Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation.

INTRODUCTION: Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters. MATERIALS AND METHODS: This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded. RESULTS: There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group. CONCLUSION: Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully.

Hip arthroscopy versus total hip arthroplasty-A study on patients with obesity above 40 years of age.

Patients older than 40 years with a body-mass-index (BMI) >30 kg/m2 , a femoroacetabular-impingement (FAI) and little cartilage damage are a challenge for hip surgeons. Hip-arthroscopy (HAS) or conservative therapy until a total hip arthroplasty (THA) is needed are possible treatments. Our research purpose was to compare the clinical results and complication/reoperation rate after HAS and THA in patients with obesity over 40 years. This retrospective study includes a consecutive series of patients with obesity (BMI >30 kg/m2 ) who underwent HAS (19 hips) and THA (37 hips) over 40 years of age between 2007 and 2013 at our institution with a minimum of 12-months follow-up. Outcome measures were WOMAC (Western Ontario und McMaster Universities Arthritis Index), subjective-hip-value (SHV), residual complaints and the reoperation rate. Patient data and scores were collected pre-operative, 12 months post-operatively and at the last follow-up. Both groups showed a comparable age (mean 48 years). Regarding SHV-Scores the THA-group shows continuous significant improvements. Reaching 87% (range 50%-100%), the HAS-group showed in case of the SHV no significant change after 1 year and an improvement from preoperative to the last follow-up reaching 72% (range 30%-100%) at the last follow-up. Residual groin pain was significant higher in the HAS-group. Two deep infections (5.4%) requiring reoperations were reported in the THA-group. The conversion rate to THA after a mean time of 60 months was 26% (5 of 19). Patients with obesity over 40 years demonstrated inferior SHV, more often residual pain and revision surgery after HAS, when compared to THA at short-term, with conversions rate of one fourth. However, THA in this patient group showed high infection rate of 5%. This information is relevant for counselling above-mentioned patients.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon.

The modified "Lapidus" procedure (MLP) describes the arthrodesis of the first tarsometatarsal joint. We investigate if there are detectable changes of the tendon or the function of the muscle and clinical outcome after MLP. We reviewed 22 feet. All patients underwent magnetic resonance imaging (MRI) at an average of 27 (range, 12-49) months. Clinical outcome was evaluated using the European Foot and Ankle Society score. Strength was measured and complications were assessed. MRI revealed signs of tendinopathy of the tibialis anterior tendon in 13 feet (59%). The mean total European Foot and Ankle Society score at final follow-up was 17 (range, 6-24) points. The mean postoperative Visual Analog Scale score was 1.4 (range, 0-5). Range of motion and force data were not significantly different to the contralateral side. In conclusion, MRI showed signs of tendinopathy in 59%, which does not seem to affect clinical outcome, but has to be considered when choosing the desired implant and placement. MLP leads to high patient satisfaction rates and significant improvement at midterm follow up.

The Metatarsal Cortical Index as an Indicator of Insufficiency Fracture of the Foot.

The diagnosis of metatarsal stress fractures is challenging. Standard imaging often shows false-negative results. The aim of this study was to create reliable radiologic outcome parameters to predict insufficiency fractures of the metatarsals. We performed an age- and sex-matched case-control study of patients with (n = 18) and without insufficiency fracture (n = 18) of the foot. The metatarsal cortical index (MCI) for each metatarsal was developed to predict an insufficiency fracture. The MCI of each metatarsal was significantly decreased in the insufficiency fracture group compared with the control group (p < .01). The MCI of the fourth ray yielded the highest area under the curve among the analyzed MCI values (area under the curve, 0.79; 95% confidence interval, 0.61-0.90). A cut-off value of 1.62 for the MCI of the fourth ray yielded a sensitivity of 78% and a specificity of 78% to predict insufficiency fracture of the foot (odds ratio, 12.25; 95% confidence interval, 2.54-58.97), and enabled accurate allocation to the insufficiency fracture group versus the control group in 74% of cases. In conclusion, a decreased MCI is associated with metatarsal insufficiency fractures and enables an accurate diagnosis in 3 out of 4 cases. The MCI might aid clinicians in identifying insufficiency fracture, and raise the suspicion of the diagnosis without additional imaging studies.

