Function after correction of a clawed great toe by a modified Robert Jones transfer

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.     

Prevention: can we stop problems before they arise?

It is estimated that 50% of diabetic ulcerations and amputations can be prevented by identifying the at-risk foot and implementing preventative strategies. Patients with diabetes mellitus (DM) should be screened and placed in the appropriate risk category. Risk factors for the development of ulcer in several prospective studies include neuropathy, deformity, limited joint mobility, vascular disease, and history of previous ulceration or amputation. Early identification of the at-risk foot and placing the patient in the appropriate risk category is essential to prevention. Once the at-risk foot is identified, abnormal foot pressures should be reduced or eliminated using several treatment options. Repetitive, moderate mechanical stress (the pressure time integral) is often the initial mechanism of injury in the formation and/or recurrence of diabetic foot ulcers. Once conservative treatment options to off load the foot have failed, surgery should be considered. There are patients with diabetic foot ulcers for whom a combination of surgery (intrinsic off loading) and extrinsic off loading is better than either method alone. These difficult wounds are characterized by a combination of variables acting singularly or together, such as neuropathy, rigid deformity, limited joint mobility, and activity level. Our experience dictates, patients with rigid deformity and limited joint mobility get caught in the cycle of repetitive stress and cannot break the cycle until the etiology of the structural deformity is addressed surgically and preventative strategies for off loading, temperature monitoring, and activity level are implemented. If a structural deformity exists, the deformity will delay or prevent healing of the ulcer. Once the ulcer is healed, the likelihood for recurrence is high unless the deformity is corrected. When a structural deformity exists, the patient should be referred for evaluation and possible prophylactic surgery.     

脊柱畸形手术失败原因与对策

目的探讨脊柱矫形手术失败原因、预防措施、处理方法及翻修手术适应证。方法31例患者,男18例,女13例;翻修手术时年龄4～35岁,平均14.7岁;既往平均手术史1.5次。初次手术距翻修手术时间平均47.9个月(13～114个月)。术前出现腰背部酸困疼痛、活动后加重16例,内植物并发症(断裂、松脱或外露等)5例,畸形进行性加重21例,下肢部分肌力和感觉障碍5例。翻修术前平均侧凸角75.3°,脊柱柔韧性9.8%;后凸角76°,柔韧性25.2%。分别采用脊椎截骨、椎弓根螺钉固定,原位固定和分期手术治疗。结果20例患者平均随访31.8个月,侧后凸平均矫正率分别为55.2%和67.5%。手术并发症:出现暂时性神经功能障碍4例(12.9%),经脱水、激素和电脉冲刺激等治疗,均在术后1～3周内得到完全恢复;内植物断裂2例,无其他严重并发症。结论正确掌握脊柱矫形手术治疗原则、良好的植骨融合、对先天性侧凸进行必要的内固定以及避免过早拆除内固定等,是防止矫形手术失败的有效手段。对有顽固性腰背痛、脊柱假关节和术后畸形进行性加重者,应根据患者年龄、畸形程度和脊柱柔韧性,采用不同的治疗方法。     

Surgical management of posttraumatic thoracolumbar kyphosis

BACKGROUND CONTEXT: Spine trauma is relatively common, and each year approximately 10,000 to 17,000 people in the United States will sustain a spinal cord injury and approximately 150,000 to 160,000 will fracture their spinal column. Posttraumatic spinal deformity is a common potential complication of spinal injury and poses one of the greatest challenges in spinal surgery. PURPOSE: To provide a comprehensive and current review of posttraumatic deformity focusing on the epidemiology, clinical and radiographical presentation, treatment options, and prognosis. STUDY DESIGN/SETTING: A thorough review of the English literature on the management of posttraumatic deformity was performed. Pertinent articles were identified by using PubMed and a review of publications by the American Academy of Orthopaedic Surgeons. METHODS: Each article was reviewed, and findings were analyzed to formulate a concise review of current treatment methods for posttraumatic deformity. RESULTS: Successful treatment of posttraumatic deformity is dependent on careful patient selection and appropriate surgical intervention, which should be considered in the presence of significant or increasing deformity, increasing back and/or leg pain, "breakdown" at levels above or below the deformity, pseudarthrosis or malunion, and increasing neurological deficit. The goals of surgery should be to decompress the neural elements if neurological claudication or a neurological deficit is present, to recreate normal sagittal contours and balance, and to optimize the chances for successful fusion; these goals can be achieved through an all-anterior, all-posterior, or a combined anterior/posterior approach assuming that close attention is paid to using the appropriate bone-grafting techniques, selecting technically sound segmental instrumentation, and providing appropriate biomechanical environment for maintenance of correction and successful fusion. CONCLUSIONS: Posttraumatic spinal deformity is a common complication of spinal injury, and it is therefore essential for patients with vertebral column injuries to have a careful initial evaluation, close follow-up, and early intervention when needed. Once posttraumatic deformity is present, successful outcome is achievable assuming a thorough, systematic, and technically well-executed surgical intervention is performed.     

