Should We Use Intermetatarsal Angle as Primary Determinant to Define the Limits of Distal Chevron Osteotomy?

Classic treatment algorithms limit the use of distal chevron osteotomy (DCO) to cases with an intermetatarsal angle (IMA) <14°. As the IMA increases, it is accepted that the contact between the metatarsal head and shaft will be insufficient. We have investigated the reliability of IMA to predict contact area percentage after DCO. Preoperative radiographs of patients with hallux valgus were subdivided as mild, moderate, and severe using traditional algorithms. After excluding the mild cases, we randomly selected 100 patients (50 moderate and 50 severe) and calculated the estimated bony contact (EBC) with our method and investigated the percentage of patients who could have >50% contact area if we perform a DCO. Thirty of 50 (60%) and 17 of 50 (34%) patients had >50% EBC in moderate and severe groups, respectively. We performed DCO for 24 patients (14 moderate and 10 severe cases). The 100-point American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarso-phalangeal-interphalangeal scale was used to assess the clinical outcome. For the moderate group, we calculated mean IMA 16° (standard deviation [SD] ± 1.4°) and mean EBC 66.9% (SD ± 10.8%). For the severe group, we calculated mean IMA 20.9° (SD ± 0.7°) and mean EBC 63.1% (SD ± 10.4%). Paired t tests showed significant improvement comparing preoperative and postoperative AOFAS scores, IMA, hallux valgus angle, and sesamoid position for all operated patients (p < .001). We did not see any recurrence of hallux valgus or hallux varus and had only 1 minor complication that we managed conservatively. IMA may not always be a reliable parameter to predict the stability of DCO. Because the stability depends on the contact surfaces of osteotomy fragments, metatarsal head diameter and remaining bone contact should be the primary concerns. Two patients with the same IMA can have a different contact surface varying on a broad spectrum.

The effect of dehydration and irrigation on tendon adhesion formation after tendon exposure.

OBJECTIVE: The aim of this study was to evaluate the effects of dehydration due to tendon exposure on adhesion formation on the tendon surface. METHODS: Achilles tendons of 60 New Zealand white rabbits were surgically exposed and evaluated. In the control group (Group 1), the wound was closed immediately; and in the remaining two groups, Achilles tendons were exposed to air for 60 minutes without (Group 2) or with (Group 3) regular saline irrigation. After undergoing clinical examination, 50% of rabbits in each group were sacrificed 3 weeks postoperatively and 50% at the 6th postoperative week. RESULTS: All tendons exposed to air exhibited mild or moderate degrees of adhesion. Compared to the control group, the incidence of adhesion formation was significantly higher in the groups where tendons had been exposed to air for 60 minutes, whereas no significant difference was found between the irrigated and non-irrigated groups. No limitations or contractures were detected in the hind limbs of the animals at the clinical examination. CONCLUSION: Regardless of irrigation, tendons are not prone to form clinically apparent adhesions during operations under 60 minutes of duration.

Comparison of early results of vascularized and non-vascularized fibular grafting in the treatment of osteonecrosis of the femoral head.

OBJECTIVE: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with the collapse of the articular surface and subsequent arthrosis. Some authors have reported good results with the use of vascularized and non-vascularized fibular grafts to treat osteonecrotic lesions of the femoral head. The aim of this study was to compare the results of vascularized fibular grafting with that of non-vascularized fibular grafting in the treatment of femoral head osteonecrosis. METHODS: Between January 1999 and June 2008, 11 osteonecrotic hips of 8 patients who underwent vascularized fibular grafting and 15 osteonecrotic hips of 13 patients who underwent nonvascularized fibular grafting were compared according to etiology, stage, age, sex, preoperative and postoperative first year Harris hip and VAS scores. RESULTS: Steroid use was the most common etiologic factor, found in 26 hips of 21 patients in the entire patient population. There was no significant difference between the two groups according to their age, sex and preoperative Harris hip scores (p>0.05). According to the Ficat staging system for radiological evaluation, 4 hips were Grade 2A, 4 hips were Grade 2B, and 3 hips were Grade 3 in the vascularized group and 8 hips were Grade 2A, 3 hips Grade 2B, 3 hips Grade 3 and one hip was identified as Grade 4 in the non-vascularized group. When the Harris hip and VAS scores of both groups were evaluated, the group treated by vascularized fibular grafting had significantly higher scores than the ones treated by non-vascularized fibular grafting in the other group (p<0.05). Furthermore, when the Harris hip and VAS scores of preoperative and postoperative first year of vascularized fibular grafting patients were compared, there were significantly higher scores after the surgery. CONCLUSION: Although there was no significant radiological difference in the early results of both surgical techniques, the clinical results of vascularized fibular grafting treatment were significantly better than the results of non-vascularized fibular grafting treatment in the osteonecrosis of the femoral head. Vascularized fibular grafting improves the clinical status at an early period and prevents subchondral collapse.

