The single medial approach to triple arthrodesis: a cadaver study

BACKGROUND: Triple arthrodesis is traditionally done through a two-incision approach. In certain high-risk patients, it may be desirable to do the procedure through a single medial incision to avoid lateral wound healing problems. METHOD: A cadaver study was undertaken to determine the percentage of surface area of each hindfoot joint that could be prepared through a single medial incision. Five cadaver legs were assigned to the single-incision group, and one cadaver leg was used as the "standard" two-incision specimen. RESULTS: Through the single-incision approach, 91% of the talonavicular joint, 91% of the subtalar joint, and 90% of the calcaneocuboid joint could be prepared. These results were comparable to the two-incision cadaver specimen results. CONCLUSIONS: A single-incision medial approach for triple arthrodesis is a safe and effective technique in the management of hindfoot deformity and arthritis in certain high-risk patients.     

Inlay triple arthrodesis: A technique for the undeformed or valgus foot

Surgical Principles Combined intra- and extraarticular arthrodesis of the talocalcaneal, talonavicular and calcaneocuboid joints with autogenous corticocancellous bone grafting and minimal bone resection.     

Equivalent results of medial and lateral parapatellar approach for total knee arthroplasty in mild valgus deformities

Purpose

When performing total knee arthroplasty (TKA) in valgus knee deformities, a medial or lateral parapatellar approach can be performed, but the lateral approach is often considered technically more difficult. The purpose of this study was to compare intra-operative, early clinical and radiological outcomes of medial and lateral parapatellar approaches for TKA in the setting of moderate knee valgus (<10°).

Methods

We prospectively analysed 424 knees with pre-operative valgus deformity between 3° and 10° that underwent TKA over an 18-year period; 109 were treated with a medial approach and 315 with a lateral approach. Intra- and post-operative outcomes and complication rates after a minimum follow-up of one year were compared.

Results

Tourniquet (p?=?0.25) and surgical (p?=?0.62) time were similar between groups. The popliteus tendon was released more frequently in the medial-approach group (p?=?0.04), while the iliotibial band was released more frequently in the lateral-approach group (p?<?0.001). A tibial tuberosity osteotomy was performed more frequently in the lateral- than medial-approach group (p?=?0.003). No significant differences in limb alignment (p?=?0.78), or Knee Society Score (KSS) knee (p?=?0.32) and function (p?=?0.47) results were noted based on surgical approach, and complication rates were similar between groups (p?=?0.53).

Conclusions

Lateral parapatellar approach is a safe and effective surgical technique for performing TKA in moderately valgus knees. These equivalent early results are encouraging for systematic use of the lateral approach in moderately valgus knees.

     

Management of the rigid arthritic flatfoot in adults: triple arthrodesis

The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.     

Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities

PURPOSE: The purpose of this investigation was to evaluate the outcome of tibiocalcaneal arthrodesis using an adolescent condylar blade plate for severe ankle and hindfoot deformities. MATERIALS AND METHODS: We retrospectively reviewed the records of patients managed at our institutions between 1989 and 1996 whose tibiocalcaneal arthrodeses were performed with adolescent condylar blade plates and allograft bone. In these 30 patients (14 men, 16 women; average age, 53 years), the etiologies of the nonbraceable deformity included: diabetic neuroarthropathy with talar fragmentation and resorption (26), inflammatory arthritis (3), and posttraumatic avascular necrosis of the talus with collapse (1). Due to the severity of the deformity in 28 of these patients, the alternative treatment would have been amputation. Thirteen patients had undergone previous surgeries, eight had documented osteomyelitis, and 13 had ulcers ranging from 2 to 27 mm. At surgery, the remnants of the talus were removed. Morcellized bone graft mixed with tobramycin/vancomycin powder was inserted into the arthrodesis site and then fixed with a rigid plate. Intravenous antibiotics, followed by oral antibiotics, were given until wound healing and suture removal. Follow-up averaged 48 months (19 to 112 months). RESULTS: Tibiocalcaneal fusion was achieved in 28/30 patients at an average of 16 weeks (12 to 18 weeks). Complications occurred in seven patients: two developed stress fractures of the tibia at the proximal end of the blade plate, three had superficial cellulitis that resolved with antibiotic therapy, and two had nonunions. CONCLUSION: Tibiocalcaneal arthrodesis using an adolescent condylar blade plate and allograft bone can be a successful procedure in the patient with severe neuropathic ankle deformity and can achieve a stable plantigrade foot for limited community ambulation with relatively few complications.     