Non-Adherence to Pain Medication Increases Risk of Postoperative Frozen Shoulder.

BACKGROUND: Postoperative frozen shoulder (FS) or adhesive capsulitis is a relatively frequent complication (5-20%), even after simple arthroscopic shoulder surgeries. The pathophysiology is still unclear, but psychological factors may play a pivotal role. From clinical experience, we hypothesized that patients, who are reluctant to take medications, particularly "pain-killers," have an increased incidence of postoperative FS. METHODS: We identified twenty patients who underwent limited arthroscopic operations of the shoulder and developed postoperative FS. Twenty patients with matching type of surgery, age, and gender served as control group (n = 20). All patients were at least one year postoperative and asymptomatic at the time of examination. Demographic data, the patient's adherence to self-medication (including self-medicating scale, SMS), development the Quality of life (QoL), and depression scale (PHQ-4-questionnaire) were assessed. RESULTS: Patients with FS had a 2-fold longer rehabilitation and 3-fold longer work inability compared to the patients without FS (P < 0.009 and P < 0.003, respectively). Subjective shoulder value SSV (P = 0.075) and post-operative improvement of QoL (P = 0.292) did not differ among the groups. There was a trend-but not significant-toward less coherence to self-medication in the FS-group (26.50 vs. 29.50; P = 0.094). Patients with postoperative FS significantly more often stated not to have "taken pain-killers as prescribed" (P = 0.003). CONCLUSIONS: Patients reporting unwillingness to take the prescribed pain medications had a significantly higher incidence of postoperative FS. It remains unclear whether the increased risk of developing FS is due to reduced postoperative analgesia or a critical attitude toward taking medication. However, patients who are reluctant to take painkillers should strongly be encouraged to take medications as prescribed.

Quality of Life after Rhinoplasty: A Prospective Study.

As our previous studies have shown, cosmetic surgery has a positive correlation with postoperative well-being. The aim of this study was to prospectively examine the postoperative changes in quality of life (QoL) after a rhinoplasty. Thirty-four patients who underwent septorhinoplasty performed by a single surgeon from July 2015 to October 2018 reported in indication-specific self-developed and different validated questionnaires (FLZM or Fragen zur Lebenszufriedenheit Module, Freiburg Personality Inventor, Rosenberg self-esteem scale, Functional Rhinoplasty Outcome Inventory 17 [FROI-17], and Glasgow Benefit Inventory [GBI]) on the status of their QoL preoperatively (T0) and 6 months' follow-up (T1). Our goal was to assess the difference in psyche and self-esteem and to get objective insights into the effect of the operation. Significant improvements in QoL in terms of general module, health, and appearance were noted. The general part of the FLZM showed increasing T1 values in the sum scores (p = 0.005). With regard to the item "health," T1 was better than the norm data (p = 0.003). The statistically significant improvement for the item nose appearance (p < 0.0001) after operation and T1 versus reference data (p < 0.010) should be highlighted. The subjective patient ratings showed statistically significant T1 improvements for all items of the FROI-17: overall nose (p < 0.0001), nasal function (p = 0.001), general/further symptoms (p = 0.006), and confidence increased by aesthetic changes (p < 0.0001). Furthermore, the GBI score shows an improved QoL after rhinoplasty (p < 0.0001). Based on the assessment of a variety of disease- and nondisease-specific validated questionnaires, numerous improvements in the QoL of the patients were observed. Therefore, we support septorhinoplasty as a meaningful procedure regarding QoL improvement. The level of evidence is Level II prospective cohort study.

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet.

BACKGROUND: Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia. METHODS: We enrolled 106 patients (118 feet) and assessed patients' pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted. RESULTS: Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45mm. The Coughlin method showed the highest interrater reliability (ICC=0.96). CONCLUSIONS: Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability. LEVEL OF EVIDENCE: Level IV.

Limb and component alignment after total knee arthroplasty comparing 28 consecutive iAssist and 28 conventional TKAs: A prospective study.

