOFAS ankle-hindfoot score, and AOS pain and disability score were improved postoperatively (p < 0.001). Postoperative ROM of ankle was also improved (p = 0.003). Within 6 weeks of postoperation, radiolucent line arose around tibial implant in 39 cases and disappeared at mean 5.5 ± 2.6 months. 28 patients with postoperative mean 8.5 ± 4.5 months appeared radiolucent area. Osteolysis was found in 28 patients with mean 18.1 ± 8.2 months postoperatively. 13 patients suffered heterotopic ossification which appeared 9.4 ± 4.3 months after operation. Conclusion: At the last followup, obvious pain relief and satisfactory results were achieved in most of the patients. Different from previous studies on Salto prosthesis, we considered that the early radiolucent line around the tibial implant is likely due to the tiny gap between the implant and bone contacted interface, and it would disappear at the time of osseous integration. The lucent area and osteolysis occurred frequently around the tibial keel and tray due to the stress shielding of the tibial component. However, longer follow-up is necessary to determine the durability of this implant.

Category: Ankle, Trauma Introduction/Purpose: This prospective study aimed to evaluate the usefulness of ultrasound (US)-guided nerve block (NB) for emergency external fixation of lower leg fractures, by investigating real time before the operation and the clinical result according to the anesthesia method (US-guided NB or general anesthesia [GA]). Methods: From June 2014 to April 2016, 40 patients who underwent emergency surgery for external fixator application were enrolled in this study. We performed a randomized trial for US-guided NB and GA. We measured the lead time before the start of the operation after the decision to perform emergency surgery in both groups. Results: The US-guided NB group comprised 17 men and 3 women with a median age of 55.6 (33–77) years. Twelve of these patients had conditions such as diabetes mellitus, hypertension, and kidney-related diseases. Fracture types 42, 43, and 44 in the AO classification were observed in 3, 12, and 5 cases, respectively. The average time taken to emergency operation was 4.3 (2– 6.25) h. However, in the GA group, the average time taken to emergency operation was 9.4 (3–14) h. In the US-guided NB group, no cases of anesthesia failure and unstable vital signs during the operation occurred. Moreover, there were no postoperative complications related to the anesthesia method, such as aggravation of the general condition. Conclusion: Emergency external fixation with US-guided NB in patients with lower-extremity trauma can be implemented in less time regardless of preoperative preparation, which is a requirement in GA.

Category: Diabetes Introduction/Purpose: Orthopedic physicians encounter many diabetes patients who receive anticoagulant treatment because vascular diseases are the chief causes of death and disability in these patients. In these patients, if surgery or other procedures are required, it is still unclear whether anticoagulation therapy administration should continue. After discontinuation of anticoagulation therapy, the risk of cardiovascular complications is increased, although complications of bleeding after surgery are decreased; this is a dilemma in the treatment of diabetic foot ulcer. The purpose of this study was to examine the effectiveness, safety, and hemostatic effect of kaolin-impregnated gauze on diabetic foot ulcer patients who continue to receive anticoagulants after surgical debridement. Methods: Twenty patients receiving anticoagulant medication with diabetic foot ulcers requiring surgical debridement were enrolled. Diabetic foot ulcers were treated using surgical debridement and a basic dressing protocol, which involved direct application of the dressing material to the wound bed. For the study group, a kaolin-impregnated dressing was used, and dry gauze was applied to patients in the control group. Patients were randomly assigned to either group, and we compared hemostatic efficacy and adverse effects between the two groups. The presence or absence of hemostasis was assessed 5 and 10 minutes after dressing application. Treatment was considered successful if bleeding ceased adequately and no extra hemostatic measures were required within 10 minutes. Results: In the 20 patients undergoing surgical debridement, there was no evidence of bleeding within 10 minutes of dressing application. Eight of the 10 patients treated with a kaolin-impregnated dressing achieved complete hemostasis within 5 minutes. Five of the 10 patients in the control group failed to achieve hemostasis within 10 minutes. No adverse effects were noted. Conclusion: The use of a kaolin-impregnated dressing appears to be a safe, feasible, and beneficial option for the management of diabetic foot ulcer patients with a high risk of bleeding.

