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Background S1 transforaminal epidural steroid injection (S1-TFESI) results in positive clinical outcomes for the treatment of pain associated with the S1 nerve root. S1-TFESI via the transforaminal approach is commonly performed under fluoroscopic guidance. Ultrasound guidance is an alternative to mitigate radiation exposure. However, performing spinal procedures under ultrasound guidance has some limitations in confirming the position of the needle tip and vascular uptake. New techniques are therefore needed to make ultrasound and fluoroscopy complementary. Our objective was to describe a novel technique for S1-TFESI and confirm its reproducibility. Methods Records of patients with S1 radiculopathy were reviewed retrospectively; those treated using the new S1-TFESI technique were selected. Initially, ultrasound was used to distinguish anatomy of the sacral foramen and guide initial placement of the needle entry point. Fluoroscopy was subsequently used to confirm needle tip position and vascular injection. The number of times the needle required reinsertion was recorded, and ultrasound and C-arm images were stored. Results Sixty-seven S1-TFESIs were performed in 56 patients. All injections exhibited epidural spread of contrast media, not only to the S1 nerve. The cephalad angle was 16.25 ± 6.75° (range, 5–27°), the oblique angle was 2.48 ± 2.62° (range, 0–7°), and the mean number of attempts was 1.24 ± 1.25. Conclusions The new technique, involving the use of ultrasound to guide initial placement of the needle entry point, followed by confirmatory imaging and any needed adjustment with the use of fluoroscopy, can be a technique to complement the shortcomings of using ultrasound or fluoroscopy alone.

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 (pConclusion: The MIS using percutaneous technique for hallux valgus deformity achieved enough correction and relief of pain. All patients were satisfied with the clinical assessments. However, a long-term study is necessary to compare with other techniques.

ObjectiveWe sometimes encounter unintentional flow of contrast into the facet joints during cervical interlaminar epidural injection, which leads to false-positive epidural injection. The purposes of this study were to evaluate the rate of facet flow of contrast and to investigate various factors associated with injection into the space of Okada during fluoroscopy-guided cervical interlaminar epidural injection.Setting and SubjectsImages from consecutive cases of fluoroscopy-guided cervical interlaminar epidural injection performed at a single institution between July 2015 and July 2018 were obtained and reviewed.MethodsCases of epidural injection were classified as either facet flow or no facet flow. Multivariate logistic regression was used to identify the predictive factors of unintended injection into the Okada space.ResultsA total of 2,006 cases were included. Intra-articular flow was identified in 6.0% of cases (121/2,006). All cases of flow of contrast into the facet joints were recognized, and appropriate epidurograms were obtained during the procedures. The highest rate of unintended facet flow of the contrast (10.1%, 44/436) occurred at C5–6. Cervical interlaminar epidural injection at C5–6 and above (adjusted odds ratio [aOR] = 1.929, P = 0.001) and the paramidline approach for epidural injection (aOR = 2.427, P ConclusionsWe detected injection into the space of Okada during fluoroscopy-guided cervical interlaminar epidural injection in 6.0% of procedures. Cervical interlaminar epidural injection at C5–6 and above and the paramidline approach for epidural injection were positive predictors of unintentional facet flow of the contrast.

Background: The mobile-bearing Salto total ankle prosthesis has been reported to have promising outcomes. However, clinical reports on this prosthesis are few, and most have been published by the inventors and disclosed consultants. Methods: We retrospectively reviewed 59 patients who received Salto prosthesis unilaterally. The average follow-up was 35.9 (range, 6-56) months. Clinical and radiologic results were evaluated. Clinical results were evaluated according to visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS) pain and disability score, and ankle range of motion (ROM) in dorsiflexion/plantarflexion. In the radiographic evaluation, we measured the tibial angle (TA), talar angle (TAL), tibial slope, and talocalcaneal angle (TCA) on weightbearing radiographs. Results: By the last follow-up, 7 of 59 patients (11.9%) had undergone reoperation, and 3 of 59 implants (5.1%) had been removed. The prosthesis survival was 94.9% (95% CI, 89.1%-100%). With any reoperation as the endpoint of follow-up, the clinical success rate was 88.1% (95% CI, 79.4%-96.9%). The mean postoperative visual analog scale score, AOFAS ankle-hindfoot score, and Ankle Osteoarthritis Scale pain and disability score improved significantly ( P < .001). The ankle range of motion also improved from preoperative 33.4 ± 16.6 to 40.3 ± 15.5 postoperatively ( P < .001); however, there was no statistically significant change in plantarflexion ( P = .243). Radiolucent areas and osteolysis were found in 28 (47.5%) and 27 (45.8%) patients, respectively. Heterotopic ossification was observed in 13 patients (22.0%). Conclusions: In this series, early clinical and radiographic outcomes of this prosthesis were promising. We believe the early radiolucent lines were probably due to the gap at the implant and bone interface, and they disappeared at the time of osseous integration. However, longer follow-up is necessary to determine the long-term durability and survivorship of this implant, particularly given the high incidence of postoperative osteolysis. Level of Evidence: Level IV, case series.

