Is step-cut shortening osteotomy a better choice than transverse osteotomy for total hip arthroplasty for Crowe type III-IV hip dysplasia?

INTRODUCTION: Total hip arthroplasty for developmental hip dysplasia is a challenging surgery due to anatomic abnormalities. Crowe III and Crowe IV hip dysplasia generally necessitates a subtrochanteric shortening osteotomy. Transverse and step-cut osteotomy are the most common procedures for shortening of femur although there is still no consensus which one is a superior method. The objective of this study was to demonstrate whether transverse or step-cut osteotomy is superior in hips who undergo arthroplasty for high riding hip dysplasia. HYPOTHESIS: Our hypothesis was that higher rates of union would be achieved in patients with Crowe III-IV hip dysplasia when the step-cut osteotomy was performed compared to transverse osteotomies. MATERIAL AND METHODS: A total of 99 hips from 90 patients (9 bilateral, 81 unilateral; 79 female, 11 male), each with a minimum follow-up duration of two years, were included in this study. The hips were classified as Crowe III (n=16) or IV (n=83). All hips were implanted cementless. Transverse or step-cut osteotomy was chosen for osteotomy type. The clinical and functional outcomes were assessed using the Harris Hip Score (HHS), limb length discrepancy (LLD), and limping. The complications and management of these were noted. The union rates were compared between osteotomy types. RESULTS: The mean age at surgery was 48.8 (range, 21-79 years). The follow-up period was 64.3 months in average (range, 24 to 192 months). The mean Harris Hip Score before surgery was 35.6 (range, 18-50), and increased to 88.1 (range, 61-98) points at the most recent follow-up. The preoperative leg length discrepancy (LLD) measured 5.3cm (with a range of 3 to 6.8), while the postoperative LLD reduced to 0.8cm (with a range of 0 to 1.6). There were a total of 38 complications in 35 patients out of 99 cases, resulting in a complication rate of 38.4%. The most frequent complication observed was intraoperative femoral fractures, occurring in 13 cases. Residual limping was seen in 73.7% of all. Step-cut osteotomy was performed in 64 hips (35 CDH stem [Zimmer Biomet, Warsaw, IN, USA], 29 Wagner Cone stem [Zimmer Biomet, Warsaw, IN, USA]) and, transverse in 35 hips (22 CDH, 13 Wagner Cone). Six hips had nonunion problem and all of them were operated with a step-cut osteotomy (z-score: -7.12 and p<0.00001, Mann-Whitney U Test). CONCLUSION: Transverse osteotomy may be a better option while performing a shortening subtrochanteric level osteotomy for total hip arthroplasty for Crowe III-IV hips. LEVEL OF EVIDENCE: Level III; observational retrospective cohort study.

Early Results and Patient-Reported Outcome Measures (PROMS) of an Intraosseous Device for Arthrodesis of the First Tarso-Metatarsal (TMT) Joint.

Background: We describe a new surgical technique for arthrodesis of the first tarso-metatarsal (TMT) joint using an intraosseous fixation device and the early results including patient-reported outcome measures (PROMS). Materials and Methods: Seventeen consecutive procedures with this method were included. Indication for surgery was hallux valgus. The average age was 42 years (range 26-65). PROMS were collected and the patients were asked to fill out a satisfaction questionnaire. A retrospective review of radiographs and electronic medical notes was conducted. Results: Overall fusion rate was 94%. Complications included a case of failed fusion, a superficial wound infection and a deep vein thrombosis (DVT). At a mean follow-up of 24 months (range 10-38) radiographic results demonstrated significant improvement in the intermetatarsal angle or IMA (11.7 ± 2.8 degrees to 6.9 ± 2.4 degrees, P < 0.001) and hallux valgus angle or HVA (28.1 ± 7.3 degrees to 12.2 ± 4.3 degrees, P < 0.001). The mean visual analog scale (VAS) score improved significantly from a mean of 7.6 (SD 0.85) preoperatively, to a mean of 2.1 (SD 1.83) post-operatively (P < 0.0001). The Manchester-Oxford Foot Questionnaire (MOXFQ) significantly improved from a mean of 35.8 (SD 10.2), to a mean of 9.2 (SD 17) (P < 0.0001). The final result was satisfactory for 88% of the patients. Conclusions: The early results show intraosseous fixation to be a safe and efficient method for the fusion of the first TMT joint providing good patient satisfaction.