BACKGROUND: The objective of this study was to assess limb and component alignment after total knee arthroplasty (TKA) on long leg X-rays and to compare the use of iAssist, an accelerometric based computer-assisted device (CAD), with conventional jigs. METHODS: We prospectively recruited 56 consecutive patients undergoing primary unilateral TKA by a single surgeon into this study. In the first 28 patients iAssist navigation system was utilized and in the following 28 conventional jigs were used. The groups were comparable with regard to age, sex distribution, body mass index and preoperative hip-knee-ankle (HKA) angle. Our aim was to restore neutral coronal alignment and a five degree tibial slope. RESULTS: The mean postoperative mechanical axis was 179.4° in the CAD group and 180.1° in the conventional group (P = 0.187). There were five TKAs deviating more than three degrees from neutral (18.5%) in the conventional group and none in the CAD group (P = 0.051). The mean femoral mechanical-condyles-angle was significantly closer (P < 0.001) to our target of 90° in the conventional group but contained more outliers (P = 0.67). The sagittal tibial slope was closer (P = 0.047) to our target of 85° in CAD-navigated TKAs with fewer outliers (P < 0.0001). The Oxford Knee Score showed comparable (P = 0.271) and good clinical outcome in both groups. The mean operation time was significantly longer in the CAD group (P < 0.001). CONCLUSIONS: This study shows that the use of iAssist accelerometric CAD facilitates comparable good leg alignment after TKA in the frontal plane and more accurate tibial slope with fewer outliers in the sagittal plane compared with a conventional technique. Our operation time was longer with CAD.

Risk factors for secondary displacement in conservatively treated proximal humeral fractures.

AIMS: Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. METHODS: A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. RESULTS: Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. CONCLUSION: During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881-889.

Hip arthroscopy versus total hip arthroplasty in patients above 40 differences: outcome and residual complain.

This study aimed to compare patient outcomes and residual complains after hip arthroscopy (HAS) and total hip arthroplasty (THA) to improve patient counseling. It includes 140 hips/129 HAS-patients and 77 hips/62 THA-patients aged 40 to 55 years with a BMI under 30. All patients underwent primary HAS or primary THA in our hospital from 2007 until 2014. Exclusion criteria were a history of prior hip surgery or suffering sequels of childhood's hip disease, systemic inflammatory disease or avascular hip osteonecrosis. Outcome measures were WOMAC, subjective hip value, residual complains, the need of infiltrations and the complication and conversion rate. Patient data and scores were collected pre-operative, after one year and at the last follow-up. Scores indicated significant patient benefits in both groups (p < 0.0001). Variability of outcome was significantly higher and less predictable in the HAS group (HAS: 1.9 vs. THA: 0.9). While THA showed significant improvement mainly after one year, HAS showed significant improvements after one year and the latest follow-up. Residual complains were more frequent after HAS (p = 0.026). Groin pain was the main complain after HAS, limping and disturbing leg length discrepancy after THA. THA more predictably improves patient's outcome with shorter recovery time. Limping and leg length discrepancy are predominant after THA.

The influence of obesity and gender on outcome after reversed L-shaped osteotomy for hallux valgus.

