Rapidly increasing incidence in scoliosis surgery over 14 years in a nationwide sample

Purpose

Severe scoliosis is primarily managed with surgery. This cohort study describes the incidence of surgically treated scoliosis among Swedish youth and young adults, stratified by age, sex, scoliosis type, and surgical approach and identifies changes in incidence rate and hospital length of stay (LOS), infections requiring re-surgery and mortality within 90 days.

Methods

Swedish youth, 0–21 years, (n = 3062) with a diagnostic code for scoliosis and spine surgery between 2000 and 2013 were selected from the National Patient Register. Incidence was computed by comparing individuals with surgically treated scoliosis to the total at risk population. Linear regression models and Spearman correlation coefficients analyzed trends over time.

Results

Overall annual incidence per 100,000 individuals was 9.1 (5.9 males/12.5 females). Annual incidence increased over 14 years from 5.1 to 9.8; an average 4.6% per year (p < 0.001). Adolescent idiopathic scoliosis was most common (4.5 per 100,000; n = 1516) followed by neuromuscular 2.7 (n = 913) and congenital 0.7 (n = 236). Average LOS decreased among scoliosis types except infantile and neuromuscular scoliosis. Posterior fusion was the most common surgical approach (75%) followed by anterior (18%) and anteroposterior fusion (7%). Posterior fusions significantly increased with a resultant decrease in anterior and anteroposterior fusion over time. Individuals with neuromuscular scoliosis exhibited the highest mortality (n = 12; 1.3%) and (n = 59; 6%) of individuals with neuromuscular scoliosis and (n = 12; 15%) with scoliosis related to MMC required revision surgery due to post-op infection.

Conclusions

Surgical management of scoliosis is increasing with a concurrent decrease in hospital LOS. Surgical management of neuromuscular scoliosis is associated with high 90-day post-operative infections and mortality rate.

     

Subtalar dislocation: two cases requiring surgery and a literature review of the last 25 years

Background

Subtalar dislocations are uncommon, representing ~1 % of all traumatic dislocations. We present two cases of closed medial subtalar dislocation and a systematic literature review of the last 25 years.

Methods

We performed an Embase, Medline, Pubmed and Cochrane search of the literature written in English between January 1988 and December 2012. Keywords used were subtalar, peritalar, subastragalar, luxatio pedis sub talo, dislocation and dislocations. All articles presenting original patient data were included. All available data regarding gender, age, direction, affected side, open or closed injury, accompanying fractures, reduction, time of immobilization and outcomes were collected in a database.

Results

Seventy-six articles were included with a total of 528 reported cases. Males (318/419 = 76 %) and the right foot (122/200 = 61 %) were affected more often than females and the left foot. Average age was 33.8 years (range 19 months–86 years). Cause of injury was a traffic accident in 43.7 % (157/359), a fall in 32.9 % (118/359), sports injuries in 13.9 % (50/359), sprain injuries in 5.3 % (19/359) and other causes in 4.2 % (15/359). The direction of the dislocation was medial in 71.5 % (352/492), lateral in 26.0 % (128/492), posterior in 1.6 % (8/492) and anterior in 0.8 % (4/492). Open dislocation was reported in 22.5 % (67/298). In 61.4 % (216/352) an additional osseous injury was diagnosed. Closed reduction was unsuccessful in 14.0 % (51/364) requiring immediate open reduction. Overall outcomes in the literature were good in 52.3 % (172/329), fair in 25.2 % (83/329) and poor in 22.5 % (74/329).

Level of clinical evidence

4.     

Anatomy of the Medial Patello-Femoral Ligament: a systematic review of the last 20 years literature

Background

Although many studies have investigated the anatomy of the Medial Patello-Femoral Ligament (MPFL), some studies have even questioned its existence. In the last 20 years, there is a renewed interest on the role of the MPFL in patello-femoral instability. As a result, several studies have been published that describe the anatomy, function and possible surgical reconstruction of the MPFL. Despite the large amount of literature produced, there is still a lack of consensus on what is its real anatomy as there are currently no systematic reviews on this topic.

Purposes

Thus, the aim of this review is to systematically report the results in literature regarding in anatomical papers, the existence, size, insertion sites and relationships of this ligament with the other medial structures of the knee.