Is Obesity Associated with Higher Complication Rates in Total Hip Arthroplasty for High-Riding Dysplastic Hips?

OBJECTIVE: Developmental dysplasia of the hip (DDH) is a disabling pathology leading to hip problems, such as painful arthritic hip, unstable hip, etc. Total hip arthroplasty (THA) is an effective treatment modality for this condition. Obesity has been shown to be associated with increased rates of complications following orthopaedic surgeries (Journal of Arthroplasty 20:46-50). The hypothesis of this study was that patients with a body mass index (BMI) greater than 30 (obese), who undergo total hip arthroplasty for dysplastic hip, are associated with longer operative and anaesthetic times, longer hospital stays and higher re-admission rates within 30 days. METHODS: All the cases of total hip arthroplasty in patients with high-riding dysplastic hips were reviewed. Evaluation was made of a total of 68 patients comprising 64 females and 4 males, classified into two groups. Patients with BMI < 30 kg/m2 formed the non-obese group and patients with BMI ≥ 30 kg/m2 the obese group. RESULTS: The mean age was 44.67 ± 6.49 years. BMI was < 30 in 44 (64.7%) patients and > 30 in 24 (35.3%) patients. The data analysis showed that mean surgical time, anaesthesia duration and re-admission rate were significantly higher in the group with BMI ≥ 30(obese) as compared to the group with BMI < 30 (non-obese) (p < 0.01). The complication rate was determined to be higher in the obese group (p < 0.05). CONCLUSION: Obese patients performed with total hip arthroplasty for high-riding dysplastic hips had more complications and higher rates of re-admission to hospital compared with the non-obese patients.

The Role of the Pie-Crusting Technique of the Medial Collateral Ligament in the Arthroscopic Inside-out Technique for Medial Meniscal Repair With or Without Anterior Cruciate Ligament Reconstruction: A Satisfactory Repair Technique.

PURPOSE: To assess the results of a technique for pie crusting of the medial collateral ligament (MCL) and inside-out medial meniscal repair and perform a comparison with the literature. METHODS: This retrospective study consisted of electronic data collection between 2012 and 2017 with a minimum of 2 years' follow-up. The inclusion criteria were the presence of difficult medial meniscal tears with joint tightness requiring pie crusting and the presence of acute or chronic tears of zone I or II with or without anterior cruciate ligament reconstruction (ACLR) using hamstring autograft during the same session. The primary outcome of the study was the achievement of good results with the aforementioned technique. There was no control group. All patients underwent assessments at 1, 2, and 6 months in outpatient clinics. At 6 months, the Lysholm knee score was calculated. For statistical analysis, the Social Science Statistics online program was used to perform descriptive analysis and assess any associations between the variables. RESULTS: This study included 53 patients from a single surgeon's practice; of these patients, 31 underwent additional ACLR using hamstring autograft during the same session. The mean age was 29.43 years (range, 14-49 years), and the mean increase in the medial joint space width was 3.21 mm (range, 2-5 mm) with pie crusting. At 6 months, the average Lysholm score was 93 (range, 67-100) and the average visual analog scale score was 0.8 (range, 0-4). There was no meaningful association between age, tear pattern, chronicity of tear, joint space width obtained after pie crusting, and associated anterior cruciate ligament tear. Patients returned to their daily activity level at 4.5 months on average and returned to sporting activities at 7.4 months on average. Saphenous nerve symptoms were observed in 5 patients, but no infection or instability was documented in the follow-up period. CONCLUSIONS: In this study, we obtained good outcomes using arthroscopic inside-out medial meniscal repair combined with pie crusting for the release of the MCL, with or without ACLR. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Intraosseous device for arthrodesis in foot and ankle surgery: Review of the literature and biomechanical properties.