Ascher syndrome: Review of literature and case report

A 13 year old girl presented with aesthetic deformity of upper lip since birth. She also presented with eyelid swelling on and off for 11 months. She was diagnosed to be a rare case of Ascher syndrome. Ascher syndrome commonly presents with double lip and blepharochalasis, sometimes associated with goitre. The deformity of her double upper lip was corrected by appropriate surgery. Because her blepharochalasis is in active stage now, she is under periodic follow up for appropriate intervention. This article describes the management of the patient and brief overview of the syndrome. Ascher syndrome is often missed or misdiagnosed commonly.     

Analytical radiography and the progressive approach in talipes equinovarus

1. A radiographic method is described for making the diagnosis of talonavicular subluxation before ossification of the navicular occurs. 2. Seven basic deformity combinations are thought to occur in clubfoot. 3. Preoperative analytical radiography enables the surgeon to determine which of these combinations exists in a particular foot. 4. The progressive approach, a comprehensive sequential plan of corrective surgery, indicates the appropriate treatment for each of the seven deformity combinations that may exist in a clubfoot following initial conservative treatment. 5. At the time of surgery the surgeon uses analytical radiography during the operation to determine whether the surgery has been successful or whether the next stage of the progressive approach will be required to correct the deformity combination.     

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.     

Pollex flexus congenitus]

The authors report on the incidence, clinical picture, etiology, pathogenesis and treatment of congenital pollex flexus, and communicate the results of surgery on 52 thumbs. The permanent flexion anomaly in the interphalangeal joint and a hard, palpable knot in the long flexor tendon of the thumb over the metacarpophalangeal joint are typical for the deformity. Although these changes are sometimes observed immediately post partum, delayed diagnosis and treatment are more common. The hypothesis that it is a hereditary, endogenous condition is supported by observations in twins, relatively frequent bilateral occurrence and a high familial incidence. Constriction of the synovial sheath over the basal joint of the thumb is a key pathogenetic factor, although little is known about its causes; anatomical factors, influences affecting the growth of the sesamoid bones, and mechanical causes have been postulated. A more plausible hypothesis was first advanced by Jeannin. Like Hueston and Wilson 100 years later, he compared the tendon to a thick thread which had to be passed through a narrow eye of a needle: as a result, the "thread" would be frayed and compressed. The knot in the tendon is held to be a secondary phenomenon. The pathologicoanatomical picture varies. Lymphocyte and monocyte infiltration, and metaplasias to fiber cartilage have been detected in specimens excised from the tendon and the synovial sheath. However, pathologic changes have not been found in all cases. In the first year of life conservative therapy may be attempted, with temporary splinting of the thumb following manual correction of the flexion anomaly in the interphalangeal joint.(ABSTRACT TRUNCATED AT 250 WORDS)     

Kyphectomy for myelodysplasia

A progressive kyphotic deformity occurs in 15% of children with myelomingocele. The more common problems caused by the gibbus are recurrent or recalcitrant skin ulceration and seating difficulties. The only effective treatment is surgery. Excellent correction is possible by vertebrectomy of a portion of the cephalad limb of the deformity. Superior maintenance of the correction is accomplished by segmental spinal instrumentation. Alternative techniques that spare growth are currently being investigated. Vertebral body decancellation is one such method that is less extensive than vertebrectomy and, theoreticallty, allows continued spinal growth. It seems most appropriate for the younger patient with a less rigid and dramatic deformity.     

