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Background: The optimal surgical procedures for chronic Lisfranc injuries are controversial. This study aimed to demonstrate the clinical outcomes of fiber tape fixation for chronic Lisfranc injuries under early full weightbearing protocols. Methods: This study included 11 feet from 10 patients who underwent fiber tape fixation for chronic Lisfranc injuries (undiagnosed for more than 6 weeks from injuries). All patients were allowed full weightbearing with normal shoes 4 weeks after the surgery. Clinical outcomes were evaluated with the Self-Administered Foot Evaluation Questionnaire. Radiographic outcomes were evaluated with a first cuneiform (C1)-second metatarsal (M2) distance from weightbearing anteroposterior plain foot radiography. Results: The median follow-up period was 12 months (IQR, 12-16). The median C1-M2 distance improved significantly from 3.3 mm (IQR, 2.9-5.2) to 1.6 mm (IQR, 1.5-2.2). The pain, physical functioning, social functioning, shoe-related, and general health subscales of SAFE-Q improved significantly after the surgery, whereas the sports subscale did not reach statistical significance (P = .063). Five patients, who regularly participated in sports activities, were able to return to their preinjury sport level by 12 months. There were no complications, such as infection, nerve or tendon injuries, or hardware-related discomfort, in the entire cohort. Conclusion: The fiber tape fixation device under early full weightbearing protocols led to short-term improvements in pain, function, and radiographic stability for chronic Lisfranc injuries, with no observed complications. Level of Evidence: Level IV, case series. Graphical Abstract

Aims Mitral stenosis (MS) occasionally coexists with aortic stenosis (AS). Limited data are available regarding the functional class and clinical outcomes of patients who undergo transcatheter aortic valve implantation (TAVI) for combined AS and MS. This study compared the clinical outcomes in patients with and without MS who underwent TAVI for severe AS and assessed the impact of mitral annulus calcification (MAC) severity, transmitral gradient (TMG) and mitral valve area (MVA) on outcomes in patients with combined AS and MS. Methods We investigated patients in the OCEAN‐TAVI registry who underwent TAVI. MS was defined as an MVA ≤ 1.5 cm2 or TMG ≥ 5 mmHg. The composite of all‐cause death and admission for heart failure was compared between patients with and without MS. The impact of MAC, TMG and MVA on outcomes was assessed in patients with combined AS and MS. Results We identified 106 patients with MS (MAC 84%; TMG 6.4 ± 2.6 mmHg; MVA 1.10 ± 0.31 cm2) and 6570 without MS as controls. The MS group was older (85 ± 5 vs. 84 ± 5 years, P = 0.033), more of women (85 vs. 67%, P < 0.01), and had a higher risk of surgery (the Society of Thoracic Surgeons Mortality Score 8.7 ± 5.1 vs. 7.6 ± 5.9, P = 0.047) than the controls. In the MS group, the New York Heart Association Functional Class was 3 or 4 in 56% of the patients at baseline and 6% at 1 year after TAVI. Thirty‐day mortality (2.8% vs. 1.3%, P = 0.18) and early composite outcomes (17% vs. 15%, P = 0.56) were comparable between patients with and without MS. During a median follow‐up of 2.1 years, the presence of MS was associated with a higher incidence of adverse events compared with controls (adjusted hazard ratio [HR] 1.84; 95% confidence interval [CI] 1.34–2.51, P < 0.01), even on propensity score matched analysis (adjusted HR 1.91; 95% CI 1.14–3.22, P < 0.01). Moderate or severe MAC contributed to increased risk of adverse events in patients with MS (adjusted HR 2.89; 95% CI 1.20–6.99, P = 0.018), but TMG and MVA did not. Conclusions In patients undergoing TAVI for severe AS, those with moderate or severe MS experienced worse outcomes after TAVI compared with those without MS. Patients with combined AS and MS sustained symptom improvement at 1‐year post‐TAVI. MAC severity was a useful predictor of adverse events compared with MS haemodynamics such as TMG and MVA in patients with combined AS and MS.