BACKGROUND: Arthrodesis is the surgical fusion of a diseased joint for the purposes of obtaining pain relief and stability. There have been numerous fixation devices described in literature for foot and ankle arthrodesis, each with their own benefits and drawbacks. AIM: To review the use of intraosseous devices in foot and ankle surgery. METHODS: There were 9 papers included in the review (6 clinical and 3 experimental studies) all evaluating arthrodesis in the foot and ankle using the IOFIX device (Extremity Medical™, Parsippany, NJ, United States). Outcome scores, union rates, as well as complications were analysed. RESULTS: IOFIX appears to be safe and effective in achieving arthrodesis of the 1st metatarsophalangeal, and talonavicular joints with early rehabilitation. In comparison to plate/screw constructs there were fewer soft tissue complications and issues of metalwork prominence. Cadaveric and biomechanical studies on the use of intramedullary fixation for fusion of the tarsometatarsal and ankle joint showed decreased load to failure, cycles to failure and stiffness in comparison to traditional fusion methods using plates and screws, however IOFIX devices produced higher compressive forces at the joint. CONCLUSION: We describe the reasons for which this biomechanical behavior of the intraosseous fixation may be favorable, until prospective and comparative studies with larger sample size and longer follow-up confirm the effectiveness and limitations of the method.

Clinical and radiological outcomes of high tibial osteotomy with combined fixator-assisted nailing and subtubercle tibial osteotomy.

OBJECTIVE: The aim of this study was to assess the clinical and radiological results of our high tibial osteotomy technique combining fixator-assisted nailing and subtubercle tibial osteotomy in varus malalignment. METHODS: This was a retrospective study of a consecutive series of 32 knees in 32 patients ('2 follow-up loss' 12 males and 18 females; mean age at the time of operation: 50.6±7.8 (36-62) years) operated on between 2014 and 2016. Radiographic and clinical measurements were assessed pre- and postoperatively. Kolmogorov-Smirnov, paired t and Wilcoxon rank tests were used in the statistical analyses. RESULTS: The mean follow-up period was 36.1±8.15 (31-53) months, the mean duration of the hospital stay was 3.6±0.1 (2-6) days, and the mean Kellgren-Lawrence score was 2.4±0.6 (2-4). Time to bony union was an average of 16.17 (12-29) weeks. Compared to the preoperative mechanical medial proximal tibial angle, femorotibial angle and mechanical axis deviation measurements, all the postoperative values showed significant changes (p<0.01). However, there was no statistical difference between the preoperative and postoperative tibial slopes (p>0.05), and the postoperative Caton-Deschamps index did not show a meaningful change (p>0.05). The postoperative visual analog scale, Knee Society Score, and Modified Hospital for Special Surgery Knee Scoring System measures showed significant improvement compared to the preoperative values (p<0.01). The postoperative walking distance increased to 1137.50±845.1 meters, from 359.4±306.2 meters (p<0.01). CONCLUSION: This percutaneous technique is minimally invasive, corrects the alignment in two planes, and does not affect patellar height. We believe that this technique could be a promising alternative to other knee preserving surgeries in correcting varus malalignment. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?

We report the outcomes of mechanical prophylaxis and chemoprophylaxis in patients who underwent elective surgery for idiopathic adolescent scoliosis (AIS).We retrospectively studied the patients who underwent posterior spinal instrumentation for AIS. The patients were divided into three groups: Group A low-molecular-weight heparin (LMWH) started at 8 hours after surgery; Group B LMWH started at 24 hr after surgery; Group C did not receive chemoprophylaxis. The data about wound oozing, need for transfusion, preoperative and postoperative hemoglobin level, length of stay in hospital, interval from the surgery to removal of closed suction drainage tube, postoperative blood loss from closed suction drain, deep venous thrombosis (DVT), and pulmonary embolism (PE) were investigated.The mean age and Lenke classification for all the groups were similar. No DVT or PE was detected in any group. The mean blood loss from the drain was higher in Group A (400 mL) and Group B (450 mL) when compared to Group C (150 mL) (P = .001). There were more wound oozing in Groups A (5) and B (6) than in Group C (3) (P = .585). Three patients in Group B, 3 patients in Group A, and no patient in Group C had superficial infections. However, there was no statistical difference between the groups (P = .182). Postoperative hospital stay was significantly longer in Groups A (6 days) and B (6 days) then in Group C (5 days) (P = .001).Our current study claims that chemoprophylaxis is not necessary for the patients without risk factors after AIS surgery. Early mobilization and mechanoprophylaxis represents adequate prophylaxis in addition to pain management and well hydration in patients' routine treatment. The complications of chemoprophylaxis are not correlated to the initiation time of prophylaxis.

