MICA Procedure vs Open Chevron Osteotomy for Hallux Valgus Correction: A Prospective Cohort Study.

Background: Currently, more than 150 surgical techniques have been described for the treatment of hallux valgus. The abundance of techniques indicates that there is no technique that has been designated as a gold standard. In recent years, a particular interest in the use of minimally invasive techniques has grown. The aim of this study was to prospectively compare clinical, radiologic, and postoperative outcomes between the MICA technique and open chevron technique over a 1-year follow-up period. Methods: Between January 2016 and August 2020, data were prospectively collected from consecutive patients preoperatively and at 6 weeks, 3 months, and 12 months following minimally invasive chevron and Akin (MICA) or open chevron osteotomies. Radiographic outcomes were measured using weightbearing radiographs preoperatively and at 3 and 12 months postoperatively. Clinical outcomes were measured using the American Orthopaedic Foot & Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), VAS (visual analog scale), Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), and Euro-QoL-5D (EQ5D) questionnaires. Results: Of the 68 patients, 42 patients (62%) underwent a MICA surgery and 26 patients (38%) underwent open chevron osteotomy. Both groups showed significant improvement in HVA, IMA, and DMAA at the 1-year follow-up. Our findings show that both clinical and radiologic outcomes of the MICA technique are comparable to the conventional open technique. No significant differences were found in clinical outcomes (VAS, AOFAS, MOXFQ, FFI, and FAOS), complication rate, and operative times. Conclusion: These results show that MICA is a safe alternative for chevron osteotomy. The clinical and radiologic outcomes of these 2 techniques by 12 months are comparable. Level of Evidence: Level II, prospective cohort study.

Effectiveness of Different Antimicrobial Strategies for Staphylococcal Prosthetic Joint Infection: Results From a Large Prospective Registry-Based Cohort Study.

Background: Treatment of staphylococcal prosthetic joint infection (PJI) usually consists of surgical debridement and prolonged rifampicin combination therapy. Tailored antimicrobial treatment alternatives are needed due to frequent side effects and drug-drug interactions with rifampicin combination therapy. We aimed to assess the effectiveness of several alternative antibiotic strategies in patients with staphylococcal PJI. Methods: In this prospective, multicenter registry-based study, all consecutive patients with a staphylococcal PJI, treated with debridement, antibiotics and implant retention (DAIR) or 1-stage revision surgery between January 1, 2015 and November 3, 2020, were included. Patients were treated with a long-term rifampicin combination strategy (in 2 centers) or a short-term rifampicin combination strategy (in 3 centers). Antimicrobial treatment strategies in these centers were defined before the start of the registry. Patients were stratified in different groups, depending on the used antimicrobial strategy. Cox proportional hazards models were used to compare outcome between the groups. Results: Two hundred patients were included and stratified in 1 long-term rifampicin group (traditional rifampicin combination therapy) or 1 of 3 short-term rifampicin groups (clindamycin or flucloxacillin or vancomycin monotherapy, including rifampicin for only 5 postoperative days). Adjusted hazard ratios (aHRs) for failure in patients treated with short-term rifampicin and either flucloxacillin or clindamycin were almost equal to patients treated with long-term rifampicin combination therapy (aHR = 1.21; 95% confidence interval, .34-4.40). Conclusions: A short-term rifampicin strategy with either clindamycin or flucloxacillin and only 5 days of rifampicin was found to be as effective as traditional long-term rifampicin combination therapy. A randomized controlled trial is needed to further address efficacy and safety of alternative treatment strategies for staphylococcal PJI.

A model-based radiostereometric analysis (RSA) randomized control trial evaluating the stability of the cementless Taperloc hip stem: the TapHip study.

Background and purpose - The Taperloc Complete hip is the successor of the Taperloc hip, aiming to increase range of motion and optimizing femoral fit with intermediate stem sizes. We evaluated whether these design changes affect fixation, and this RSA study compares 2-year migration. Patients and methods - In this prospective, multi-arm study, 100 patients were randomized to cementless total hip arthroplasty (THA) with Taperloc Complete full profile (TCFP), Taperloc Complete reduced distal (TCRD), Taperloc full profile (TFP), or Taperloc reduced distal (TRD). Migration was measured with model-based RSA postoperatively, and after 3, 12, and 24 months. Results - Results based on mixed-model analysis on 2-year postoperative RSA data from 74 patients showed similar subsidence (mm) in the first 3 months (mean [95% CI] TCFP 0.44 [0.20-0.69], TCRD 0.91 [0.40-1.42], TFP 0.71 [0.22-1.19], TRD 1.25 [0.58-1.91]) and stabilization afterwards. The TCFP showed statistically significantly less retroversion (°) at 2-year postoperatively compared with TFP and TCRD (mean [95% CI] TCFP: -0.13 [-0.64 to 0.38], TCRD: 0.84 [0.35-1.33], TFP: 0.56 [0.12-1.00], TRD: 0.37 [-0.35 to 1.09]). Interpretation - As expected in successful cementless THA, RSA shows stabilization after initial subsidence. Based on these results the Taperloc Complete stem is expected to have similar long-term fixation to the Taperloc stems. The reduced distal groups have larger, but statistically non-significant, initial migration compared with the TCFP group, which could be due to implantation in Dorr B, C femur types. It may be important to consider the femur shape for choosing a full profile or reduced distal stem to minimize migration.

