The interpubic cavity: A scoping review.

The interpubic cavity (cleft) is a narrow, slit-like, oval-shaped cavity which has frequently been described within the fibrocartilaginous interpubic disc. The aim of this article is to thoroughly analyze what is known about the interpubic cavity. The following three scientific databases (PubMed, Web of Science and Google Scholar) were systematically searched. Combinations of the search terms "interpubic cleft", "interpubic cavity", "symphysis pubis cleft", "symphysis pubis cavity" and "symphysis cleft sign" were used. All databases were searched from inception until August of 2022. Searching of the three databases resulted in 711 hits, of which 280 remained after checking for duplicates. In the first step, 152 studies were excluded due to irrelevant content. Thus, 128 proceeded to the second step, of which 23 were finally selected for meeting the objectives of this review. Until now the reason for the cavity forming remains unclear. The interpubic cavity is present in the anterior portion of the interpubic disc, within 2 mm from its anterior margin. There is no predilection in the craniocaudal dimension. The secondary cavity is usually called a "cleft sign". The results of our scoping review summarize information about the interpubic cavity. Its composition and morphology are still not well understood.

Calcaneal osteotomy due to insertional calcaneal tendinopathy: preoperative planning.

PURPOSE: Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet's (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (ß) of the calcaneus (CL angle = α - ß). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet's angle. METHODS: The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient-horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and ß angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed. RESULTS: The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy. CONCLUSION: Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning.

Biomechanical Study Concerning the Types of Resection in Arthrodesis of First Metatarsophalangeal Joint.

This work concerns a biomechanical study aiming to ascertain the optimal type of joint resection when performing a joint arthrodesis. A 3-dimensional digital model of the first metatarsophalangeal joint including the entire first metatarsal bone and proximal phalanx using CT scans of the forefoot was created. Using this computer model, 4 types of resections; ball-and-socket, flat-on-flat, wedge 90°, and wedge 100° were simulated. Parameters measured using this model were the force necessary to separate the 2 fused surfaces, the surface area of the resected surfaces and the shortening of the first ray. By measuring the reactive force necessary to separate the phalanx from the first metatarsal, the 90° wedge resection was found to be the most stable, with comparable results in the case of the 100° wedge resection. Wedge resections are also more favorable when comparing the shortening of the first ray. Wedge resections, though being more technically difficult to perform prove to be the most stable for metatarsophalangeal joint-1 arthrodesis using this model.

The change of first metatarsal head articular surface position after Lapidus arthrodesis.

BACKGROUND: The Lapidus procedure has been used for hallux valgus deformity correction since 1931. In some cases, the arthrodesis results in an unfavourable lateral inclination of first metatarsal head articular surface. The objective of our study was to evaluate the change of orientation of this articular surface in relation to the second metatarsal axis by comparing pre- and postoperative radiographs. The secondary target was to evaluate possible benefits of combination of Lapidus and Akin procedures in the reduction of hallux valgus deformity. METHODS: We evaluated 449 pre- and postoperative radiographs of 134 operations from 2010 to 2015. Routinely used angle measurements were performed on all X-rays. A sum of tangential angle to the second axis and distal articular set angle values was chosen as the best indicator for the deformity correction success. RESULTS: The mean value of these angles total was 5.2° ±9.3° before and 14.2° ±7.8° after the operation. In the group of patients, where the additional Akin osteotomy was used, the mean value was 5.3° ±8.4° before and 6.9° ±10.2° after the surgery. The mean difference in values between the two groups (with and without Akin procedure) was 7.3° of extra correction in favour of the group with the Akin osteotomy. CONCLUSIONS: The mean worsening of the tangential angle after Lapidus operation was 6.1° ±6.9°, which counts for significant deterioration after a surgery. The Akin osteotomy was found to be a valuable addition to the Lapidus arthrodesis, which improves the position of articular surfaces in first metatarsophalangeal joint.

Range of motion after total knee arthroplasty in hemophilic arthropathy.

