Tibial Sesamoid Position Influence on Functional Outcome and Satisfaction After Hallux Valgus Surgery.

BACKGROUND: During hallux valgus surgery, the abnormal position of the first metatarsal bone relative to the sesamoids is addressed. Our study aimed to investigate the influence of postoperative tibial sesamoid position (TSP) on functional outcome and patient satisfaction after hallux valgus surgery. METHODS: Between February 2007 and November 2011, 250 patients who underwent hallux valgus surgery at our tertiary hospital were followed for 2 years after surgery. They were categorized into 2 groups based on Hardy and Clapham's TSP classification, recorded on postoperative weight-bearing anteroposterior (AP) radiographs: (1) normal (grades I-IV) and (2) outliers (grades V-VII). RESULTS: The mode TSP improved from grade VII preoperatively to grade IV postoperatively (P < .001). The visual analog scale for pain was 1 (95% CI 0, 1) point better in the normal group compared to the outlier group at 2 years after surgery (P = .050), whereas the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale was 6 (95% CI 2, 11) points higher in the normal group (P = .009). Patients in the outlier group were also more likely to be dissatisfied with the surgery performed when compared to the normal group (OR 3.881, 95% CI 1.689, 8.920, P = .001). CONCLUSION: We recommend correcting the TSP to grade of IV or less to improve functional outcome and satisfaction after hallux valgus surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Bisphosphonate-associated peri-implant fractures: a new clinical entity? A series of 10 patients with 11 fractures.

BACKGROUND AND PURPOSE: The current definition of atypical femoral fractures (AFFs) associated with bisphosphonate use includes only de novo fractures. However, in recent years reports of bisphosphonate-associated periprosthetic fractures involving stemmed arthroplasty implants have emerged. In a case series of peri-implant fractures in femurs with plate/screw constructs, we aimed to assess similarities with classical AFFs and how their location may have implications for the pathogenesis and management of AFFs. PATIENTS AND METHODS: We retrospectively identified 10 patients with 11 peri-implant fractures. RESULTS: The patients were ambulant women, mean age 80 (70-92) years. Mean duration of bisphosphonate use was 5 (1-10) years. The peri-implant fractures were sustained an average of 4 years (6 months to 9 years) from the time of index surgery. They were all associated with low-energy mechanisms. 8 fractures occurred near the tip of a plate, while 3 traversed the penultimate screwhole of a plate. The peri-implant fractures showed clinical and radiological features of atypicality such as lateral cortical thickening, simple fracture pattern, and lack of comminution. The patients underwent revision surgery, with bone grafting used in all but 1 case. Radiological union was evident after 2-4 months. INTERPRETATION: Atypical peri-implant fractures of the femur associated with bisphosphonate use may be a new entity. Stress lesions and atypical fractures may tend to develop over stress risers along the operated femur. This finding has implications for the pathogenesis and clinical management of AFFs.