[Joint-preserving osteotomy of malunited ankle and pilon fractures]. / Gelenkerhaltende Osteotomien fehlverheilter Sprunggelenk- und Pilonfrakturen.

Malunion and nonunion after ankle and pilon fractures regularly lead to the development of painful functional impairment even in cases of only mild axial deviation or residual joint incongruity. Involvement of the tibial pilon results in rapid progression of posttraumatic ankle arthritis. Corrective osteotomy with joint preservation aims at secondary anatomical reconstruction with functional rehabilitation. This requires a careful preoperative analysis and will be possible in carefully selected cases only. Prerequisites for successful reconstruction are intact cartilage, sufficient bone quality, residual joint function and good patient compliance. Since the works of B. G. Weber, joint-sparing osteotomy is an established treatment option for malunited malleolar fractures with reliable long-term results and low rates of complications and secondary fusions. Key to success is the re-establishment of the length of the distal fibula and repositioning into the tibial incisura in cases of syndesmotic instability. Corrections of the medial malleolus and posterior tibial fragment are less frequent. Corrective intra-articular osteotomies for malunited pilon fractures are rarely feasible because of manifest arthritis at the time of patient presentation in most cases. Besides case reports there is only one series of 14 patients available in the literature. At 5-year follow-up, a good to excellent result was seen in 10 cases and secondary ankle fusion was done in 2 patients with a poor result. Anatomical reconstruction of malunited tibial pilon fractures appears to be a viable treatment option besides arthroplasty and fusion in carefully selected patients.

Shoulder fusion in two patients with a long-standing proximal humerus resection.

With a "headless" humerus active abduction and elevation of the arm are hardly possible. Especially if the humeral head was removed because of an infection, shoulder fusion is often the only safe solution for this disabling condition. Large corticocancellous, autologous bone grafts are interposed between the thin humeral stump on one side and its broad glenoid-acromion counterpart on the other. A 4.5 narrow AO-plate stabilizes the fusion. The technique is described and the functional result of two patients is shown. Ten years after the operation, both patients were free of pain and very satisfied about the utility of the arm. The fusion had convincingly healed in the planned position. Shoulder fusion proved to be a safe and good solution for both our patients with a longstanding headless humerus. Ten years after the operation they were free of pain and had regained a useful arm.

Ankle fusion using a 2-incision, 3-screw technique.

OBJECTIVE: Reliable fusion and optimal correction of the alignment of the ankle joint using a 2-incision, 3-screw technique. INDICATIONS: Symptomatic osteoarthritis of the ankle joint after insufficient other treatment, severe deformity of the osteoarthritic ankle joint, or salvation procedure after failed arthroplasty. CONTRAINDICATIONS: Active osteomyelitis, very poor soft tissues, or severe peripheral arterial occlusive disease. SURGICAL TECHNIQUE: Osteotomy and excision medial malleolus. Osteotomy, dislocation, and denudation of the distal fibula. Osteotomy of distal tibia and talus in the desired position for optimal alignment. Temporary tibiotalar fixation with two Weber reposition clamps. Final tibiotalar fixation with a medial and lateral 4.5 mm full threaded cortical lag screw. Reduction of the distal fibula and fibulotibial fixation using a similar technique. POSTOPERATIVE MANAGEMENT: A nonweight-bearing circular below knee cast for 6 weeks, followed by a walker or weight-bearing cast for another 6 weeks. RESULTS: A total of 30 ankle fusions in 26 patients were analyzed. Mean age at fusion was 50 years (range 11-72.1 years). Mean follow-up time was 9.2 years (3.4-18.8 years). Radiological and clinical fusion in 28 (93%) of the primary arthrodeses. The mean American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 66 ± 12. Of the 26 patients, 22 (85%) were satisfied. Deep wound infection occurred once (3%). No other serious complications were encountered. The described technique provides reliable long-term follow-up results for a wide range of indications for ankle fusion.

Treatment of malunited fractures of the ankle: A long-term follow-up of reconstructive surgery.