BACKGROUND: Hallux valgus deformity (HV) affects around every fourth individual, and surgical treatment is performed in every thousandth person. There is an ongoing quest for the best surgical management and reduction of undesirable outcomes. The aim was to explore associations of obesity and gender with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL) for HV. MATERIALS AND METHODS: This study was carried out in a retrospective cohort design at a single University Hospital in Switzerland between January 2004 and December 2013. It included adult patients treated with ReveL for HV. The primary exposure was body mass index (BMI) at the time of ReveL. The secondary exposure was gender. The primary outcome was radiological relapse of HV (HV angle [HVA] > 15 degrees [°]) at the last follow-up. Secondary outcomes were improvable patient satisfaction, complication, redo surgery, and optional hardware removal. Logistic regression analysis adjusted for confounders. RESULTS: The median weight, height, and BMI were 66.0 (interquartile range [IQR] 57.0-76.0) kilograms (kg), 1.65 (IQR 1.60-1.71) metres (m), and 24.0 (IQR 21.3-27.8) kg/m2. Logistic regression analysis did not show associations of relapse with BMI, independent of age, gender, additional technique, and preoperative HVA (adjusted odds ratio [ORadjusted] = 1.10 [95% (%) confidence interval (CI) = 0.70-1.45], p = 0.675). Relapse was 91% more likely in males (ORadjusted = 1.91 [95% CI = 1.19-3.06], p = 0.007). Improvable satisfaction was 79% more likely in males (ORadjusted = 1.79 [CI = 1.04-3.06], p = 0.035). Hardware removal was 47% less likely in males (ORadjusted = 0.53 [95% CI 0.30-0.94], p = 0.029). CONCLUSIONS: In this study, obesity was not associated with unsatisfactory outcomes after ReveL for HV. This challenges the previous recommendation that preoperative weight loss may be necessary for a successful surgical treatment outcome. Males may be informed about potentially higher associations with unfavourable outcomes. Due to the risk of selection bias and lack of causality, findings may need to be confirmed with clinical trials.

Radiological and Clinical Outcome After Reversed L-Shaped Osteotomy: A Large Retrospective Swiss Cohort Study.

The objective was to report radiological and clinical outcomes after reversed L-shaped osteotomy (ReveL) for hallux valgus (HV). A retrospective cohort study was performed between January 2004 and December 2013. The primary outcome was radiological recurrence of HV (HV angle [HVA] >15°). There were various exposure and secondary outcome variables. The results showed a median follow-up of 12.0 months (N = 827). Radiological recurrence, limited patient satisfaction, complication, revision surgery, and elective hardware removal were found in 25.0%, 15.3%, 4.6%, 2.5%, and 26.7%. Median pre- to postoperative changes were highest for HVA (delta = -16.7°). Recurrence was more likely in cases with preoperative HVA ≥40° (adjusted odds ratio [ORadjusted]) 3.63, p < .001). Revisions were more likely with concomitant diseases and bilateral surgery (ORadjusted 12.53, p = .010; ORadjusted 3.35, p = .030). Hardware removal was less likely in patients ≥50 years (ORadjusted 0.67, p = .014). In conclusion, ReveL was a good surgical option for HV because of the relatively low rates of unfavorable outcomes.

The influence of the number of screws and additional surgical procedures on outcome in hallux valgus treatment.

BACKGROUND: Surgical treatment of hallux valgus (HV) is one of the major flagships of orthopedic surgeons. Due to relatively unsatisfactory radiological and clinical outcomes, the search for the best surgical technique and causes for unsatisfactory outcomes continues. The objective was to investigate associations of the number of screws and additional surgical techniques for HV with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL). METHODS: A retrospective cohort study of adults from a single University Hospital between 2004 and 2013 was performed. The primary exposure was the number of screws (one vs two) used for osseous fixation after ReveL. The secondary exposure was an additional surgical technique for HV (e.g., Akin osteotomy). The primary outcome was a radiological recurrence of HV (HV angle (HVA) > 15°) at last follow-up. The secondary outcomes were limited patient satisfaction, complication, revision surgery, and elective hardware removal. Odds ratio (OR) and 95% confidence interval (CI) were estimated by logistic regression adjusting for confounders. RESULTS: The recurrence was 45% less likely with the use of one screw, independent of age, sex, additional technique, and preoperative HVA (odds ratio (ORadjusted) = 0.55 [95% CI 0.30-0.98], p = 0.043). The recurrence was 162% more likely with an additional surgical technique for HV (ORadjusted = 2.62 [1.24-5.52], p = 0.011). CONCLUSION: In ReveL for HV, a single screw (instead of two screws) may be sufficient enough for a similar or even better outcome, which may also reduce costs. Additional surgical procedures for HV may be refrained from if possible. Due to limitations of a retrospective study, results may need validation with clinical trials.

Experience of total knee arthroplasty using a novel navigation system within the surgical field.