BACKGROUND: Outcomes of total knee replacement in cases of hemophilic patients are worse than in patients who undergo operations due to osteoarthritis. Previous publications have reported varying rates of complications in hemophilic patients, such as infection and an unsatisfactory range of motion, which have influenced the survival of prostheses. Our retrospective study evaluated the data of hemophilic patients regarding changes in the development of the range of motion. METHODS: The data and clinical outcomes of 72 total knee replacements in 45 patients with hemophilia types A and B were reviewed retrospectively. Patients were operated between 1998 and 2013. All of the patients were systematically followed up to record the range of motion and other parameters before and after surgery. RESULTS: The mean preoperative flexion contracture was 17° ± 11° (range, 0°-40°), and it was 7° ± 12° (range, 0°-60°) postoperatively. The mean flexion of the knee was 73° ± 30° (range, 5°-135°) before the operation and 80° ± 19° (range, 30°-110°) at the last follow-up. The mean range of motion was 56° ± 34° (range, 0°-130°) before the operation and 73° ± 24° (range, 10°-110°) at the last follow-up. CONCLUSIONS: Statistical analysis suggested that the range of motion could be improved until the 9th postoperative week. The patient should be operated on until the flexion contracture reaches 22° to obtain a contracture < 15° postoperatively or until the contracture reaches 12° to obtain less than 5°. The operation generally does not change the flexion of the knee in cases of hemophilic patients, but it reduces the flexion contracture and therefore improves the range.

Medial calcar of proximal humeral fracture as landmark in restoration of humeral length in case of hemiarthroplasty.

PURPOSE: Several methods to restore the appropriate length of the humerus in the case of proximal humeral fractures treated by hemiarthroplasty have been previously published. Our study evaluates the possibility of using the medial calcar of humerus for humeral length reconstruction not based on preoperative planning. METHODS: Preparations of 320 dry humeral bones were used for the purpose of the study. Points of interest were marked on each bone: the most proximal point of the humeral head, the crest of greater tuberosity, diameters of the head, the anatomical and surgical necks. Proximal parts of bones were then scanned from two angles with a digital camera and all measurements were performed on calibrated photographs. We compared accuracy in humeral length reconstruction using insertion of the pectoralis major and the area of medial calcar where usually a fracture develops. RESULTS: The distance between the top part of the humeral head and the insertion of pectoralis major was 54.1 ± 6.0 mm. The distance between the lateral margin of the anatomical neck and the medial calcar was 51.4 ± 4.3 mm. We compared these data with diameters of the humeral head. CONCLUSIONS: The site of the fracture can be used for the reconstruction of the humeral length with greater accuracy than area of the pectoralis major insertion. We suggest that to obtain the final distance between the lateral margin of the artificial head and medial calcar of the fracture 2-3 mm should be added to the diameter of the head.

Lateral release in hallux valgus deformity: from anatomic study to surgical tip.

The important part of hallux valgus deformity operations, especially in the case of an incongruent joint, is the release of the soft tissue on the lateral side of the first metatarsophalangeal joint. The purpose of the present anatomic study was, with preparation of the lateral structures of the joint and lateral conjoined tendon, to provide a background for a surgical tip of the release of the joint for an additional metatarsal osteotomy. For the present study, we used 30 specimens (15 left and 15 right) from 19 cadavers at the Institute of Anatomy, First Faculty of Medicine, Charles Faculty (Prague, Czech Republic). Only specimens that met the criteria of hallux valgus were included in the present study. The technique was based on the incision of the lateral sesamoid ligament and partial tenotomy of the lateral conjoined tendon from the first interdigital web space. The release was done gradually with supination and abduction of the big toe to achieve the smallest size of the tenotomy. The median of the tenotomy size of the conjoined tendon was 6.5 (range 5 to 14) mm. The median size of the conjoined tendon in the frontal plane just ventral to the sesamoid bone was 10.6 (range 8 to 14) mm. The technique of the release, in which the big toe was abducted and supinated, can minimize the size of the lateral conjoined tendon release and can minimize the possibility of a postoperative deformity.

Hypermobility of the first metatarsal bone in patients with rheumatoid arthritis treated by Lapidus procedure.

BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3%) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9%). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.

Ankle block implemented through two skin punctures.