Category: Bunion Introduction/Purpose: Over recent years, a proximal opening wedge osteotomy (POWO) using a novel low-profile plate have gained in popularity for the correction of moderate to severe hallux valgus. However, the proximal opening wedge osteotomy was known to increase the length of the first metatarsal, resulting in tightening of the soft tissues around the first metatarsophalangeal (MTP) joint and predisposing to jamming of the joint and subsequent arthritis. The purpose of this study was to evaluate the arthritic change of first MTP joint after POWO using a low-profile plate for correction of moderate to severe hallux valgus. Methods: We retrospectively reviewed 100 consecutive POWOs using a low-profile plate performed in 87 patients with moderate to severe hallux valgus deformity. After excluding 17 cases, 83 cases in 73 patients were included. For clinical assessment, VAS, the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score and Foot and Ankle Outcome Score (FAOS) were obtained. The hallux valgus angle (HVA), the intermetatarsal angle (IMA), the relative first metatarsal length which is the first metatarsal length divided by the second metatarsal length and the first MTP joint radiographic arthritic grade by Coughlin and Shurnas were assessed on standard weight bearing radiographs of the foot for radiographic evaluation. Results: Mean follow-up period was 16.1 (12-45) months. The mean VAS, AOFAS score and most of FAOS subscales improved significantly. Significant corrections in the HVA and IMA were obtained and the mean increase in the relative first metatarsal length was 3.8% at last follow-up (P < 0.001). There were 15 (18.1%, 15/83) cases of the first MTP joint arthritis at last follow-up (Radiographic grade I: 5, II: 8, III: 2). Of 62 cases using a large wedge plate (≥5.0 mm), 12 (19.4%, 12/62) cases showed poorer outcomes and a significant progression of the arthritic grade at last follow-up (Fisher's exact test, P=0.031) comparing to using a small wedge plate (< 5.0 mm) (Table 1). Conclusion: The POWO using a low-profile wedge plate is effective and reproducible technique for correction of moderate to severe hallux valgus deformity. However, the exacerbation of preexisting first MTP joint arthritis and the subsequent arthritis can occur after POWOs using a large wedge plate (≥5.0 mm) at short to mid-term follow-up. Therefore, POWOs with a low-profile wedge plate should be used judiciously for correction of moderate to severe hallux valgus.

Category: Ankle Introduction/Purpose: Chronic lateral ankle instability (CLAI) has shown significant relationship with cavovarus deformity in prior studies. Isolated lateral ankle ligament reconstruction in patients who have CLAI with cavovarus deformity has been shown poor outcome if the deformity had not been corrected. Traditionally, cavovarus foot has been associated with neuromuscular conditions, however, nowadays it occurs in a less severe form even in the normal population. Mild cavovarus deformity is thought to be an anatomical risk factor for CLAI, but there are still debates on the correction of the mild deformity. The purpose of the current study was to evaluate clinical and radiographic outcomes of the modified Broström operation (MBO)s with additional procedures for the CLAI with mild cavovarus deformity. Methods: We reviewed total 12 patients who underwent MBOs with additional procedures for CLAI with mild cavovarus deformity between August 2009 and September 2013. Patients were evaluated by visual analogue scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the Karlsson-Peterson (KP) ankle score. The talar tilt angle and the anterior displacement of the talus on ankle stress radiographs and the first metatarsal- talus angle, the arch height between cuneiform and fifth metatarsal base and the calcaneal pitch angle on foot lateral standing radiographs were examined. Results: The mean follow-up period was 31.5 months. Calcaneal lateral closing wedge osteotomy was performed in 6 patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy in 9 patients to correct remnant plantarflexion of the first ray. Three of 12 patients underwent both calcaneal and first metatarsal osteotomies. The mean VAS score decreased from 5.5 to 1.7 at last follow-up (p=0.002). The mean AOFAS score and the mean KP ankle score were significantly improved (61.0 to 85.3 (p< 0.001), 56.8 to 83.1 (p < 0.001)) and there was no recurrence of instability. Radiographically, the mean talar tilt angle and the anterior displacement of the talus were decreased (p=0.001, p=0.007), and the first metatarsal- talus angle and the arch height were decreased at last follow-up (p=0.001, p=0.003). Conclusion: Concomitant correction of mild cavovarus deformity with MBO for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for deformity should be followed when treating patients with chronic ankle instability.

