Global differences in the treatment of Legg-Calvé-Perthes disease: a comprehensive review.

INTRODUCTION: Global discussions regarding the treatment of Legg-Calvé-Perthes disease (LCPD) are still controversial. The aim of this study was to characterize the worldwide regional differences in nonoperative and operative treatment for LCPD. MATERIALS AND METHODS: Based on a comprehensive literature search, 123 studies describing the results of nonoperative and operative treatment for LCPD were included. Overall, disease and outcome parameters of 6,968 hips were recorded and compared among the continents-Europe, North America, Asia, Africa, South America, and Australia. RESULTS: Our results showed that the continents differed regarding initial disease progression and therapeutic decision-making, but the final outcome was comparable. The reported proportion of affected hips with mild presentation tended to be higher in Europe, North America, and Africa, whereas disease progression was more severe in Asia, Australia, and South America. Nonoperative treatment was reported more frequently in Europe and North America, while operative management was more common in the rest of the world. Femoral osteotomy was performed more frequently than pelvic osteotomy worldwide, but pelvic osteotomy was comparably more common in North America, Australia, and South America. CONCLUSIONS: The continents differed in terms of therapies for LCPD, while the final outcome was similar. Studies with greater evidence and larger sample size are needed to evaluate the effect of therapeutic measures on LCPD outcome. LEVEL OF EVIDENCE: III (systematic review of level III studies).

Tarsometatarsal bone remodelling after subtalar arthroereisis.

PURPOSE: Subtalar arthroereisis has been described for the treatment of flexible juvenile flatfoot. However, the mechanism responsible for deformity correction has not yet been investigated adequately. The aim of this study was to document the effect of subtalar arthroereisis on the tarsometatarsal bone morphology. METHODS: We retrospectively reviewed the clinical and radiological data of 26 patients (45 feet) with juvenile flexible flatfoot deformity treated by subtalar arthroereisis at our department between 2000 and 2018. Radiological evaluation included angular measurements of tarsometatarsal bone morphology as well as hindfoot and midfoot alignment. Mean radiographic follow-up was 19.4 months (sd 8.8; 12 to 41). RESULTS: A significant change of angular measurements of tarsometatarsal bone morphology was found after subtalar arthroereisis (p < 0.001). While there was an increase of the distal medial cuneiform angle (DMCA) and the medial cuneo-first metatarsal angle on the anteroposterior view, a decrease of the naviculo-medial cuneiform angle and the medial cuneo-first metatarsal angle was seen on the lateral view. Furthermore, we found significant improvements of all hindfoot and midfoot alignment parameters except the lateral tibio-calcaneal angle and the calcaneal pitch angle (p < 0.001). CONCLUSION: Our data support the theory of tarsometatarsal bone remodelling, which may contribute to the effect of subtalar arthroereisis for the treatment of flexible juvenile flatfoot. LEVEL OF EVIDENCE: IV.

Patella Height Correlates With Trochlear Dysplasia: A Computed Tomography Image Analysis.

PURPOSE: The aim of this study was to investigate the position of the patella relative to the trochlea for a possible correlation with radiologic parameters characterizing the form of the trochlea. METHODS: The computed tomography scans of 36 cases with patellofemoral instability and 30 without (mean age, 24.7 ± 6.8 years) were studied. The height of the patella relative to the trochlea was evaluated as the distance between the axial slice where the patella (P) showed its widest diameter, as the patella at this level has the greatest potential to form the trochlea, and the proximal entrance of the femoral trochlea (TE). The correlations between this parameter and several radiologic parameters used to evaluate trochlear dysplasia, including trochlea height, transverse trochlea shift, trochlea depth, sulcus angle, lateral and medial trochlea slope, trochlea facet asymmetry, and the Dejour trochlea type, were calculated. RESULTS: The P-TE distance correlated significantly with all trochlea parameters evaluated, with a more dysplastic trochlea in cases of higher position of the patella: medial, central, and lateral trochlea height (0.287

Continuous Wound Infiltration After Hallux Valgus Surgery.

BACKGROUND: Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery. METHODS: In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction. RESULTS: No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed. CONCLUSION: CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting. LEVEL OF EVIDENCE: Level I, prospective randomized trial.