In this retrospective study, using the prospectively collected database of the AO-Documentation Centre, we analysed the outcome of 57 malunited fractures of the ankle treated by reconstructive osteotomy. In all cases the position of the malunited fibula had been corrected, in several cases it was combined with other osteotomies and the fixation of any non-united fragments. Patients were seen on a regular basis, with a minimum follow-up of ten years. The aim of the study was to establish whether reconstruction improves ankle function and prevents the progression of arthritic changes. Good or excellent results were obtained in 85% (41) of patients indicating that reconstructive surgery is effective in most and that the beneficial effects can last for up to 27 years after the procedure. Minor post-traumatic arthritis is not a contraindication but rather an indication for reconstructive surgery. We also found that prolonged time to reconstruction is associated negatively with outcome.

Tibial spine fractures: a long-term follow-up study of open reduction and internal fixation.

OBJECTIVE: To analyze the long-term (5-27 years) functional and radiologic results of surgically treated tibial spine fractures. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS AND METHODS: Forty-four surgically treated consecutive patients with 44 displaced tibial spine fractures were included in this study. All fractures were classified according to a modified Meyers and McKeever classification. There were 24 men and 20 women. The mean age at time of accident was 24 years (range 9-57 years). Sixteen patients had an open physis at the time of trauma. There were 36 patients with isolated fractures and 8 with multiple fractures. All patients were seen for a 1-year follow-up, and 37 patients (84%) were seen for a long-term follow-up visit. Functional results of these 37 patients were graded using the Lysholm, SF-36, and the Western Ontario and McMaster Universities scores. Radiologic results were graded using the Ahlbäck score. RESULTS: At 1-year follow-up, in all 44 patients, the fracture was fully healed. One patient (3%) needed revision of the osteosynthesis due to hardware failure, and in 1 patient (3%), a deep infection (purulent arthritis) developed that was treated by surgical irrigation. The median knee range of motion (ROM) after 1 year was 125 degrees (range 110-140 degrees). The ROM did not change significantly at long term. After a mean follow-up of 16 years (range 5-27 years), the median knee ROM was 130 degrees (range 115-140 degrees). As measured with an objective testing device, no statistically significant difference of anteroposterior stability between the injured and uninjured legs was found, with a mean difference of 1 mm (range -3.9 to 6.9 mm). The Lysholm score showed good to excellent results in 86% of the patients; the Western Ontario and McMaster Universities score showed a mean of 93 (range 40.63-100) points. The mean SF-36 general health score was 77 (24-99). The Ahlbäck score showed a moderate development of secondary osteoarthritis in 2 of the 37 patients (5%). The 16 patients with an open physis at the time of the operation did not develop axial malalignment at long term. CONCLUSIONS: Surgical treatment of tibial spine fractures offers the possibility to regain full stability of the knee joint and good long-term results after open reduction and internal fixation with low infection rates. Knee function is adequately restored in most patients with a minimal risk of developing secondary osteoarthritis.

The long-term outcome of the cemented Weber acetabular component in total hip replacement using a second-generation cementing technique.

We report the long-term outcome of a modified second-generation cementing technique for fixation of the acetabular component of total hip replacement. An earlier report has shown the superiority of this technique assessed by improved survival compared with first-generation cementing. The acetabular preparation involved reaming only to the subchondral plate, followed by impaction of the bone in the anchorage holes. Between 1978 and 1993, 287 total hip replacements were undertaken in 244 patients with a mean age of 65.3 years (21 to 90) using a hemispherical Weber acetabular component with this modified technique for cementing and a cemented femoral component. The survival with acetabular revision for aseptic loosening as the endpoint was 99.1% (95% confidence interval 97.9 to 100 after ten years and 85.5% (95% confidence interval 74.7 to 96.2) at 20 years. Apart from contributing to a long-lasting fixation of the component, this technique also preserved bone, facilitating revision surgery when necessary.

Supracondylar correction osteotomy to prevent repetitive posterior dislocation of a hip prosthesis.

