Prior Pelvic Osteotomy Affects the Outcome of Subsequent Total Hip Arthroplasty

BackgroundAlthough pelvic osteotomy (PO) is an important surgical procedure that can alleviate symptoms and potentially slow progression of osteoarthritis in patients with development dysplasia of the hip, some patients eventually require conversion to total hip arthroplasty (THA). This study aimed to determine the outcome of conversion THA in patients with prior PO.MethodsForty nine patients with a history of prior PO who underwent conversion THA at a single institution were matched at a 1:3 ratio based on the date of surgery, age, gender, and body mass index with 147 developmental dysplasia of the hip patients who underwent primary THA without prior PO. A retrospective chart review was performed to compare outcomes at a minimum follow-up of 2 years.ResultsPatients with prior PO required more supplemental screw fixation for the acetabular component (59.2% vs 38.1%, P = .016), more autologous bone grafting (24.5% vs 11.6%, P = .048), had a longer mean operative time (106.0 vs 79.8 minutes, P < .001), and greater estimated blood loss (350.0 vs 206.8 mL, P = .015). Patients with prior PO had smaller cup version angle (26.0° vs 29.0°, P = .012) and greater discrepancy in the limb length (10.3 vs 7.26 mm, P = .041). Eight hips (16.3%) with prior PO and 6 (4.1%) without osteotomy required reoperation (P = .008). There was no difference in outcome scores at the latest follow-up.Conclusion: THA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.ConclusionTHA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.     

High Rates of Spacer Fracture in the Setting of Extended Trochanteric Osteotomy With a Specific Thin-Core Articulating Antibiotic Hip Spacer

BackgroundTwo-stage revision remains the standard of care for prosthetic joint infection after total hip arthroplasty. However, there are substantial complications associated with articulating antibiotic hip spacers. Handmade and molded spacers have been shown to have higher rates of spacer fracture than antibiotic-coated prostheses (ACPs). The aim of this study is to review outcomes with an implant that is often categorized as an ACP spacer, the Zimmer-Biomet StageOne Select Femoral Spacer (ZBSO).MethodsA retrospective review was performed of 63 patients who underwent placement of a ZBSO. Patients were compared based on whether or not an extended trochanteric osteotomy (ETO) was performed using Fisher’s exact and t-tests.ResultsFive patients were excluded due to lack of follow-up or death shortly after stage 1 surgery, leaving 58 patients. Spacer fracture was noted in 5 of 58 patients (8.6%). Sixteen patients underwent ETO and 25.0% suffered a spacer fracture compared to 2.3% without ETO (odds ratio 13.7, P = .0248). There was no association between patient demographics or ETO length and spacer fracture. Two patients had periprosthetic fractures (3.4%) and 4 had dislocations (6.9%). Forty-nine patients (84.4%) went on to second-stage revision; of those 26.5% failed to clear the infection and required an average of 2.2 additional surgeries.ConclusionThe ZBSO spacer has overall complication rates similar to previously reported spacer series. Although the ZBSO looks like an ACP spacer, in the setting of ETO, it behaves like a molded or handmade spacer with a high rate of spacer fracture (25%) due to the small diameter of the core. This implant should be used with caution in combination with an ETO.     

Role of high tibial osteotomy in medial compartment osteoarthritis of the knee: Indications,surgical technique and outcomes

Knee osteoarthritis (OA) is the most common joint disorder worldwide. In particular, primary knee OA often presents with a varus malalignment. This increases the loads going through the medial compartment resulting in cartilage degeneration and symptomatic arthritis. High tibial osteotomy (HTO) is the workhorse surgical procedure for treating medial knee OA. When performed precisely in the hands of an experienced surgeon, HTO can delay or avoid knee arthroplasty. Of note, outcomes of knee arthroplasty are at best unpredictable in patients of younger age. Hence, there is a growing need for joint preservation procedures for younger patients presenting with knee OA, of which HTO is one. Through this article, the authors of whom all are joint preservation surgeons with a special interest in osteotomy hope to share from their experience as well as the available literature on the indications, perioperative planning, surgical technique, outcomes as well as pearls and pitfalls of HTO.     

Comprehensive review of surgical approaches to the elbow

The choice of the most suitable surgical approach to the elbow forms the foundation of any successful elbow surgery. The surgical approach is based on the injury or pathology to be addressed and therefore specific anatomical details need to be considered. The surgeon must be comfortable with the bony, ligamentous and neurovascular anatomy of the elbow to consider and execute the best approach for each problem. This is an imperative to avoid iatrogenic injury.This article provides a detailed analysis, valuable technical tips, advantages and disadvantages of the most common approaches to the elbow. The lateral approaches include the Kocher, Kaplan and Extensor Digitorum Communis (EDC) Split approaches, the medial approaches include the Hotchkiss, Flexor carpi ulnaris (FCU) splitting approach, the Taylor and Scham approach. The anterior approach includes the anterior neurovascular interval approach and the posterior approaches include the Olecranon osteotomy, triceps sparing, triceps reflecting approach and finally the Boyd interval approach. The text and illustrations will provide a structured overview for the practicing surgeon.     

