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Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Lisfranc ligament is a strong interosseous ligament located between the medial cuneiform (C1) and base of the second metatarsal (M2). Lisfranc injuries occur in approximately 0.2% of all fractures and are often overlooked or misdiagnosed. Weightbearing radiograph of the foot has been used as a diagnostic method for Lisfranc injuries; however, there is no study to evaluate the reliability of the measurement techniques on weightbearing radiographs. While several measurement techniques on weightbearing radiograph have been proposed for evaluating Lisfranc injuries, it remains unclear which measurement is the most reliable. This study aimed to evaluate the intra- and inter-observer reliability of the measurement techniques using weightbearing radiographs. Methods: Seventeen patients who were diagnosed with Lisfranc injuries using weightbearing radiographs and were treated with open reduction and internal fixation in our hospital between January 2013 and April 2019 were included in this study. Patients with multiple fractures were excluded. Four observers were selected, of which two were orthopedic specialists with more than six years of experience, while the remaining two were orthopedic surgeons with less than five years of experience. Observers evaluated the intra- and inter-observer reliability of the five measurement points on weightbearing radiographs on the affected and unaffected sides. The measurement points included the proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 and C1- the medial cuneiform (C2). Results: The proximal, middle, and distal C1-M2 distance and parallel distance of C1-M2 of The affected sides were wider than those of the unaffected sides with significant difference (p

Category: Ankle, Arthroscopy Introduction/Purpose: Ankle sprain commonly occurs in sports activities and most patients are successfully managed with conservative treatment. An incidence of 10–30% of patients will fail conservative treatment and result in chronic lateral ankle instability (CLAI) that may require surgical treatment. Recently, several systematic reviews reported that arthroscopic lateral ankle ligament repair for CLAI are provided good clinical results. However, the pathologic condition of the lateral ankle ligament after anatomical repair has not been clarified. Previous investigations have reported that ligament signal intensity using MRI has a strong negative linear relationship with material biomechanical strength properties. The purpose of this study was to report the clinical outcome and evaluation of the anterior talofibular ligament (ATFL) using MRI after arthroscopic lateral ankle ligament repair. Methods: We retrospectively reviewed 40 patients (40 ankles) who underwent arthroscopic lateral ankle ligament repair for CLAI. The average age at the time of surgery was 28 years (range 12–66 years). The average follow-up was 13 months (range 12– 18 months). Clinical outcomes were assessed preoperatively and 12 months postoperatively using Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale and Self-Administered Foot Evaluation Questionnaire (SAFE-Q). The ATFL was evaluated using 3.0-T MRI at the preoperatively, six months postoperatively and 12 months postoperatively. The ATFL characteristics classified into the following categories: nonvisualization of the ligament, discontinuity, a wavy or curved contour, or high signal intensity within the ligament. Results: The mean JSSF score increased from 72 preoperatively to 95 at 12 months postoperatively. The preoperative MRI findings of the ATFL were categorized as discontinuity (11 ankles), a wavy or curved contour (14 ankles), or high signal intensity within the ligament (22 ankles). The all ATFL findings at the six months postoperatively had straight band extending from the talus to the fibular malleolus, and nine of 40 ankles had high signal intensity within the ligament. The ATFL findings at the 12 months postoperatively revealed residual high signal intensity within the ligament in six of nine ankles. A comparison of the postoperative ATFL with high signal intensity and with low signal intensity group, there were no significant difference in postoperative clinical outcomes between the groups. Conclusion: This study demonstrated that arthroscopic lateral ankle ligament repair was an effective procedure for the treatment of CLAI and restored the condition of ATFL.

Category: Ankle, Arthroscopy Introduction/Purpose: Osteochondral talar lesions (OCL) are infrequent in children, and little is known about the treatment and clinical outcome of these defects. Clinicians normally first attempt nonoperative treatment of these lesions, but if such treatment fails, surgical many treatments including retrograde drilling (RD), are attempted. RD is usually reserved for large OCLs with intact overlying cartilage. Good clinical outcomes have been reported in RD. However, the clinical outcomes of RD for OCL in children remains unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of RD in skeletally immature children. Methods: From January 2015 to April 2018, RD was performed on eight feet with OCL in six consecutive patients in skeletally immature children. Arthroscopic lateral ankle ligament repair was also performed in one of the eight feet, and one foot was excluded; therefore, we studied seven feet in five patients. The patients comprised three boys and two girls with a mean age at surgery of 11 (range, 9–12) years. All patients were followed for a minimum of 6 months postoperatively, the average follow-up was 19.1 (range, 8–39) months. All patients were grade 0, determined according to a modified Pritsch classification system. All patients were evaluated for Japanese Society for Surgery of the Foot (JSSF) scale and radiographic outcomes at preoperatively and postoperatively final follow up. Results: The average JSSF scale improved from 79.4 points (range, 69–90 points) to 100 points in all feet at final follow-up (p