Background Interest in less invasive surgeries for Weber type B distal fibular fracture has increased recently. This study aimed to demonstrate that nitinol staple-only fixation is less invasive compared to antiglide plate fixation. Materials and methods This retrospective review involved 59 patients with Weber type B fibular fractures who underwent surgery between 2018 and 2023. Twenty-eight patients underwent antiglide plate fixation, whereas 31 underwent multiple nitinol staple-only fixation. The intraoperative assessment included skin incision length and operative time. The radiographic outcomes were bone union and fibular length. The clinical outcomes included delayed wound healing, infection, discomfort from the implant, implant removal, and the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score administered at the last visit. Results The mean skin incision length and operative time of nitinol staple-only fixation were 3.8 ± 0.5 cm and 19.6 ± 3.6 min, compared with 8.7 ± 1.3 cm and 48.8 ± 10.6 min for plate fixation, respectively. Bone union was confirmed in all patients without fibular shortening. Although no significant differences in patients with delayed wound healing, infection, or postoperative SAFE-Q scores were found between the two groups, more patients with plate fixation reported discomfort from the implant (71.4% vs. 32.3%) and requested its removal (75.0% vs. 35.5%). Conclusion Multiple nitinol staple-only fixations offer the advantages of a smaller skin incision, shorter operative time, lesser discomfort from the implants, and a reduced need for implant removal compared with antiglide plate fixation. Furthermore, staple-only fixation could achieve bone union without loss of correction. This suggests that multiple nitinol staple-only fixation may be less invasive and more beneficial for patients than antiglide plate fixation.

Purpose The relationship between ligament remnant quality and postoperative outcomes after arthroscopic lateral ankle ligament repair for chronic lateral ankle instability is controversial. This study aimed to determine whether the signal intensity of the anterior talofibular ligament on preoperative magnetic resonance imaging and ligament remnant quality identified on arthroscopy are associated with recurrent ankle instability after arthroscopic lateral ankle ligament repair. Methods A total of 68 ankles from 67 patients with chronic lateral ankle instability who underwent arthroscopic lateral ankle ligament repair were retrospectively studied. The signal intensity of the anterior talofibular ligament was evaluated using T2-weighted magnetic resonance imaging. Arthroscopy was used to evaluate the thickness and mechanical resistance of the anterior talofibular ligament by hook palpation and to classify ankles into two groups: the present anterior talofibular ligament group with adequate mechanical resistance and the absent anterior talofibular ligament group with no mechanical resistance. The outcomes included recurrent ankle instability (respraining of the operated ankle after surgery) and Self-Administered Foot Evaluation Questionnaire scores. Results Thirteen ankles were diagnosed with recurrent ankle instability. Patients with a high anterior talofibular ligament T2 signal intensity experienced more recurrent ankle instability than those with a low intensity. As determined via arthroscopy, the absent anterior talofibular ligament group had a higher rate of recurrent ankle instability than the present anterior talofibular ligament group. There were no significant differences in Self-Administered Foot Evaluation Questionnaire scores between patients with high and low anterior talofibular ligament T2 signal intensity, as well as between absent and present anterior talofibular ligament groups based on arthroscopy. Conclusion Poor quality of the anterior talofibular ligament remnant could result in recurrent ankle instability after arthroscopic lateral ankle ligament repair. Therefore, when treating chronic lateral ankle instability, surgeons should consider ligament quality. Level of Evidence IV.