Longer Term Outcomes Following High Tibial Osteotomy for Osteoarthritis: A Prospective,Multi-Centre Observational Study Comparing Tomofix and OPTY-LINE Devices

PurposeAssessing surgical accuracy and patient-recorded outcome measures for patients fitted with either the OPTY-LINE intramedullary realignment system or the Tomofix plate for medial opening wedge high tibial osteotomy (HTO).Patients and methodsTwo matched case series of patients with symptomatic medial compartment osteoarthritis without other significant knee pathology. One group comprised of 19 patients receiving the Tomofix plate, whereas another comprised of 12 patients receiving the OPTY-LINE intramedullary nail. Patella-centred long leg alignment radiographs were assessed to calculate surgical accuracy in all cases. Patients completed knee injury osteoarthritis outcome scores (KOOS) and osteotomy surgery patient satisfaction questionnaires pre-operatively and at 24 months post-surgery.ResultsAbsolute surgical accuracy at 2 years post-surgery was a mean 4.2 [standard deviation 3.7] for OPTY-LINE versus 9.2 [SD 7.8] for Tomofix (p = 0.11, Mann–Whitney U test). On average, patients in either the OPTY-LINE or Tomofix cohort reported at least a minimal perceptible clinical improvement—minimum average improvement of 15—for all five KOOS themes. No significant difference in change of KOOS scores over time or patient satisfaction levels were observed between the two cohorts.ConclusionThe OPTY-LINE device for HTO performs to a similar level as the Tomofix device. Surgical accuracy data are promising for OPTY-LINE, but does not seem to readily translate into difference in patient-reported outcomes compared to Tomofix. Even longer follow-up periods, to measure survival rates, and true randomised trials on larger samples can elucidate if there is a benefit for using one device over the other.     

尺骨截骨位置不同对手术治疗儿童陈旧性孟氏骨折预后的影响

目的 探讨手术治疗儿童陈旧性孟氏骨折尺骨截骨点位置不同对疗效的影响。方法 回顾性队列研究。纳入2015年6月—2021年6月安徽省儿童医院骨科收治的68例儿童陈旧性孟氏骨折患者的临床资料,其中男42例、女26例,年龄3~12（6.6±2.4）岁。受伤至手术时间1~60个月,平均8.6个月。BadoⅠ型骨折60例,Ⅲ型8例。患儿均采用尺骨近端截骨矫形治疗,术中选择尺骨畸形最明显处截断尺骨,按照截骨点至尺骨近端间距占尺骨全长的比例不同分为3组,A组（占比≤25%）27例、B组（25%<占比<30%）20例、C组（占比≥30%）21例。观察指标：（1）对比3组患儿临床基线资料。（2）对比3组患儿手术时间,观察术后患肘肱桡关系恢复情况,尺骨截骨处愈合情况,以及并发症发生情况。（3）术后定期随访。取出内固定前,测量对比3组患儿肘关节旋前、旋后、伸肘、屈肘角度,采用Kim肘关节功能评分表评估并对比3组患儿肘关节功能;拆除内固定后,采用影像学Nakamura分级标准评估并对比3组患儿肘关节功能。结果 （1）3组患儿性别、年龄、患肢侧别、骨折分型、受伤至手术时间、术前患肢肘关节活动度等基线资料比较,差异均无统计学意义（P值均>0.05）。（2）3组患儿均顺利完成手术,A组手术时间为（100.6±31.7）min,B组为（133.0±24.2）min,C组为（94.9±28.6）min,差异无统计学意义（F=1.02,P=0.367）。术后第3天肘关节正侧位X线片示肱桡关系均恢复正常。A组有1例术后切口感染,予以抗感染治疗后愈合。68例患儿均获得随访,随访时间6~36个月,平均8.7个月。A组术后发生肱桡关节再脱位3例、半脱位3例,B组发生半脱位3例,C组发生半脱位2例、尺骨延迟愈合1例;3组间并发症发生情况比较,差异均无统计学意义（P值均>0.05）。3组患儿尺骨截骨处愈合时间比较,差异无统计学意义（F=0.01,P=0.989）。（3）3组患儿取出内固定前,肘关节旋前、旋后、伸肘、屈肘角度,以及Kim肘关节功能评定比较,差异均无统计学意义（P值均>0.05）。拆除内固定后,影像学Nakamura分级评定肘关节功能比较,3组间差异无统计学意义（Z=1.73,P=0.422）。结论 儿童陈旧性孟氏骨折采用尺骨近端截骨矫形治疗,术中选择尺骨畸形最明显处截断尺骨,尺骨截骨点位置的不同对患儿预后无明显影响。     