BACKGROUND: With the aim of improving component alignment and outcome in total knee arthroplasty (TKA), several computer-assisted devices (CAD) have been developed. METHODS: In February 2014, the present unit started to use a new imageless navigation system with accelerometric pods within the surgical field for all primary TKAs; there was no need for optical trackers or cameras. This paper presents the results of the first 72 TKAs using this iAssist system in 71 prospectively collected and retrospectively analyzed patients. It analyzed component positioning in standard and full-length leg x-rays. RESULTS: The mean age of the patients was 70years (range 52-88). The center of hip, knee and ankle (mechanical axes) deviated on average 0.5° (standard deviation (SD) of 1.8) valgus from the targeted straight alignment. Three TKAs had >3° deviation (i.e. four degree varus, five degree and seven degree valgus). The frontal tibial tray alignment was an average of 89.9° (range 86.4-100.1°, SD ±2.0) with the target being 90°, and the sagittal slope was as targeted at 85.0° (range 78.4-88.8°, SD ±1.7). CONCLUSIONS: This CAD facilitated good mechanical alignment and reproducible accuracy in component positioning. Pods clipped onto cutting jigs within the surgical field provided simple and accurate navigation, with little extra time needed for calibration and no need for optical trackers or pre-operative imaging.

The Psychologic and Psychosocial Impact of Otoplasty on Children and Adults.

BACKGROUND: In previous studies, our research group already evaluated the impact of aesthetic surgery on "quality of life" (QoL). This study evaluates QoL factors and perceptions of well-being after otoplasty as a single indication. METHODS: Eighty-one patients who underwent otoplasty were divided into three age groups: Youth 1 (Y1) = 8-12 years (n = 17), Youth 1 (Y2) = 13-17 years (n = 13), and Adult ≥18 years (n = 51). For competitive analysis, 2 groups of tests were used: a standardized self-assessment test on life satisfaction (FLZ(M)), the Glasgow Benefit Inventory (GBI), the standardized Rosenberg Self-Esteem Scale (RSES), the standardized Freiburg Personality Inventory (FPI-R), the Patient Health Questionnaire 4 (PHQ-4), and a self-developed and indication-specific questionnaire for "Adult" group. The tools for the groups Y1 and Y2 were: PHQ-4, KINDL(R), the Glasgow Child Benefit Inventory (GCBI), and a self-developed and indication-specific questionnaire either. RESULTS: Our data bared numerous significant improvements on patients' QoL. In the items "friends" (P = 0.036) and "freedom of anxiety" (P = 0.034) of the FLZ(M), important improvements were found. In section "satisfaction with appearance" (body image), the items "hair" (P = 0.003) and "ear" (P = 0.034) were to point out. The RSES (P = 0.001) and the FPI-R (P = 0.035) data indicated a well-balanced emotional stability. The results of the GBI/GCBI (P = 0.000/P = 0.000) showed a higher QoL of postsurgery patients. The data of the KINDL questionnaire provided increasing values in the modules "friends" (P = 0.033) and "total score" (P = 0.040) for boys of the ages 8 to 12. For all age groups, there was a less affinity to depression (PHQ-4) and a high satisfaction with the aesthetical result (indication-specific questionnaire). CONCLUSIONS: This study showed higher QoL in all age groups by using standardized tools in comparison with the norm data. The knowledge of postoperative psychologic benefits, such as "satisfaction with appearance" (body image) and "different areas of life," self-confidence, and self-esteem as well as lower level of depression support meaningfulness of otoplasty. LEVEL OF EVIDENCE: Therapeutic, III: Retrospective cohort or comparative study.

Intra-articular giant synovial osteochondroma: case reports of the ankle and knee joint.

Two cases of giant intra-articular osteochondromas (knee and ankle joint) are reported; pathologically they are rare representations of synovial chondromatosis. A 17-year-old man presented with a tumorous mass which had been localized in his left ankle for many years, increasing in volume during the last months. The lesion was removed by posteromedial ankle arthrotomy. The second case was observed in a 39-year-old woman with a slow-growing mass in her right knee joint. The lesion was removed from the Hoffa fat pad by open anteromedial arthrotomy.