[Partial removal of nail matrix in the treatment of ingrowing toe nail]. / Tirnak batmasi tedavisinde kismi matriks eksizyonu.

OBJECTIVES: Ingrowing toe nail is a frequent disorder of the foot. In this study, we evaluated the results of surgical treatment of ingrowing toe nail. METHODS: Sixty-two patients (31 males, 31 females; mean age 38 years; range 11 to 72 years) with ingrowing toe nail underwent partial removal of the nail matrix according to the Winograd technique. The presenting complaints were pain, foul-smelling drainage, deformity, and difficulty in walking. According to the Heifetz's staging system, 18 patients had stage I, 23 patients had stage II, and 21 patients had stage III disease. Forty-four patients had active drainage due to an infectious process. The infected cases were operated on after improvement of inflammation by antibiotic treatment. One patient underwent excision of subungual exocytosis causing severe deformity of the toe. Time to return to work, time to recurrence, and patient satisfaction were evaluated. The mean follow-up period was 26 months (range 24 to 42 months). RESULTS: Recurrence was seen in four patients (6.5%) within a mean of 4.2 months (range 3 to 7 months). The remaining patients returned to normal daily activities after a mean of 12 days (range 10 to 16 days). The mean time to work was five days (range 3 to 16 days). All but two patients who developed recurrences expressed satisfaction with surgery. None of the patients had deep infection or neurovascular complications. CONCLUSION: Partial removal of the nail matrix is associated with a very low recurrence rate and a higher rate of patient satisfaction.

The effect of dehydration and irrigation on the healing of Achilles tendon: an experimental study.

BACKGROUND: Air exposure is a factor that inhibits in vitro cellular proliferation and matrix synthesis in tendons. Aim of this experimental study was to evaluate effect of dehydration and irrigation on healing of Achilles tendon. METHODS: Achilles tenotomy was done in forty-five Sprague-Dawley rats. In control group, tendon was sutured immediately. In the remaining two groups, the Achilles tendons were allowed to direct exposure of air. Irrigation of Achilles tendon was performed in one of exposed groups, while irrigation was not done in other group. After 60 minutes, tendons of both groups were sutured same as control group. Rats were sacrificed at postoperative day 28. Achilles tendons were dissected and histological and biomechanical evaluations were performed. RESULTS: Histological evaluation revealed intense fibrosis formation with adhesion of tendon to surrounding tissues in the air exposed groups. The quantity of angiogenesis and inflammatory reaction were also higher in experimental groups regardless of irrigation. Air exposed tendons had higher tensile strength however lower stiffness than control group in biomechanical evaluation. CONCLUSION: Air exposure decreases quality of healing by increasing fibrosis and adherence formation. These negative effects of exposure to air were not counteracted by irrigation. However, air exposure didn't affect tensile strength of the healing.

Spiral-shaped metallic implant in the treatment of Achilles tendon ruptures: an experimental study on the Achilles tendon of sheep.

There are 2 main factors contributing to the strength of tendon repair: the tensile strength of the material used in repair and the tendon-holding capacity of the suture configuration. In the current study, we aimed to find a technique with high repair strength by increasing both the tensile strength of the material and the tendon-holding capacity of the configuration. We developed metal implants (models 1 and 2) made from stainless-steel wire with 2 different spiral-shaped configurations. We measured tendon-holding capacities of these alternative implants biomechanically and compared them with frequently used suture techniques, the Bunnell and locking loop, which were achieved with 5 Ticron sutures. Sixty-four sheep Achilles' tendons were used in the study as 16 tendons in each group. Model 2 was more resistant to deformation under loading when compared with model 1. The results demonstrated that model 2 was superior to model 1 and both suture techniques. This study could be accepted as a step for reaching a strong tendon repair technique. It should be emphasized that the technique needs to be improved technically to make it convenient for clinical use.

The effect of proteolytic enzyme serratiopeptidase in the treatment of experimental implant-related infection.