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.

Postdural puncture headache is a leak of cerebrospinal fluid that lowers intracranial pressure and usually presents as a positional headache. If conservative treatments are not successful, the epidural blood patch is the gold standard of the treatment for dural puncture. The interlaminar approach is the most commonly used technique for an epidural blood patch. This case report describes a patient who was treated with a transforaminal epidural blood patch for postdural puncture headache following an acupuncture procedure on his lower back after two epidural blood patches using an interlaminar approach had failed. The patient underwent an acupuncture therapy for management of chronic low back pain due to postlaminectomy syndrome. After the procedure, the patient had a severe headache and the conservative treatment was not effective. The two interlaminar epidural blood patches at the L2–3 level and at the L3–4 level were failed. We performed transforaminal epidural blood patch at the L3–4 and L4–5 levels on the left side, the site of leakage in the MRI myelogram. His symptoms finally subsided without complication. This case demonstrates that targeted transforaminal epidural blood patch is a therapeutic option for the treatment of postdural puncture headache when epidural blood patch using an interlaminar approach is ineffective.

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 (pConclusion: Bone graft for periprosthetic osteolysis may improve patient’s clinical outcome and give support to the structures surrounding the implant. Bone grafting in optimal timing may also improve implant survivorship. However, further study is needed for the etiology of newly developed painless osteolysis even after the bone graft.

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: 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’), (pConclusion: A single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture can be performed in fractures with small fragment size and minimal displacement. We found that it can be a effective method to achieve early and wide range of motion of ankle joint after posterior mallolus fracture.

Background: Recent studies have reported promising clinical results after osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the talus (OLT). However, no study has yet compared clinical outcomes between primary and secondary OAT for large OLT. Purpose: To compare clinical outcomes among patients with large OLT who receive primary OAT versus those who receive secondary OAT after failure of marrow stimulation and to identify factors associated with clinical failure. Study Design: Cohort study; Level of evidence, 3. Methods: From 2005 to 2014, 46 patients with large OLT (≥150 mm2) underwent OAT: 18 underwent OAT as initial surgical management (primary OAT group), and 28 patients underwent secondary OAT after failure of previous arthroscopic marrow stimulation (secondary OAT group). In both groups, OAT procedures included arthroscopic inspection and debridement of concomitant soft tissue injuries. Clinical outcomes were assessed using pain visual analog scale (VAS), the Roles and Maudsley score, Foot and Ankle Outcome Scores (FAOS), and revisional surgery rates. Factors associated with clinical failures were evaluated using bivariate and logistic regression analyses. Survival outcomes were compared using Kaplan-Meier analysis. Results: Mean follow-up time was 6 years (range, 2-10.8 years). Mean lesion size was 194.9 mm2 (range, 151.7-296.3 mm2). There were no significant differences between groups in patient demographics and preoperative findings. Postoperative pain VAS, Roles and Maudsley score, FAOS, and revisional surgery rates were not significantly different at last follow-up. Prior marrow stimulation was not significantly associated with clinical failure on bivariate analysis. Lesion size greater than 225 mm2 on preoperative magnetic resonance imaging was significantly associated with clinical failure. Survival probabilities from Kaplan-Meier plots were not significantly different between the primary and secondary OAT groups ( P = .947). Conclusion: Clinical outcomes of patients with large OLT treated with secondary OAT after failed marrow stimulation were found to be comparable with those who were treated with primary OAT. These results may be helpful to orthopaedic surgeons deciding appropriate surgical options for patients with large OLT.

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 (pConclusion: Bone graft for periprosthetic osteolysis may improve patient’s clinical outcome and give support to the structures surrounding the implant. Bone grafting in optimal timing may also improve implant survivorship. However, further study is needed for the etiology of newly developed painless osteolysis even after the bone graft.

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: 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.

