Periprosthetic joint infection (PJI) is a challenging complication of any arthroplasty procedure. We reviewed our use of static antibiotic-loaded cement spacers (ABLCSs) for staged management of PJI where segmental bone loss, ligamentous instability, or soft-tissue defects necessitate a static construct. We reviewed factors contributing to their failure and techniques to avoid these complications when using ABLCSs in this context. A retrospective analysis was conducted of 94 patients undergoing first-stage revision of an infected knee prosthesis between September 2007 and January 2020 at a single institution. Radiographs and clinical records were used to assess and classify the incidence and causes of static spacer failure. Of the 94 cases, there were 19 primary total knee arthroplasties (TKAs), ten revision TKAs (varus-valgus constraint), 20 hinged TKAs, one arthrodesis (nail), one failed spacer (performed elsewhere), 21 distal femoral endoprosthetic arthroplasties, and 22 proximal tibial arthroplasties.Aims
Methods
Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique. 89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months. All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies. Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity.
Charcot neuroarthropathy is a debilitating condition that frequently leads to skeletal instability, and has an increased risk of ulceration leading to infection and amputation. However, surgical reconstruction may offer limb salvage and restauration of an ulcer-free, plantigrade stable foot for functional weight-bearing. We report on our case series according to a prospective protocol and analyse factors leading to a favourable outcome. We report a prospective follow-up of 62 patients undergoing Charcot reconstruction, May 2014- Jan 2022, by two surgeons. Peripheral vascular disease was routinely assessed using Duplex scan and major arterial disease was treated before reconstruction. Utilising 3D modelling, pre-operative planning and standardised osteotomies, we performed anatomical correction with radiological evidence. Definitive fixation was undertaken with internal fixation to stabilise the hindfoot. Multivariant analysis was performed to assess risk factors for failure (P>0.05 statistical significance).Introduction
Methods
Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the five-year clinical and radiological outcomes following third-generation MIS hallux valgus surgery. A retrospective observational single surgeon case series of consecutive patients undergoing primary isolated third-generation percutaneous Chevron and Akin osteotomies (PECA) for hallux valgus with a minimum 60 month clinical and radiographic follow up. Primary outcome was radiographic assessment of the hallux valgus angle (HVA) and intermetatarsal angle (IMA) pre-operatively, 6 months and ≥60 months following PECA. Secondary outcomes included the Manchester-Oxford Foot Questionnaire, patient satisfaction, Euroqol-5D Visual Analogue Scale and Visual Analogue Scale for Pain.Background
Methods
There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures.Background
Objective
The April 2024 Foot & Ankle Roundup360 looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.
Aims. Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model. Methods. Staphylococcus aureus was inoculated into a humeral osteotomy in 17 rabbits after plate osteosynthesis. Infection developed for one week (early group, n = 6) or four weeks (delayed group, n = 6) before DAIR (systemic antibiotics: two weeks, nafcillin + rifampin; four weeks, levofloxacin + rifampin). A control group (n = 5) received revision surgery after four weeks without antibiotics. Bacteriology of humerus, soft-tissue, and implants was performed seven weeks after revision surgery. Bone healing was assessed using a modified radiological union scale in tibial fractures (mRUST). Results. Greater bacterial burden in the early group compared to the delayed and control groups at revision surgery indicates a retraction of the infection from one to four weeks. Infection was cleared in all animals in the early and delayed groups at euthanasia, but not in the control group.