Conversion of Failed Hip Hemiarthroplasty to Low Friction Arthroplasty (LFA).

Purpose: We aimed to study clinical and radiological outcomes of conversion from hemiarthroplasty to Charnley hip replacement (CHR) with a particular concern over reported increased dislocation rate and literature review. Conversion of hip hemiarthroplasty to total hip replacement (THR) is a procedure reported to have high rates of complications. In the literature, there is no specific study on small head conversion. The purpose of this study was to evaluate the conversion of failed hip hemiarthroplasty to CHR with the use of modern implants. Methods: The study included 42 patients, who underwent the above procedure. The operations were carried out using a modern Charnley-type THR with a 22-mm diameter of femoral head and a trans-trochanteric approach. The mean follow-up was 75.7 months (range 25-171). Radiographs from the last follow up were evaluated for loosening and other reasons of failure. Clinical outcome was assessed using postoperative pain, function scores, complications and implant survivorship as well as radiological evaluation. Charnley's modified pain and mobility scoring system were used for clinical and Hodgkinson and Harris' criteria were used for radiological assessment. Results: Functionally, all of the patients showed improvement. Mean improvement in the pain level was by average of 2.4. On mobility assessment, 38 patients (90.4%) improved. Three patients (7.1%) had recurrent infections and three (4.8%) cases were treated with revision surgery and pseudarthrosis. Further complications occurred in 19.1%, not requiring operative treatment. On radiological evaluation, one (2.4%) case showed cup demarcation without bone loss, two (4.8%) cup migration, and one (2.4%) stem demarcation. Kaplan Meier survival analysis showed a survival of 90% at 96 months of follow up (95% CI (confidence interval), 60-90). Conclusion: Larger head might not be the answer to decrease the dislocation rate. Complication rates during revision of hip hemiarthroplasty to modern CHR with 22.225-mm head diameter were comparable to first-time THR revision despite having a smaller head.

Comparison of 2-year clinical and radiological outcomes between volar plating and external fixation with additional K-wires for AO Type C distal radius fractures.

BACKGROUND: Surgical treatment of distal intraarticular radius fractures remains controversial. Our aim was to compare the clinical and radiological outcomes between volar plating (VP) and external fixation (EF) for distal intraarticular radius fractures two years postoperatively. METHODS: This retrospective study included 59 patients with 62 intraarticular AO Type C distal radius fractures. We distinguished two groups: patients treated with internal fixation (volar locking plate, VP group: 41 fractures), and patients treated with an external fixator and K-wires (EF group: 21 fractures). The clinical assessment included range of motion, grip strength, disability of the arm, shoulder, and hand (DASH), and visual analog scale scores. Radiological measurements comprised flexion and extension, radial volar tilt, inclination, height, shortening, and ulnar variance. RESULTS: Postoperative grip strength and flexion angles were better after VP (P = 0.004, P = 0.009), but there was no difference in DASH scores (P = 0.341). Radial inclination was significantly different compared to that of the uninjured hand after VP (P = 0.0183), but not EF (P = 0.11). DISCUSSION: VP and EF result in similar clinical and radiological outcomes after 2 years. Function is not restored to the functionality of the contralateral and noninjured hand.

A comparative study of three commonly used fixation techniques for isolated medial malleolus fracture.