Recurrent dislocation of a total hip prosthesis can be a challenging and often disappointing problem. This case report describes a 78-year-old woman who had recurrent posterior dislocations of a revision total hip replacement (THR) that occurred on flexion and internal rotation of the hip. The initial THR for posttraumatic osteonecrosis and extensive revision THA were performed through an anterolateral approach. Conservative treatment was not successful in preventing posterior re-dislocation, neither was open surgery in which offset was improved. Investigation under anesthesia by means of an image-intensifier showed that the prosthesis was easily dislocated posteriorly on flexion and internal rotation. On external rotation the hip was completely stable. Flexion-internal rotation is a rare motion which, if the patient is clearly instructed should be avoidable. The mechanism of an anterior dislocation caused by external rotation, extension and adduction is more common, especially since an anterolateral approach was used in all procedures. We describe the surgical technique of performing an supracondylar external rotating osteotomy of the femur to avoid further dislocation. Fixation was performed with a condylar plate fixation of which the proximal part is fixated above the distal point of the femur component to avoid a stress riser. Since the foot and knee of the patient are now internally rotated, the patient is forced to produce an external rotation in the hip to have a normal leg alignment, therefore preventing the internal rotation on which the dislocation occurred. In the prevention of a re-dislocation, solutions other than performing a revision of the THA can successfully solve the problem and should therefore be considered.

The validity of patient satisfaction as single question in outcome measurement of total hip arthroplasty.

Patient satisfaction is an important goal in orthopaedic surgery; however, it may not always reflect the surgical result that is obtained. By means of a systematic review according to the QUOROM criteria, we investigated how often satisfaction measured by a single question was used in trials reporting on the clinical outcome of total hip arthroplasty. This review showed that in 2006, 24.4% of these trials reported on satisfaction obtained by a single question. To assess the validity of satisfaction as a single question, a randomly selected group of 106 patients were questioned at an average of 15.5 years after a total hip arthroplasty (THA; range 4.2 -29.8 years). Questioning consisted of a Likert 5 scale satisfaction question and the Harris Hip Score. Satisfaction as a single question showed to have a poor construct and content validity. Despite the fact that satisfaction may be an important outcome measure, it cannot be judged as a reflection of a good result of the surgical intervention alone when evaluated using a single question.

Awareness and use of intertrochanteric osteotomies in current clinical practice. An international survey.

Current literature shows that intertrochanteric osteotomies can produce excellent results in selected hip disorders in specific groups of patients. However, it appears that this surgical option is considered an historical one that has no role to play in modern practice. In order to examine current awareness of and views on intertrochanteric osteotomies among international hip surgeons, an online survey was carried out. The survey consisted of a set of questions regarding current clinical practice and awareness of osteotomies. The second part of the survey consisted of five clinical cases and sought to elicit views on preoperative radiological investigations and preferred (surgical) treatments. The results of our survey showed that most of these experts believe that intertrochanteric osteotomies should still be performed in selected cases. Only 56% perform intertrochanteric osteotomies themselves and of those, only 11% perform more than five per year. The responses to the cases show that about 30-40% recommend intertrochanteric osteotomies in young symptomatic patients. This survey shows that the role of intertrochanteric osteotomies is declining in clinical practice.

Outcome of Kienböck's disease 22 years after distal radius shortening osteotomy.

Loading of the lunate in patients with Kienböck's disease and a negative ulnar variance provide the rationale for a radial shortening osteotomy. This osteotomy decreases forces transmitted from the radius to the lunate. We retrospectively reviewed 12 patients with Kienböck's disease who had 13 radial shortening osteotomies to ascertain whether the reported short- and medium-term results endured in the long-term. We evaluated nine osteotomies in nine of the 12 patients with a minimum of 16 years followup (average, 22 years; range, 16-31 years). Three patients died and one was lost to followup. For the nine patients, the range of motion was impaired compared with the normal side. Grip strength was on average 90% of the unaffected side. The average visual analog scale score for pain was 2.4 and the average Disabilities of the Arm, Shoulder, and Hand score was 14 at latest followup. In eight patients, the Lichtman classification of Kienböck's disease did not change at followup, but in three patients there was radiographic progression of the disease, which occurred during the first 10 years postoperatively. The medium- and long-term results therefore were comparable. We recommend radial shortening in stable wrists (Stage 3A or less) with a negative ulnar variance. The radius should be shortened to the level of the ulna, normally 4 to 6 mm, after which stable (plate) fixation should be performed under compression.

Operative treatment of 109 tibial plateau fractures: five- to 27-year follow-up results.