Methods

We have systematically analyzed anatomical studies currently available in literature between 1980 and December 2012. The search was carried out on Medline, Embase, Cochrane Library and Google Scholar. We checked reference lists of articles, reviews and textbooks identified by the search strategy for other possible relevant studies.

Results

The outcomes examined are the presence of the ligament, its size (length, width, thickness), and its patellar and femoral insertions. A total of 312 cadaveric knees were included in the 17 studies; the MPFL was identified in 99 % of cases (309).

Conclusions

The consensus is that the MPFL is almost always present in the dissected knees. The size and insertions of the ligament demonstrate great variation between cadavers.

Level of evidence

Systematic review of anatomical study, Level 1.

     

Prevalence of thoracic scoliosis in adults 25 to 64 years of age detected during routine chest radiographs

Purpose

To investigate the prevalence of thoracic scoliosis and determine the effect of both age and gender on coronal curve magnitude among asymptomatic adults aged 25–64 years old, using standing posterior-anterior chest radiographs.

Methods

This was a retrospective, cross-sectional study evaluating 500 randomly selected digital posterior-anterior chest radiographs taken at a single institution on an outpatient basis between January 2010 and December 2011. Males (n = 184) and females (n = 316) ranged in age from 25 to 64 years. Patients with symptoms of back pain; including a history of back pain, spinal instrumentation, or known pre-existing spinal disease were excluded. Radiographs were evaluated using Centricity PACS Web Diagnostic 2.1 system (General Electric Co. Fairfield, CT). Coronal Cobb angle measurements of the thoracic spine were quantified by the authors, with scoliosis defined as coronal curves greater than 10°. Curvatures were subdivided into groups: a control group with coronal curves less than 10°, curves measuring 10° to 19°, 20° to 29°, and greater than 30°. The effect of age and gender on curve magnitude was examined using Pearson correlation analysis and linear regression analysis.

Results

There was a 13.4 % (67 patients) prevalence of thoracic scoliosis. The prevalence among asymptomatic males was 10.9 %, while the prevalence among asymptomatic females was 14.9 %. 11.6 % demonstrated a coronal curvature between 10° and 19° (58 patients), 1.6 % between 20° and 29° (8 patients), and 0.2 % greater than 30° (1 patient). Age and gender were not found to be significant independent predictors of curve severity.

Conclusions

We found a 13.4 % prevalence of thoracic scoliosis among asymptomatic adults aged 25–64 years on routine outpatient chest radiographs. 11.6 % of patients demonstrated a coronal curvature between 10° and 19°. Unlike prior studies evaluating asymptomatic thoracic curves in elderly patients, age and gender did not significantly affect curve magnitude in our younger cohort. These data may provide a reference point to help clinicians counsel asymptomatic patients diagnosed with thoracic scoliosis on routine chest radiographs.

     

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years

Background

Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued.

Methods

Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors’ institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed.

Results

In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries.

Conclusion

Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.     

Spinal surgery in children with idiopathic and neuromuscular scoliosis. What's the difference?

We compared children who were hospitalized for the management of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) via analysis of the 2000 Healthcare Cost and Utilization Project Kid Inpatient Database. Children with NMS had longer lengths of stay (9.2 vs. 6.1 days, P < 0.001), higher total charges (66,953 US dollars vs. 47,463 US dollars, P < 0.001), more diagnoses (6.3 vs. 2.5, P < 0.001), and more total procedures (4.2 vs. 3.0, P < 0.001) than did children with IS. Children with NMS more frequently developed pneumonia (3.5% vs. 0.7%, P < 0.001), respiratory failure (24.1% vs. 9.2%, P < 0.001), urinary tract infections (5.3% vs. 0.7%, P < 0.001), and surgical wound infections (1.3% vs. 0.3%, P < 0.001). Overall, 1570 children with NMS underwent spinal surgery, totaling to 105 US dollars million in hospital charges and 14,444 hospital days. We conclude that children with NMS experience significantly more complicated and costly hospitalizations than do children with IS. These results may add information on preoperative care, surgical decision-making, discussions of informed consent, and the provision of anticipatory guidance for children and their caregivers.     

Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years

Background  

Worldwide the incidence of necrotizing fasciitis (NF) is on the rise. This rapidly progressive infection is a true infectious disease emergency due to its high morbidity and mortality. The mainstay of therapy is prompt surgical debridement, intravenous antibiotics, and supportive care with fluid and electrolyte management. Because of its high mortality rate, patients are increasingly referred to burn centres for specialized wound and critical care issues.     

Analysis of complications from 600 retroperitoneoscopic procedures of the upper urinary tract during the last 10 years

INTRODUCTION: The aim of this study is to review 10 years experience of retroperitoneoscopy procedures. METHODS: A total of 600 patients treated between 1995 and 2007 by retroperitoneoscopy (nephrectomy, partial and total nephrectomy, adrenalectomy, pyeloplasty, renal cyst, calyceal diverticulectomy) were reviewed for per, peri and postoperative complications including patients in the learning curve. RESULTS: The mean blood loss was 159 mL. Conversion to open surgery was required in 28 patients (4.6%) primarily due to technical problems during dissection (elective). There were 32 (5.3%) surgical complications, including bleeding or hematomas in 12 cases and 2 of them required reintervention, urinomas in 8 which were treated by installation of a ureteral drainage (JJ stent). Wound or deep abscesses happened in four, urinary fistula in one and pancreatic fistula in another. Evisceration (hernias) was seen in three patients. Intestinal injury occurred in two. The complication rate depended on the difficulty of the procedure and learning curve of the surgeon. A total of 28 patients (4.6%) presented medical postoperative complications (hyperthermias, deep venous thrombosis, pyelonephritis, pulmonary superinfections, pulmonary atelectasia and transient vascular ischemic accident). Mean postoperative hospital stay was 6.2 days (ranged from 2 to 20). CONCLUSION: Retroperitoneoscopy can be the technique of choice for accessing and carrying out all the surgery of the upper urinary tract respecting the principles of oncological surgery. After experience with 600 cases during the last 10 years the technique has become safe, simplified, reproducible and effective although not easy. Most complications are minor and easily managed.     

Prognosis factors in incisional hernia surgery: 25 years of experience

Background Incisional hernia underwent a change from conventional techniques to mesh implantation. The relevance of different factors, like operative technique, mesh material, and patient-related parameters concerning the outcome following mesh repair, are still under debate.Methods In a comparative retrospective study of 421 incisional hernia operations on 348 patients, we investigated 241 Mayo procedures and 180 mesh repairs over a 25-year period. In addition to the quality of life following mesh implantation, the prognostic relevance of demographic, preoperative and intraoperative parameters, surgical technique, mesh material, and the surgeons experience were analysed, both in a univariate and multivariate manner.Results With a mean follow-up of 9.7±8.8 years, the total recurrence rate following Mayo overlap was 37%, in contrast to 15% after mesh implantation (P=0.001). Mesh size was the only significant prognostic factor concerning quality of life following mesh implantation, and 86% of the patients with mesh repair were satisfied. The complication rate was determined significantly by patients risk factors, size of hernia, operative technique, and the surgeons experience, whereas the rate of recurrences was significantly influenced by the parameters obesity (BMI>25), size of hernia, and surgical experience. The recurrence rate decreased significantly with surgeons experience—a minimum of 16 mesh repairs led to a recurrence rate of less than 10%. Conclusions Only the mesh repair revealed acceptable recurrence rates with high patient comfort. From a surgical point of view, the most important prognostic factor following mesh repair is the surgeons experience.This paper was presented to the American Hernia Society Congress in Orlando, Fla., USA, on Feb. 26, 2004.     

The lifetime risk of pneumonia in patients with neuromuscular scoliosis at a mean age of 21?years: the role of spinal deformity surgery

Background

Patients with neuromuscular disorders often have an increased risk of pneumonia and decreased lung function, which may further be compromised by scoliosis. Scoliosis surgery may improve pulmonary function in otherwise healthy patients, but no study has evaluated its effect on the risk of pneumonia in patients with neuromuscular scoliosis (NMS).

Methods

The patient charts of 42 patients (mean age 14.6 years) who had undergone surgery for severe NMS (mean scoliosis 86°) were retrospectively reviewed from birth to a mean of 6.1 years (range 2.8–9.5) after scoliosis surgery. The main outcome was radiographically confirmed pneumonia as a primary cause for hospitalization. We excluded postoperative (3 months) pneumonia from the analyses.