Category: Ankle, Sports Introduction/Purpose: The arthroscopic bone marrow stimulation (ABMS) promotes repaired tissue healing of the osteochondral defect. Recently, T2 mapping has been used to evaluate the repair of cartilage tissue; however, the prognostic worth of T2 values after ABMS has not yet been clarified. Several articles have reported that the subchondral condition affects the articular cartilage condition, and subchondral bone edema (SBE) is reportedly associated with inferior outcome after ABMS. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS. The purpose of the present study was to investigate the relationship between SBC/SBE and T2 values of repaired tissue on MRI after ABMS. We hypothesized that the presence of SBC/SBE would affect the characteristics of the repaired tissue after ABMS. Methods: We prospectively enrolled 18 patients (18 ankles) scheduled to undergo treatment with ABMS for OLT. The patients were six males and 12 females (age, 29.3 ± 22.1 years; lesion length, 10.8 ± 3.0 mm; lesion area, 59.7 ± 26.0 mm2). Repair tissue was assessed using a 3 T MRI unit, and T2 maps were calculated. Patients were divided into two groups for investigating effect of the SBE: those with SBE and those without SBE based on MRI performed pre-ABMS and 1 year post-ABMS. We investigated the relationship between T2 value and SBE presence. For investigating the relationship between SBC and T2 value, the patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. Clinical results were assessed using JSSF scale. Results: There were no significant differences in mean T2 values and JSSF score before ABMS between those with SBE versus those without SBE (T2 values, P = 0.5; JSSF score, P = 0.9). At 1 year post-ABMS, there was no significant difference between groups in T2 value (P = 0.8), but the JSSF score was significantly lower in the SBE group (P = 0.02). No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values, P=0.7 / JSSF scale score, P=0.25).Lesion length/area were correlated with T2 values of repaired tissue (length: r = 0.50, P = 0.005; area: r = 0.29, P = 0.04). Conclusion: The presence of pre- and/or post-ABMS SBE does not affect the T2 values of repaired tissue after ABMS for OLT. The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, post-ABMS SBE was associated with poorer clinical outcome. Larger lesion size is correlated with poorer condition of repaired tissue.

Category: Ankle Arthritis Introduction/Purpose: Arthroscopic ankle arthrodesis (AAA) is a good clinical outcome, because the arthroscopic method has been deemed to have shorter union time, less blood loss, less morbidity, shorter hospital stays, and more rapid mobilization. However, it is unclear about the relationship between progression of adjacent-joint arthritis and clinical outcome at long-term follow-up. The purpose of this study was to investigate the relationship between AAA and adjacent-joint arthritis at 2 years postoperatively. Methods: We evaluated 17 feet of 17 patients at a minimum of two years after surgery that were able to be followed, from among 59 feet in 55 patients with ankle osteoarthritis who underwent AAA between January 2006 and April 2015. The mean age was 66.1 ± 8.1 (range, 57-79) years, and postoperative follow-up was performed at a mean of 4.5 ± 2.3 (range, 2-10) years after surgery. The radiographic evaluation examined a union rate of the ankle, and a progression of adjacent-joint osteoarthritis (OA) change. We examined the relationship between the presence of adjacent-joint OA and Japanese Society for Surgery of the Foot (JSSF) score before surgery and last follow up. Additionally, we examined the relationship between the presence of adjacent-joint OA and Self-Administered Foot Evaluation Questionnaire (SAFE-Q) at last follow up. Results: JSSF score was improved to 56.9 points before surgery and 89.2 points last follow up, and the union rates was 17 feet of 17 feet (100%). At the last follow-up, radiographic signs of developed or progressing arthritis were observed in ten feet at subtalar joint (58.8%) and in three patients at talonavicular joint (17.6%). The postoperative JSSF scale regarding the presence or absence of the adjacent joint OA, there were no significant differences (89.3 ± 6.0 points in the absence group and 89.2 ± 6.1 points in the presence group). Postoperative SAFE-Q was not significantly different, pain and pain-related physical functioning and daily living, social functioning, shoe-related, and general health and well-being. Conclusion: There was no significant difference in the JSSF score of presence or absence of the adjacent-joint OA before surgery and at the final follow-up. Additionally, there was no significant difference in the SAFE-Q of presence or absence of the adjacent-joint OA at the final follow-up. The adjacent-joint OA was progressed after AAA, however clinical outcome was relatively maintained.

