Surgical Treatment of End-Stage Hallux Rigidus Using a Total All-Ceramic Endoprosthesis: A Short-Term case series and literature review.

Aim: Hallux rigidus is a disease characterized by degeneration of the first metatarsophalangeal (MTF-1) joint. The choice of arthroplasty instead of arthrodesis in the surgical treatment of advanced hallux rigidus is still controversial. In this study, we aimed to report the early treatment results of a number of patients who had advanced hallux rigidus and underwent new-generation three-component press-fit total joint arthroplasty. Materials and Methods: The patients were evaluated in terms of degrees of MTF-1 joint dorsiflexion, plantar flexion, and total joint range of motion (ROM), scores of AOFAS, VAS, SF-12 PCS, and satisfaction survey results. The preoperative and postoperative values were analyzed statistically. Radiologically, anteroposterior (AP) and lateral radiographs were taken and examined for loosening, wear, and alignment. Results: Nineteen joints (14 female, 5 male) of 17 patients were included in the study. The mean age was 59 (49–67) years. The mean patient follow-up was 15 (12–22) months. The mean dorsiflexion degree was 12.7° (range 2.1°–22.1°) preoperatively and 30.1° (11.6°–47.3°) postoperatively. The mean plantar flexion degree was 16° (7.8°–24.2°) preoperatively and 9.2° (2.3°–16.5°) postoperatively. The total range of motion (ROM) of the MTF-1 joint improved from a preoperative 28.4° to a postoperative 39.4°. The mean postoperative AOFAS, VAS, and SF-12 PCS scores were calculated as 85.3 (57–96), 1.3 (0–5), and 57.7 (53.7–59.9), respectively. The increase in the patients’ AOFAS and SF-12 PCS scores and the decrease in the VAS scores were found to be statistically significant. Discussion and Conclusion: Advanced MTF-1 joint osteoarthritis is a disease that causes severe pain and loss of motion. The method for a standard surgical treatment is still controversial. It has been reported in the literature that satisfactory results have been achieved in applications of three-component cementless press-fit total prostheses, in contrast to older prosthetic applications that cause serious complications. The pain relief and the increase in AOFAS scores are considered the most successful aspects of the treatment. Based on the information obtained from this study, we think that application of new-generation three-component press-fit total prostheses is an effective method in the treatment of advanced hallux rigidus, and that the early results are satisfactory when it has been applied to appropriate patients.

This article provides a summary of orthopaedic foot and ankle research from September 2021 to September 2022. The included studies were published in The Journal of Bone & Joint Surgery, Foot & Ankle International, Foot and Ankle Surgery, Clinical Orthopaedics and Related Research, the Journal of Orthopaedic Trauma, The American Journal of Sports Medicine, JAMA (Journal of the American Medical Association), The New England Journal of Medicine, The Bone & Joint Journal, and the Journal of the AAOS (American Academy of Orthopaedic Surgeons). Forefoot Minimally invasive techniques involving the lesser metatarsals continue to grow in popularity. Neunteufel et al.1 reported a case series of 30 patients (31 feet) who underwent minimally invasive distal metatarsal metaphyseal osteotomy for metatarsalgia of ≥1 lesser metarsals2–5. All clinical scores (American Orthopaedic Foot & Ankle Society [AOFAS] Forefoot Score, Foot Function Index, Foot and Ankle Outcome Score [FAOS], and visual analog scale [VAS] pain score) improved significantly at a mean follow-up of 15.5 months. Plantar peak pressure at the relevant area was also reduced significantly. The mean metatarsal shortening across all osteotomies was 6.6 mm. Del Vecchio et al.2 reported the results of a sliding distal metatarsal minimally invasive osteotomy for the correction of a bunionette deformity in 57 patients (74 feet). At a minimum follow-up of 30 months, all radiographic and clinical outcome measures improved, with 89.1% of patients rating the procedure as excellent. The overall complication rate was 6.75%. Syndactyly release remains surprisingly problematic. Langlais et al.3 retrospectively reviewed 38 pediatric patients with 68 syndactylies who underwent syndactyly release with a dorsal commissural flap and cutaneous resurfacing. The recurrence rate was 28.1% and the complication rate was 11.7% at a mean follow-up of 6.9 years. Age of >2 years at the time of the surgical procedure was a risk factor for recurrence. Of the patients with simple syndactylies, only one-half were satisfied. Hallux Valgus Further data continue to demonstrate short-term equivalency but not superiority for minimally invasive hallux valgus surgery compared with open techniques. Hernández-Castillejo et al.4 performed a