Results

The lifetime annual incidence of pneumonia was 8.0/100 before and 13.4/100 after scoliosis surgery (p > 0.10). The mean number of hospital days per year due to pneumonia were 0.59 (SD 2.3) before scoliosis surgery and 2.24 (SD 6.9) after surgery (p > 0.10). Multivariate analysis demonstrated that lifetime risk factors for pneumonia were epilepsy (RR 15.2, 95 % CI 1.3–176.8, p = 0.027), non-cerebral palsy (CP) etiology (RR = 10.2, 95 % CI 3.2–32.7, p < 0.001) and major scoliosis (main curve >70°; RR = 11.3, 95 % CI 1.8–70.7, p = 0.01).

Conclusions

Epilepsy, non-CP etiology and major scoliosis are significant risk factors for pneumonia in patients with NMS. Scoliosis surgery does not decrease the incidence of pneumonia in patients with severe NMS.

Level of Evidence

Retrospective comparative study, Level III.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0682-8) contains supplementary material, which is available to authorized users.     

Pinealectomy in the chicken: a good model of scoliosis?

The phenomenon of spinal deformity in the pinealectomized chicken has led researchers to postulate a disturbance of melatonin activity as a potential cause of adolescent idiopathic scoliosis (AIS). More recently, structural differences between curves seen in this model and those seen in scoliosis have been highlighted suggesting the deformities observed are not as similar as first thought. We examined melatonin levels, and the radiological and histological characteristics of scoliosis after pinealectomy in chickens. They underwent pinealectomy (P) at 2 days of age, sham surgery (S) or served as controls (C). Mean melatonin levels were 32.9 pmol/L (P), 175 pmol/L (S) and 227.3 pmol/L (C). Scoliosis developed in 75% of chickens after pinealectomy and 38% after a sham procedure. Nineteen percent of unoperated controls also developed scoliosis. A lower melatonin level was associated with the development of scoliosis (p ≤ 0.001), but exceptions were seen with levels up to 265 pmol/L observed in one case. Most of the curves occurring spontaneously and after sham surgery and almost half after pinealectomy were short angular curves: distinct from those resembling idiopathic scoliosis. These occur over one or two segments and are characterized by marked apical wedging, frequently associated with subluxation or dislocation. The intervertebral joint in the chicken is more like a synovial joint histologically than an intervertebral disc. This study highlights important differences between the chicken and the human, and between their respective spinal deformities. Caution is advised when drawing conclusions regarding the pathogenesis of AIS from this model.     

The impact of the Harmonic FOCUS™ on complications in thyroid surgery: a prospective multicenter study

In recent years, newer tools have been developed and used in thyroid surgery. This study compared patients with multinodular goiter undergoing thyroidectomy using the Harmonic FOCUS? with patients undergoing the clamp-and-tie technique. Medical records of 268 patients with multinodular goiter undergoing thyroidectomy from December 2006 to July 2011 in two centers in Italy, the Department of Surgery of Pisa and the General Surgery Unit of Grosseto, were prospectively evaluated. Patients were divided into group A (Harmonic FOCUS? Shear), and group B (clamp-and-tie technique). Patient demographics and specific end points analyzed included age, sex, diagnosis, thyroid gland volume, operative time, complications, need for clips and hemostatic agents, need for suction balloon, postoperative blood loss, and postoperative hospital length of stay. 141 patients were included in group A, and 127 patients were included in group B. The two groups were similar in age, sex ratio, indication for surgery, and thyroid volume. Mean operative time was significantly shorter with the Harmonic FOCUS? Shear (51.8 min) than with the clamp-and-tie technique (70.9 min). The mean postoperative amount obtained from the suction balloon was similar. Vascular clips were needed significantly more frequently in group A (26.2 %) than in group B (12.5 %), whereas the need for hemostatic agents was significantly reduced in group A (4.2 %) compared with group B (14.9 %). The decision to leave a suction drain at the end of the operation occurred significantly more frequently in group B (96 %) than in group A (78 %). Mean postoperative hospital length of stay was 2.02 days in group A compared with 3.1 days in group B, which was significant. No definitive postoperative complications were documented in either group, except a higher rate, but not statistically significant, of permanent hypoparathyroidism in group B versus Group A. Transient laryngeal nerve injury was similar in both groups, whereas transient hypoparathyroidism occurred more frequently in Group B (4.7 %) than in Group A (2.4 %). Harmonic FOCUS device was significantly associated with lower rate of postoperative transient hypocalcemia, decreased operative time, shorter hospitalization, and lesser need for hemostatic agents and postoperative drain balloon. These results might be considered “indirect” money-saving factors, despite the cost of the device, especially in countries where the cost of thyroidectomy is influenced also by the hospital length of stay.     