BACKGROUND: Infection around an implanted orthopaedic device is a devastating complication, and the treatment of infections involving slime-forming bacteria is especially difficult. The purpose of the present study was to evaluate the effectiveness of a proteolytic enzyme, serratiopeptidase, in the eradication of a periprosthetic infection in an in vivo animal model. METHODS: In sixty Sprague-Dawley rats, the medullary canal of the right femur was drilled through the intercondylar notch and was inoculated with a Staphylococcus epidermidis strain (ATCC 35984) with a high slime-producing capacity. The cavity was filled with polymethylmethacrylate cement, and a Kirschner wire that had contact with the knee joint was inserted. None of the animals received any treatment for two weeks. Twenty rats were killed at two weeks after the inoculation in order to determine if the infection had become established. The remaining forty rats were randomized into two groups. One group received serratiopeptidase enzyme injections into the knee joint in addition to antibiotic therapy for four weeks, and the other group received intra-articular saline solution injections together with the same antibiotic therapy. The animals from both groups were killed two weeks after the end of therapy (on Day 56). The knee specimens were evaluated bacteriologically and histologically to determine the prevalence of persistent infection and the effects of the enzyme on local tissue. RESULTS: At two weeks, inoculated bacteria grew on culture of specimens from twelve (63.2%) of nineteen animals in the no-treatment group. Microbiological testing suggested that infection persisted in only one (5.6%) of eighteen animals in the serratiopeptidase-and-antibiotic group, whereas it was present in six (37.5%) of sixteen animals in the antibiotic-only group (p = 0.001). Histological evaluation showed similar results (kappa = 0.92). CONCLUSIONS: Serratiopeptidase was effective for eradicating infection caused by biofilm-forming bacteria in this experimental animal model. The antibiofilm property of the enzyme may enhance antibiotic efficacy in the treatment of staphylococcal infections.

[Tendon holding capacities of the suture materials used in repairing Achilles tendon rupture]. / Asil tendonu tamirinde kullanilan dikis materyallerinin tendonu tutma kapasiteleri.

OBJECTIVES: We evaluated tendon holding capacities of suture materials that are commonly used in repair of Achilles tendon ruptures. METHODS: Achilles tendons of 60 sheep were removed by incisions 2-cm proximal to the calcaneal insertion and 1-cm distal to the musculotendinous junction. The tendons were randomly divided into six groups and sutures were placed with the Kessler technique at the distal end of the tendons using one of the following suture materials: 2 polydioxanone (PDS), 1 PDS, 2 Vicryl, 1 Vicryl, 2 Ethibond, and 1 Prolene. The distal end of the suture material was left free. Each specimen was mounted in an Instron machine, with the tendon being placed proximally and the suture material distally. The system was loaded with a displacement rate of 20 mm/min. RESULTS: Failure of all the specimens was due to pull-out of the suture material through the tendon. There were no failures due to suture breakage. The highest and the lowest tendon holding capacities were found with 2 PDS and 2 Ethibond sutures, respectively. CONCLUSION: Following Achilles tendon repair, the healing period, in particular the first three weeks, is precarious for pull-out of the suture material through the tendon. Thus, tendon holding capacity of the suture material is an important factor for the strength of the repair. Among the tested suture materials, 2 PDS was found to have the highest tendon holding capacity.

Suture holding capacity of the Achilles tendon during the healing period: an in vivo experimental study in rabbits.

BACKGROUND: Early motion and weightbearing is known to promote the healing of Achilles tendon repair. It is important to be informed about the repair strength for a secure rehabilitation. There are reports about the initial repair strength of Achilles tendons; however, they are mainly in vitro studies that represent the time zero strength of the repair. Softening of the tendon observed during the biological process of the tendon healing, which may effect the suture holding capacity and in turn the repair strength of the tendon has not been evaluated before. METHODS: In the current study, the suture holding capacity of rabbit Achilles tendon was observed at various times during the healing period. RESULTS: The suture holding capacity of the tendon at the end of the first and third weeks after surgery was found to be similar within 30% of the control tendon. However, at the end of the fourth week it was doubled reaching 65% of the control tendon. CONCLUSIONS: Intrinsic tendon insufficiency which causes a decrease in the suture holding capacity of the tendon may lead to pull-out of the suture material during the postoperative third week. This period is precarious for early motion and weightbearing since the suture holding capacity of the tendon doubled relative to the previous three weeks.