OBJECTIVE: To analyze the long-term (5-27 years) functional and radiologic results of surgically treated fractures of the tibial plateau. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS AND METHODS: Two hundred two consecutive tibial plateau fractures were included in this study. All fractures were classified according to both the AO and the Schatzker classification. There were 112 men and 90 women. The mean age at injury was 46 years (16 to 88). One hundred sixty-three patients had isolated fractures and 39 had multiple fractures. A 1 year follow-up was done in all 202 patients. One hundred nine of these patients also had an additional long-term follow-up visit. Functional results of these 109 patients were graded with the Neer- and HSS-knee scores. Radiologic results were graded with the Ahlbäck score. Statistical analysis was performed by means of the SPSS data analysis program. RESULTS: An uneventful union was present at the 1 year follow-up in 95% of the patients, along with a mean knee ROM of 130 degrees (range, 10-145 degrees). One hundred nine patients had a long-term follow-up visit after a mean period of 14 years (range, 5-27 years). The mean ROM at this time was 135 degrees (range, 0-145 degrees). Functional results showed a mean Neer score of 88.6 points (range, 56-100 points) and a mean HSS score of 84.8 points (range, 19-100 points). Monocondylar fractures showed statistically significant better functional results compared to bicondylar fractures. In 31% of the patients, secondary osteoarthritis had developed but was well tolerated in most (64% of the patients). Patients with a malalignment of more then 5 degrees developed a moderate to severe grade of osteoarthritis statistically significant more often (27% of the patients) compared to patients with an anatomic knee axis (9.2%; MWU, P = 0.02). Age did not appear to have any influence on the results. CONCLUSION: Long-term results after open reduction and internal fixation for tibial plateau fractures are excellent, independent of the patient's age.

Bilateral varus osteotomies in hip deformities: are early interventions superior? A long-term follow-up.

Coxa valga (with or withour excessive femoral anteversion) combined with acetabular dysplasia is a well-known cause of early osteoarthritis. Many authors have stated that the best result of an osteotomy can be achieved at an early stage of these osteoarthritic changes. In this study, we present 26 patients with a symmetrical hip deformity for which we performed a therapeutic osteotomy on the symptomatic hip. The contralateral hip had the same anatomical predisposition to develop an OA, but there were only minor to no complaints. We advised and performed an early osteotomy on these hips. On radiological evaluation, an average Sharp angle of 42.2 degrees and an average CCD of 142 degrees was present. During an average follow-up period of 19.9 years (range 15.0-25.9), 14 hips were converted to THR after the primary osteotomy, whereas there were only 6 after the early osteotomy (chi-square P<0.05). Using a Pearson correlation analysis, the age, preoperative grade of OA, preoperative Merle d'Aubigne score and excessive femoral anteversion were significantly correlated with the outcome. Our results show that the effect of an early, more prophylactic varus osteotomy in patients with a coxa valga with excessive femoral anteversion and acetabular dysplasia can be superior to the results achieved when surgery is postponed until the complaints and arthrosis have become more severe.

Long term results of surgical intervention for osteoarthritis of the trapeziometacarpal joint : comparison of resection arthroplasty, trapeziectomy with tendon interposition and trapezio-metacarpal arthrodesis.

Trapeziometacarpal osteoarthritis is a common entity, often bilateral and predominantly affecting postmenopausal women. In the case of failure of conservative treatment, surgery is a good option. The aim of this study was to compare three surgical procedures. 63 patients (74 thumbs) with osteoarthritis of the trapezio-metacarpal joint were surgically treated; 54 patients were seen for follow-up, 7 had died and 2 were lost to follow-up. The patients were stratified according to treatment; resection arthroplasty (the joint surface's of the metacarpal and the trapezium are resected) (18 thumbs), trapeziectomy with tendon interposition (17 thumbs) or trapezio-metacarpal arthrodesis (28 thumbs). Baseline characteristics were comparable in the three groups for mean age at operation, Eaton classification, left right distribution and dominant hands operated. The average follow-up was 13 years for the resection group, 8 years for the trapeziectomy group and 9 years for the arthrodesis group. No statistically significant difference between the three groups was found for the visual analogue pain and satisfaction scale, pain frequency nor DASH score. Patients in the trapeziectomy group had significantly less pain compared to the arthrodesis group (p=0.025). Statistically, radial abduction was significantly better after trapeziectomy compared to resection arthroplasty (p<0.01) or arthrodesis (p=0.01). There was no difference among the three groups in grip and tip pinch strength nor in pain on palpation. None of the patients in the trapeziectomy group needed a re-operation, one patient in the resection arthroplasty group had a re-operation, and 22 patients in the arthrodesis group had one or more re-operations for hardware removal or because of a complication. This study shows that the resection arthroplasty has equally good long term results compared to trapeziectomy combined with tendon interposition or arthrodesis. Resection arthroplasty is performed through a single incision and is technically simple. In our clinic resection arthroplasty is therefore the preferred technique for the treatment of osteoarthritis of the trapeziometacarpal joint.

