Calcaneal osteotomy for retrocalcaneal exostosis

In cases in which radiographic and clinical criteria warrant surgical management of Haglund's deformity, calcaneal osteotomy should be considered. Although postoperative recuperation is extended with this procedure as compared with simple exostectomy, the long-term results have proved more successful. Because of the relative technical difficulty in performing the procedure, perioperative planning and anatomic considerations are essential.     

Calcaneal osteotomy for the treatment of plantar fasciitis

Background  

Plantar fascia release is the main procedure for plantar fasciitis which does not respond to conservative treatment. However, this procedure is sometimes accompanied by lateral column pain due to loss of the longitudinal arch height after surgery. To avoid this complication, we performed calcaneal osteotomy. The aim of this study was to clarify the efficacy of this procedure.     

Transverse femoral osteotomy for revision surgery — an alternative to the transfemoral approach

Objective  Exchange of a loosened femoral component in the presence of large proximal bone defects which require a distal anchorage of the revision stem. Indications  Removal of remaining cement fragments from distal femur. Extraction of broken part(s) of femoral component. Marked anterior bowing of femoral shaft before insertion of revision stem. Contraindications  Severe osteopenia of the femoral shaft. Infection. Poor general health. Surgical Technique  Removal of femoral component. Transverse femoral osteotomy at least 12 cm distal to the tip of the greater trochanter. Removal of remaining cement from distal and proximal fragments. Conical reaming of distal femur. If necessary, prophylactic wire cerclage of distal fragment. Inserttion of revision stem through the proximal fragment and impaction into the distal fragment. Packing of the defect of the proximal fragment with corticocancellous bone grafts to increase stability. Results  Assessment of twelve patients (eight women, four men, average age at surgery 70 years and 1 month). Average length of follow-up 2 years and 11 months (1 year, 9 months to 5 years, 10 months). Average Harris hip score 80.2 points. Merle d’Aubigné score: four excellent, one good, two satisfactory, four acceptable, and one poor result. A sufficient bony bridging of the osteotomy gap was seen radiologically in all patients.     

Neck-shaft angle remodelling after derotation varus osteotomy for severe Perthes disease

Sixteen patients with a severe form of Perthes disease who underwent containment derotation varus osteotomy (DVO) of the proximal femur were studied retrospectively for the neck-shaft angle (NSA) remodelling. Analysis of results after a mean follow-up of 7 years (minimum of 5 years and maximum of 8.7 years) showed mean preoperative, immediate postoperative and the latest follow-up neck-shaft angles (NSA) as 135 degrees, 110 degrees (none had varus less than 90 degrees) and 125 degrees, respectively. A statistically significant relationship between NSA remodelling and the immediate post-op NSA (P = 0.0035) was established. Patients with smaller postoperative NSA showed better remodelling compared with those who had higher degrees of NSA immediately after the surgery. No significant relationship was found between the degree of NSA remodelling and the patient's age at diagnosis, age at surgery, severity of Perthes or the Stulberg grading at maturity. The authors conclude that up to 90 degrees or more varization after DVO for Perthes disease can remodel with time, and the remodelling process is independent of the patient's age at diagnosis, age at surgery, or severity of Perthes or Stulberg grading at maturity.     

Role of talocalcaneal osteotomy in clubfoot surgery: results in 31 surgically treated feet

The most important deformities in clubfeet can be demonstrated by simultaneous arthrography of the talonavicular and talocrural joints. In patients with a severe talar deformity, wedge osteotomy through the talar neck and calcaneus has been performed as a prerequisite for correction. Our series consisted of 20 patients with 31 idiopathic clubfeet with pronounced talar deformity. The mean observation time after osteotomy was 11 years 3 months. The principles and aims are described, as are the indications for talocalcaneal osteotomy. Results were good in 19 feet (60%), fair in six (20%), and poor in six (20%).     

