Ulnar shortening osteotomy (USO) is a procedure performed to alleviate ulnar sided wrist pain caused by ulnar impaction syndrome (UIS) and/or triangular fibrocartilage complex (TFCC) injury. Presently, non-union rates for ulnar shortening osteotomy is quoted to be 0–18% in the literature. However, there is a dearth of literature on the effect of site of osteotomy and plate placement on the rate of complications like a delayed union, symptomatic hardware and need for second surgery for hardware removal. In this study, we performed a multi-centered institutional review of ulnar shortening osteotomies performed, focusing on plate placement (volar vs. dorsal) and osteotomy site (distal vs. proximal) and determining if it plays a role in reducing complications. This study was a multi-centered retrospective chart review. All radiographs and charts for patients that have received USO for UIS or TFCC injury between 2013 and 2017 from hand and wrist fellowship-trained surgeons in Calgary, Alberta and Winnipeg, Manitoba were examined. Basic patient demographics including age, sex, past medical history, and smoking history were recorded. Postoperative complications such as delayed union, non-union, infection, chronic regional pain syndrome, hardware irritation requiring removal were evaluated with a two-year follow-up period. Osteotomy sites were analyzed based on the location in relation to the entire length of the ulna on forearm radiographs. Surgical techniques including volar vs. dorsal plating, oblique vs. transverse osteotomy cuts, and plate type were documented. Continuous variables of interest were summarized as mean or medians with standard deviation or inter-quartile range as appropriate. Differences in baseline characteristics were determined by t-test or one-way ANOVA for continuous variables and chi-square or Fischer exact test for dichotomous variables. All analyses were conducted using SPSS V24.0 (Chicago, IL, USA). All statistical tests were considered significant if p < 0.05. Between 2013–2017 there were 117 ulnar shortening osteotomies performed. The average age of patients was 46.2 ± 16.2, with 62.4% being female. The mean pre-operative ulnar variance was +3.89 ± 2.17 mm and post-operative ulnar variance was −1.90 ± 1.80 mm. 84.6% of the plates were placed on the volar aspect of the ulna and 14.5% were placed on the dorsal aspect. An oblique osteotomy was made 99.1% of the time. In measuring osteotomy placement, the average placement was made in the distal 1/3 of the ulna. Overall, there was a 40% complication rate. Hardware irritation requiring removal encompassed 23%, non-union 14%, and wound infection covered 0.8%. When comparing dorsal vs volar plating, there was no statistically significant difference for non-union or hardware removal. Similarly, in evaluating osteotomy level, there was no statistical difference between proximal vs
Introduction. Limb deformity is usually assessed clinically assisted by long leg alignment radiographs and further imaging modalities (MRI and CT). Often decisions are made based on static imaging and simple gait interpretation in clinic. We have assessed the value of gait lab analysis in surgical decision making comparing surgical planning pre and post gait lab assessment. Materials & Methods. Patients were identified from the local limb reconstruction database. Patients were reviewed in the outpatient clinic and long leg alignment radiographs and a CT rotational limb profile were performed. A surgical plan was formulated and documented. All patients then underwent a formal gait lab analysis. The gait lab recommendations were then compared to the initial plan. Results. Twelve patients (8 female) with mean age of 14 (range 12–16) were identified. Nine were developmental torsional malalignments, one arthrogryposis, one hemiparesis secondary to spinal tumour resection and one syndromic limb deficiency. The gait lab recommended conservative management in four patients and agreed with eight surgical plans with one osteotomy level changing. Five patients are post-operative: two bilateral
Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous
We present a retrospective review of a single-surgeon series of 30 consecutive lengthenings in 27 patients with congenital short femur using the Ilizarov technique performed between 1994 and 2005. The mean increase in length was 5.8 cm/18.65% (3.3 to 10.4, 9.7% to 48.8%), with a mean time in the frame of 223 days (75 to 363). By changing from a distal to a proximal osteotomy for lengthening, the mean range of knee movement was significantly increased from 98.1° to 124.2° (p = 0.041) and there was a trend towards a reduced requirement for quadricepsplasty, although this was not statistically significant (p = 0.07). The overall incidence of regenerate deformation or fracture requiring open reduction and internal fixation was similar in the distal and proximal osteotomy groups (56.7% and 53.8%, respectively). However, in the proximal osteotomy group, pre-placement of a Rush nail reduced this rate from 100% without a nail to 0% with a nail (p <