Category: Diabetes Introduction/Purpose: Ulcer healing in the diabetic patients is challenging due to a prolonged inflammatory response, extracellular matrix degradation irregularities, and increased bacteria presence. Collagen components are fundamental to the process of wound healing and skin formation. Recently, collagen-containing wound dressings, which create a biological scaffold matrix, have been used in the treatment of diabetic foot ulcer (DFU). However, there is not enough evidence to support that 100% collagen dressing can replace the diabetic wound management. In this study, we examined the effectiveness and safety of a new collagen dressing material in the treatment of DFU. Methods: This study was a prospective, randomized, placebo-controlled, single-center study conducted between November 2011 and September 2014. The inclusion criteria were type 1 or 2 diabetes, a ulcer size ≥ 1.0 cm2 that did not exhibit signs of healing for 6 weeks, Wagner grade 1 or 2, and palpable pulses at the ankle. The assessments of DFU included size, microbial culture study, detailed description of DFU, and clinical photos. Patients in the study group were treated with a collagen dressing material (100% porcine type I collagen) and foam dressing, while patients in the control group were treated with only foam dressing. Dressing changes had been performed two or three times per week. Complete ulcer healing rate was evaluated as a primary endpoint and ulcer size were compared between the two groups as a secondary endpoint. Results: Thirty patients were included in the final analysis (study group: 17 patients, control group: 13 patients). There were no significant differences between two groups regarding demographic factors and baseline DFU characteristics. The study group presented a higher rate of complete healing as compared to that in the control group [82.4% (14/17), 38.5% (5/13), respectively, P = 0.022]. At the last follow-up, ulcer sizes of the study group were smaller than those of the control group (P = 0.048). The Kaplan-Meier analysis for the complete ulcer healing also showed a significantly higher rate of complete healing in the study group (Hazard ratio = 3.0, log-rank P = 0.025). There were no adverse events related to the dressing materials. Conclusion: This study supports that the wound dressing using 100% collagen materials may offer a safe and effective treatment for DFU.

Category: Ankle Introduction/Purpose: The optimal treatment for symptomatic osteochondral lesion of the talus (OLT) after failed arthroscopic microfracture has been a controversial issue. The use of viscosupplementation for treatment of OLT has been gradually increasing. The hyaluronic acid (HA) injection is believed to play an important role in reducing pain and inflammation, and promoting tissue repair. The purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection for the patients with failed arthroscopic microfracture in OLT. Methods: This study included 12 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between October 2014 and October 2015. Five men and seven women were included in this study. The average age at the time of injection was 41 years (range, 19-63 years). All patients had recurrent pain for at least 6 months after the index surgery. The patients were followed for 6.1 months (range: 5.0-7.0). At each visit, the efficacy of HA injection was evaluated by a Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot and Ankle Outcome Score (FAOS) pain subscale. In addition, subjective satisfactions were assessed by the Alexander scale. Results: The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS decreased from 6.7 ± 1.1 at pre-injection to 2.4 ± 1.6 at post-injection six weeks (p < 0.001), 3.1 ± 1.5 at three months (p = 0.002) and 3.8 ± 2.3 at six months (p = 0.02). Mean AOFAS score improved from 61.0 ± 9.1 at pre-injection to 85.3 ± 11.3 at post-injection six weeks (p < 0.001), 82.9 ± 10.4 at three months (p < 0.001) and 80.4 ± 13.8 at six months (p = 0.001). Mean FAOS pain subscale also improved from 53.2 ± 4.2 at pre-injection to 71.1 ± 9.4 at post-injection six weeks (p < 0.001), 66.7 ± 7.2 at three months (p = 0.001) and 64.4 ± 9.5 at six months (p = 0.036). According to the Alexander scale, there were 58.3% (7/12) good, 25.0% (3/12) fair, and 16.7% (2/12) poor results at post-injection six months. There was no adverse effect. Conclusion: In this study, we found that the main improvement in clinical outcomes occurred during the first six weeks and significantly maintained until at least three or six months. We believe that the HA injection could be a useful treatment option after failed arthroscopic microfracture in OLT.