Modified technique for varus derotation osteotomy of the proximal femur in children

Background: The results of a study in which the Richards’ intermediate hip screw and the AO (Association for the Study of­­Internal Fixation (ASIF)) 908 fixed‐angle blade plate were compared for use in proximal femoral osteotomy in children have previously been reported. In that study loss of position at the osteotomy site was reported as a specific complication associated with the use of the Richards’ intermediate hip screw. Methods: The authors devised a simple modification of surgical technique using the Richards’ intermediate hip screw to enhance the stability of the fixation. In the present article the results of a prospective study of that modified technique are reported and compared with the results of the previous study. Results: During a 2‐year period 24 proximal femoral osteotomies were performed on 12 children with cerebral palsy, using the modified technique by two surgeons. Only two of the 12 patients (16%) required postoperative immobilization in a hip spica cast. This represents a significant reduction in the level of spica casting when compared with the previous cohort study (61%). Conclusion: A simple modification of surgical technique improves the stability of fixation in proximal femoral osteotomy in children who have cerebral palsy. This resulted in a decreased need for supplementary hip spica casting and may reduce morbidity.     

Calcaneal lengthening osteotomy in spastic planovalgus feet

Purpose of StudyPlanovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.Methods17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.ResultsImprovement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.ConclusionCalcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.     

External fixation for femoral derotation osteotomy in developmental dysplasia of the hip

We present a technique for the external fixation of femoral derotation osteotomy performed as part of the management of patients who present with developmental dysplasia of the hip. The technique was used following open (25 hips) or closed (31 hips) reduction and clinical and radiologic review was undertaken between 5 and 18 years (mean 11 years) after the procedure. Eighty-four percent of the patients (43 patients, 47 hips) were found to have a Severin clinical grading of 1 or 2 and over 70% were grade 1 or 2 radiologically. Nine hips/patients had required further surgery following the reduction (open or closed) and osteotomy. The complications of the procedure are described; whilst some of these are clearly associated with the osteotomy it is probable that others, such as avascular necrosis, are attributable to the method of reduction. The overall results are thought to stand up well to comparison with other series, suggesting that the technique has no major disadvantage, apart from being unable to control the pins and pin holes and to detect discharge and infection underneath the spica, which did not seem to be a problem in our study. It is suggested that the main advantages are: (1) a lower risk of damage to the trochanteric growth cartilage in comparison with other fixation techniques, because soft tissue dissection is less extensive and the implant is already removed after 6 weeks; (2) a greater accuracy with regard to the derotation angle; and (3) the avoidance of a further open procedure to remove the implant, which can be difficult with plates if the removal is postponed for too long.     

Intestinal derotation in emergency surgery

Intestinal derotation (ID) is a rarely used surgical technique which allows elegant and effective surgical access to the superior mesenteric axis and third and fourth portion of the duodenum. ID proves an extremely useful technique especially in the emergency setting when access to the “surgical soul” is needed. To master this technique the surgeon has to become familiar with the anatomical landmarks of that area along with the embryological background.     

保留距下关节的跟骨截骨矫形术治疗跟骨骨折畸形愈合

目的以保留距下关节的跟骨截骨矫形术治疗跟骨骨折畸形愈合,并探讨其适应证及优缺点。方法1998年11月至2003年5月,对伤后1～9个月,共24例(26足)跟骨骨折畸形愈合采用保留距下关节的跟骨截骨矫形术进行治疗。患者平均年龄32.6岁(28～42岁)。患者术前均摄跟骨侧位、轴位及足斜位X线片,并行CT三维重建检查。骨折按Sanders分型,Ⅱ型13足(Ⅱb9足,Ⅱc4足),Ⅲ型13足(Ⅲac8足,Ⅲab5足)。选择跟骨外侧改良“L”形切口,用骨刀切除外膨的跟骨外侧壁,然后将后关节面骨折块向上、向后撬起复位后关节面。跟骨内骨缺损处采用自体骨植骨,其中髂骨植骨19足,劈下的跟骨外侧壁植骨7足。最后以钢板螺钉固定。结果21足术后获得9～22个月(平均14.5个月)随访。所有患者术后均未发生切口感染、螺钉断裂及跟骨内翻等并发症。截骨植骨处愈合时间平均为11.2周(10.5～13.3周)。按Maryland足部评分标准评价术后功能,优8足,良10足,可3足,优良率为86%。术后X线检查见Bhler角、Gissane角、距骨倾斜角、跟骨宽度及丘部高度的恢复接近正常。结论保留距下关节的跟骨截骨矫形术是治疗跟骨骨折畸形愈合的有效方法之一,具有跟骨畸形矫正明显、后足外形及功能恢复满意等优点。     