The aim of this study was to report the five scales comprising the rating system that the Japanese Society for Surgery of the Foot (JSSF) devised (JSSF standard rating system) and the newly offered interpretations and criteria for determinations of each assessment item. We produced the new scales for the JSSF standard system by modifying the clinical rating systems established by the American Orthopaedic Foot and Ankle Society (AOFAS scales) and the Japanese Orthopaedic Association’s foot rating scale (JOA scale). We also provided interpretations of each assessment item and the criteria of determinations in the new standard system. We improved the ambiguous expressions and content in the conventional standard rating systems so they would be easily understood by Japanese people. The result was five scales in total. Four were designed for use specifically for ankle-hindfoot, midfoot, hallux metatarsophalangeal- interphalangeal, and lesser metatarsophalangeal- ineterphalangeal sites; and the fifth was for the foot and ankle with rheumatoid arthritis. Furthermore, we described interpretations and criteria for determinations with regard to evaluation items in each scale. Conventionally, the AOFAS scales or the JOA scale have been separately applied depending on the sites or disorders concerned, but it was often difficult to decide on scores during practical evaluations because of differing expressions in different languages and also because of ambiguity in the interpretation of each evaluation item and in scoring standards as well. JSSF improved these scales and added definite interpretations of evaluation items as well as criteria for the rating (to be reported here in part I). Because these steps were expected to improve the reliability of outcomes assessed by each scale, we examined the reliability in scores of the newly developed scales, which are reported in part II (in this issue).

•Subclinical hemolysis after TAVI has occasionally been documented.•Decompensated hemolytic anemia requiring specific treatment has been rare.•The incidence of hemolytic anemia after TAVI using S3UR was not negligible.•PVL ≥ mild was associated with an increased risk of hemolytic anemia. Decompensated hemolytic anemia after transcatheter aortic valve implantation (TAVI) requiring specific treatment is rarely encountered in actual clinical practice. Nevertheless, there have been several cases of clinically relevant hemolytic anemia following implantation of the recently launched SAPIEN 3 Ultra RESILIA (S3UR). This study aimed to elucidate the clinical features of hemolytic anemia following S3UR implantation. Patients who underwent TAVI using S3UR from the end of March 2023 to November 2023 were enrolled from the Japanese multicenter OCEAN (Optimized CathEter vAlvular iNtervention)–TAVI registry. Hemolytic anemia was defined as (1) a drop in hemoglobin level by >2.0 g/dL within 3 months after the index TAVI procedure and (2) the diagnosis of mechanical hemolysis as the cause of anemia made by the attending physician and hematologist based on the presence of any 2 of the following criteria: (1) serum lactate dehydrogenase level >220 IU/L; (2) haptoglobin level <0.5 g/L; and (3) reticulocyte count ≥2%. Of the 1,070 patients, 18 (1.7%) patients developed hemolytic anemia after TAVI. These patients had a significantly lower prosthesis oversizing relative to native annulus (−3.7% [−5.9% to 0.1%] vs 7.5% [0.6% to 14.0%], p <0.001) and a higher prevalence of paravalvular leakage (PVL) ≥mild (mild PVL: 61.1% vs 12.4%; moderate-to-severe PVL: 16.7% vs 0.2%; p <0.001) than those without hemolytic anemia. PVL ≥mild was associated with a higher incidence of hemolytic anemia particularly in patients with oversizing of <−5% (33.3% vs 1.3%, p <0.001) and in those with −5%≤ oversizing <10% (8.3% vs 0.7%, p <0.001). In conclusion, the incidence of decompensated hemolytic anemia after S3UR implantation was not negligible, and the results of the present study support the importance of selecting a prosthesis size with a sufficient oversizing relative to native annulus to minimize residual PVL ≥mild leading to hemolytic anemia after TAVI. [Display omitted]

Hindfoot varus alignment is a risk factor for chronic lateral ankle instability (CLAI) and recurrent ankle instability following anterior talofibular ligament (ATFL) repair for CLAI. This study aimed to assess whether combining calcaneofibular ligament (CFL) repair with ATFL repair can correct hindfoot varus alignment and reduce recurrent ankle instability. This study retrospectively examined 74 ankles from 71 patients with hindfoot varus alignment who had lateral ankle ligament repair for CLAI. Arthroscopic ATFL repair was performed on 37 ankles (from 36 patients) between 2018 and 2021 (ATFL-only group), whereas open ATFL and CFL repair were conducted on another 37 ankles (from 35 patients) between 2021 and 2023 (CFL-repair group). Long axial hindfoot alignment radiographs were utilized to measure tibiocalcaneal angles (TCA) pre- and postoperatively. The primary outcome includes recurrent ankle instability (i.e., respraining of the operated ankle after surgery), whereas the secondary outcome involves Self-Administered Foot Evaluation Questionnaire (SAFE-Q) scores. A comparison of patient demographics between the two groups revealed no marked differences. Additionally, pre- and postoperative TCA demonstrated that neither ATFL repair only nor CFL repair combined with ATFL repair corrected hindfoot varus alignment. Furthermore, no significant differences were observed in postoperative recurrent ankle instability and SAFE-Q scores between the two groups. Combining ATFL and CFL repair could not correct hindfoot varus alignment, and this procedure for CLAI with hindfoot varus alignment was not more effective in reducing recurrent ankle instability than ATFL repair alone.