BACKGROUND: Recently, peripheral nerve blocks have increasingly been used in orthopedic surgery. The foot block is an alternative for anesthesia in cases of forefoot and midfoot operations. We propose a modification of the block technique due to potential difficulties concerning the tibial nerve. MATERIALS AND METHODS: The spatial position of the tibial nerve in the neurovascular bundle, proximal to entering the tarsal tunnel and sural nerve behind lateral malleolus was measured on 60 dissected preparations. Modification of the block technique was proposed. A tibial nerve block was administered by inserting a needle, at an area above the upper edge of the heel bone, tangential to the Achilles tendon. The needle was then withdrawn and redirected to the frontal plane and inserted through the tissue, anterior to the Achilles tendon and laterally behind the lateral malleolus to block the sural nerve. A block of the saphenous nerve superficial and deep peroneal nerves was implemented by needle insertion subcutaneously two centimeters proximal to the crest of the ankle joint. The technique was then evaluated in the clinical part of the study in 84 operative procedures. RESULTS: The tibial nerve is located 21.1 mm +/- 2.1 mm from the medial aspect of the Achilles tendon and 11.6 mm +/- 1.3 mm deep in the neurovascular bundle. The distance from the posterior margin of the lateral malleolus to the sural nerve is 18.3 mm +/- 1.9 mm. We achieved a 93% success rate in implementation of the complete foot block in 84 operations. CONCLUSION: The technique, proposed in the anatomical portion of the study and evaluated in the clinical part, had a similar success rate when compared to techniques published in the literature. Though comparable to currently used techniques, this technique provides easier positioning of a patient and a complete block of the foot can be done with two skin injection sites.

Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction.

BACKGROUND: The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture. METHODS: Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery. RESULTS: The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case. CONCLUSIONS: Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.

Lesser tuberosity is more reliable than bicipital groove when determining orientation of humeral head in primary shoulder arthroplasty.

PURPOSE: The objective of the study was to provide statistical evaluation of position of bone landmarks of proximal humerus in relation to transepicondylar line and find out which one is the most suitable for setup of the head retroversion in case of humeral head destruction. METHODS: We measured 185 dry humeral preparations (92 left, 93 right). Structures of interest on the proximal humerus were marked with pointers of custom made steel frame. Angular relationships between the humeral head axis and medial margin of the greater tuberosity, lateral margin of the lesser tuberosity, bicipital groove, and crest of the greater tuberosity were evaluated with respect to intramedullary axis of the proximal humeral shaft. RESULTS: The angle between the humeral head axis and medial margin of greater tuberosity was 11.5 +/- 9.0 degrees , the angle between the lateral margin of the lesser tuberosity and the axis was 47.5 +/- 7.4 degrees , the angle between the bicipital groove and the axis was 31.6 +/- 8.8 degrees at the level of the humeral head. The angle between the crest of the greater tuberosity and the axis was 26.6 +/- 9.6 degrees in plane of the surgical neck. CONCLUSIONS: We statistically proved that the lateral margin of lesser tuberosity is more reliable than the bicipital groove; medial margin of the greater and transepicondylar line for reconstruction of humeral head retroversion. We suggest that the lesser tuberosity should be used to determine the retroversion, especially in cases when the margin of humeral head was destructed.

Attachments of muscles as landmarks for implantation of shoulder hemiarthoplasty in fractures.

BACKGROUND: The attachments of muscles and the position of the humeral head are important for a good functional outcome of shoulder hemiarthroplasties after displaced fractures of the proximal humerus. Deviations in the attachments and changes in their spatial position with respect to the humeral head during surgical reconstruction change the biomechanics and reduce the range of motion of the should joint postoperatively. METHODS AND RESULTS: We used 198 humerus preparations and using 3-dimensional analysis measured the angular relationships between the humeral head axis and medial margin of the greater tuberosity (11.9 degrees +/- 9.1 degrees ), lateral margin of the lesser tuberosity (48.0 degrees +/- 7.8 degrees ), and the crest of the greater tuberosity (27.1 degrees +/- 9.6 degrees ). CONCLUSION: This study provides average values of the positions of the greater and lesser tuberosities with respect to the humeral head axis. We show that the greater and lesser tuberosities are more reliable than the transepicondylar line for reconstruction of humeral head retroversion. LEVEL OF EVIDENCE: Basic Science.