Synovial sarcoma in patients under 20 years of age: a multicenter study with a minimum follow-up of 10 years

Purpose  

Synovial sarcoma (SS) is an aggressive soft-tissue tumor noted for late local recurrence and metastasis. This study investigates the long-term outcome of SS in patients of pediatric age and evaluates potential prognostic factors for SS.     

Prevalence of benign prostatic hyperplasia in a population-based study in Iranian men 40 years old or older

Epidemiology of benign prostatic hyperplasia (BPH) is incompletely understood. The following study was done to estimate the prevalence of BPH according to obstructive and irritative symptoms of prostate obstruction determined by uroflowmetry and prostate size. In a cross-sectional study a total of 8,466 men aged 40 or older were interviewed by 74 general practitioners and answered the International Prostate Symptom Score (I-PSS) questionnaire. The subjects were randomly identified from 30 counties of Iran. They were invited to have a digital rectal examination (DRE), serum total prostate-specific antigen (tPSA) assay, abdominal ultrasonography to measure prostate size and measurement of maximum urinary flow rate (Qmax). Data on medical history, toxic habits, and current use of medications were obtained. Of the men interviewed, the prevalence of BPH, defined as I-PSS greater than 7, maximum flow less than 15 ml/s and prostate size greater than 30 gm, was 23.8%. The prevalence increased with age, from 1.2% in men 40–49 to 36% in those >70 years (tested for trend, P = 0.001). A positive association was found between BPH and body mass index (BMI) (P = 0.04), height (P = 0.03), diabetes mellitus (P = 0.04), increased total energy intake (P = 0.02), age-adjusted levels of total PSA (P = 0.02), heart disease (P = 0.03), and marital status (P = 0.01). The prevalence of BPH is relatively high in Iran. The provided bothersome due to BPH did not correlate to symptom severity and should be considered independently in clinical decision-making.     

The effect of simulation in improving students’ performance in laparoscopic surgery: a meta-analysis

Background

There is increasing interest in using simulators for laparoscopic surgery training, and simulators have rapidly become an integral part of surgical education.

Methods

We searched MEDLINE, EMBASE, Cochrane Library, and Google Scholar for randomized controlled studies that compared the use of different types of simulators. The inclusion criteria were peer-reviewed published randomized clinical trials that compared simulators versus standard apprenticeship surgical training of surgical trainees with little or no prior laparoscopic experience. Of the 551 relevant studies found, 17 trials fulfilled all inclusion criteria. The effect sizes (ES) with 95?% confidence intervals [CI] were calculated for multiple psychometric skill outcome measures.

Results

Data were combined by means of both fixed- and random-effects models. Meta-analytic combined effect size estimates showed that novice students who trained on simulators were superior in their performance and skill scores (d?=?1.98, 95?% CI: 1.20–2.77; P?<?0.01), were more careful in handling various body tissue (d?=?1.08, 95?% CI: 0.36–1.80; P?<?0.01), and had a higher accuracy score in conducting laparoscopic tasks (d?=?1.38, 95?% CI: 0.30–2.47; P?<?0.05).

Conclusion

Simulators have been shown to provide better laparoscopic surgery skills training for trainees than the traditional standard apprenticeship approach to skill development. Surgical residency programs are highly encouraged to adopt the use of simulators in teaching laparoscopic surgery skills to novice students.     