OBJECTIVES: This study aims to compare the three most commonly used fixation techniques: tension-band wire fixation, partially threaded cannulated screws, and fully threaded cannulated headless compression screws. PATIENTS AND METHODS: Ninety patients with medial malleolus fractures were included in the study. Patients were divided into three groups. Group A included patients who underwent tension-band wire fixation (n=26), Group B partially threaded cannulated compression screws (n=32), and Group C fully threaded cannulated headless compression screws (n=32). The type of medial malleolus fracture, healing rates, implant-related complications, rate of infection, hardware removal, weight-bearing restrictions, mean interval time from the injury to the surgery, and Body Mass Indexes (BMIs) were investigated. The patients' radiographs (standard anteroposterior, lateral, and mortise) were reviewed. The American Orthopedic Foot and Ankle Society (AOFAS) scoring system was used for clinical evaluation. RESULTS: No significant difference was observed between the three groups in terms of age, gender, BMI, follow-up period, and fracture type. Union rate for group C was significantly shorter than groups A and B. There was no implant failure or irritation in group C and this was statistically significant comparing to group A and B (p=0.037). However, there was no significant difference between group A and B (p=0.41). There were no significant differences in the three groups according to AOFAS. Patients with low BMI in groups A and B had a high rate of implant-related complications. There was a significant correlation between low BMI and implant-related complication (p<0.001). CONCLUSION: Union rate in the group who were operated with fully threaded cannulated headless compression screws was significantly shorter than the other groups. This study has shown that tension band wiring and partially threaded cannulated compression screws can cause irritation of soft tissues and pain over the hardware implantation site. Patients with low BMI are vulnerable for implant-related complications.

Early results of an intraosseous device for arthrodesis of the hallux metatarsophalangeal joint.

BACKGROUND: Arthrodesis of the hallux metatarsophalangeal (MTP) joint is commonly done as a primary procedure either to correct severe hallux valgus deformities or for rheumatoid arthritis, hallux rigidus, in patients with neuromuscular disorders and as a salvage procedure for failed bunion surgery or infection. Prominent metalwork frequently can cause soft tissue impingement and thus require removal. In contrast, osteosynthesis with a completely intraosseous implant has the advantage of less damage to the periosteal circulation. We describe a surgical technique and the early results of arthrodesis of the hallux metatarsophalangeal (MTP) joint using an intraosseous fixation device. MATERIALS AND METHODS: Twelve consecutive patients operated with this method were retrospectively reviewed. The average age was 57 years (range 44-88 years). A retrospective review of radiographs and electronic medical notes was conducted. The patients were also asked to fill a satisfaction questionnaire. RESULTS: Overall fusion rate was 91% with a mean hallux valgus angle of 15° (range 4-20°) and a mean dorsiflexion angle of 20° (range 7-30°). Complications included a case of failed fusion, a delayed union, and a case of persisting transfer metatarsalgia. At a mean followup of 14 months (range 5-28 months), the mean visual analog scale improved significantly from a mean of 8.4 (range 7-10) preoperatively, to a mean of 3.1 (range 0-7) postoperatively (P < 0.0001). The mean American Orthopaedic Foot and Ankle Society hallux score also significantly improved from 29.4 (range 10-54) to a mean of 73.3 (range 59-90) (P < 0.0001). The final result was satisfactory for 83% of the patients. CONCLUSIONS: The early results show intraosseous fixation to be a safe and efficient method for the fusion of the hallux MTP joint providing relief from pain and patient satisfaction.

Testing Shoulder Pain Mapping.