longitudinal, prospective study on 72 patients (72 feet) who underwent open chevron, open scarf, or percutaneous Reverdin-Isham osteotomy for the correction of hallux valgus deformity. At a mean follow-up of 17.7 months, all patient-reported outcome measures, including the VAS pain score and Manchester Oxford Foot Questionnaire (MOXFQ), demonstrated significant improvement independent of the preoperative radiographic parameters and type of surgical procedure. Lewis et al.5 prospectively reported on 106 consecutive feet (78 patients) that underwent third-generation minimally invasive chevron and Akin (MICA) osteotomies for severe hallux valgus. In the 86 feet (81.1%) with a minimum 2-year follow-up, there was significant improvement in all MOXFQ domains. The mean intermetatarsal angle and hallux valgus angle also improved significantly. The authors reported an 18.8% overall complication rate. Mikhail et al.6 retrospectively reviewed 248 patients (274 feet) who underwent MICA osteotomies for hallux valgus correction. At a mean follow-up of 12.9 months, the intermetatarsal angle, hallux valgus angle, and Foot Function Index improved significantly. The overall satisfaction rate was 91.6%, the mean number of 5-mg oxycodone tablets consumed postoperatively was 2.2 tablets, and the complication rate was 8.4%. The Lapidus procedure continues to grow in popularity. A retrospective review comparing Lapidus bunionectomy (73 patients) with scarf bunionectomy (63 patients) found no difference in Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function scores between groups, although patients in the scarf group had a 25% lower chance of achieving a normal intermetatarsal angle, at a mean follow-up of 17.8 months7. Veracruz-Galvez et al.8 prospectively followed 82 patients who underwent scarf osteotomy for moderate to severe hallux valgus. Normal postoperative sesamoid position (48 patients) was associated with significantly less pain (VAS), higher Self-Reported Foot and Ankle Score, and higher patient satisfaction (Likert scale) than the group with outlier sesamoid positions (34 patients). In a retrospective study comparing patients with hallux valgus (34 feet) with normal controls (20 feet), Lalevée et al.9 found that the distal metatarsal articular angle was overestimated on conventional radiographs compared with weight-bearing computed tomographic (CT) scans by a mean of 14°. However, even after computerized correction of the first metatarsal rotation and plantar flexion, the valgus alignment of the first metatarsal distal articular surface was 8.6° higher in patients with hallux valgus than in the control patients on weight-bearing CT scans. Hallux Rigidus Cichero et al.10 retrospectively reviewed 280 first metatarsophalangeal arthrodeses. The overall nonunion rate was 7.9% (22 feet). The risk of nonunion was >3 times higher in patients who had a single-construct locking plate with an interfragmentary compression screw inserted through the plate compared with patients who had a locking plate and a lag screw inserted outside of the plate. Hindfoot Tarsal Tunnel Syndrome The results of tarsal tunnel release remain inconsistent. Bouysset et al.11 retrospectively reviewed 73 patients (84 feet) who underwent tarsal tunnel release with follow-up of at least 1 year. The effectiveness of the release, based on patient willingness to repeat the procedure under similar preoperative circumstances, was significantly lower in patients with marked hindfoot varus or valgus and in patients with plantar fasciitis. Patients in only 51% of cases (43 feet) said that they would undergo the procedure again. Plantar Fasciitis Bildik and Kaya12 performed a double-blinded, randomized controlled trial that compared platelet-rich plasma (30 patients) with autologous blood (30 patients) for the treatment of plantar fasciitis. At 6 months after the injection, both groups demonstrated significant and similar improvements in the VAS pain scores and the Foot and Ankle Disability Index health-related quality-of-life scores compared with baseline. Kaiser et al.13 performed a prospective randomized controlled trial comparing a 6-week formal physical therapy program (27 patients) with a 6-week home stretching program (30 patients) for the treatment of plantar fasciitis. At 6 months, both groups significantly and identically improved from baseline in terms of VAS pain scores, Foot and Ankle Ability Measure scores, and Short Form-36 (SF-36) scores, and results were maintained through the 1-year follow-up. Insertional Achilles Tendinitis Arunakul et al.14 compared conventional rehabilitation (18 patients) with accelerated rehabilitation (31 patients) after debridement and reattachment of the Achilles tendon. At 3 months, the mean scores for VAS pain, Foot and Ankle Ability Measure, and SF-36 were significantly better in the accelerated rehabilitation