Background: Several studies have reported on the outcome of arthroscopic treatment or osteochondral autologous transplantation (OAT) for osteochondral lesions of the talus (OLT), with mixed results. None of these studies has compared the results of repeat arthroscopy and OAT after failed primary arthroscopic treatment. Purpose: To compare the outcomes of OAT and repeat arthroscopy for the treatment of OLT after primary arthroscopy Study Design: Cohort study; Level of evidence, 3. Methods: This study included 22 patients who underwent OAT (group A) and 22 patients who underwent repeat arthroscopy (group B) after failed treatment of OLT among 399 patients who received primary arthroscopic marrow stimulation at single institution between 2001 and 2009. All patients were evaluated clinically using the visual analog scale (VAS) for pain and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. The cumulative success rates were compared by use of Kaplan-Meier life table analysis. Results: The patients’ demographic and clinical characteristics and indications for surgery were comparable between the groups. Both groups showed significantly improved ( P < .001) VAS and AOFAS scores 6 months after surgery. However, group B showed significant deterioration over a mean follow-up period of 50 months. Overall, 18 of 22 (81.8%) patients in group A and 7 of 22 (31.8%) patients in group B achieved an excellent or good (≥80) AOFAS score ( P < .001). No patient in group A and 14 of 22 (63.6%) in group B required further revisions. Conclusion: Osteochondral autologous transplantation was significantly superior to repeat arthroscopic treatment of OLT after a mean follow-up period of 48 months. Therefore, repeat arthroscopy should be used judiciously for the treatment of OLT after failed arthroscopic treatment.

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.

Background: Among the types of osteochondral lesions of the talus (OLTs), the osteochondral and chondral types make up the majority of OLTs. There is a possibility that between these two types of lesions, the clinical outcomes and characteristics may differ. Purpose: This study was designed to compare the clinical outcomes, demographics, and characteristics of osteochondral- and chondral-type lesions of OLTs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed 298 ankles that underwent arthroscopic marrow-stimulating procedures for OLTs between 2001 and 2009 that had been arthroscopically determined as either chondral type (210 ankles) or osteochondral type (88 ankles). Clinical outcomes, demographics, and characteristics of the lesions were compared. Results: The age distribution showed that the chondral type reached its peak in patients in their 50s, whereas the osteochondral type had a peak distribution for those in their 20s. The average duration of symptoms was greater in the chondral type (28.3 months; range, 7-240 months) than in the osteochondral type (14.4 months; range, 8-120 months) ( P < .001). With regard to the characteristics of the lesions, differences only existed in the combined intra-articular lesions between the two types. Subchondral cysts (odds ratio [OR], 3.71; 95% CI, 1.61-8.55; P = .001) and soft tissue impingement (OR, 1.82; 95% CI, 1.10-3.03; P = .021) were more frequently present in the chondral type. The American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) for pain showed significant improvement from preoperative to postoperative scores in both groups. However, the preoperative and postoperative VAS and AOFAS scores did not differ significantly between the groups. Conclusion: Differences were found with age distribution, duration of symptoms, and combined intra-articular lesions between the osteochondral- and chondral-type lesions of OLTs. We achieved similar successful clinical outcomes in both types of lesions using arthroscopic marrow stimulating procedures, such as microfracture or abrasion arthroplasty.

Iatrogenic vascular injury as a result of closed hip nailing is not common, but is a regularly reported complication after hip fracture surgeries. To prevent vascular injury in closed hip nailing by identifying the range of distances and angles between deep and superficial femoral arteries (DFAs and SFAs) and distal screws. Forty subjects who underwent computed tomography angiographies were included in this study. Imaginary lines marking the distal screws (proximal femoral nail antirotation-II [PFNA-II], 180 and 300 mm; inter-trochanteric/sub-trochanteric nails [ITST], 200 and 300 mm) were drawn on the scout film. On arterial phase images, angles between distal screw lines and those marking DFAs or SFAs, as well as the distance between each artery and far cortex, were measured using the cross-reference capabilities of the picture archiving and communication system. The short nails (PFNA-II 200 mm and ITST 180 mm) were closest to the DFAs, indicating that these nails are most likely to cause injury (PFNA-II 200 mm: 11.2 ± 13.7° anterior and 9.87 ± 5.83 mm; ITST 180 mm: 22.56 ± 15.92° posterior and 9.24 ± 4.74 mm). The short nails were relatively distant from the SFAs, which were located posteriorly to the long nails (PFNA-II 300 mm and ITST 300 mm). These data indicate that insertion of distal screws into intramedullary nails increases the risk of injury to vascular structures. Surgeons must take care in drilling or inserting screws to ensure the prevention of vascular injury.