Intertrochanteric osteotomies do not impair long-term outcome of subsequent cemented total hip arthroplasties.

UNLABELLED: The literature contains contradictory evidence as to whether previous proximal femoral osteotomy impairs the long-term outcomes of total hip arthroplasty. We therefore examined whether our patients with cemented total hip arthroplasties after previous osteotomies had inferior outcomes. We also investigated whether the intraoperative complication rate and the clinical and radiologic outcomes were altered by a previous osteotomy. We compared a group of 121 consecutive patients who had total hip arthroplasties (1974-1993) after osteotomies with a group of 290 consecutive patients who had total hip arthroplasties (1974-1987) without previous surgery. There was no difference in survival rate. There was a 10-year survival rate of 90% compared with 92% for the control group. The 15-year survival rates were 83% and 81%, respectively. There were no differences in radiologic and clinical followups. Intraoperative perforation of the femur occurred more often in patients with a total hip arthroplasty after an osteotomy. Our data suggest the long-term outcome of a cemented total hip arthroplasty is not impaired by a previous well-performed osteotomy. LEVEL OF EVIDENCE: Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Total hip replacement with a superolateral bone graft for osteoarthritis secondary to dysplasia: a long-term follow-up.

We evaluated the long-term results of 116 total hip replacements with a superolateral shelfplasty in 102 patients with osteoarthritis secondary to developmental dysplasia of the hip. After a mean follow-up of 19.5 years (11.5 to 26.0), 14 acetabular components (12%) had been revised. The cumulative survival at 20 years was 78%, with revision for loosening of the acetabular component as the end-point. All grafts were well integrated and showed remodelling. In six grafts some resorption had occurred under the heads of the screws where the graft was not supporting the socket. Apart from these 14 revisions, seven acetabular components had possible radiological signs of loosening at a mean follow-up of 14.5 years, one had signs of probable loosening, and five had signs of definite loosening. These results indicate that this technique of bone grafting for acetabular reconstruction in hip dysplasia is a durable solution for cemented acetabular components.

[Arthrodesis of the talonavicular joint]. / Arthrodese des Talonavikulargelenks.

The talonavicular joint as part of the coxa pedis plays a pivotal role in the overall motion of the foot. The necessity for talonavicular fusion arises from isolated arthritis of posttraumatic, rheumatoid, degenerative, or idiopathic etiology. Posttraumatic arthritis is seen after malunited mid-tarsal (Chopart) fracture-dislocations and is frequently accompanied by malalignment due to an imbalance between the medial and lateral columns of the foot. In these cases a corrective arthrodesis becomes necessary. In cases of poor bone stock or arthritis of the calcaneocuboid joint, a double arthrodesis is preferred over isolated talonavicular fusion. Fusion with mini-plates is biomechanically superior to fusion with screws and especially staples, the latter being associated with non-union rates of up to 37%. Talonavicular fusion allows reproducible pain reduction in isolated arthritis with subjective patient satisfaction of between 86% and 100% in a literature review. The substantial reduction of movement in the triple joint complex leads to overload of the adjacent joints with development of arthritis in about 30% in the medium term.

Multi directional intertrochanteric osteotomy for primary and secondary osteoarthritis--results after 15 to 29 years.

Between 1974 and 1987, 276 intertrochanteric osteotomies were performed in 217 patients. In 48 hips the osteotomy was done for idiopathic osteoarthritis. In 166 hips the osteoarthritis was secondary to acetabular dysplasia, in 23 to trauma, in 14 to slipped capital femoral epiphysis, in five to Legg-Calvé-Perthes' disease and in 20 to avascular necrosis of the femoral head. Good results were achieved in young females with mild osteoarthritis secondary to acetabular dysplasia, and in patients with posttraumatic osteoarthritis. All other indications showed a poorer long-term survival. Our study shows that acetabular dysplasia and posttraumatic arthritis remain valid indications for intertrochanteric osteotomy.