后路经椎间隙截骨的临床分型及应用

【摘要】 目的：介绍脊柱后路经椎间隙截骨术（trans-intervertebral space osteotomy,TIO）的技术理念、临床分型和应用策略。方法：根据TIO技术特点、手术操作过程中截骨切除范围所涉及的解剖结构,将其分为3大类型及2种扩大（+）型：围绕椎间盘及关节突关节为Ⅰ型,扩大至楔形切除椎间隙一侧终板为Ⅱ型（头尾双侧终板则为Ⅱ+型）。扩大至楔形切除椎间隙一侧椎弓根为Ⅲ型（双侧椎弓根则为Ⅲ+型）;收集2003年1月~2012年12月接受后路经椎间隙截骨术治疗的30例胸腰椎侧后凸畸形患者的临床资料,其中男12例,女18例,年龄29~69岁（51.4±10.4岁）。由5位脊柱外科医师先后对患者的临床资料进行独立评估与分型（间隔2周）,进行Kappa一致性检验以分析其可信度及可重复性。结果：30例患者中行Ⅰ型TIO 15例,Ⅱ型TIO 6例,Ⅱ+型TIO 3例,Ⅲ型TIO 4例,Ⅲ+型TIO 2例。观察者间一致性的Kappa系数0.806~0.953;观察者内一致性的Kappa系数为0.837~0.953,可信度及可重复性满意。结论：经椎间隙截骨临床分型实用可靠,可作为理论基础用于比较不同研究中经椎间隙截骨技术的手术效果,有利于指导脊柱侧后凸畸形的截骨矫形治疗。     

后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸

【摘要】 目的：评价经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙矫形治疗青少年重度脊柱侧后凸畸形的安全性和早期临床效果。方法：2014年5月~2016年12月对我院15例青少年重度脊柱侧后凸患者行经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙手术治疗,术前仅1例严重脊柱侧后凸患者行头盆环牵引。男6例,女9例,年龄13～18岁（16.1±1.6岁）。其中先天性脊柱侧后凸3例,特发性11例,神经纤维瘤病性1例。术前侧凸Cobb角82°～144°（102.5°±17.6°）,侧凸的柔韧性为6.4％～28.5％[（21.56±5.70）%];后凸50°～95°（68.1°±15.3°）,冠状位躯干偏移距离（C7中垂线与骶骨中垂线距离）2.0～6.8cm（3.40±1.37cm）。术前四肢肌力及感觉均正常。观察治疗效果。结果：椎板楔形截骨5.20±0.56个（4~6个）,松解椎间隙5.20±0.56个（4~6个）,手术时间6.1～7.9h（7.00±0.51h）,术中出血量1050～2500ml（1450.0±521.3ml）。术后侧凸Cobb角18°～40°（28.0°±6.6°）,矫正率72.5%;后凸22°～42°（27.8°±6.1°）,矫正率58.4%;冠状位躯干偏移距离0～2cm（0.85±0.74cm）,矫正率72.8%。随访25～41个月（33.1±5.4个月）。末次随访时侧凸Cobb角19°～43°（30.0°±6.9°）,矫正率70.6%;后凸22°～42°（28.6°±6.5°）,矫正率57.2%;冠状位躯干偏移距离0.2～2.3cm（1.10±0.72cm）,矫正率71.3%。无胸膜破裂,无假关节形成,无内固定断裂及松动,矫正度无显著丢失。1例患者术前骨盆牵引发生钉道感染,经局部换药及抗生素应用,2周后感染控制;1例术后第3天发生十二指肠系膜上动脉综合征,采取禁食水、持续胃肠减压、维持水电解质平衡、左侧卧位,术后2周痊愈;1例T4左侧椎弓根螺钉侵入椎管压迫神经,术后5h发生左下肢不完全性瘫痪,术后8h去除T4左侧椎弓根螺钉,术后5个月左下肢功能完全恢复。结论：采用后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸畸形,不需要剥离椎体侧方胸膜,手术解剖层次表浅和创伤小,不仅有助于增加脊柱柔韧性,而且可提供足够的压缩和闭合空间来矫正脊柱侧后凸,能获得良好的脊柱三维矫正。     

Scarf osteotomy for hallux valgus deformity: Radiological outcome,metatarsal length and early complications in 118 feet

BackgroundScarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia.MethodsWe enrolled 106 patients (118 feet) and assessed patients’ pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted.ResultsHallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45 mm. The Coughlin method showed the highest interrater reliability (ICC = 0.96).ConclusionsSignificant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability.Level of evidenceLevel IV.