Intermetatarsal ligament section assisted with sonography for the percutaneous surgery of Morton's disease: Cadaveric study.

BACKGROUND: Surgical treatment of Morton's neuroma remains controversial. Several surgical techniques have been described including percutaneous transection of the deep metatarsal transverse ligament (DMTL). PURPOSE: To evaluate the efficacy and safety of percutaneous release of the DMTL under ultrasound guidance for the treatment of Morton's syndrome. MATERIALS AND METHODOLOGY: Percutaneous release of the DMTL was performed with ultrasound guidance in 48 intermetatarsal spaces of 16 cadaveric specimens. Specimens were then dissected to assess the completion of the release and the presence of any injuries of the neurovascular and tendinous adjacent structures. RESULTS: The DMTL was visualized with ultrasound in all cases. Complete release of the ligament was achieved in 87.5% (42/48) cases. One case of interdigital nerve injury was found. CONCLUSION: Percutaneous release of DMTL with ultrasound guidance for the treatment of Morton's disease has an acceptable rate of complications but care must be taken to ensure the complete release of the ligament.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus.

BACKGROUND: Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus. METHODS: We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134). RESULTS: The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SRpo) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SRpo influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SRpo. CONCLUSION: Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Simulation on synthetic bone: A tool for teaching thoracolumbar pedicle screw placement.

INTRODUCTION: Simulation workshops for surgical training of residents are becoming popular. The gold standard for teaching thoracolumbar pedicle screw placement are cadaver labs; however, the availability of human bodies is limited. The primary objective of this study was to determine if training on a synthetic bone model improves the apprenticeship of accurate pedicle screw placement. The secondary objective was to check the influence of residents' previous experience in spine surgery. HYPOTHESIS: The main hypothesis was that theoretical learning with practical application on synthetic bone was superior to theoretical learning alone. METHODS: Twenty-three orthopedic residents were taught about free-hand pedicle screw placement using a theoretical presentation. Six residents had previous experience with screwing techniques. After randomization in two groups, 11 residents (group 1) participated in a workshop on synthetic bone, whereas 12 residents received only theoretical instruction (group 2). Each resident was asked to place two thoracic screws (T7-T11) and two lumbar screws (L1-L5) on a cadaver. Screw placement accuracy was analyzed using the Gertzbein classification on computed tomography (grades 0 and 1=accurate positioning; grades 2 and 3=malposition>2mm). RESULTS: Rates of accurate screw positioning were 64.0% and 62.5% for thoracic levels, and 72.7% and 66.6% for lumbar levels in group 1 and 2, respectively. There was no significant difference in malposition rates on cadavers between the groups (p=0.1809). A resident who was first trained by simulation had a chance of decreasing the Gertzbein score with an odds-ratio of 1.7714 [0.7710-4.1515]. The odds ratio was 4.5188 [0.0456-0.8451] when comparing residents with previous experience in spinal surgery to novice residents. DISCUSSION: Theoretical teaching associated with a simulation model is relevant for learning a surgical technique. A single simulation workshop on synthetic bone seems insufficient to improve pedicle screw placement accuracy compared to theoretical teaching alone. Progressive experience and the repetition of technical gestures during hands-on supervised learning in spine surgery with a senior surgeon had an influence on the accuracy of pedicle screw placement. LEVEL OF EVIDENCE: II.

Biomechanical effects of stitches on the intra-articular mid-substance of quadruple hamstring-tendon grafts for anterior cruciate ligament reconstruction - a pilot comparative cadaveric study.

BACKGROUND: There is little data in the literature regarding the preparation methods of the intra-articular portion of quadruple hamstring-tendon grafts for anterior cruciate ligament (ACL) reconstruction. The aim of this study was to compare the biomechanical properties of a sutured transplant to that of a non-sutured transplant. The hypothesis was that adding stitches to the intra-articular portion of the graft increased its resistance. METHOD: A comparative cadaveric study was carried out on five pairs of knees. The average age of the cadavers was 68 years. The exclusion criterion was past knee surgery. In the Sutured Group (SG) two stitches were made on the grafts. No stitches were made on the grafts of the Non-sutured Group (NSG). A tensile failure test was carried out using an Instron® loading machine. The maximal load to failure and stiffness were recorded and we observed the mode of failure for each graft. Statistical analysis was performed using the Wilcoxon rank sum test. Level of significance was set at p < 0.05. RESULTS: The hypothesis proposed was not confirmed; adding stitches to the intra-articular portion of the four-strand hamstring-tendon graft does not increase its biomechanical properties. The maximal load to failure was 233.5 N ± 40.6 (186.7-274.5 N) for the NSG, 19.6% higher than for the SG which was 195.2 N ± 42.9 (139.0-238.2 N). Nevertheless, the difference observed was not statistically significant (p = 0.188). The stiffness of the grafts for the NSG was 23.5 N/mm ± 5.3 (17.8-29 N/mm) and 19.7 N/mm ± 5.5 (13.2-24.7 N/mm) for the SG grafts. Overall stiffness values for the NSG were 19% higher than those of the SG; however, the results were not statistically significant (p = 0.438). The failure mode was a rupture at the fixation point except for one sample from the SG which failed at an intra-articular stitch. CONCLUSION: Whilst the initial hypothesis was not verified, nevertheless, the maximal loads to failure and stiffness were approximately 20% higher when there were no intra-articular stitches compared to the situation where stitches were added to the intra-articular portion of the graft. This was a cadaveric pilot study and, therefore, whilst we are not able to extend our results to clinical practice, the outcomes would indicate the need for further development of this and related protocols deriving from the question of whether there is weakening the graft when adding stitches to its mid-substance. These results remain to be confirmed by further research.

Carpal scaphoid non-union treatment: a retrospective trial comparing simple retrograde percutaneous screw fixation versus percutaneous screw fixation plus pulsed electromagnetic fields (Physiostim®).

BACKGROUND: The purpose of this retrospective comparative study was to assess whether a complementary treatment by pulsed electromagnetic field could increase the bone-healing rate of scaphoid non-union without SNAC (scaphoid non-union advanced collapse) treated by retrograde percutaneous screw fixation. CASE DESCRIPTION: Eighteen patients with scaphoid non-union were included in this retrospective study. The group 1 was made of nine cases (seven stage IIA and two stage IIB) of scaphoid non-union treated by retrograde percutaneous screw fixation and pulsed electromagnetic fields (Physiostim®). The group 2 was made of nine cases (six stage IIA and three stage IIB) treated by simple retrograde percutaneous screw fixation. RESULTS: With a 10-month follow-up in group 1 and a 9.5-month follow-up in group 2, there were three cases of non-union in group 1 and two cases in group 2. Regarding the type of non-union, there was one case among the stage IIB and four cases among the stage IIA. CLINICAL RELEVANCE: The results of the study did not show any interest in the use of pulsed electromagnetic field for the treatment of carpal scaphoid non-union. They should be dropped. LEVEL OF EVIDENCE: III.