The purpose of this study was to evaluate the effectiveness of arthroscopy combined with hardware removal for chronic pain after satisfactory healing of an ankle fracture. We hypothesized that combining hardware removal with arthroscopy for the intra-articular pathology would improve residual complaints more so than hardware removal alone. The outcomes of the 53 young male patients with chronic pain after healed ankle fracture treated with two different therapeutic plans: (1) conservative treatment after hardware removal (group A) and (2) arthroscopic intervention with hardware removal (group B) were prospectively studied. Patients were reviewed preoperatively and 6 and 12 months postoperatively using American Foot and Ankle Society (AOFAS) scale. Median AOFAS scores improved from 74 (66–80) points to 76 (73–92) points in group A and from 75 (64–80) points to 85 (72–100) points in group B, and this improvement was significantly higher for patients in group B (p = 0.001). This study supports the notion that when there is a definite diagnosis such as loose body, bony impingement, or anterolateral soft-tissue impingement causing chronic pain after healed ankle fracture, arthroscopic treatment with hardware removal is a better treatment option than hardware removal and conservative treatment. Prospective comparative study, Level II.

Predicting rotation of proximal femur in femur fracture surgeries is important to prevent malrotation.We aimed to prevent malrotation by developing a simple guideline that enables the prediction of proximal femur rotation using translucent 3-dimensional computed tomography (3D CT).Retrospective.One tertiary general hospital in the Republic of Korea.Thirty-six subjects who underwent CT angiographies for vascular evaluation.Translucent 3D CT images were created from the CT data.Morphologic ratios of the great trochanter (GT) and lesser trochanter (LT) with the hip center as a basic point were measured at neutral position and at 5°, 10°, 15°, 20°, 25°, and 30° of internal rotation (IR) and external rotation (ER). The rotation angles at which the GT ratio becomes 0.5 and 0.33 and the rotation angles at which the LT ratio becomes 0.0 and 1.0 were determined to serve as guide angles.Both the proportion of GT and LT compared with proximal femur with hip center as a reference (GT and LT ratio) gradually increased in the shift from IR to ER. At a neutral position, the GT and LT ratios were approximately 0.4 and 0.5, respectively. At 10°-15° of ER, the approximate GT and LT ratios were 0.5 and 1.0, respectively. At 30° of ER, the GT ratio exceeded 0.6, and the LT ratio exceeded 1.0. Between 10° and 15° of IR, the GT ratio decreased to approximately 0.33 and the LT ratio decreased to 0.0, which indicated that the LT was invisible.We suggested practical values which might be useful as a reference in the operating room practically and hope that our findings would be helpful to prevent malrotation while performing proximal femur or femur shaft surgeries.

The purpose of this study was to present the results of the metatarsal fractures treated with a closed antegrade intramedullary pinning technique. The records of 35 consecutive patients with metatarsal fractures operated on from August 2005 to June 2010 by the authors were retrospectively reviewed. Four patients were not contactable and 1 patient refused to participate. Accordingly, the study cohort was composed of 30 patients (24 male, 6 female) with 46 metatarsal head, neck, or shaft fractures. Inclusion criteria were metatarsal head, neck, or shaft fractures with a displacement of more than 3 to 4 mm or an angulation of more than 10° in the sagittal plane. Fractures combined with Lisfranc injury or metatarsal base fractures were excluded, as were bicortical comminuted fractures or long oblique fractures. Times to bone union, limitations of motion at affected metatarsophalangeal joints, and residual pain were evaluated at 6 weeks after surgery and at final follow-up. American Orthropedic Foot and Ankle Society scale was evaluated at final follow-up. Fracture union was obtained at an average of 7.1 (range 6 to 10) weeks. Two patients had moderate limitation of metatarsophalangeal joint at 6 weeks but recovered to full range at final follow-up. Average American Orthropedic Foot and Ankle Society score at final follow-up was 96.7 (range 83 to 100) points. Closed antegrade intramedullary pinning was found to be a useful method for treating displaced metatarsal fractures and to allow immediate joint motion and partial weightbearing in a stiff-soled shoe.