Total hip replacement using hemi-circumferential interposition acetabuloplasty for acetabular deficiency in post-Perthes deformities: technique and long-term results.

We describe a technique of hemi-circumferential interposition grafting that allows placement of the cup in the anatomical position of the original acetabulum in the rare cases of post-Perthes or Perthes-like deformities of the femoral head combined with a steep and shallow acetabulum. This technique was performed on 10 hips (9 patients, with an average age of 56 years). One revision was performed for septic loosening after 2.1 years; however, the graft was well integrated and provided sufficient support for the revision cup. All the others had a good clinical and radiological result after an average of 11.4 years with an average Harris Hip Score of 97. The authors have found this an easy-to-use method, which can give an excellent, long-lasting result. It also provides important bone stock for possible subsequent revisions.;

Effects of mechanical compression of a fibrous tissue interface on bone with or without high-density polyethylene particles in a rabbit model of prosthetic loosening.

BACKGROUND: The mechanisms leading to aseptic loosening of a total hip replacement are not fully understood. A fibrous tissue interface can be present around the implant. Hypothetically, component micromovements can compress this interface and cause increased fluid pressure according to biphasic models. We tested the hypothesis that compression of a fibrous membrane with or without the presence of high-density polyethylene particles leads to bone degradation. METHODS: A titanium implant was inserted in forty-five rabbit tibiae, and, after osseous integration was achieved, a fibrous tissue interface was generated. The animals were randomized to undergo a sham operation, treatment with compression of the fibrous membrane, treatment with high-density polyethylene particles, or treatment with both compression and particles. Morphometric analysis of the surrounding bone was performed on cryostat sections after Giemsa staining and staining of tartrate-resistant acid phosphatase activity. RESULTS: Forty specimens were available for analysis; five tibiae with an infection were excluded. After nine weeks, the controls showed vital bone, whereas the specimens treated with compression showed necrosis of bone and replacement of bone by cartilage in a discontinuous layer (p < 0.05 for both) but not fibrous tissue. Treatment with high-density polyethylene particles caused replacement of bone by fibrous tissue (p < 0.05) but not necrosis or cartilage formation. Compression combined with the presence of high-density polyethylene particles caused bone necrosis and loss of bone with replacement by cartilage and fibrous tissue (p < 0.05). CONCLUSIONS: In this in vivo study in rabbits, fibrous membrane compression led to bone necrosis and cartilage formation, possibly because of fluid pressure or fluid flow, whereas the presence of high-density polyethylene particles led to the loss of bone with replacement of bone by fibrous tissue. Cartilage formation may be a protective response to fluid pressure and/or fluid flow. Fibrous membrane compression may play an important role in the early stages of loosening of a total hip replacement.

Intertrochanteric osteotomy combined with acetabular shelfplasty in young patients with severe deformity of the femoral head and secondary osteoarthritis. A long-term follow-up study.

Intertrochanteric osteotomy may postpone the need for total hip replacement (THR). In young patients with an acquired deformity of the femoral head and secondary osteoarthritis, a valgus intertrochanteric osteotomy may allow better congruency but the acetabular cover may become insufficient because of subluxation of the femoral head. In patients with a spherical femoral head and acetabular dysplasia, cover can still remain insufficient after varus displacement osteotomy. We present the long-term results of intertrochanteric osteotomy combined with an acetabular shelfplasty in both these circumstances. Sixteen hips (15 patients) with a deformed femoral head, and ten (seven patients) with a spherical femoral head, underwent an intertrochanteric osteotomy and acetabular shelfplasty. The mean age at the time of surgery was 30 and 37 years and the mean final follow-up was 15 and 19 years, respectively. Six patients in the deformed group, but only one in the spherical group, had required a THR by the time of their final follow-up. In both groups, those who had not undergone a THR had a good result. Acetabular shelfplasty is an excellent addition to an intertrochanteric osteotomy and gives full cover of the femoral head in patients with a deformity of the head and secondary osteoarthritis.