0.001). When comparing a
The purpose of this study was to evaluate and to compare the mechanical stability of external fixation with and without ankle spanning fixation using a foot plate in an in-vitro model of periarticular
Distal radius fracture is one of the most common fractures in older women (∼70,000 cases annually in Canada). Treatment of this fracture has been shifting toward surgery (mainly volar locking plate (VLP) technology), which significantly enhances surgeon's ability to maintain correction. However, current surgical outcomes are far from perfect. There is a need for an implant which maintains the corrected position (reduction), minimizes soft tissue disruption, and is technically easy to perform. A novel internal, composite-based implant was designed to achieve these ends. It is unclear, however, whether this novel implant offers similar fracture fixation as the VLP. As such, the objective of this research was to evaluate the fracture stability (assessed by calculating change in fracture length) of the novel implant and VLP under cyclic fatigue loading. Specimens: Seven radius specimens derived from older female cadavers (mean = 82.3 years, SD = 11.3 years) were used for the experiment. Preparation: A standardized dorsal wedge was removed from the cortex. The distance from the proximal and
Biological reconstruction techniques after diaphyseal tumour resection have increased in popularity in recent years. High complication and failure rates have been reported with intercalary allografts, with recent studies questioning their role in limb-salvage surgery. We developed a technique in which large segment allografts are augmented with intramedullary cement and fixed using compression plating. The goal of this study was to evaluate the survivorship, complications and functional outcomes of these intercalary reconstructions. Forty-two patients who had reconstruction with an intercalary allograft following tumour resection between 1989 and 2010 were identified from our prospectively collected database. Allograft survival, local recurrence-free, disease-free and overall survival were assessed using the Kaplan-Meier method. Patient function was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS). The 23 women and 19 men had a mean age of 33 years (14–77). The most common diagnoses were osteosarcoma (n=16) and chondrosarcoma (n=9). There were 9 humerus, 18 femur and 15 tibia reconstructions. At a mean follow-up of 95 months (5–288), 31 patients were alive without disease, 10 were dead of disease and 1 was deceased of other causes. There were 4 local recurrences and 11 patients developed metastatic disease. 5-year local recurrence free survival was 92%, 5-year disease-free survival was 70% and overall survival was 75%. Fourteen of 42 patients (33%) experienced complications: 5 wound healing complications, 4 infections, 2 non-unions, 2 fractures and 1 nerve palsy. Four allografts (9.5%) were revised for complications and 2 (5%) for local recurrence. Mean allograft survival was 85 months (4–288). Mean time to union was 8.2 (3–36) months for the proximal osteotomy site and 8.1 (3–23) months for the
Following a careful in-depth preoperative plan for revision TKR, the first surgical step is adequate exposure. The following steps should be considered: 1.) Prior incisions: due to the medially based vascular supply to the skin and superficial tissues about the knee, consideration for use of the most LATERAL incision should be made. 2.) Avoid the use of flaps which may compromise the skin and soft tissue. 3.) Exposure options can be broken down into: PROXIMALLY based techniques: medial parapatella arthrotomy, establish medial and lateral gutters, eversion or subluxation of the patella, extension of arthrotomy proximal, if unable to “mobilise” patella, consider inside out lateral release, if still unable to mobilise: QUAD SNIP, in rare instances, connect lateral release with quad snip resulting in a V-Y quadplasty, may now turn down for excellent exposure. DISTALLY based techniques: tibial tubercle osteotomy technique described by Whiteside, roughly 8 cm osteotomy segment with