Category: Diabetes Introduction/Purpose: Fast and complete healing of a diabetic foot ulcer (DFU) is challenging due to the hostile wound healing environment of the diabetic patients. As a part of a multimodal treatment approach, advanced dressing material using hyaluronic acid (HA) has been found to be effective. However, previous studies have used HA with additional biologics, which interferes in determining the true clinical effect of HA in DFU. The purpose of this study is to examine the effectiveness and safety of a new HA dressing material in the treatment of DFU. Methods: This study was a prospective, randomized, placebo-controlled, single-center study conducted between September 2012 and January 2014. The inclusion criteria were type 1 or 2 diabetes, a ulcer size ≥ 1.0 cm2 that did not exhibit signs of healing for 6 weeks, Wagner grade 1 or 2, and palpable pulses at the ankle. The assessments of DFU included size, microbial culture study, detailed description of the DFU, and clinical photos. Patients in the study group were treated with an HA dressing material (hyaluronic acid 80 ± 5% and poloxamer 10 ± 5%), while patients in the control group were treated with a conventional moisture- retentive dressing (petrolatum gauze). Weekly follow-up was conducted with the dressing change up to maximum 12 weeks. Complete ulcer healing rate was evaluated as a primary endpoint. Additionally, healing velocity and the mean duration for achieving a 50% ulcer size reduction was compared between the two groups as a secondary endpoint. Results: Twenty-five patients were included in the final analysis (study group: 13, control group: 12). There were no significant differences between two groups regarding demographic factors and baseline DFU characteristics. The study group presented a significantly higher complete healing rate as compared to that in the control group [84.6% (11/13), 41.6% (5/12), respectively, P = 0.041]. Faster ulcer healing velocity and shorter mean duration for achieving a 50% ulcer size reduction were observed in the study group (P = 0.022, P = 0.004, respectively). The Kaplan-Meier analysis for the median time for 50% ulcer healing rate also showed a significantly shorter duration in the study group (21 days vs 39 days, P = 0.012). There were no adverse events related to the dressing materials. Conclusion: This study supports that a HA dressing without additional substances may offer a safe and effective treatment for DFU.

The rabbit has been extensively used for preclinical models, especially in orthopedic applications. One of the more troubling features of this model is the high interindividual variability that is encountered and that requires a careful experimental design with sufficient sample size to make judgments valid. We have processed 241 individual preparations of rabbit bone marrow-derived mesenchymal progenitor cells (MPCs) over the last 3 years and have kept detailed records of the performance of these cells in various assays. This communication details the lack of correlation between the analyzed parameters. Bone marrow was harvested from 4-month-old rabbits; the cells were centrifuged, resuspended, and cultured. When cells reached 80% of confluence, they were removed from the plates with trypsin and assayed for their osteo- and chondrogenic potential. The average yield of the 241 individual MPC preparations exhibited a coefficient of variation of 77. An in vivo implantation assay with porous calcium phosphate ceramic cubes exhibited scores with a coefficient of variation of 65. Lastly, an in vitro assay of alkaline phosphatase enzyme activity exhibited the most variability with a coefficient of variation of 132. All of the cell preparations tested in an in vitro aggregate culture assay underwent chondrogenic differentiation. No relationships between any of these parameters were found. The variability of the results within the different assays is interpreted to be the result of the heterogeneity of the preparations. The lack of correlation between the parameters studied shows the importance of the conditions intrinsic to the different assays. These results serve to emphasize that any experimental design involving rabbit progenitor cells must include a sufficiently large sample size to allow statistically significant and rigorous conclusions.