Management of the rigid arthritic flatfoot in the adults: alternatives to triple arthrodesis

Every alternative to triple arthrodesis in the rigid acquired flatfoot deformity is predicated on limiting the patient exposure to the complication associated with triple arthrodesis. When possible, avoiding arthrodesis of either the talonavicular and calcaneocuboid joints, with their higher nonunion rates, seems a cogent option. Successful treatment is dependent on thoughtful patient evaluation and examination, meticulous joint preparation, careful positioning with rigid fixation, and judicious use of adjunctive procedures to achieve the goal of a plantigrade foot that functions well and is minimally painful.     

Arthrodesis of the hindfoot for valgus deformity. An entirely medial approach

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach. In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation. We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8 degrees (45 degrees to 66 degrees) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6 degrees (7 degrees to 23 degrees). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9). We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.     

Comparison of arthroscopic to open tibiotalocalcaneal arthrodesis in high-risk patients

BackgroundOpen tibiotalocalcaneal arthrodesis (TTCA) is associated to high complication rates, which led to the development of arthroscopic techniques. Aim was to compare complication rates of open to arthroscopic TTCA in high-risk patients.MethodsSingle-center, retrospective case-control study. Patients were selected from the authors’ TTCA database. Eligible were high-risk patients receiving arthroscopic-, or open TTCA retrospectively suitable for arthroscopic TTCA. Primary outcome were major complications.ResultsEight open and 15 arthroscopic TTCAs were included. Three open and 4 arthroscopic TTCAs presented preoperative plantar ulceration. Fusion rates were similar (75% vs. 67%; p = 0.679). Major complications occurred in 63% of open (80% surgical-site-infections (SSI)) and 33% of arthroscopic (100% non-unions) TTCA. Preoperative plantar ulceration did not affect major SSI in open TTCA (67% vs. 60%) but resulted in a significant increase of non-union rates for arthroscopic TTCA (75% vs. 18%; p = 0.039). In patients without plantar ulceration the union-rate was 80% for both, open and arthroscopic TTCA.ConclusionArthroscopic TTCA drastically reduced major SSI. Patients without preexisting ulceration had excellent union-rates for open and arthroscopic TTCA.     

Indications and technique of partial arthrodesis of the carpus]

Partial arthrodesis of the carpus has again become a topical method. The technique has been improved and the range of indications has been extended. Fusion of certain areas has indeed been propagated as first-line therapy, for example in lunatum necrosis or as an important additional operation in substitution plastic surgery. Partial arthrodesis of the carpus is intended to eliminate mechanisms which has become pathological whilst preserving the best possible mobility. Partial arthrodesis alters the movement pattern of the individual ossae carpi. Moreover, the pressure in the adjacent joints also rises. The risk of a new pathological process is considerable. Recent publications report on a rapid development of impingement and symptoms. The most frequent partial arthrodeses are discussed. The indications and the direct consequences are critically analysed and explained with reference to examples. Technical details and potential dangers are described. An STT-arthrodesis is indicated for osteoarthritis of these bones. The radio-lunar arthrodesis is recommended for ulnar drifting of the carpus in cases of rheumatoid arthritis. Reconstruction of the central axis with arthrodesis of the capitate-lunate is indicated for pseudarthrosis of the scaphoid with carpal collapse. Other combinations are possible, they cause however greater functional deficits. We recommend a critical analysis of the function of the entire carpus before the operation. Caution is called for when an incipient arthrosis is present in the adjacent joint. Partial arthrodesis of the carpus is rather a temporary solution, since it enables time to be gained. Total arthrodesis is the ultimate resort.     