Background. Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at mean 24-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) for the treatment of distal radius fractures. Materials and methods. We performed a prospective study including all patients who were treated for unstable distal radius fracture with a CFR-PEEK volar fixed angle plate. We included 70 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 35 fractures were type C1, 13 were type C2, 6 were type C3, 5 were type B1 and 11 were type B2. Results. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 5.2 points. The average grip strength, expressed as a percentage of the contralateral limb, was 94 %. Three cases of hardware breakage were reported. Two cases were due to intraoperative plate rupture caused by the attempt to achieve the reduction of the fracture in 1 case and while inserting a distal screw in the other case. In the last case hardware breakage was caused by a fall on the injuried arm 1 week after surgery. No cases of loss of the surgically achieved fracture reduction were documented. Hardware removal was performed in 3 cases, for the occurrence of extensor tenosynovitis in 2 patients and tenosynovitis of flexor pollicis longus in 1 case. Conclusion. The major advantage of CFR-PEEK plate is its radiolucency. This characteristic allows direct visualization of osseous callus formation, allowing monitoring of the healing of the fracture, thereby improving clinical assessment and accuracy. Therefore, specific indications for this new radiolucent plate can be represented by fractures with significant metaphyseal comminution and in cases of nascent malunion where a
Recent Department of Health guidelines have recommended that bunion surgery should be performed as a day case in a bid to reduce hospital costs, yet concurrently improving patient outcomes. Following an audit in 2012/3, we implemented a number of measures in a bid to improve the rates of day case first ray surgery. In this paper, we look to see if these measures were effective in reducing the length of stay in first ray surgery. We performed a prospective case note review of all patients undergoing first ray surgery between 01/01/2012 and 01/02/2013, and found the rates of same day discharge in this group to be lower than expected at just 24.19%. We recognised that the most commonly cited reasons for delayed discharge were that patients not being assessed by physiotherapy, and were unable to have their take home medication (TTO's) dispensed as pharmacy had closed. To address this, we implemented a pre-operative therapy led foot school, and organised ward analgesia packs which may be dispensed by ward staff, thus bypassing the need for pharmacy altogether. Together, we coined the term “care package” for these measures. We then performed a post implementation audit between 01/01/2014 to 01/01/2015 to ascertain if these measures had been effective. We identified 62 first ray procedures in the preliminary audit, with an average age of 50.5 years (range 17–78 years) and a M:F ratio of 1:5. The most commonly performed procedures were Scarf osteotomy, 1st MTPJ fusion, and
Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score.Aims
Patients and Methods
Chevron osteotomy is a commonly performed procedure for the treatment of hallux valgus and results in AVN of the first metatarsal head in up to 20% of cases. This study aims to map out the arrangement of vascular supply to the first metatarsal head and its relationship to the limbs of the chevron cuts. Ten cadaveric lower limbs were injected with an Indian ink/latex mixture and the feet dissected to evaluate the blood supply to the first metatarsal. The dissection was carried out by tracing the branches of dorsalis pedis and posterior tibial vessels. A
A fracture of the distal radius may lead to malunion of bone segments, which gives discomfort to the patient and may lead to chronic pain, reduced range of motion, reduced grip strength and finally to early osteoarthritis. A treatment option to realign the bone segments is a corrective osteotomy. In this procedure the surgeon tries to improve alignment by cutting the bone at, or near, the fracture location and by fixating the bone segments in an improved position, using a plate and screws. Standard corrective osteotomy of the distal radius is most often planned using two orthogonal radiographs to find correction parameters for restoring the radial inclination, palmar tilt and ulnar variance, to normal. However, 2D imaging techniques hide rotations about the bone axis and may therefore cause a misinterpretation of the correction parameters. We present a