Category: Arthroscopy Introduction/Purpose: The arthroscopic bone marrow stimulation (ABMS) technique is the first-line procedure for the treatment of osteochondral lesions of the talus (OLT). Recently, T2 mapping was used to evaluate repair cartilage tissue, but the prognostic factors for T2 values after ABMS have never been clarified. Some patients have OLT with sclerotic changes in the subchondral bone, and several articles have suggested that the subchondral bone condition affects the condition of the articular cartilage. Furthermore, subchondral bone sclerosis (SBC) was found to be associated with an inferior outcome after ABMS.The purpose of this study was to investigate the relationship between subchondral bone sclerotic changes and repair tissue T2 values on MRI after ABMS. Methods: Twenty ankles in 20 patients treated with ABMS for OLT were evaluated. The patients included 7 males and 13 females (age, 30.52±21.44 years, lesion length 10.4±3.0mm, lesion area 55.7±26.5mm2). Repair tissue was assessed using a 3T MRI unit, and T2 maps were calculated at the one-year post-ABMS follow up. The patients were divided into two groups; with SBC and without SBC on pre-ABMS CT images. We investigated the relationship between T2 values and SBC. Clinical results were measured using the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale. Results: No significant mean differences were found in T2 values or JSSF scores between the with SBC and without SBC groups post-ABMS (T2 values; 48.2±3.3ms vs. 50.1±2.9ms, P=0.7 / JSSF scale score; 89.4±5.8 points vs. 93.3±8.2 points, P=0.25). Lesion length was correlated with the T2 values of repair tissue (Length; r=0.3 P=0.01). Age and BMI were not significantly correlated with T2 values of the repair tissue. Conclusion: The presence of SBC prior to ABMS did not affect the T2 values of repair tissue after ABMS. However, we believe that lesion size affected the condition of the repair tissue.

Category: Basic Sciences/Biologics Introduction/Purpose: Arthroscopic bone marrow stimulation techniques including excision with curettage and microfracture are recommended as initial treatments for osteochondral lesions of the talus (OLT). However, several reports have indicated that lesion size and location are important prognostic factors for the clinical outcomes. A cutoff point regarding the risk of clinical failure exists for a lesion size of approximately 15 mm diameter or 150 mm2 area. A recent study reported that shoulder-type lesions had significantly worse clinical outcomes than nonshoulder-type lesions. However, to the best of our knowledge, no previous reports have provided biomechanical data for how nonshoulder-type and shoulder-type OLT affect the clinical outcomes. The purpose of this study was to clarify the stress distribution in articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using finite element (FE) analysis. Methods: The healthy 33-year-old male and 29-year-old female volunteers participated in the present study. They underwent computed tomography (CT) scans, and three-dimensional FE models of his ankle joint were created from the CT data using Mechanical Finder software (version 7.0, extended edition; Research Center of Computational Mechanics, Tokyo, Japan). Six different sizes of nonshoulder-type and shoulder-type OLT were simulated in the present study. For the nonshoulder-type lesion models, circular cartilage defects with diameters of 5, 7, 9, 11, 13, and 15 mm were created on the medial half of the talar dome using a cutting tool. The shoulder-type lesion models were created in the medial half of the talar shoulder, also with cartilage defect diameters of 5, 7, 9, 11, 13, and 15 mm. We set the loading condition at 686 N on the upper part of the tibia from the tibial axis for body-weight loading. The peak and average articular cartilage stress and defect rim stress were compared between the two models and among the six different defect sizes. Results: In both lesion models, stress concentration was seen at the cartilage defect rim. The peak and average cartilage stress and defect rim stress increased with increasing defect size of the two models. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models. Conclusion: Lesion size of OLT was the most powerful predictor of the clinical outcome by arthroscopic bone marrow stimulation. The shoulder-type OLT experience a worse clinical outcome than the nonshoulder-type OLT, even after adjustment for OLT size and regardless of location. In the present study evaluated the stress distribution in the articular cartilage of the talus with nonshoulder-type and shoulder-type OLT using FE analysis. In the cartilage defect with the diameter of 13 mm and more, the shoulder-type lesion models exhibited higher peak defect rim stress than the nonshoulder-type lesion models.