Five-Year Prospective Roentgen Stereophotogrammetric and Clinical Outcomes of the BioPro MTP-1 Hemiarthroplasty.

BACKGROUND: Mixed results for functional outcomes and long-term fixation have been reported for first metatarsophalangeal arthroplasty. This prospective study was designed to evaluate the migration of the BioPro metatarsophalangeal-1 (MTP-1) joint hemiprosthesis with Roentgen stereophotogrammetric analysis (RSA). Migration patterns of the prosthesis, prosthesis-induced erosion of the metatarsal bone, and clinical outcomes were evaluated sequentially to 5 years postoperation (PO). METHODS: Eleven female patients received the BioPro-1 hemiprosthesis. Prosthesis translation and metatarsal erosion were measured with RSA at immediately PO, 6 weeks, and 3, 6, 12, 36, and 60 months postoperatively. Clinical assessment was done by patient questionnaires. RESULTS: RSA data of 9 patients were available for analysis. Median (range) number of markers used in RSA analysis, condition number, and mean error of markers around the prosthesis were 4 (3-7), 320 (208-862), and 0.13 (0.02-0.28), respectively. Progressive subsidence was seen up to 3 years PO (mean 2.1 mm, SE 0.32). Progressive metatarsal erosion was found from 1 year PO (mean 0.49 mm, SE 0.15). Pain, function, and quality scores improved after surgery and did not deteriorate at later follow-up moments. CONCLUSION: Model-based RSA of the BioPro-1 prosthesis shows nonstabilizing medial and distal translation and metatarsal erosion. Despite the measured migration and erosion, clinical outcomes improved and remained similar up to 5 years postoperation. LEVEL OF EVIDENCE: Level II, prospective analysis of MTP-1 hemiprosthesis.

Joint needle aspiration compared to tissue samples in septic arthritis of the native knee.

Culture of the causative infectious agent is the only definitive method of diagnosing septic arthritis and can be identified by culture of synovial fluid (SF) or by tissue cultures (TC) obtained at surgery. The aim of this study is to compare the cultures of joint needle aspiration (JNA) with tissue cultures obtained at surgery. 52 patients treated for a suspicion of a septic arthritis of the native knee were retrospectively reviewed. In 84% tissue cultures were equal to joint needle aspiration. Median Gächter classification was 1.0 (range 1-3). 60% of the patients underwent multiple procedures. All patients were successfully treated with an average of 2.0 (range 1-6) arthroscopies. Our results showed that if a patient with a clinical suspicion of septic arthritis is treated, starting antibiotic therapy prior to surgery can be considered, but only after joint needle aspiration to obtain samples for bacteriologic culture. Arthroscopic surgery must be the treatment of choice in Gächter stage 1 to 3, although it might be necessary to perform multiple procedures.

Fixation of the short global tissue-sparing hip stem.

AIMS: Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome. METHODS: In total, 50 consecutive patients ≤ 70 years old with end-stage symptomatic osteo-arthritis were randomized to receive THA with the GTS stem or the conventional Taperloc stem using the anterior supine intermuscular approach by two experienced hip surgeons in two hospitals in the Netherlands. Primary outcome was implant migration. Patients were followed using routine clinical examination, patient reported outcome using Harris Hip Score (HHS), Hip Disability And Osteoarthritis Outcome Score (HOOS), EuroQol five-dimension questionnaire (EQ5D), and Roentgen Stereophotogrammetric Analysis (RSA) at three, six, 12, and 24 months. This study evaluated the two-year follow-up results. RESULTS: In addition to the initial migration pattern of distal migration (subsidence, Y-translation) and retroversion (Y-rotation) also exhibited by the Taperloc stem, the GTS stem showed an initial migration pattern of varization (X-translation combined with Z-rotation) and posterior translation (Z-translation). However, all components stabilized aside from one Taperloc stem which became loose secondary to malposition and was later revised. Clinical outcomes and complications were not statistically significantly different with the numbers available. CONCLUSION: A substantially different and more extensive initial migration pattern was seen for the GTS stem compared to the Taperloc stem. Although implant stabilization was achieved, excellent long-term survival similar to that of the Taperloc stem should not be inferred. Especially in the absence of clinically proven relevant improvement, widespread usage should be postponed until long-term safety has been established. Cite this article: Bone Joint J 2020;102-B(6):699-708.

Intra- and Interobserver Agreement in Hallux Valgus Angle Measurements on Weightbearing and Non-Weightbearing Radiographs.