new technique that uses preoperative 3-D imaging techniques to plan positioning and to design a patient-tailored fixation plate that only fits in one way and realigns the bone segments as planned in six degrees of freedom. The procedure uses a surgical guide that snugly fits the bone geometry and allows predrilling the bone at specified positions, and cutting the bone through a slit at the preoperatively planned location. The patient-tailored plate fits the same bone geometry and uses the predrilled holes for screw fixation. The method is evaluated experimentally using artificial bones and renders realignment highly accurate and very reproducible (derr < 1.2 ± 0.8 mm and ϕerr < 1.8 ± 2.1°). In addition, the new method is evaluated clinically (n=1) and results in accurate positioning (derr ≤ 1.0 mm and ϕerr ≤ 2.6°). Besides using a patient-tailored plate for corrective
After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. The contralateral unaffected radius is often used as a reference in planning of a corrective osteotomy procedure of a malunited distal radius. In the conventional procedure, radiographs of both the affected radius and the contralateral radius have been used for planning. The 2D nature of radiographs renders them sub-optimal for planning due to overprojection of anatomical structures. Therefore, computer-assisted 3D planning techniques have been developed recently based on CT images of both forearms. The accuracy of using the contralateral forearm for CT based 3D planning the surgery of the affected arm and the optimal strategy for planning have not been studied thoroughly. To estimate the accuracy of the planned repositioning using the contralateral forearm we investigated bilateral symmetry of corresponding radii and ulnae using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography scan of both forearms. The left radius and ulna were segmented to create virtual 3 dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored CT-image of the contralateral side. This allowed estimation of the accuracy by calculation of relative displacements (Δx, Δy, Δz) and rotations (Δψx, Δψy, Δψz) required to align the left bone with the right bone segments as a reference. We also investigated the relationship between longitudinal length differences in radius and ulna and utilised this relationship to arrive at an optimal planning of the length of the affected radius after surgery. Relative differences in displacement and orientation parameters after planning based on the contralateral radius were (Δx, Δy, Δz): −0.81±1.22 mm, −0.01±0.64 mm, and 2.63±2.03 mm; and (Δψx, Δψy, Δψz): 0.13°±1.00°, −0.60°±1.35°, and 0.53°±5.00°. The same parameters for the ulna were (Δx,Δy, Δz): −0.22±0.82 mm, 0.52±0.99 mm, 2.08±2.33 mm; and (Δψx, Δψy, Δψz): −0.56°±0.96°, −0.71°±1.51°, and −2.61°±5.58°. The results also point out that there is a strong linear relationship between absolute length differences (Δz) of the radius and ulna among the individuals. Since we observed substantial length difference of the longitudinal bone axes of both forearms in healthy individuals, including the length difference of the adjacent forearm bones in the planning turned out to be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies. The improved planning markedly reduces length positioning variability, (from 2.9± 2.1 mm to 1.5 ± 0.6 mm). We expect this approach to be valuable for 3-D planning of a corrective
Femoral lengthening using the Intramedullary Skeletal Kinetic Distractor is a new technique. However, with intramedullary distraction the surgeon has less control over the lengthening process. Therefore, 33 femora lengthened with this device were assessed to evaluate the effect of operative variables under the surgeon’s control on the course of lengthening. The desired lengthening was achieved in 32 of 33 limbs. Problems encountered included difficulty in achieving length in eight femora (24%) and uncontrolled lengthening in seven (21%). Uncontrolled lengthening was more likely if the osteotomy was placed with less than 80 mm of the thick portion of the nail in the distal fragment (p = 0.052), and a failure to lengthen was more likely if there was over 125 mm in the distal fragment (p = 0.008). The latter problem was reduced with over-reaming by 2.5 mm to 3 mm. Previous intramedullary nailing also predisposed to uncontrolled lengthening (p = 0.042), and these patients required less reaming. Using the Intramedullary Skeletal Kinetic Distractor, good outcomes were obtained; problems were minimised by optimising the position of the osteotomy and the amount of over-reaming performed.