Is bilateral hallux valgus chevron osteotomy a safe procedure for ambulatory surgery?

IntroductionSeveral osteotomies of the first metatarsal have been described for treatment of hallux valgus but chevron osteotomy is one of the most common and well-established procedure for treating this deformity. Although there is a trend towards considering bilateral surgery there is lack of publications addressing bilateral treatment in ambulatory units. The aim of this study is to analyze results of bilateral and unilateral distal chevron osteotomies associated with lateral soft tissue release as ambulatory procedures.Materials and MethodsA retrospective review was made about the patients treated at our ambulatory unit over a period of five years. Initially, general information as patient’s satisfaction’s rate and return to normal activity’s time and evaluation of standardized follow-up charts and records made by the surgeon were recorded. Secondly, the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopedic Foot & Ankle Society was used.ResultsA total of 194 patients with 230 feet operated were included in this study. We found 29 patients that didn’t meet the inclusion criteria and were excluded. The unilateral group was composed by 139 feet and the bilateral group by 52 feet. The improvement between preoperative and discharge clinical and radiographic results was significant independently in both groups. A total of 14% of complications were found in our study, 19% in the unilateral group and 12% at the bilateral group. None of them required revision surgery.ConclusionBilateral distal chevron osteotomies, associated with lateral soft tissue release, are safe and effective ambulatory procedures. It was found a satisfactory deformity correction in moderate HV. Both patients that underwent unilateral and bilateral procedures had similar clinical and radiological outcomes with no increase in complications or return to normal activity time. With this study it was demonstrated that bilateral chevron osteotomies can be performed as ambulatory procedures.     

Is knee osteotomy still indicated in knee osteoarthritis?

This study was undertaken to investigate whether high tibial osteotomy (HTO) still had a role in the treatment of osteoarthritis of the knee joint. The author has performed photoelasticity studies which confirmed abnormal stress distribution over the joint, as soon as its mechanical axis was deviated and the joint line had an obliquity over 10 degrees. High tibial osteotomy to correct varus or valgus deformity restores a symmetrical stress distribution and represents the only etiological treatment of secondary osteoarthritis of the knee. Two hundred and fifty HTO's were performed between 1971 and 1985 for osteoarthritis of the knee. The short-term result was good or very good in 75%, fair in 20% and poor in 5%. Fair and poor results were related to insufficient correction, to infection or mostly to incorrect indications. In 152 cases with a good or very good short term result, a further evaluation was made between 8 years and 15 years after operation. It was noted that osteoarthritis had been arrested in 105 cases (69%) whereas it had deteriorated in 47 cases. The main factors associated with further deterioration were insufficient correction and persistence of joint line obliquity. Provided on optimal correction is achieved (3 degrees to 6 degrees hypercorrection in valgus osteotomy, 0 degree in varus osteotomy) and provided a horizontal joint line is restored, HTO performed in good indications (Ahlback grade I or II) may provide good results for at least 10 to 15 years.     

Which is a better method for Perthes' disease: femoral varus or Salter osteotomy?

The optimum surgical treatment of patients with Perthes' disease has not been decided. We compared the clinical and radiographic results at skeletal maturity of the femoral varus osteotomy and the Salter innominate osteotomy for treatment of patients with Perthes' disease. Treatment in 46 patients was by femoral varus osteotomy and in 30 patients by Salter innominate osteotomy. There were no significant differences between the two groups. The clinical results were similar in the two groups except for scarring after surgery, which was more prominent in the femoral varus osteotomy group. There was no significant difference in the sphericity of the femoral head and congruity of the hip between the two groups. However, coverage of the femoral head by the acetabulum, the neck-shaft angle, and the articular-trochanteric distance were closer to normal in the Salter innominate osteotomy group. We think that the Salter innominate osteotomy is the better treatment for patients with Perthes' disease to decrease residual problems such as coxa vara, trochanteric prominence, poor acetabular coverage, and the surgical scar.Level of Evidence: Therapeutic study, Level IV (case series-no, or historical control group).     