Morton neuroma: comparative results of two conservative methods.

BACKGROUND: The initial treatment of Morton neuromas consists of conservative methods that include shoe modifications and steroid injections. The purpose of this prospective study was to compare the efficacy of these two methods to determine which is more effective as the initial treatment method. METHODS: Eighty-two patients with Morton neuromas were randomly assigned to receive either footwear modification with orthoses or steroid injections as initial treatment. Outcomes were evaluated at 1 month, 6 months, and 12 months. RESULTS: Patient satisfaction was significantly better (p < 0.01) in the group treated with steroid injections than those treated with shoe modifications at all three followup intervals. At 12-month followup, 82% of those treated with steroid injections had complete or partial relief of pain compared to 63% of those treated with footwear modifications alone. CONCLUSION: Steroid injections as initial treatment and shoe modifications with steroid injections at 6 months appear to give better results in Morton neuromas than shoe modifications alone, but the difference in the two groups were not statistically significant at one year followup.

Effect of metatarsophalangeal joint position on the reliability of the tangential sesamoid view in determining sesamoid position.

BACKGROUND: Lateral displacement of the sesamoids of the first toe relative to the metatarsal head is a common finding in hallux valgus deformity. Several methods have been described for quantifying the amount of subluxation from anteroposterior radiographs but a tangential sesamoid radiograph has been determined to be the best view to evaluate sesamoid displacement. METHOD: We evaluated the sesamoid position at different angles of the first metatarsophalangeal (MTP) joint to determine the effect of first MTP joint dorsiflexion on sesamoid position when tangential sesamoid view radiographs are made. Sesamoid positions of 22 feet with hallux valgus were graded from the short axis computed tomography (CT) images obtained with the MTP joint in 0, 35, and 70 degrees of dorsiflexion. RESULTS: Approximation of the sesamoids to reduction was apparent as dorsiflexion of the first MTP joint increased. CONCLUSION: Different dorsiflexion degrees of the first MTP joint when tangential sesamoid radiographs are made modulate the position of the sesamoids and may lead to misclassification on grading.

[Foot and ankle injuries in child and adolescent athletes]. / Cocukluk ve ergenlik dönemindeki sporcularda ayak ve ayak bilegi yaralanmalari.

Foot and ankle injuries are most commonly encountered in athletes. Of these, pediatric and adolescent injuries have unique characteristics because of the distinct growth potentials and their consequences specific to this age group. In this article, foot and ankle injuries in child and adolescent athletes are reviewed in the light of the literature.

Lateral shifting of the first metatarsal head in hallux valgus surgery: effect on sesamoid reduction.

Thirty feet with hallux valgus (HV) having grade 2 and 3 sesamoid stations on AP radiographs were examined after Lindgren-Turan oblique distal metatarsal osteotomy with a minimum follow-up of 12 months. Adductor tendon release from the lateral sesamoid was not performed to determine the isolated effect of distal metatarsal osteotomy on metatarsosesamoidal reduction. Of the 30 feet, 20 (67%) had reduced and 10 (33%) unreduced sesamoids at the follow-up. Ultimately, distal metatarsal osteotomy (DMO) with lateral shifting of the first metatarsal head more than 7.2 mm was found to reduce the sesamoids in the great majority of the cases (95% CI 7.243-9.757). Sesamoid release is redundant for metatarsosesamoidal reduction if sufficient lateral shift of the first metatarsal head over the sesamoids is accomplished.

Initial pull-out strength of tendon sutures: an in vitro study in sheep Achilles tendon.

Forty-eight fresh frozen sheep Achilles tendons were used to compare the pull-out strengths of Kessler, Bunnell and locking loop techniques which are the standard configurations described for Achilles tendon repair. A simulated Achilles tendon rupture was done with a tenotomy made 2 cm proximal to the calcaneal insertion. One of the configurations was placed at the distal end of the proximal portion of the tendon specimens using No. 5 Ticron. The distal ends of the suture materials were left free and were not used to connect the proximal and distal portions of the tendon. Using a servohydraulic materials testing machine, each tendon was tested to failure in tension at a displacement rate of 20 mm/min. All the specimens failed due to pull-out of the suture material. Since the cause of failure was suture material breakage in the previous studies reporting repair strength, they were unable to represent the effect of configuration on the strength. This study is the first to represent the effect of configuration on the initial strength since there is no failure due to suture material breakage.