Changes in posterior tibial slope (PTS) and patellar height (PH) following proximal tibial osteotomies have been a recent focus for knee surgeons. Increased PTS and decreased PH following medial opening wedge high tibial osteotomy (MOWHTO) have been repeatedly reported in the literature. However, this has been disputed in more recent biomechanical studies. A total of 62 cases who underwent MOWHTO were included. Surgery was performed using a dedicated step-by-step protocol focusing on the risks of unintentional slope changes. Clinically, all patients were evaluated preoperatively and at 2 years follow-up with the KOOS scores and UCLA physical activity scale. Preoperative and postoperative radiographic lower limb alignment parameters were measured on full-length lower limb radiographs, including (HKA), (MPTA), (mLDFA), proximal posterior tibial angle (PPTA), (JLCA) and(JLO). PH measurements were assessed on radiographs.Abstract
Introduction
Methodology
Several emerging reports suggest an important involvement of the hindfoot alignment in the outcome of knee osteotomy. At present, studies lack a comprehensive overview. Therefore, we aimed to systematically review all biomechanical and clinical studies investigating the role of the hindfoot alignment in the setting of osteotomies around the knee. A systematic literature search was conducted on multiple databases combining “knee osteotomy” and “hindfoot/ankle alignment” search terms. Articles were screened and included according to the PRISMA guidelines. A quality assessment was conducted using the Quality Appraisal for Cadaveric Studies (QUACS) - and modified methodologic index for non-randomized studies (MINORS) scales. Three cadaveric, fourteen retrospective cohort and two case-control studies were eligible for review. Biomechanical hindfoot characteristics were positively affected (n=4), except in rigid subtalar joint (n=1) or talar tilt (n=1) deformity. Patient symptoms and/or radiographic alignment at the level of the hindfoot did also improve after knee osteotomy (n=13), except in case of a small pre-operative lateral distal tibia- and hip knee ankle (HKA) angulation or in case of a large HKA correction (>14.5°). Additionally, a pre-existent hindfoot deformity (>15.9°) was associated with undercorrection of lower limb alignment following knee osteotomy. The mean QUACS score was 61.3% (range: 46–69%) and mean MINORS score was 9.2 out of 16 (range 6–12) for non-comparative and 16.5 out of 24 (range 15–18) for comparative studies.
Conventional proximal tibial osteotomy is a widely successful joint-preserving treatment for osteoarthritis; however, conventional procedures do not adequately control the posterior tibial slope (PTS). Alterations to PTS can affect knee instability, ligament tensioning, knee kinematics, muscle and joint contact forces as well as range of motion. This study primarily aimed to provide a comprehensive investigation of the variables influencing PTS during high tibial osteotomy using a 3D surgical simulation approach. Secondly, it aimed to provide a simple means of implementing the findings in future 3D pre-operative planning and /or clinically. The influence of two key variables: the gap opening angle and the hinge axis orientation on PTS was investigated using three independent approaches: (1) 3D computational simulation using CAD software to perform virtual osteotomy surgery and simulate the post-operative outcome. (2) Derivation of a closed-form mathematical solution using a generalised vector rotation approach (3) Clinical assessment of synthetically generated x-rays of osteoarthritis patients (n=28; REC reference: 17/HRA/0033, RD&E NHS, UK) for comparison against the theoretical/computational approaches. The results from the computational and analytical assessments agreed precisely. For three different opening angles (6°, 9° and 12°) and 7 different hinge axis orientations (from −30° to 30°), the results obtained were identical. A simple analytical solution for the change in PTS, ΔPs, based on the hinge axis angle, α, and the osteotomy opening angle, θ, was derived: ΔPs=sin-1(sin α sin θ) The clinical assessment demonstrated that the absolute values of PTS, and changes resulting from various osteotomies, matched the results from the two relative prediction methods. This study has demonstrated that PTS is impacted by the hinge axis angle and the extent of the osteotomy opening angle and provided computational evidence and analytical formula for general use.