收肌与囊筋膜瓣吻合治疗外翻

２２只外翻患足接受了囊筋膜瓣中１／３经第一跖骨头横孔与收肌吻合的矫形手术，经６个月～４年的随诊，效果满意，优良率９０．９％，前足缩窄最大者达１０ｍｍ。６只足在术后３～５个月，开始穿高跟鞋，经２～３年随访无复发，但本术式不适用于外翻合并第一跖骨头关节面有倾斜者     

Functional dystonia: A pitfall for the foot and ankle surgeon

Functional dystonia represents a condition where psychological distress is being expressed as involuntary muscle contractions. In the foot and ankle, it most commonly presents as a sudden onset of a painful fixed ankle/hindfoot deformity in a female patient with a history of trivial trauma or surgery. The “fixed deformity” found on clinical examination is usually correctable under general anesthesia. Less commonly, it can present in the toes or may present as paroxysmal muscle movements rather than a fixed deformity. CRPS may occur concurrently with the dystonia.Failure to consider the diagnosis leads to a long delay in appropriate diagnosis, patient distress and unnecessary or even harmful surgery. A better approach to this clinical syndrome is to define it as fixed abnormal posturing that is most commonly psychogenic. Early referral to a movement disorder clinic is recommended. The prognosis is generally poor as less than a quarter of patients report subjective long-term improvement even when managed in a movement disorder clinic. Foot and ankle surgeons should, whenever possible, avoid operating on patients with functional dystonia in order to avoid symptomatic deterioration.     

Acute traumatic hallux valgus

Post-traumatic hallux valgus is an uncommon condition with sporadic reports. The deformity usually develops in a gradual manner following direct injury to the first ray; including injury to the first metatarsophalangeal joint, the first metatarsal bone or the first metatarsal-cuneiform joint. A case of acute traumatic hallux valgus following metatarsal neck fractures of the lesser rays is reported. We believe that understanding the importance of the transverse ‘tie-bar’ system in the pathogenesis of post-traumatic hallux valgus deformity avoids unnecessary surgery to the great toe.     

Cervical deformity: Pre-operative evaluation and surgical treatment options

Cervical deformity is a major cause of cervical myelopathy and often leads to poor health-related quality-of-life outcomes. These deformities are complex in nature and require a thorough understanding of the radiographic parameters used to measure the degree of malalignment in order to develop an appropriate pre-operative plan. The magnitude and rigidity of the deformity often dictates whether an anterior, posterior, or combined approach is required to achieve the goals of surgery, which are to decompress the neural elements, as well as reestablish regional and global spinal alignment.     

胸腰椎骨折术后后凸畸形分析：39例报道

［摘要］ 目的 总结分析胸腰椎骨折短节段内固定术后继发后凸畸形的原因。方法 回顾性分析我科自2014年至2018年胸腰椎骨折行短节段内固定治疗术后继发后凸畸形39例。结果 胸腰椎骨折术后脊柱后凸原因较多,早期主要在于手术操作有欠缺;1年内发生后凸畸形,多为固定节段短或螺钉短,不能有效支撑固定;未佩戴外固定支具或支具不牢靠且活动量大;患者骨质疏松;取出内固定后发生脊柱后凸主要在于稳定性差的骨折减压固定未给予充分植骨融合;椎间盘严重损伤,取出后再次塌陷。结论 从当前病例总结,胸腰椎骨折的手术治疗效果在于胸腰椎骨折的正确诊断、合适手术方式和有效的植骨融合。     

Anterior stabilization, instrumentation, and decompression for post-traumatic kyphosis

Thirty-seven patients underwent surgery for late post-traumatic kyphosis in the lumbar, thoracolumbar, or thoracic spine. Indications for surgery included: increasing deformity, pain, and persistent neurologic deficit with paraparesis in eight, and development of late spinal stenosis in a further nine patients. All patients underwent anterior correction with Kostuik-Harrington instrumentation. Seventeen patients with neurologic deficit underwent decompression over appropriate levels as well. No posterior fusions or instrumentation were carried out. Stable arthrodesis with correction of the deformity occurred in 36 of 37 patients with only one nonunion. Pain was reduced significantly in 78% of patients. Late neurologic improvement of a significant functional degree occurred in three of eight paraparetics. All patients with spinal stenosis had relief of their symptoms and signs.     