Category: Hindfoot Introduction/Purpose: Distal first metatarsal osteotomies are recommended for surgical treatment of mild to severe hallux valgus (HV) deformities. Angthong et al. reported that minimally invasive distal linear metatarsal osteotomy (DLMO) exhibited good outcomes, with no major complications. However, avascular necrosis of the metatarsal head following a distal osteotomy has been reported, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. The purpose of this study was to evaluate the in vivo blood flow of the pre- and post-osterotomy metatarsal head in patients with HV using laser Doppler flowmetry (LDF). Methods: Between April and November 2015, DLMO was performed on seven patients with HV. The patients comprised one male and four females, with a mean age at surgery of 43.4 (21–62) years. The primary surgical indications for DLMO were all levels of severity of possible manual correction in patients with foot pain. The patients were placed in the supine position, and without a tourniquet, a 1.5-cm skin incision was centered over the medial aspect of the first metatarsal neck. A 2.0-mm Kirschner wire was inserted manually from the wound to the medial side of the hallux using a retrograde technique. Under direct vision, the Kirschner wire was introduced into the medullary canal of the first metatarsal shaft. Blood flow measurements of the pre- and post-osteotomy first metatarsal head in the seven patients were performed by LDF (ALF21 N; ADVANCE Co., Tokyo, Japan). The probe was touched to the first metatarsal head. The blood flow measurements were repeated three times, and the mean values were calculated. Results: On preoperative plain radiographs, the mean hallux valgus angle was 38.0° (range: 22.4–45.8°), and the mean intermetatarsal angle was 17.0° (range: 10.4–21.9°). The mean pre- and post-DLMO systolic blood pressure at the time of the measurements was 87.3±7.76 and 88.1±8.25 mmHg, respectively (P=0.85). The mean pre- and post-DLMO blood flow rate was 1.71±0.68 and 1.66±0.49 ml/min/100 g, respectively (P=0.90). Conclusion: Steven et al. reported that a distal osteotomy can lead to avascular necrosis of the metatarsal head, because an aggressive plantar cut can disrupt the soft tissue plantarly, thereby disrupting the blood supply of digital arteries. However, we found that blood flow of the pre- and post-osteotomy metatarsal head was present in all patients examined, with no significant difference in the blood flow rates of the metatarsal head before and after DLMO. Based on the present results, it is possible to avoid major complications, such as avascular necrosis of the metatarsal head, because DLMO is minimally invasive and involves less release of the soft tissue.

Category: Arthroscopy Introduction/Purpose: The gold standard for chronic lateral ankle ligament injury is ligament repair via the modified Broström- Gould procedure. Recently, lateral ankle ligament repair has been performed arthroscopically. This requires the insertion of one to three suture anchors in the fibula from anterior to posterior via the accessory portal. It is important to insert the suture anchors completely into the fibula bone. Because the distal fibula is tapered and has a fossa on the posterior surface, unfavorable insertional direction of the suture anchor can lead to complications such as inadequate suture anchor stability or friction between the suture anchor and the peroneus tendons. This study aimed to investigate the distance between the insertion point of the suture anchors and the posterior surface of the fibula on computed tomography (CT) images. Methods: Twenty ankles from 16 patients who had undergone three-dimensional CT scans for foot or ankle disorders without deformity of the fibula were assessed (10 male, 10 female; mean age, 32 years; age range, 12–78 years). The shortest distance from the insertion point of the suture anchor to the deepest point of fossa/the top of the convex of fibula was measured on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. We also measured the distance from the insertion point of the suture anchor to the posterior surface of the fibula, in a direction parallel to the sagittal plane of the lateral surface of the talus on the axial planes tilting from the longitudinal axis of the fibula at 90°, 75°, 60°, and 45°. Results: The posterior fossa was observed in all cases on the 90° and 75° images. The distance from the insertion point to the posterior surface of the fibula in a parallel direction was 15.6 mm at 90°, 18.0 mm at 75°, 21.5 mm at 60°, and 24.8 mm at 45°. The posterior points in a parallel direction were located on the posterior fossa in 40% of cases at 90°, in 10% at 75°, and in 0% at 60° and 45°. Conclusion: We suggest that the suture anchor should be directed from anterior to posterior at an angle of less than 60° to the longitudinal axis of the fibula, parallel to the lateral surface of the talus, in order to avoid passing through the fibula.