Custom-made hinged total knee arthroplasties in the context of extra-articular deformity: a case series.

PURPOSE: Treatment of secondary knee osteoarthritis with a significant extra-articular deformity can be challenging. In such cases, an osteotomy or a custom-made hinged knee arthroplasy (CMH) are treatment options. However, there are limited data on the outcomes of using CMHs. Thus, the aim of this retrospective study was to assess the clinical results and subjective outcomes of CMHs. METHODS: We reviewed 9 CMHs (Endo-Model, LINK) in 7 patients with a minimum of 2-year follow-up. Upon the last follow-up, we evaluated MA, stability and range of movement (ROM). Oxford Knee Score (OKS) was used to evaluate patient-reported outcomes. RESULTS: The average age upon surgery was 61 years (48-76 years), and the follow-up period was 66 months. There were no early complications. Two CMHs were revised, one due to aseptic loosening and one due to late-onset haematogenic infection. Pre-operatively, MA varied from 18° (average 11°) valgus-deformity to 30° (average 17°) varus-deformity. Post-operatively, 7/9 (78%) of patients achieved better MA. Upon follow-up, the average OKS was 41/48, and ROM was 113°. CONCLUSIONS: Patients treated with CMHs achieved good clinical and patient-reported outcomes. There were no early reoperations, and revision rate was relatively low. Overall, CMH could be considered for low-demand patients with increased operative risks.

Lateral approach for fixation of the fractures of the distal tibia. Outcome of 20 patients. Technical note.

INTRODUCTION: The treatment of fractures of the distal third of the tibia remains still controversial. It is often difficult to get and retain good reduction by non-operative or nailing methods. Open reduction and plate fixation offers good reduction and retention of the achieved position. However, increased soft tissue damage and high complication rate has led to search less invasive surgical methods such as minimal invasive plating technique. MATERIAL AND METHODS: Lateral approach for the distal tibia allows to reduce and to plate both the fibula and the tibia using only one skin incision. We have used lateral approach for 20 consecutive tibia fracture patients and report clinical and radiological results after an average follow-up of 31 months. RESULTS: All fractures united, but two malunions were developed after good primary reduction. Seventeen patients achieved excellent or good subjective result while one had moderate and two poor results. Four superficial wound infections were noticed and they were treated conservatively. CONCLUSION: We conclude that lateral approach for the distal tibia is a demanding, but useful surgical method for treatment of the distal tibia fractures especially in cases where no medial comminution of the tibia is present and when the fibula has to be fixed, too.

Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. A retrospective study.

A total of 167 feet in 125 patients were treated with a proximal osteotomy of the first metatarsal for hallux valgus. In addition, in 115 feet a resection of the base of the proximal phalanx was conducted, and in 25 feet the head of some lesser metatarsal bone was resected. Eight years (range 5-10 years) postoperatively the patients were sent a questionnaire concerning the present state of their feet. In all, 105 patients (142 feet) replied, and 63% stated that they felt no pain in their feet at all. Indeed, 86% of the patients indicated that, everything considered, the operation was worthwhile. The most common complaint was the difficulty of finding shoes to fit; 22.5% of the patients stated that they had a hard time with this. The average preoperative metatarsophalangeal angle was 38 degrees, reduced by 22 degrees postoperatively. The average preoperative first intermetatarsal angle was 15 degrees, reduced by 5 degrees after the operation. In the statistical analysis, no correlation between the preoperative body mass index, the hallux angle, the first intermetatarsal angle, the reduction achieved in the above mentioned angles by the operation, and patient satisfaction was found.

Mandibular osteotomy fixed with biodegradable plates and screws: an animal study.

The objective of the study was to evaluate the use of a totally biodegradable fixation device in the fixation of mandibular osteotomy in sheep. Mandibular unilateral body osteotomies were fixed with biodegradable self-reinforced poly-L-lactide (SR-PLLA) multi-layer plates and screws in nine sheep. The unoperated sides acted as control. The follow-up times were 6, 12 and 24 weeks, after which radiological, mechanical and histological studies were carried out. An analysis of the implanted material was also carried out. The results showed that the SR-PLLA plates and screws were strong enough to fix the osteotomy and that the osteotomies healed mainly with callus formation. Therefore we conclude that SR-PLLA multi-layer plates and screws can be used together successfully in the fixation of mandibular osteotomies without maxillomandibular fixation. However, before they can be used in humans, the size of the plate and screws should be decreased.

Intramedullary nailing of the cortical bone osteotomies in rabbits with self-reinforced poly-L-lactide rods manufactured by the fibrillation method.

Right femoral, cortical bone osteotomies of 42 rabbits were fixed with fibrillated, self-reinforced (SR) poly-L-lactide (PLLA) rods, 4.5 mm in diameter. Follow-up times were from 3 to 48 wk. None of the rods broke during this period. There was one non-union at three weeks and one non-union at 12 weeks. Radiographic, histologic, microradiographic and oxytetracyclic fluorescence studies showed normal healing. Shear load carrying capacity of the osteotomy plane was measured from 30 bone samples; the shear force at breaking increased during the follow-up time to 450 N, while the mean shear force of intact, left-side control femurs was 440 N. Before shear tests of the bones, the SR-PLLA rods were taken away from the medullary cavities of the femurs. The rods were also tested mechanically. About 25% of the initial 136 MPa shear-strength of the rods was left after 24 wk. The results show that fibrillated SR-PLLA rods are strong enough to be used in intramedullary nailing of femoral cortical bone osteotomies in rabbits.

Polylactide screws in the fixation of olecranon osteotomies. A mechanical study in sheep.

We studied absorbable self-reinforced poly-L-lactide screws in the fixation of osteotomies in sheep. A left olecranon osteotomy in 10 sheep was fixed with polylactide screws and in an additional 10 sheep with metallic AO cortical screws. Follow-up times were 6 and 12 weeks. 8 polylactide fixations healed and 2 failed. All metal fixations united; one of them had a fracture of the proximal fragment resulting in malposition. After killing the sheep the olecranons were radiographed and the shear strengths of the osteotomies were compared with those of the non-operated contralateral bones. After 6 weeks the mean comparative strength was 74 percent in the polylactide group and 83 percent in the metallic control group. After 12 weeks the corresponding values were 112 and 47 percent (P less than 0.05). Our study demonstrated that the mechanical weakening of fixed bone can be avoided by using absorbable polylactide screws instead of metallic screws. However, polylactide screws are not recommended for use without external support in places of high mechanical strain.

Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties.

The records of 172 patients with repair of incisional hernia in 1976-1985 were reviewed. Follow-up data were collected with a questionnaire and the 40% of patients with symptoms were clinically re-examined. The follow-up time was 3 months to 12 years, mean 4.5 years. The median time between primary operation and first symptoms of incisional hernia was 7 months. Sex, age, smoking, chronic lung disease, obesity, fascial diastasis, site of hernia, surgeon's experience, closure method and suture material were among the factors evaluated as possibly causal. At the time of follow-up 34% of the patients had recurrent hernia. A multifactorial logistic regression analysis revealed obesity as the only factor clearly impairing the result of incisional hernioplasty--good in 87% of the patients with normal weight and in 61% of the overweight. Repeat hernioplasty was performed in 35 cases, but succeeded in only 17. In obese patients repair of an incisional hernia that does not cause serious symptoms is not indicated. More careful selection of patients would improve the results of incisional hernia repair.