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.

Intramedullary and intra-osseous arthrodesis of the hallux metatarsophalangeal joint.

PURPOSE: To review the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint in 23 patients. METHODS: Records of 9 men and 14 women aged 27 to 88 (mean, 57) years who underwent arthrodesis of the hallux MTP joint using an intramedullary device and an intra-osseous device were reviewed. Indications for surgery were severe hallux valgus (n=15), hallux rigidus (n=6) and rheumatoid arthritis (n=2). Outcome measures included visual analogue score (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, bone union, hallux valgus angle (HVA), dorsiflexion angle (DA), complications, revision, and patient satisfaction. RESULTS: The mean follow-up was 19 (range, 6-38) months. The mean AOFAS score improved from 29 to 75.4 (p<0.0001) and the mean VAS for pain improved from 8.1 to 2.4 (p<0.0001). 20 (86%) of the patients were satisfied with the outcome. The mean HVA was 14º and the mean DA was 22º. 19 (83%) of the toes had a well-aligned hallux. 21 (91%) of the patients achieved arthrodesis of the hallux MTP joint. The remaining 2 patients underwent revision surgery for failed fusion or infected non-union; they continued to have transfer metatarsalgia despite bone union. CONCLUSION: The intramedullary and intra-osseous devices for arthrodesis of the hallux MTP joint achieved good outcome in terms of AOFAS score, VAS for pain, HVA, DA, bone union, and patient satisfaction.

A national questionnaire survey on knee manipulation following total knee arthroplasty.

BACKGROUND: Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we aim to determine the current practice and trend among knee surgeons throughout the United Kingdom. MATERIALS AND METHODS: Postal questionnaires were sent out to 100 knee surgeons registered with British Association of Knee Surgeons, ensuring that the whole of United Kingdom was well represented. The questions included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. RESULTS: We received 82 responses. 46% of respondents performed MUA routinely, 43% sometimes, and 11 never. Majority (71.23%) performed MUA within 3 months of the index procedure. 68% routinely used CPM post-manipulation while 7% of the respondents applied splints or serial cast post MUA. 41% of the surgeons routinely used Patient Controlled Analgaesia ± Regional blocks. Majority (55%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. CONCLUSIONS: Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion achieved. Manipulation should be reserved for the patient with difficult and painful flexion in the early postoperative period.

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.

Distal metatarsal coalition: A rare case report.

INTRODUCTION: Metatarsal coalition is an extremely rare condition. We report the second documented case of 4th and 5th distal metatarsal coalition in the literature. PRESENTATION OF CASE: An eight-year-old girl was referred to an orthopaedic clinic with a four-month history of forefoot pain and swelling on the plantar aspect of the right little toe. Radiograph and clinical examination confirmed distal metatarsal coalition between the 4th and 5th metatarsals. Following a period of conservative treatment, excision was eventually performed due to worsening symptoms. Patient re-attended two years later with a recurrence of the coalition confirmed by computed tomography (CT) scan. The case was discussed at a tertiary paediatric orthopaedic insititution. Decision was made to manage patient conservatively with insole and physiotherapy until skeletal maturity. A year later, patient's symptoms did not worsen, and her foot displayed no evidence of change in the arch and shape. DISCUSSION: The timing of ossification of coalition varies from one anatomical site to another. Surgery when performed before ossification is complete runs the risk of recurrence. CONCLUSION: Our case report illustrates the importance of restoring normal weight bearing dynamics and pain relief when managing metatarsal coalition, or synostosis in skeletally immature patients. We recommend persevering with conservative treatment, with operative treatment reserved only as a later option, and ideally, until skeletal maturity is achieved.

Acute nontraumatic clavicle fracture associated with long-term bisphosphonate therapy.

Cases of osteonecrosis of the jaw, insufficiency fractures and atypical low energy or atraumatic fractures of pelvis, femur (subtrochanteric/mid-shaft/distal-third), tibia, fibula, metatarsal, humerus, and ulna related to long-term bisphosphonate therapy have been reported in the literature. We present the case of an acute nontraumatic clavicle fracture, associated with long-term bisphosphonate therapy, which to our knowledge has not been reported previously. This case highlights the need of critical evaluation of patients with atypical fractures during long-term bisphosphonate therapy.

Surgical tip: Titanium foam blocks can simplify fusion of failed total ankle replacements.

Ankle arthrodesis following failed ankle replacements is a technically challenging task because of the large defect left behind after the prosthesis is removed. The usual practice is to use bulk grafts which are either autografts or allografts to fill the defect. We report our experience with the use of a titanium foam block specifically designed for fusion of failed ankle replacements. This particular method was chosen to avoid the technical difficulties and morbidities associated with the use of bulk autografts and allografts. We describe the surgical technique and early results in the first two cases performed in our unit. The satisfactory clinical and radiologic results in the two cases demonstrate the ability of the titanium foam block to simplify an otherwise complex procedure without compromising the outcome.