Correction of severe wrist deformity following physeal arrest of the distal radius with the aid of a three-dimensional computer simulation

Growth arrest following physeal injury may result in severe limb deformity. We report a case of complex wrist deformity caused by injury to the distal radial physis resulting in radial shortening and abnormal inclination of the radial articular surface, which was successfully treated by gradual correction after computer simulation. The simulation enabled us to develop an appropriate operative plan by accurately calculating the axis of the three-dimensional (3D) deformity using computer bone models. In the simulative surgery with a full-size stereolithography bone model, an Ilizarov external fixator was applied to the radius such that its two hinges were located on the virtual axis of the deformity, which was reproduced in the actual surgery. This technique of 3D computer simulation is a useful alternative to plan accurate correction of complex limb deformities following growth arrest.     

Patient selection for minimally invasive spine surgery

Minimally invasive approaches to treat lumbar spine disease may carry many benefits over traditional open surgery with comparable patient outcomes. However, this advantage is conferred through appropriate patient selection. Not only do patient-specific anatomic factors influence the use of these techniques, but also surgeon familiarity with approaches. Adult spinal deformity surgery represents an area where minimally invasive spine (MIS) techniques have demonstrated significant impact in appropriately selected patients. Conversely, applying MIS techniques in patients inappropriate for minimally invasive surgery can result in complications, reoperations, and adverse outcomes. This chapter will highlight algorithms to guide patient and technique selection for MIS deformity surgery.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Scarf osteotomy for correction of hallux valgus. Historical perspective, surgical technique, and results

The Scarf osteotomy has proven to be a versatile and powerful procedure to correct various degrees of hallux valgus deformity. Through modifications of bone-cut lengths and in combination with a phalangeal osteotomy, most hallux valgus deformities can be addressed. In cases of extreme hypermobility of the first ray or arthrosis of the first metatarsocuneiform joint, the Lapidus operation may be more appropriate. Hallux valgus rigidus or hallux valgus with severe rheumatoid joint disease usually requires alternative procedures. The results of the Scarf osteotomy compare favorably with the results reported for other popular bunion surgeries. When choosing a procedure, the clinician should consider that the Scarf osteotomy allows the patient to ambulate postoperatively without a cast or the use of crutches, to return to bathing and a closed athletic shoe in one week, and to have bilateral surgery, which maintains cost-effectiveness and returns the patient to his or her desired lifestyle more quickly. It has been said that surgery is both a science and an art. The author often believes that bunion surgery is more art than science, hence the success of so many procedures in one surgeon's hands and the failure in another's hands. The Scarf bunionectomy is a technically demanding procedure that has a large learning curve. Once mastered, however, the Scarf bunionectomy can provide a predictable and satisfying outcome for both patient and foot surgeon.     

Correction of hallux valgus deformity using the center of rotation of angulation method

Background  To correct a hallux valgus (HV) deformity quantitatively and prevent unexpected postoperative deformity, the center of rotation of angulation (CORA) method was applied during HV surgery. To correct a hallux valgus (HV) deformity quantitatively and prevent unexpected postoperative deformity, the center of rotation of angulation (CORA) method was applied during HV surgery. Methods  To create a normal foot model, radiographs of 64 normal female feet were measured. Points A and B were defined as the intersection of the intermetatarsal angle and the HV angle. CORA1 and CORA2 were defined as the intersection of the axes of the first metatarsal and the first proximal phalanx in the normal and HV models, respectively. Procedures to correct HV deformity using the CORA method were devised and were applied to HV feet, which underwent a focal dome osteotomy or medial wedge osteotomy. Results  Point A was 2.3 times the length of the second metatarsal proximally from the top of the second metatarsal head, and point B was 0.17 times the length of the first metatarsal proximally from the top of the first metatarsal head. Two methods were used to correct the deformity. With one method, a focal dome osteotomy was performed at the first metatarsal on the circle at the CORA1 and the distal fragment was moved to the standard first metatarsal axis. The first proximal phalanx was then moved around the metatarsal head to the standard axis of the first proximal phalanx at the CORA2. With the other method, a medial wedge osteotomy was performed on or proximal to the CORA2, and the distal fragment was moved to the first standard metatarsal axis. Conclusions  We propose a preoperative plan to use the CORA method to correct deformities that prevent translation of the axis or an angulation deformity. HV deformity can be corrected effectively using the CORA method.