Surgery for symptomatic Freiberg's disease: Extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage.

The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.     

Periacetabular osteotomy. Good pain relief in symptomatic hip dysplasia, 32 patients followed for 4 years

BACKGROUND: When surgical treatment of dysplastic hip osteoarthrosis is necessary, osteotomy is preferable to fusion or THR. We evaluated periacetabular osteotomy as a method of choice. PATIENTS AND METHODS: We treated 36 symptomatic dysplastic hip joints (32 patients) with the Bernese periacetabular osteotomy (PAO) between 1994 and 2001. We used the ilio-inguinal (I-I) approach in 32 hips and a modified Smith-Petersen (S-P) approach in 4. The patients were followed for mean 4 (1.5-8) years. In 1 patient with coxa valga, a varus femoral osteotomy was performed 1 year after PAO. 2 hips, in which we used the modified S-P approach, necessitated a capsulotomy. RESULTS: The median Merle d'Aubignè score increased from 13 points preoperatively to 16 points postoperatively. This improvement in terms of pain, motion and ambulation was accompanied by spatial reorientation and correction. The lateral center edge angle of Wiberg (CE) improved from an average of 7 degrees to 28 degrees. The anterior center edge angle of Lequesne (FP) improved from an average of 18 degrees to 28 degrees. The acetabular index angle (AC) improved from an average of 22 degrees to 10 degrees. Major complications included 1 partial lesion of the sciatic nerve, 1 malunion and 1 combined nonunion of the pubic and ischiatic osteotomy. 2 patients underwent subsequent total hip replacement (THR) for progressive osteoarthrosis with pain. INTERPRETATION: We found good radiographic correction of deformities, improvement of hip function and pain relief with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of symptomatic hip dysplasia in young adults. In addition to relieving symptoms, it may prevent and postpone the development of secondary osteoarthrosis.     

Modified Chiari osteotomy for arthrosis after Perthes' disease: 14 hips followed for 2-12 years

Between 1983 and 1995, a modified Chiari pelvic osteotomy was performed for coxarthrosis after Perthes' disease in 13 patients (14 hips). The median age at operation was 33 (16-56) years. The median duration of follow-up was 6 (2-12) years.

The center-edge angle, Sharp's angle, acetabulum head index and acetabular edge angle improved substantially. The median hip score substantially improved from 76 (46-90) points to 91 (71-100) points at the most recent follow-up examination. We recommend this procedure for patients who have early arthrosis, acetabular dysplasia, pain and good range of motion.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

20 patients, who had had total hip replacements for symptomatic osteoarthrosis secondary to Paget's disease, were followed for a mean of 6 (4-8) years. Proximal hydroxyapatite-coated stems were implanted in all patients. 12 patients received hydroxyapatite-coated, 2 cemented (Muller type) and 6 cementless cups (Morsher type). The mean Harris hip score was 31 (7-40) points preoperatively and 88 (74-100) postoperatively. The radiographic evaluation revealed good stability and fixation using Engh's criteria. One stem subsided early more than 5 mm and then seemed to stabilize. Our findings support the use of hydroxyapatite total hip implants for patients with this disease and osteoarthrosis.     

Surgery for old ankle fracture: 13 cases followed for 9 (5-15) years

Between 1978 and 1988, we treated 13 cases of neglected ankle fractures by open reduction and internal fixation or osteotomy 11 (2-36) months after the accident. Having been followed for 9 (5-15) years, the results were evaluated. All the patients were improved, even though restoration of the anatomy of the joint often was difficult. Those operated on after less than 6 months had better function than those with longer delays.     

Extra-articular dorsal closing-wedge osteotomy to treat late-stage Freiberg disease using polyblend sutures: technical tips and clinical results

Purpose

The purpose of this study was to evaluate the clinical outcomes regarding the dorsal wedge osteotomy fixed using a polyblend suture and describe the usefulness of this fixation method for the treatment of Freiberg disease.