The choice of treatment of hallux valgus deformity is influenced by angles measured on radiographs. Angles of interest are the hallux valgus angle (HVA), 1,2-intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), as well as the presence of first metatarsophalangeal joint (MTPJ) subluxation. Guidelines for measuring those angles have been distributed by American Orthopaedic Foot and Ankle Society (AOFAS), although the influence of weightbearing on these angles and its clinical relevance is not clear. We conducted a study to determine the influence of weightbearing and the inter- and intraobserver agreement in the measurement. A total of 104 patients were enrolled in this study. Both weightbearing and non-weightbearing radiographs were obtained. In 2 rounds, 2 orthopedic surgeons and 2 musculoskeletal radiologists measured the angles in blinded digital radiographs according to AOFAS guidelines. Agreement on measurement of HVA, IMA, and DMAA in both weightbearing and non-weightbearing radiographs, as well as the presence of MTPJ subluxation, was calculated using the linear-weighted kappa coefficient and the intraclass correlation coefficient (ICC). Examiner agreement strength was defined according to the guidelines of Landis and Koch. HVA decreases significantly with weightbearing, whereas IMA significantly increases. The change in magnitude was 1° to 2° on average. No significant influence on DMAA could be noted. Interobserver agreement was excellent in both weightbearing and non-weightbearing radiographs for HVA (ICC 0.99 and ICC 0.99, respectively), IMA (ICC 0.98 and ICC 0.86, respectively), and DMAA (ICC 0.95 and ICC 0.97, respectively). The agreement on presence of subluxation was moderate to good (Fleiss kappa 0.50 to 0.63). Weightbearing alters forefoot geometry significantly. Adhering to AOFAS guidelines yields excellent interobserver agreement on HVA, IMA, and DMAA. First MTPJ subluxation presence is not an alternative for DMAA. The magnitude of change in IMA and HVA is small and therefore not clinically important. Both weightbearing and non-weightbearing radiographs can be used for determination of the correct treatment of hallux valgus deformity.

Prospective comparison of the anterior and lateral approach in hemiarthroplasty for hip fractures: a study protocol.

BACKGROUND: The Direct Anterior Approach (DAA) is an alternative approach to the currently most used Lateral Approach (LA) for hip replacement in femoral neck fracture patients. Compared to the LA, the DAA minimizes soft tissue damage. Sparing muscle tissue may facilitate early and improved postoperative mobility. It may also be associated with fewer complications, increased quality of life and lower 1-year mortality. The aim of this study is to compare postoperative complications, hip function and patient mobility after hemiarthroplasty via the anterior or lateral approach following a displaced femoral neck fracture. METHODS: 138 elderly patients with displaced femoral neck fractures will be operated using either the direct anterior approach or the lateral approach for a hemiarthroplasty in a single centre, prospective, comparative cohort study. The choice of surgical approach will depend on the expertise of the trauma surgeon on call. The primary outcome of this study will be the functionality of the hip after surgery measured using the Harris Hip Score during routine outpatient check-ups. Secondary outcomes include surgical and non-surgical complication rates, admission time, postoperative pain, rehabilitation time, performance in activities of daily living, health-related quality of life measured, cognitive function and balance. DISCUSSION: Many approaches are known for hip replacement arthroplasty in trauma patients with little consensus on the preferred method. Identifying the best approach facilitating an adequate and fast recovery could optimize patient independence and quality of life and minimize rehabilitation costs, morbidity and mortality rates. The study design will reflect daily clinical practice and aims to present an accurate depiction of clinical outcomes. TRIAL REGISTRATION: This trial entered the Dutch Trial Registry with registration number (NTR)6238 on the 24th of April 2017. http://www.trialregister.nl/trialreg/index.asp . Protocol version 2.0 16-03-2017.

[A man with a contorted knee]. / Een man met een verdraaide knie.

A patient presented with an isolated anterolateral dislocation of the proximal tibiofibular joint. Closed reduction under general anaesthesia was performed by external rotation of the lower leg with the knee in 90 degrees of flexion and the ankle dorsiflexed with an audible pop.

[Ossification of the syndesmosis following trauma to the ankle]. / Ossificatie van de syndesmose na enkeltrauma.

BACKGROUND: Ossification of the ankle syndesmosis can occur following trauma to the ankle. Little is known about the treatment of syndesmosis ossification. CASE DESCRIPTION: A 49-year-old man was referred to the orthopaedic outpatients' clinic by his GP with swelling on the lateral side of his right ankle. A few months earlier the patient had sustained an injury to his ankle while playing football, for which he had not been treated. X-ray examination revealed ossification of the ankle syndesmosis with an old posterior tibial fracture. CONCLUSION: The patient had ossification of the right ankle syndesmosis. This type of ossification has a benign natural course and a policy of wait and see, plus pain relief, is usually sufficient. Surgical removal of the ossification should only be considered in active sportsmen and sportswomen with persistent symptoms that do not respond to conservative treatment.