The aims of this study were to characterize the incidence and risk factors associated with stress fractures following periacetabular osteotomy, and to determine their effect on osteotomy union. We retrospectively reviewed all periacetabular osteotomies (PAOs) performed for developmental dysplasia of the hip (DDH) at one institution over a six-year period between 2012 and 2017. Perioperative factors were recorded, and included demographic and surgical data. Postoperatively, patients were followed for a minimum of one year with anteroposterior and false profile radiographs of the pelvis to monitor for evidence of stress fracture and union of osteotomies. We characterized the incidence and locations of stress fractures, and used univariate and multivariable analysis to identify factors predictive of stress fracture and the association of stress fracture on osteotomy union.Aims
Methods
Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23).Introduction
Materials and Methods
Complex spinal deformities can cause pain, neurological symptoms and imbalance (sagittal and/or coronal), severely impairing patients’ quality of life and causing disability. Their treatment has always represented a tough challenge: prior to the introduction of modern internal fixation systems, the only option was an arthrodesis to prevent worsening of the deformity. Then, the introduction of pedicle screws allowed the surgeons to perform powerful corrective manoeuvres, distributing forces over multiple levels, to which eventually associate osteotomies. In treating flexible coronal deformities, in-ternal fixation and corrective manoeuvres may be sufficient: the combination of high density pedicle screws and direct vertebral rotation revolutionized surgical treatment of scoliosis. However, spinal osteotomies are needed for correcting complex rigid deformities; the type of osteot-omy must be chosen according to the aetiology, type and apex of the deformity. When dealing with large radius deformities, spread over multiple levels and without fusion, multiple posterior column os-teotomies such as Smith-Petersen and Ponte (asymmetric, when treating scoliosis) can be performed, dissipating the correction over many levels. Conversely, the management of a sharp, angulated de-formity that involves a few vertebral levels and/or with bony fusion, requires more aggressive 3 col-umn osteotomies such as Pedicle Subtraction
Pelvic re-orientation osteotomy is a well-recognised treatment of young adults with developmental dysplasia of the hip (DDH). The most commonly used technique is the periacetabular osteotomy (PAO), however, some surgeons favour a triple osteotomy. These techniques can also be utilised for acetabular retroversion leading to FAI. Despite the published literature on these techniques, the authors note a scarcity of evidence looking at patient reported outcome measures (PROMs) for these procedures. This was a retrospective analysis of prospectively collected data utilising the UK NAHR. All patients who underwent pelvic osteotomy from January 2012 to November 2019 were identified from the NAHR database. Patients who consented to data collection received EQ-5D index and iHOT-12 questionnaires, with scores being collected pre-operatively and at 6, 12 and 24 months post-operatively. Nine hundred and eleven (911) patients were identified with twenty-seven (27) undergoing a triple osteotomy, the remaining patients underwent PAO. Mean age was 30.6 (15–56) years and 90% of patients were female. Seventy-nine (79) (8.7%) of patients had the procedure for acetabular retroversion leading to FAI Statistical analysis, of all patients, showed significant improvement (p<0.001) for; iHOT-12 scores (+28 at 6-months, +33.8 at 12-months and +29.9 at 24-months) Similarly there was significant improvement (p<0.001) in EQ-5D index (+0.172 at 6-months, +0.187 at 12-months and +0.166 at 24-months) Pre-operatively, and at each follow-up time-period, raw scores were significantly better in the DDH group compared to the FAI group (p<0.05); however, the improvement in scores was similar for both groups. For both scoring measures, univariable and multivariable linear regression showed poorer pre-operative scores to be strongly significant predictors of greater post-operative improvement at 6 and 12 months (p<0.0001). This study shows that pelvic osteotomy is a successful treatment for DDH and FAI, with the majority of patients achieving significant improvement in outcome scores which are maintained up to 24 months post-operatively. The patients with FAI have significantly reduced raw scores preoperatively and, perhaps, are functionally more limited.Conclusions/Discussion
Fracture fixation has advanced significantly with the introduction of locked plating and minimally invasive surgical techniques. However, healing complications occur in up to 10% of cases, of which a significant portion may be attributed to unfavorable mechanical conditions at the fracture. Moreover, state-of-the-art plates are prone to failure from excessive loading or fatigue. A novel biphasic plating concept has been developed to create reliable mechanical conditions for timely bone healing and simultaneously improve implant strength. The goal of this study was to test the feasibility and investigate the robustness of fracture healing with a biphasic plate in a large animal experiment. Twenty-four sheep underwent a 2mm mid-diaphyseal tibia osteotomy stabilized with either the novel biphasic plate or a control locking plate. Different fracture patterns in terms of defect location and orientation were investigated. Animals were free to fully bear weight during the post-operative period. After 12 weeks, the healing fractures were evaluated for callus formation using micro-computer tomography and strength and stiffness using biomechanical testing. No plate deformation or failures were observed under full weight bearing with the biphasic plate.