PURPOSE: The object of this study was to investigate the difference in torque and pullout strength between the standard anchor insertion (5.0 mm) with a small awl (3.7 mm) and larger anchor insertion (6.5 mm), with a standard awl (5.0 mm) in osteoporotic humeral head.MATERIALS AND METHODS: The embalmed 24 paired cadaveric shoulders were assigned to either Group A or B. After measuring the bone mineral density (BMD) of the ROI (region of interest) in the humeral head, 5.0 mm suture anchors were inserted using a 3.7 mm awl in Group A1, and the same 5.0 mm anchors were inserted using a 5.0 mm awl in Group A2. The 5.0 mm anchors were inserted using a 5.0 mm awl in Group B1, and 6.5 mm anchors were inserted using a 5.0 mm awl in Group B2. We measured the torques at the time of the anchor insertion and pullout strengths.RESULTS: There was no significant difference in the BMD between the groups. The torque of A1 (20.6 cN.m) was significantly higher than that of A2 (13.2 cN.m), and the torque of B2 (20.8 cN.m) was significantly higher than that of B1(12.1 cN.m). However, the difference in the increased torque between group A and B was not significant. The pullout strength of A1 (204.2 N) was significantly higher than that of A2 (152.9 N), and the pullout strength of B2 (210.9 N) was significantly higher than that of B1 (149.5 N). However, the difference in the increased pullout strength between Group A and B was not significant.CONCLUSION: In severe osteoporosis, the use of a larger suture anchor with a standard awl increased the torque and pullout strength significantly, in comparison to the use of the same sized suture anchor and awl. If there is an inadequate interval between the anchors on the greater tuberosity, the use of a 3.7 mm awl and 5.0 mm anchor will be beneficial compared to that of a 5.0 mm awl and 6.5 mm anchor, considering that an increase in the pullout strength does not depend on the awl size.

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: 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.

Gouty attacks usually occur in patients with hyperuricaemia, but patients with gout who have normouricaemia are believed to be in the minority.1,2 This is a common conception about gout because monosodium urate crystals are formed at blood concentrations of uric acid over 420 μmol/l at a body temperature of 37°C.3 Recently, two studies showed that the incidence of gouty attacks in normouricaemia was as high as 39–43%,4,5 which is much higher than our traditional view.1–3 However, few data on normouricaemia in gout have been reported so far.6–8 The prevalence of patients with gout who have normouricaemia at diagnosis has not yet been determined, and even their clinical characteristics and laboratory findings have not been reported. We designed this study to determine the …

CC Vallecular cyst is a very rare lesion. Vallecular cyst results from obstruction and retention of mucus in collecting ducts of submucosal glands [1]. Vallecular cyst can be potentially dangerous during anesthesia because they may completely obstruct the larynx or the anesthesiologist's view of the larynx causing difficult intubation and thus become life-threatening [2,3]. We recently encountered a patient with a vallecular cyst which caused near-lethal airway obstruction during the induction. The patient was scheduled to have an urgent debridement on diagnosis of septic shock, due to deep neck infection. After preoxygenation, the patient was induced with thiopental sodium and succinylcholine acetate IV. Inserted direct laryngoscopy revealed a cyst arising from the vallecula, overlying the lingual surface of the epiglottis. The cyst hanging down perpendicular to the posterior pharyngeal wall, completely prevented visualization of the glottic opening. Furthermore, it was not possible to expose the laryngeal inlet by the laryngoscope. Sedation and muscle relaxation likely propelled the cyst further downward, due to extension with the force of gravity. Three attempts at blind intubation with a styletted 7.0 mm endotracheal tube, by two anesthesiologists, were unsuccessful due to the drooping cyst. Moreover, effectively bag-ventilating the patient was impossible. Meanwhile, bradyarrhythmia (40 to 45 bpm) and subsequently ventricular tachycardia up to 160 bpm appeared on electrocardiograph. We clinically made a decision that further attempts at intubation were futile, on considering the fatal vital signs. Tracheostomy was immediately performed and completed within 3 minutes. After ventilation was resumed, vital signs stabilized. The surgeon intra-orally incised the cyst with base attached to the valleculae. The contents, consisting of 6 ml of a thick, yellow purulent material were drained. The pathology report of the surgical specimen indicated a stratified squamous epithelial lined cyst, containing inflammatory debris. Review of the preoperative cervical CT indicated the presence of vallecular cyst, which had been overlooked by both the otolaryngologists and the surgical team preoperatively (Fig. 1).

Background: Numerous metatarsal osteotomies have been developed for the treatment of Freiberg’s disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg's disease. Methods: From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg's disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients’ subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg’s disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed. Results: VAS showed improvement from 6.2 ± 1.4 to 1.4 ± 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 ± 14.9 to 80.4 ± 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 ± 10.1 to 48.3 ± 13.0 degrees at last follow-up (p < 0.0001). According to Smillie's classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, re porting excellent or good results. Conclusions: Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg's disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.