Effects of bariatric surgery on obese polycystic ovary syndrome: a systematic review and meta-analysis

BackgroundBariatric surgery has been widely used for the treatment of obesity and its related metabolic diseases, such as type 2 diabetes (T2D), hypertension, and sleep apnea syndrome. Polycystic ovary syndrome (PCOS) is a common reproductive endocrine metabolic disease; however, little attention has been paid to the efficacy of bariatric surgery on PCOS.ObjectiveTo evaluate the efficacy of bariatric surgery on obese PCOS patients.SettingA systematic review and meta-analysis at a university hospital.MethodsOnline databases were searched for all studies reporting the efficacy of bariatric surgery for obese patients with PCOS up to October 2018.ResultsA total of 9 studies with 234 obese PCOS patients were included in this article. The results of meta-analysis showed that after bariatric surgery, there was a significant reduction of the incidence of abnormal menstruation (relative risk [RR] .23; 95% confidence interval [CI] .13–.43; P < .00001) and hirsutism (RR .47; 95% CI .28–.79; P = .004). Bariatric surgery can also cause a decrease in the serum total testosterone level (mean difference [MD] = –25.82; 95% CI –30.06 to –21.58; P < .00001), serum free testosterone level (MD = –4.10; 95% CI –6.97 to –1.23; P = .005), and body mass index (MD = –14.51; 95% CI –17.88 to –11.14; P < .00001). It also showed a significant effect on T2D (RR .09; 95% CI .03–.32; P = .0002) and hypertension (RR .21; 95% CI .05–.98; P = .05) in obese patients with PCOS.ConclusionsBariatric surgery can reduce the incidence of abnormal menstruation, improve hyperandrogenism and its clinical manifestations, and decrease the body mass index, prevalence of T2D, and hypertension in obese patients with PCOS.     

Posterior approach lumbar and thoracolumbar hemivertebra resection in congenital scoliosis in children under 10 years of age: results with 3 years mean follow up

Introduction

The authors present 15 cases of congenital scoliosis with lumbar or thoracolumbar hemivertebra in children under 10 years of age (mean age at the time of surgery was 5.5 years). Patients were treated by posterior hemivertebra resection and pedicle screws two levels stabilization or three or more levels stabilization in the case of deformity above or under hemivertebra or for severe curve deformities.

Materials and methods

All operated patients had worsening curves; mean follow up was 40 months. The mean scoliosis curve value was 44° Cobb, and reduced to a mean 11° Cobb after surgery. The mean segmental kyphosis value was 19.7° Cobb, and reduced to a mean −1.8° Cobb after surgery. We did not consider total dorsal kyphosis value as all hemivertebras treated were at lumbar or thoracic lumbar level. No major complications emerged (infections, instrumentation mobilization or failure, neurological or vascular impairment) and only one pedicle fracture occurred.

Results

Our findings show that the hemivertebra resection with posterior approach instrumentation is an effective procedure, which has led to significant advances in congenital deformity control, which include excellent frontal and sagittal correction, excellent stability, short segment arthrodesis, low neurological impairment risk, and no necessity for further anterior surgery.

Conclusion

Surgery should be considered as soon as possible in order to avoid severe deformity and the use of long segment arthrodesis. The youngest patient we treated, with a completed dossier at the end the follow up was 24 months old at the time of surgery; the youngest patient treated by this procedure was 18 months old at the time of surgery.     

High tibial osteotomy for medial osteoarthritis of the knee: 15 years follow-up

We reviewed 192 patients (224 knees) to assess the results of HTO in medial gonarthrosis during the period 1982–2008. Median follow-up was about 15 years for 134 females and 58 males. Among the knees, 118 had an average opening wedge for varus angle of 13° and 106 had closing wedges of 11°. Knee Society scoring before osteotomies was 68/200 for opening wedge and 81/200 for closing wedge. Modified Ahlback classification showed preoperative grades I (n = 44), II (78), III (83) and IV (19). Healing delay was 55 days for closing and 70 for opening osteotomy. Twenty-nine knees were still painful. Twenty-eight patients were revised and 19 others had complications. After opening wedge osteotomy, scoring was 101/200 and valgus angle was 2°. After closing wedge osteotomy, scoring was 94/200 and valgus angle was 4°. Global results were as follows: very good, 12%; good, 30%; fair, 31%; and poor, 27%. HTO decreases stresses on medial compartments and widens joint space. The average of 5° mechanical valgus at the time of osteotomy seems to be quite effective at the follow-up for at least ten years. Our indications are opening wedge for grades 1–3 and wide varus angle, until the age of between 65–70. Closing wedge is indicated for medium varus in younger patients.