Arthroscopy prior to osteotomy around the knee?

Introduction  Osteotomy around the knee is well established in orthopaedic surgery in cases of congenital/posttraumatic leg deformities with mono-compartment osteoarthritis of the knee. However, there is no consensus whether there should be an arthroscopy prior to osteotomy in the same operative session, either for diagnostic or therapeutic reasons. Patients and methods  This prospective study included 340 cases of osteotomy around the knee with a routine arthroscopy. During arthroscopy indication for osteotomy was checked first. Then cartilage status was determined to modify type and degree of correction osteotomy accordingly. Finally therapeutic procedures were performed in cases of intraarticular pathologies. Results  Indication was rejected in 47 cases with ten patients receiving endoprosthetic treatment. In 157 cases the degree of correction was modified, in eleven cases the level of osteotomy. Under the 330 non-endoprothetic sessions there were 316 arthroscopies with therapeutic treatments. Conclusion  This study could demonstrate that arthroscopy in the same session is indispensable, to check the indication for osteotomy, to modify type and degree of correction according to cartilage status and to perform therapeutic procedures.     

Proximal abduction–supination osteotomy of the first metatarsal for adolescent hallux valgus: a preliminary report

Background

Surgical treatment of adolescent hallux valgus has been a challenging intervention because of high rates of postoperative recurrence. The purposes of this study were to describe a proximal abduction–supination osteotomy of the first metatarsal and prospectively review preliminary results of this procedure for correction of adolescent hallux valgus.

Methods

Eleven patients (12 feet) who had had a proximal abduction–supination osteotomy of the first metatarsal combined with a distal soft-tissue procedure to correct an adolescent hallux valgus deformity were prospectively reviewed clinically and radiologically. The average duration of follow-up was 22 months. The average age at the time of surgery was 17 years.

Results

The mean score on the Japanese Society for Surgery of the Foot standard rating system for hallux improved significantly, from 62.0 points preoperatively to 99.2 points postoperatively (p = 0.002). All patients were satisfied and would choose to have the same procedure again. The mean hallux valgus angle decreased significantly, from 32.3° preoperatively to 12.2° postoperatively (p = 0.002); mean intermetatarsal angle decreased significantly from 14.0° preoperatively to 6.2° postoperatively (p = 0.002). No feet had postoperative recurrence of hallux valgus (a hallux valgus angle ≥20°). There were no occurrences of nonunion or transfer lesions.

Conclusions

The clinical and radiological results of this study demonstrate that a proximal abduction–supination osteotomy with a distal soft-tissue procedure, which described in this study, achieved significant correction of an adolescent hallux valgus deformity, significant improvement in pain and function, and reduction in rate of recurrence.     

Which type of osteotomy for edema and ecchymosis: external or internal?

BACKGROUND: Osteotomy is one of the major parts of a rhinoplasty operation. Edema and ecchymosis most commonly appear as a result of this surgical manipulation. Different authors use different techniques to perform osteotomy. The external perforating approach and the internal continuous technique are the 2 main ways of doing osteotomy in rhinoplasty. In our study, we tried to compare the effects of these 2 techniques regarding edema and ecchymosis. MATERIAL AND METHODS: Two groups that consisted of 20 patients were studied. In group A, osteotomy was performed through an external route in a perforating fashion. In group B, the osteotomy was performed through an internal route and in a continuous fashion. The patients in each group were scored according to a visual scoring system that describes the site and extension of ecchymosis and degree of edema on the second and seventh days after the surgery. The scoring was made by 2 examiners blinded to the type of surgery. RESULTS: Edema scores were almost the same between the 2 groups on the second and seventh days after the surgery. Ecchymosis scores were the same between the groups on the seventh day. However, the score for ecchymosis on the second day is significantly less in the internal continuous technique (P < 0.05) when it is compared with the external technique. CONCLUSION: External and internal techniques of osteotomy almost give the same results regarding edema and ecchymosis, but the internal continuous technique shows a tendency to produce less ecchymosis on the second postoperative day.     

Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

BackgroundTranslation and shortening of Scarf osteotomy allows correction of severe hallux valgus deformity. Shortening may result in transfer metatarsalgia.AimTo evaluate outcome of patients undergoing shortening Scarf osteotomy for severe hallux valgus deformities.Materials and MethodsFifteen patients (20 feet, mean age 58 years) underwent shortening Scarf osteotomy for severe hallux valgus deformities. Outcomes were pre and postoperative AOFAS scores, IM and HV angles, patient satisfaction.ResultsMean follow-up was 25 months (range 22–30). The IM angle improved from a median of 18.60 (range 13.4–26.20) preoperatively to 9.70 (range 8.0–13.70) postoperatively (8.9; 95% CI = 7.6–10.3; p < 0.001). The HV angle improved from a mean of 43.2 (range 27.4–68.2) preoperatively to 13.6 (range 3.0–37.4) postoperatively (29.6; 95% CI = 26.1–33.2; p < 0.001).The median AOFAS score improved from 29.2 (range 14–60) preoperatively to 82.2 (range 55–100) postoperatively (53.0; 95% CI = 48.0–58.5; p < 0.001). All patients rated their satisfaction as either satisfied or very satisfied. None had symptoms of transfer metatarsalgia at final follow-up. All osteotomies united.ConclusionsShortening Scarf osteotomy is a viable option for treating severe hallux valgus deformities with no transfer metatarsalgia.     

Plaster slipper versus crepe bandage after Wilson’s osteotomy for hallux valgus

Much variability exists in the postoperative mobilization management after modified Wilson’s osteotomy for hallux valgus. This study aimed to elicit the differences, if any, between weightbearing following surgery as managed with a plaster slipper as compared to that of a crepe bandage. Fifty-four operated feet were randomly entered into a prospective trial. All feet underwent identical operations. When a crepe bandage was used there was no significant difference in the rate of complications, or in the patient’s assessment of postoperative pain relief. Patients treated with a crepe bandage were back to full activity as quickly as their plaster slipper counterparts and the patient’s overall assessment of the operation was no different.     

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BackgroundThe role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia.MethodsPatients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test.Results48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes.ConclusionSuperiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.     

Anterolateral approach using tibial tubercle osteotomy for total knee arthroplasty: can we predict failure?

Purpose

The purpose of this study was to identify predictive factors for the occurrence of complications in a consecutive series of patients who underwent step-cut tibial tubercle osteotomy (TTO) and subsequent screw refixation in primary total knee arthroplasty (TKA).

Methods

Using standardised conventional radiographs, critical parameters including TTO length and depth, proximal abutment width (OT), and orientation and placement of fixation screws were measured in 422 patients (mean age of 71 years and a follow-up time range of one to five years) with two screw fixations.

Results

Medial spatial orientation in the distal screw (11 %, p=0.046), the TTO length (<55.4 mm, p=0.013), the OT width (<14 mm, p=0.002) and the distance of the distal refixation screw from the TKA (<51.7 mm, p=0.003) were significant factors for the occurrence of complications.

Conclusions

Age, gender, comorbidities, height, weight and/or the body mass index had no significant influence on the occurrence of complications. The TTO-related complication rate was 3 %. Consideration of these key surgical factors leads to improved outcomes.     

Is a long leg a risk for hip or knee osteoarthritis?

Background and purpose — 7% of the asymptomatic population has leg-length inequality (LLI) greater than 12?mm. It has been proposed that LLI of >5?mm can be associated with an increased risk of osteoarthritis (OA) of the knee and hip. We studied a possible association between LLI and OA of the knee and hip joint.

Patients and methods — We followed 193 individuals (97 women, 96 men) for 29 years. The initial mean age of the participants was 43 (34–54) years, and they had no clinical histories or signs of leg symptoms. The initial standing radiographs of their hips were re-examined and measured for LLI and signs of OA. None had any signs of OA. At the follow-up, data on performed hip or knee arthroplasties were obtained.