OBJECTIVE: A previous study on shoulder pain mapping showed specific pain patterns for common shoulder disorders. This study aimed to test those patterns for accuracy, modify shoulder pain mapping as needed, and observe their reliability and validity. METHODS: This prospective study used a two-step process and was undertaken to determine its potential utility in daily practice. New shoulder pain patients marked their pain, its character and severity, on a custom-made mapping form. Then a researcher blinded to the diagnoses gave their estimations on the basis of previously established maps, and they were correlated with final diagnoses. Subsequently, a guide table was developed on how to read the maps, and intertester reliability was performed with three independent testers. RESULTS: The study included 194 patients, and the overall accuracy for estimations was between 45.4% and 49.5%. The sensitivity was high, especially for instability, followed by calcific tendinitis, acromio-calvicular joint pathology, and impingement. The intertester reliability showed clinically significant agreement between testers for both disease groups (κ = 0.70) and individual disorders (κ = 0.52). CONCLUSIONS: This was a unique and extensive study on shoulder pain mapping. The study concluded that pain mapping could be a useful adjunct to the clinical assessment of patients with shoulder pain and can be used in the primary care setting as well as secondary care and for research.

Floating patella associated with lymphoedema.

Ipsilateral injury of more than one component of the knee extensor apparatus is rare. It is mostly associated with previous trauma, surgery, immunosuppression therapy and systemic disease. We present the first documented case of a spontaneous bifocal disruption of the knee extensor apparatus (i.e. floating patella) associated with lymphoedema. This case highlights the importance of considering lymphoedema as another risk factor for rupture of the knee extensor apparatus. It also highlights the importance of assessing all components of the knee extensor apparatus in patients presenting with acute knee injuries.

Pain mapping for common shoulder disorders.

We conducted a study to ascertain specific patterns of pain in patients with common shoulder disorders and to describe a comprehensive shoulder pain map. We prospectively studied 94 cases involving an upper limb pain map and correlated the maps with the final diagnoses made by 2 clinicians who were blinded to the pain map findings. Pattern, severity, and type of pain were specific to each common shoulder disorder. In subacromial impingement, pain was predominantly sharp, occurred around the anterior aspect of the shoulder, radiated down the arm, and was associated with dull, aching pain radiating to the hand. A similar pain pattern was found in rotator cuff tears. In acromioclavicular joint pathology, pain was sharp, stabbing, and well localized to the anterosuperior shoulder area. Glenohumeral joint arthritis was marked by the most severe pain, which occurred in a mixed pattern and affected the entire arm. Whereas the pain of instability was a mixture of sharp and dull pain, the pain of calcific tendonitis was severe and sharp. Both pains were limited to the upper arm and shoulder. Pain mapping revealed definitive patterns for shoulder pathologies. We advocate using pain maps as useful diagnostic guides and research tools.

Successful repair of a giant abdominal aortoiliac aneurysm in a Jehovah's Witness.

We report the case of a 76-year-old man of the Jehovah's Witness faith who had a giant abdominal aortoiliac aneurysm that was successfully operated on using an aortoiliac Y-graft bypass technique, without the use of stored allogenic blood. Cell saver technique and recombinant human erythropoietin (epoetin beta) were used during the perioperative period. The patient had good postoperative care with a multidisciplinary approach.

Cross-sectional anatomy in postdistraction osteogenesis tibia.

BACKGROUND: Although the early period of distraction osteogenesis has been extensively investigated, there are few data describing the appearance of medium-term bone regeneration. METHOD: We investigated 10 adults with magnetic resonance imaging scans. Seven of them underwent bone transport, and three had tibial lengthening. The mean follow-up was 28 months after removal of the external fixator. The values were compared with those of the contralateral tibia, which acted as a control. RESULTS: All of the cases with bone transport had an increase in the volume of the whole tibia of 15.3%-50.8%. The diameters of the regenerated segments increased significantly (P < 0.0001) in all cases. The mean signal intensity in the regenerate decreased significantly in seven cases (P < 0.0001), which suggested a rise in the content of unhydrated tissue, such as bone and collagen. The cross-sectional area of the transported segment increased in all cases (P < 0.01). Finally, in the patients who underwent bone transport, the docking site was seen to be obstructed by unhydrated tissue. CONCLUSIONS: Contrary to previous claims, the postdistraction osteogenesis of tibia consists of areas with potentially different biomechanical properties. Recognition of these changes is essential not only for appropriate preoperative counseling but also for considering treatment modalities in case of fracture.