To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management. We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire.Aims
Methods
Treatment of segmental bone defects remains a major clinical problem, and innovative strategies are often necessary to successfully reconstruct large volumes of bone. When fractures occur, the resulting hematoma serves as a reservoir for growth factors and a space for cell infiltration, both crucial to the initiation of bone healing. Our previous studies have demonstrated very clear ultrastructural differences between fracture hematomas formed in normally healing fractures and those formed in segmental bone defects. However, there is little information available regarding potential differences in the underlying gene expression between hematomas formed in normal fractures, which usually heal by themselves, and segmental bone defects, which do not. Therefore, the aim of this study was to identify differences in gene expression within hematomas collected from 0.5 mm (normal fracture) and 5 mm (segmental bone defect) fracture sites during the earliest stages of bone healing.
During a periacetabular osteotomy (PAO), intra-operative assessment of correction of acetabular parameters is typically performed using fluoroscopy of the hip, a technique that has not been shown to produce predictable measurements. Furthermore, paralysing agents are used in order to facilitate dissection and fragment mobilization. The effect of paralysing agents on spino-pelvic posture is yet to be investigated. This study aims to: 1. Compare the reliability of intra-operative x-rays versus hip fluoroscopy in the assessment of acetabular fragment correction and 2. Evaluate the effect of changes in spino-pelvic alignment on the assessment of acetabular correction. An IRB approved, retrospective review of all patients who underwent a PAO at our institution between 2006–2018 was performed. Patient demographic data was collected and all available imaging studies were retrieved. Patients were excluded if there was no available to review intra-operative AP pelvis x-ray or intra-operative fluoroscopic PA image of the hip. Using a validated hip analysis software (Hip2Norm), the lateral center edge angle (LCEA) and acetabular index (AI) of plain radiographs were measured. The sacro-femoral-pubic angle (SFP), along with the LCEA and AI of the fluoroscopic image were measured using ImageJ. A oneway ANOVA was used to detect differences between measured parameters in the intra-operative x-ray, the post-operative x-ray and the fluoroscopic image. A total of 93 patients were identified. 26 patients were excluded due to missing data. The mean LCEA in the post-operative, intra-operative, and fluoroscopic groups were as follows: 33.67° (range 5.3° to 52.4°), 30.71°(range 9° to 55.6°), and 29.23°(range 12.4° to 51.4°) respectively. The mean AI in the post-operative, intra-operative, and fluoroscopic groups were as follows: −0.65° (range −18.10° to 27.30°), 0.35°(range −16.10° to 17.20°), and 5.54°(range −11.66° to 27.83°) respectively. When comparing intra-operative to post-operative plain radiographs, there was no statistically significant difference in AI (ΔAI −1±1.29° p=0.71) or LCEA (ΔLCEA 2.95±1.38° p=0.09). When comparing fluoroscopy to post-operative plain radiographs, there was a statistically significant difference in AI (ΔAI −6.21±1.29° p < 0 .0001) as well as LCEA (ΔLCEA 4.44±1.38° p < 0 .0001). Statistical analysis revealed no influence of demographics (age, BMI, gender), on acetabular correction parameters. The mean SPF angles measured from intra-operative and post-operative x-rays were 69.32±5.11° and 70.45±5.52°. There was a statistically significant difference between these 2 measurements with a ΔSFP of 1.03° (p < 0 .0001). The results of our study show that the use of intra-operative x-ray for the assessment of LCEA and AI is more reliable than fluoroscopic images. Further, we found a difference in SFP angle, which offers an indirect assessment of pelvic tilt, between the intra-operative and the post-operative plain x-rays. This suggests that there are changes in pelvic tilt during the surgery, which can be attributed to either patient positioning or changes in spino-pelvic posture secondary to the paralysing agents used by the anesthetists. The use of intra-operative x-rays as well as the effect of paralysing agents on spino-pelvic alignment should be considered by surgeons performing PAO's.
To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA). A consecutive series of 811 ankles (789 patients) that underwent TAA between May 2003 and December 2013 were enrolled. The influence of age on clinical outcome, including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and pain according to the visual analogue scale (VAS) was assessed. In addition, the risk for revision surgery that includes soft tissue procedures, periarticular arthrodeses/osteotomies, ankle joint debridement, and/or inlay exchange (defined as minor revision), as well as the risk for revision surgery necessitating the exchange of any of the metallic components or removal of implant followed by ankle/hindfoot fusion (defined as major revision) was calculated.Aims
Methods