The approach to dentofacial skeletal deformities using a multisegmentation technique

This article describes the authors' approach to correcting dentofacial skeletal deformities requiring multisegmentation of the maxilla. Achieving optimal results requires a close collaboration within the orthodontic-surgical team. The importance of attention to detail in the course of the surgical procedure cannot be overemphasized, because complications of avascular necrosis cannot be corrected easily. The multisegmental maxilla is a valuable technique and adds to the versatility of the LeFort I in the treatment of open bite and transverse discrepancies in dentoalveolar deformities.     

The spine in diastrophic dysplasia. The surgical arthrodesis of thoracic and lumbar deformities in 21 patients

STUDY DESIGN: Retrospective chart and radiographic film review. OBJECTIVES: To discern the deformity problems in diastrophic dysplasia and to report our results in surgical treatment. SUMMARY OF BACKGROUND DATA: Due to the rarity of the problem, the literature is very scanty as to the indications for surgery or the best technique. METHODS: Analysis of radiographic film for scoliosis, kyphosis, lordosis, and decompensation before surgery, after surgery, and at follow-up. Analysis of charts for complications and problems. RESULTS: The most common deformity pattern was a double thoracic kyphosis (79 degrees/97 degrees) with a true kyphosis at the junction of the two scolioses (101 degrees). Combined anterior-posterior arthrodesis gave the best results. CONCLUSIONS: Very severe deformity can occur in children with diastrophic dysplasia, even at a young age. Prompt anterior-posterior arthrodesis can prevent catastrophic deformity.     

Screw and tension band fixation for triple arthrodesis: A technique report

Stabilisation of the talonavicular joint in arthrodesis can be difficult, particularly in osteopoenic bone, and this may lead to non-union. A tension band technique for stabilisation is described. This has been used as part of the fixation in 44 triple arthrodeses. One hundred percent union rate has been achieved with few complications.     

Vertebral column resection and arthrodesis for complex spinal deformities.

Sixteen patients aged 13 to 55 with severe rigid spine deformities were treated by two-stage anterior and posterior vertebral column resection, fusion, and segmental spinal instrumentation. The purpose of the vertebral column resection was to eliminate pain, prevent progressive deformity, and obtain the maximum correction necessary to achieve spinal balance in the coronal and sagittal plane. The final scoliosis correction averaged 43%. Physiologic sagittal alignment was achieved in all patients. Complications occurred in seven patients (43%). It is our conclusion, based on this series, that the concept of decancellation, radical vertebral column resection, spinal shortening, and segmental instrumentation posteriorly can achieve a balanced correction and significant pain relief for the select patient who presents with severe rigid spine deformity not adequately treatable by more established techniques.     

Indications and technique for the operative treatment of hypoplastic deformities of the odontoid process

On the basis of four typical cases of congenital hypoplastic deformities of the odontoid process the clinical significance, symptoms, diagnosis and the indications for operative treatment of the malformations are described. It is further shown that these malformations lead to clinical manifestations only when associated with a primarily existing, or a later acquired inadequacy of the ligaments with movement-induced changes in the position of the atlas. The operative treatment recommended involves a special technique for a bilateral dorsal fixation with tibial grafts. By this operative technique a substantial or even completely stable fixation of the atlas can be achieved, in the acute phase by the stability of the tibial grafts and in the long term by the bony fusion which occurs.     

The SCARF osteotomy for the correction of hallux valgus deformities

The authors report their experience with a modified SCARF osteotomy with three years follow-up. Correction of moderate to severe hallux valgus deformities was achieved using a Z step osteotomy cut to realign the first metatarsal bone. A retrospective analysis was undertaken in 89 consecutive patients (111 feet). Results were analyzed by clinical examination, a questionnaire including the AOFAS forefoot score, and plain roentgenograms. Hallux valgus and intermetatarsal angle improved at mean 19.1 degrees and 6.6 degrees, respectively. Mean forefoot score improved from 50.1 to 91 points out of 100 possible points. Satisfactory healing time was expressed by an average return back to work of 5.8 weeks and back to sport of 8.3 weeks. Persistence or recurrence of hallux valgus was seen in seven patients (6%). The complication rate was 5.4% including superficial wound infection, traumatic dislocation of the distal fragment, and hallux limitus. The presented technique provides predictable correction of moderate to severe hallux valgus deformities.