Methods

The subjects consisted of 13 feet from 13 cases suffering from Freiberg disease that underwent extra-articular dorsal closing-wedge osteotomy using a polyblend suture. The average age was 31.7 (range 13–72) years. The average follow-up period was 17 (range 14–24) months. Regarding image findings, time to bone union and metatarsal shortening was reviewed. The investigation was carried out using the range of motion (ROM), visual analog scale (VAS), and Japanese Society of the Surgery of Foot lesser toe scale (JSSF score) in the MTP joint before surgery and at the latest follow-up.

Results

Calluses under the metatarsal head were not observed in any cases. The mean metatarsal shortening was 2.33 ± 2.07 mm at follow-up. The bone union required an average of 8.4 ± 0.8 weeks. The average ROM of dorsal flexion improved from 37.2 ± 5.3° before surgery to 73.6 ± 9.9° at latest follow-up (p < 0.0001). The average ROM of plantar flexion improved from 16.0 ± 10.1° before surgery to 19.5 ± 8.6° at latest follow-up (p = 0.35). The average VAS significantly improved from 75.3 ± 8.5 before surgery to 4.9 ± 4.2 at latest follow-up (p < 0.0001). The average JSSF score significantly improved from 67.3 ± 9.4 points before surgery to 98.8 ± 3.0 points at the latest follow-up (p < 0.0001).

Conclusion

Extra-articular dorsal closing-wedge osteotomy using a polyblend suture was carried out to treat Freiberg disease. The bone union was observed in all cases with improved clinical results. Fixation using a polyblend suture was considered to be useful.     

Intercorporal lumbar spondylodesis: 312 patients followed for 2-20 years

Intercorporal spondylodesis was performed for low back pain in 120 patients with spondylolisthesis and 192 patients with disc degeneration; the latter group had all had previous surgery. The operations were carried out with retroperitoneal access, in most cases using iliac grafts, and additional posterior screw fixation in a number of patients substantially shortened the postoperative immobilization time. Complications were one death from pulmonary embolism, one case of possible genital disturbance, four inconsequent infections and three vessel injuries. In each group less than 10% had an additional operation for early signs of non-fusion.

In cases without concomitant spinal problems, the overall fusion rate was 95–98 per cent. Clinically, the spondylolisthesis group was superior with 75 per cent without low back pain and 95 per cent without radicular pain posteoperatively versus 55 per cent and 77 per cent for the disc degeneration group.     

Intercorporal lumbar spondylodesis: 312 patients followed for 2-20 years

Intercorporal spondylodesis was performed for low back pain in 120 patients with spondylolisthesis and 192 patients with disc degeneration; the latter group had all had previous surgery. The operations were carried out with retroperitoneal access, in most cases using iliac grafts, and additional posterior screw fixation in a number of patients substantially shortened the postoperative immobilization time. Complications were one death from pulmonary embolism, one case of possible genital disturbance, four inconsequent infections and three vessel injuries. In each group less than 10% had an additional operation for early signs of non-fusion.

In cases without concomitant spinal problems, the overall fusion rate was 95-98 per cent. Clinically, the spondylolisthesis group was superior with 75 per cent without low back pain and 95 per cent without radicular pain posteoperatively versus 55 per cent and 77 per cent for the disc degeneration group.     

Total hip replacement in patients with hemophilia: 13 hips in 11 patients followed for 1-16 years

During 1973-88, we performed 13 total hip replacements in 11 hemophilia patients, mean age 46 (25-65) years. During the operation, blood loss averaged 920 mL, and a mean of 120, 000 units of factor VIII/IX were used. the mean duration of follow-up was 7 (1-16) years. 5 hips became loose within 6 years, and a further one after 13 years. 4 hips were revised, 2 of them due to infection in patients who were also seropositive for HIV. At the latest follow-up, 10 patients were alive. 6 had no hip pain and 7 could walk at least 1, 000 meters at a time. Although these results are inferior to those obtained in arthrosis, total hip replacement should be considered in hemophiliac patients.     