Valgus deformity following derotation osteotomy to correct medial femoral torsion

The clinical records and radiographic files of 79 patients who underwent bilateral distal femoral derotation osteotomies for severe persistent medial femoral torsion at the Alfred I. duPont Institute from 1967 to 1983 were reviewed. We excluded patients with neuromuscular disorders and those with less than 2 years of postoperative follow-up, including satisfactory radiographs at our institution. Fourteen patients were included in the study. Following the osteotomy, two of these patients developed progressive valgus deformity that was the result of medial femoral overgrowth. Both patients required a second surgical procedure to correct this deformity. To our knowledge, this progressive angular deformity has not been reported previously.     

Regional fasciocutaneous flap closure for clubfoot surgery

Skin closure after a comprehensive posteromediallateral release of clubfeet through a Cincinnati incision may be difficult. This is especially true for cases of severe deformity either primary or recurrent. To deal with this, certain techniques have been developed. These consist of casting the foot in an undercorrected position with subsequent serial cast changes, leaving the incision completely or partially open for closure by secondary intention, using tissue expanders, and using different flap techniques. Five patients with nine clubfoot deformities who were treated with a comprehensive posteromedial-lateral release through a Cincinnati incision and underwent fasciocutaneous flap closure since June 1998 were included in this study. These flaps allowed correction and complete wound closure at the end of surgery without any skin tension. These flaps were constructed either in a rotational or V-Y advancement manner. None of the patients had any major complications. In summary, this new fasciocutaneous flap is a simple and reliable method in cases with primary skin-closure difficulties. It does not require special equipment or a plastic surgeon.     

Calcaneal osteotomy and tendon sling for the management of calcaneus deformity

A one-stage operation for severe post-poliomyelitic calcaneus deformity was done in seventy-seven feet of seventy-seven patients. The operation consisted of osteotomizing the calcaneus to increase the lever arm and to reshape the hind part of the foot and using a posterior sling formed from the peroneus brevis and tibialis posterior to provide plantar-flexion power. We were able to evaluate sixty-six patients more than three years after the operation. Most of the patients had improvement in the appearance and function of the foot as a result of the operation.     

Calcaneal osteotomy for the treatment of posterior tibial tendon dysfunction.

The surgical treatment of PTTD has been well-discussed in the literature. The calcaneal displacement osteotomy is a powerful, yet relatively easy, procedure that accomplishes a significant amount of frontal plane correction in the surgical treatment of PTTD. It can be performed as a straight medialization osteotomy for moderate hindfoot valgus, and must be performed with a resectional wedge in the treatment of large valgus angles. To achieve optimal correction, it must be coupled with procedures that address the triplanar nature of the deformity. When used in combination with other reconstructive procedures, it provides a valuable alternative to other more joint-destructive procedures.     

Predictive value of intraoperative clubfoot radiographs on revision rates

The predictive value of intraoperative radiographic assessment and its correlation with short term revision rates is presented for surgical correction of resistant clubfoot. Seventy-three children (115 feet) who underwent a primary procedure at one institution for idiopathic clubfoot between January 1991 and December 1994 were reviewed. A strategy using sequential release guided by intraoperative radiographs was employed in all cases. The intraoperative radiographic findings correlated with the need for early revision surgery, with residual radiographic evidence of cavus deformity associated with the greatest risk for revision. The sequential release strategy resulted in fewer overcorrections compared with historical controls of more complete subtalar release.     

Calcaneal "L" osteotomy: a retrospective study

In this retrospective study of 36 patients and 58 feet, the "L" shaped osteotomy of the calcaneus body was investigated. The procedure, designed to add intrinsic stability to the shape of the osteotomy, was performed to correct triplane deformities of the heel in a variety of pathologic foot types. A retrospective analysis of clinical and radiographic data suggests that this procedure is a valuable alternative for surgical treatment of deformities of the calcaneus. Advantages appear to be predictability, stability, and versatility with respect to triplane reduction of deformities. A reliable method of evaluating calcaneal position both perioperatively and intraoperatively is also presented.