Results — 24 (12%) of the subjects had no discernible leg-length difference, 62 (32%), had LLIs of 1–4?mm, 74 (38%) of 5–8?mm, 21 (11%) of 9–12?mm, and 12 (6%) of over 12?mm. 16 (8%) of the subjects had undergone arthroplasty for primary OA during follow-up, and of those, 8 for both hip and knee OA. 10 individuals had undergone an arthroplasty of the longer leg and only 3 of the shorter leg. In the group of equal leg length, 3 had had an arthroplasty of hip or knee.

Interpretation — We noted that hip or knee arthroplasty due to primary OA had been done 3 times more often to the longer leg than to the shorter.     

Unicompartmental knee prosthetization: Which key-points to consider?

Unicompartmental knee arthroplasty (UKA) has evolved into a suitable option for diseased knees that cannot be managed with arthroscopic treatment and at the same time are not good candidates for total knee replacement. Since meticulous execution of the surgical technique is essential to optimizing UKA outcome, some procedural key-points are mandatory. Templates (phantoms) are then used to size the required prosthetic component (using these radiographs. Arthritic varus (or valgus) knees with an asymptomatic patello-femoral joint are typically ideal for UKA. Metal-backed tibial components should be favourite instead of all-polyethylene tibial components to avoid polyethylene creep that may occur in fixed bearings. Moreover, a proper thickness of the polyethylene layer is mandatory, in order to avoid early failure.     

Fixation of Mitchell’s osteotomy with bioabsorbable pins for treatment of hallux valgus deformity

We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.     

Is obesity A contra-indication for a successful total knee arthroplasty?

BackgroundTotal Knee Arthroplasty (TKA) is one of the most effective treatment modalities for chronic knee pain and disability. A strong association exists between obesity and early knee osteoarthritis. Various studies on outcomes of TKA in obese patients have been inconclusive. The purpose of this retrospective evaluation is to assess the influence of obesity on outcomes of TKA in Indian patients.MethodsThis retrospective study conducted from 2010 to 2016 included 402 knees in 213 patients with Body Mass Index (BMI) between 30 and 39.99 kg/m² followed up for a minimum of 12 months. All cases of revision TKAs and those with follow up less than a year were excluded from the study. Patients were followed up regularly for examining their wound healing, post operative complications if any and knee range of motion. Regular radiographs were taken to observe any evidence of loosening. Post-operative knee society scores(KSS) were recorded at each follow up. Improvement in the scores and activity level was noted.ResultsThe objective KSS improved from 55.88 to 93.01 at the last follow up while the functional scores improved from 52.91 to 80.63. Post surgery improvement in activity level was seen in 71.83% patients. Complications seen in the study included patello-femoral pain, superficial wound infections, deep vein thrombosis and delayed wound healing. No cases of deep infection or revision surgeries were seen in our series.ConclusionsThe outcome of TKA in non-morbidly obese patients is comparable to non-obese patients with excellent post-operative objective and functional scores. The benefits are sustainable over a long duration of time. The complication rates in obese patients is no different than non-obese patients.     

Is extreme flexion of the knee after total knee replacement a prerequisite for patient satisfaction?

The focus of this study was to evaluate the functional result and to specifically ascertain whether the absence of the ability to squat and sit cross-legged altered the patient's satisfaction level after a successful standard total knee replacement. Squatting and sitting cross-legged are common practices in Asia. These activities are not possible following standard total knee replacement. Patients were followed-up for a minimum of 12 months post surgery. Their level of satisfaction was assessed using a Likert scale. The Knee Society Score (KSS) was used to assess range of motion and function of the knee. Twenty-one out of 25 patients were satisfied with the surgical result in spite of an inability to squat. Deep knee flexion may not be an essential prerequisite for patient satisfaction after total knee replacement, even in a population where squatting and sitting cross-legged are part of the normal lifestyle.