A 46-year-old pregnant woman, presented with worsening episodes of intermittent chest pain. The patient was diagnosed with a non-ST-elevation myocardial infarction. On arrival, she had a stable hemodynamic status without chest pain. She was initially treated with conservative medical therapy. One day later, she complained of severe chest pain, and an electrocardiogram showed ST elevation in leads I, aVL, and V2-5. Emergency coronary angiography showed total occlusion of the left anterior descending artery (LAD) and intermediate stenosis of the left main coronary artery (LMCA). The intravascular ultrasound (IVUS) revealed an intramural hematoma (IMH) from the LMCA to the LAD, extending to the left circumflex artery (LCX) ostium. This finding was consistent with spontaneous coronary artery dissection (SCAD). After stent implantation from the LMCA to the LAD, severe stenosis was noted at the proximal site of the LCX. IVUS showed that the IMH extended to the LCX. The provisional crush stent technique was performed, and the final angiography revealed satisfactory results with thrombolysis in myocardial infarction flow grade 3 in the LAD and LCX. This case report highlighted that stent implantation in the SCAD lesions facilitated the extension of the IMH longitudinally and laterally into the side branch, resulting in stenosis or occlusion. Therefore, the side branch should be evaluated using IVUS before stent implantation. In cases where the IMH extends to the ostium of the side branch, two-stent techniques that do not require guidewire recrossing, such as crush stents, should be considered to avoid side branch occlusion.

Transcatheter aortic valve implantation (TAVI) using SAPIEN 3 Ultra RESILIA (S3UR) offers improved hemodynamic performance than its former generation, SAPIEN 3 (S3). This study compared 1-year clinical outcomes after TAVI using S3UR and S3. Among 2,369 patients from the OCEAN-TAVI registry (UMIN000020423), a 1:1 propensity score-matched analysis identified 775 matched pairs. One-year post-TAVI, S3UR showed significantly lower all-cause mortality (10.3% vs. 13.4%, p  = 0.026), stroke (0.9% vs. 3.4%, p  = 0.001), and heart failure rehospitalization (1.4% vs. 2.7%, p  < 0.001) than S3. These differences were pronounced in patients receiving smaller valves (20–23 mm). S3UR demonstrated a larger effective orifice area, lower mean pressure gradient, and lower incidence of paravalvular leakage than S3 at discharge. At 1 year, S3UR showed significantly reduced paravalvular leakage and lower incidences of mean pressure gradient ≥20 mmHg than S3. We concluded that S3UR demonstrated superior hemodynamic performance to S3, exhibiting better prognosis, particularly in patients with smaller valves.

It is important to evaluate the subtalar joint and hip-knee-ankle alignment to understand lower extremity alignment. In this review, we focused on the compensatory changes in the subtalar joint alignment for the deformity of the knee and ankle joint, reviewing previous research. The subtalar joint alignment was compensatory valgus in patients with varus knee and ankle deformity, whereas it was uncertain whether the subtalar joint alignment was compensatory varus in patients with valgus knee and ankle deformity. The subtalar joint valgus alignment improved after total knee arthroplasty or high tibial osteotomy for varus knee deformity, even if the deformity was severe. In contrast, whether the subtalar joint alignment changed after the surgery for ankle or valgus knee deformity has not been considered. Further research on the compensatory function of the subtalar joint is needed.