Dynamics of hip joint remodeling after Chiari osteotomy: 10 patients with neuromuscular disease followed for 8 years

We analyzed the development of 10 hips in 10 consecutive patients with neuromuscular disease (9 with spasticity, 1 with Charcot-Marie-Tooth disease) who had undergone Chiari osteotomy for painful hip subluxation or dislocation. The patients were 11 (5-19) years old at surgery and follow-up time was 8 (6-11) years.

The Chiari osteotomy particularly improved and maintained femoral head coverage. These parameters did not show the postoperative deterioration noted in some other studies. The osteotomy did not improve femoral head lateral displacement. Throughout the postoperative period, the configuration of the proximal femur and the height of the joint cartilage were unchanged and undisturbed, indicating that osteotomy did not place excessive or uneven pressure on the femoral head.

The ambulatory status of the patients was dependent on the severity of the underlying disease, and was not improved by osteotomy. However, pain associated with subluxation or dislocation was reduced in 9 of the patients.     

Rotational acetabular osteotomy for hip dysplasia: 61 hips followed for 8-15 years

We operated on 54 patients (61 joints) with rotational acetabular osteotomy (RAO) due to dysplasia of the hip with pre- or early-stage osteoarthritis/arthrosis. The mean follow-up was 11 (8-15) years. The Merle d'Aubigné median score increased from 14 to 15. In 2 patients (2 joints), the score decreased from 15 to 13. Progression of arthrosis was seen in 6 joints on the radiographs at follow-up. Kaplan-Meier survivorship analysis predicted an 89% (95% confidence interval 80-99) prevention of worsening of arthrosis at 10 years. Postoperative joint congruency was a risk factor for progression of arthrosis.     

Opening wedge osteotomy for malunion of the distal radius with neuropathy:13 cases followed for 6 (1-11) years

13 patients with malunion of the distal radius after Colles' fractures and electroneurographically verified median nerve compression underwent an opening wedge osteotomy without a simultaneous release of the transverse carpal ligament. 12 patients had reduction of the typical night pain with normal or almost normal sensibility within the first 2 months. In 1 patient a release of the carpal ligament was necessary after 6 months. 6 years postoperatively all patients had acceptable wrist function with normal function of the median nerve in all but one.     

Surgical treatment of tuberculous spondylitis: 50 patients followed for 2-8 years

We treated 50 adult patients with tuberculous spondylitis surgically and followed them for a mean of 5 (2-8) years. All had persistent back pain, 32 had neurologic deficit, and 13 had gibbus deformity. Anterior debridement and fusion were the main operative procedures. Additional posterior stabilization was performed in 14 patients who had loss of a vertebral body or for correction of severe kyphosis. 30 of the 32 patients with neurological impairment had an improvement of 1-3 Frankel's grades after operation. All patients had some relief of pain. Solid bony union of the fusion was found in 46 patients and 4 had nonunion after anterior operation only. The average correction of the kyphotic angle was 10 degrees.     

Intercorporal lumbar spondylodesis. 312 patients followed for 2-20 years

Intercorporal spondylodesis was performed for low back pain in 120 patients with spondylolisthesis and 192 patients with disc degeneration; the latter group had all had previous surgery. The operations were carried out with retroperitoneal access, in most cases using iliac grafts, and additional posterior screw fixation in a number of patients substantially shortened the postoperative immobilization time. Complications were one death from pulmonary embolism, one case of possible genital disturbance, four inconsequent infections and three vessel injuries. In each group less than 10% had an additional operation for early signs of non-fusion. In cases without concomitant spinal problems, the overall fusion rate was 95-98 per cent. Clinically, the spondylolisthesis group was superior with 75 per cent without low back pain and 95 per cent without radicular pain postoperatively versus 55 per cent and 77 per cent for the disc degeneration group.