group, but by 6 and 12 months there were no differences. There also were no complications. In a retrospective series of 50 open Zadek osteotomies fixed with a 6-hole lateral plate for treatment of Haglund syndrome, Tourne et al.15 reported significant improvement in the AOFAS Hindfoot scores and the Victorian Institute of Sport Assessment–Achilles scores at a mean follow-up of 7 years. Of 50 patients, 46 (92%) returned to the same or higher level of sports activity. The authors recommended using the Zadek osteotomy for the treatment of Haglund syndrome in the setting of a long calcaneus or when the novel X/Y ratio proposed in the study is <2.5, where X is the length of the calcaneus and Y is the length of the tuberosity on a lateral weight-bearing radiograph. Pes Planus In an attempt to establish the diagnostic reliability of a new classification for progressive collapsing foot deformity, Li et al.16 distributed a survey to current trainees, graduates, and faculty of 13 foot and ankle fellowship programs. For the entire cohort, the diagnostic accuracy rates were 71.0% overall, 78.3% for class, and 81.7% for stage. The misdiagnosis rates for the entire cohort for were 3.3% for class A, 17.5% for class B, 11.1% for class C, 26.0% for class D, and 3.7% for class E. Importantly, this survey used example patients for whom the physical examination findings were provided to the raters. The reliability of the scheme would likely be even lower in a real-world practice situation. The classification scheme for progressive collapsing foot deformity was evaluated with actual patients by Lee et al.17. Three independent observers assessed 92 feet (84 patients). The authors reported very good intraobserver reliability (Cohen kappa, 0.851; p < 0.001) and much worse interobserver reliability (Fleiss kappa, 0.561; p < 0.001). The classification scheme should not be considered reliable until changes result in improved interobserver reliability. The Cotton osteotomy is a dorsally based opening-wedge osteotomy of the medial cuneiform that is utilized to correct the forefoot varus component of adult-acquired flatfoot deformity, but it may not provide lasting results. Abousayed et al.18 reported a mean 8.6-year follow-up for the Cotton osteotomy performed with either allograft wedges (17 feet) or metal wedges (2 feet). Although a significant improvement was noted in the lateral talus-first metatarsal angle from preoperatively to the first postoperative follow-up (p < 0.0001), approximately one-half of the patients lost >50% of that correction at the final follow-up. The lengthened angular shape of the medial cuneiform was maintained, indicating that collapse occurred through surrounding medial column joints. Sports Osteochondral Lesions of the Talus The management of large osteochondral lesions of the talus is challenging. Shi et al.19 retrospectively compared autologous osteoperiosteal transplantation from the iliac crest (23 patients) with autologous osteochondral transplantation from the ipsilateral knee (23 patients) for the treatment of large, cystic, medial osteochondral lesions of the talus. At a mean follow-up of 48 months, there was no difference between the groups in terms of VAS pain scores, AOFAS scores, or Tegner scores. There was significantly less donor site morbidity in the autologous osteoperiosteal transplantation group. Magnetic resonance observation of cartilage repair tissue (MOCART) scores and International Cartilage Regeneration & Joint Preservation Society (ICRS) scores from second-look arthroscopy showed no differences between groups. Fletcher et al.20 reported on a prospective series of 31 patients who underwent fresh structural allograft transplantation for osteochondral lesions of the talar shoulder. At a mean 56.2-month follow-up, significant improvement was found in VAS scores, SF-36 scores, and the Short Musculoskeletal Functional Assessment Bother Index and Function Index compared with the preoperative status. The overall graft survival was 96.8%. Fifteen patients (48.4%) underwent an additional surgical procedure, typically implant removal or arthroscopic debridement. Microfracture for osteochondral lesions of the talus that have previously undergone a surgical procedure (secondary lesions) may not be as beneficial as previously reported. Arshad et al.21 performed a systematic review of 12 studies to assess patient-reported outcomes and pain scores after arthroscopic bone marrow stimulation for secondary talar lesions. No perioperative complications were noted, but, in studies that reported a revision surgical procedure as an end point, 26 (34%) of 77 patients underwent a revision procedure. Overall, patient-reported outcomes such as AOFAS score and VAS pain score showed inconsistent improvements, and many positive changes were less than the minimal clinically important difference (MCID) for these scales. Enthusiasm for subchondroplasty in the talus has waned. Hanselman et al.22 retrospectively reviewed 7 cases of talar osteonecrosis after subchondroplasty for bone marrow lesions. The mean time to radiographic confirmation of osteonecrosis was 23 months. Three of 7 patients had osteonecrosis risk factors (alcoholism and/or chronic corticosteroid use). The authors urged caution with this procedure, especially in patients with osteonecrosis risk factors. Achilles Rupture and Tendinosis Research continues on the optimal management of acute Achilles tendon ruptures. Seow et al.23 performed a meta-analysis to determine complication rates after the treatment of acute Achilles tendon ruptures and included a best-case and worst-case scenario analysis for rerupture rates. The best-case scenario assumed a 0% rerupture rate in those lost to follow-up, and the worst-case scenario assumed a 100% rerupture rate. Surgical treatment significantly reduced the risk of rerupture compared with nonoperative management. The pooled rerupture rate was 3.6% (3.4% best-case scenario, 8.3% worst-case scenario) in the surgical treatment arm and 12.1% (11.7% best-case scenario, 15.0% worst-case scenario) in the nonoperative treatment arm. The rate of complications, excluding reruptures, was significantly lower with nonoperative treatment (pooled complication rate, 7.1%) compared with surgical treatment (pooled complication rate, 18.5%). Percutaneous Achilles repair may be better paired with less aggressive rehabilitation to avoid stretching the repair. Maffulli et al.24 compared a traditional rehabilitation protocol (31 patients) with a slowed-down rehabilitation protocol (29 patients) for patients undergoing percutaneous repair of an acute Achilles tendon rupture. At a 12-month follow-up, the Achilles tendon resting angle and Achilles Tendon Rupture Score were significantly better in the slowed-down rehabilitation protocol group. Additionally, calf circumference and isometric strength were more similar to those in the contralateral, uninjured leg in the slowed-down rehabilitation protocol group. Trauma The Major Extremity Trauma Research Consortium (METRC)25 published a randomized controlled trial comparing a high perioperative FiO2 (fraction of inspired oxygen) of 80% with a standard perioperative FiO2 of 30% and its effect on surgical site infections in patients undergoing a surgical procedure for tibial plateau, tibial pilon, or calcaneal fractures. At 6 months postoperatively, they found a significant difference in overall surgical site infections (superficial and deep) between the groups: 7.0% for the experimental group compared with 10.7% for the control group (relative risk [RR], 0.65; p = 0.03). The difference was driven by fewer superficial infections in the experimental group (1.7%) compared with the control group (4.3%), for which the RR was 0.41 (p = 0.02); there was no difference in the risk of deep infections (5.6% in the experimental group compared with 6.6% in the control group [RR, 0.86; p = 0.5]). Anterior impaction of the tibial plafond has been shown to portend a particularly poor prognosis. Jo et al.26 retrospectively reviewed 50 patients (52 fractures) who underwent open reduction and internal fixation (ORIF) of OTA/AO 43B and C pilon fractures. At a mean follow-up of 25 months, the group with anterior impaction (28 fractures) had significantly higher rates of implant removal for pain, significantly greater anterior subluxation, and significantly worse posttraumatic arthritis than the group without anterior impaction. Noori et al.27 found that the Lawrence and Botte classification of proximal fifth metatarsal fractures has a low level of interrater reliability (an observed agreement of 77% compared with a chance agreement of 33%). Classification at the interface between Zones 2 and 3 was much less reliable than that between Zones 1 and 2. The authors suggested that a new classification system for these fractures is required for both clinical and research purposes. Ankle Fractures Allen et al.28 studied the effect of acute, intermediate, and late-phase synovial fluid fracture hematoma on cartilage discs from fresh allograft human tali. Compared with controls, the cartilage discs cultured in synovial fluid fracture hematoma demonstrated a significantly greater production of inflammatory cytokines, metalloproteinases, and cartilage matrix fragments, suggesting that cartilage-damaging pathways had been activated. The addition of compounds that inhibit inflammation (interleukin 1 receptor antagonist or doxycycline) decreased the pro-inflammatory effect of synovial fluid fracture hematoma on the cartilage tissue. Clinical tests for fracture stability continue to be debated. In a retrospective Level-III study of supination-external rotation 2 (SER-2) ankle fractures, Ali et al.29 reported no difference (p = 0.595) between manual stress views and gravity stress views for determining fracture stability and the need for a surgical procedure. Despite their ability to limit complications in older patients, fibular nails appear to have drawbacks when used in younger patients. Kho et al.30 retrospectively compared young patients (mean age, 41.4 years) who underwent closed reduction and intramedullary fixation (CRIF) with a fibular nail (n = 94) compared with ORIF with a locking plate (n = 110). At a minimum follow-up of 3 years, complications were lower in the CRIF group (9.5% compared with 39%; p < 0.001). However, the CRIF group demonstrated significantly higher rates of posttraumatic arthritis (21.3% compared with 9.1%; p = 0.024) and fair or poor reduction (p < 0.001) on 3-D CT scans. The authors recommended that surgeons consider ORIF in active young patients, especially for more complex fracture patterns. Stupay et al.31 performed a retrospective cohort study to identify risk factors for aseptic revision of operatively treated ankle fractures. Using multivariable logistic regression modeling, the authors reported that falls in the early postoperative period, movement-altering disorders, a nonanatomic mortise (medial clear space was greater than superior clear space) on initial postoperative imaging, more severe initial fracture displacement, substance abuse, and polytrauma are independent risk factors for aseptic revision after ankle ORIF. Identifying these risk factors may help surgeons to counsel patients and improve safety and outcomes after ankle fracture surgery. Syndesmotic Injuries Bhimani et al.32 retrospectively reviewed preoperative bilateral weight-bearing CT scans in patients with unilateral Weber B fibular fractures and a symmetric medial clear space who did (n = 23) and did not (n = 18) have intraoperatively confirmed syndesmosis instability. The authors found that weight-bearing CT was able to distinguish a stable from an unstable syndesmosis even in the presence of a Weber B fibular fracture. Syndesmotic volume measured to a height of 5 cm proximal to the tibial plafond was the best measurement for diagnosing syndesmosis instability. Wong et al.33 utilized 4-D CT scans to characterize the of ankle of on The authors found significant medial and rotation of the ankle plantar but no in with in There was no difference in between in The authors that reduction in the setting of an ankle fracture be from the uninjured ankle the ankle position is The same used 4-D CT scans to at 12 months after syndesmosis fixation (n = and syndesmosis fixation (n = Although the patient were with initial fixation demonstrated significantly reduced syndesmosis of in of 5 measures (p < when compared with the uninjured No differences in syndesmosis of between and uninjured were observed in the group with Lee et retrospectively reviewed patients with a minimum follow-up after surgical fixation of the syndesmosis in the setting of an ankle fracture. patients had chronic syndesmosis as pain with a and >2 of syndesmosis compared with the ankle on bilateral CT scans at 5 years analysis a of (p = and the presence of a fracture (p = as risk factors for chronic syndesmosis instability. et performed a study the as the of the syndesmosis on a mortise of the The authors a 12 from the which that utilized to fractures are not in the syndesmosis and not the tendon. Ankle and outcomes of 3-D and for ankle and hindfoot have been reported. In a of ankle cases with and 25 cases with standard et found no difference between the techniques for component position or of the surgical procedure. All cases were performed by a In a study of cases that utilized 3-D for of the hindfoot and/or et found that of cases required secondary and of cases required removal of the implant for or aseptic outcomes are at least similar to or better than findings using allograft for these in the of was associated with the need for a secondary procedure ratio p = 0.03). and follow-up of ankle has been including of the first Using the et found of metal to be at 5 years and at years. age, and low volume for the procedure were independent of The first data for ankle were reported by et who reviewed the cases performed by the of the Of the for the were with the in at the follow-up or at the time of The authors proposed as a for and third-generation have compared the results of ankle with those of revision ankle an important the of when a et performed a cohort study of patients with ankle and 23 patients with revision ankle No were There was significantly greater improvement (p = 0.024) in the overall MOXFQ scores for ankle compared with revision deformity for ankle or is less than previously but In an et found at follow-up of 2 to 3 years, patients with deformity of who underwent either or from the procedure. No difference between the 2 be using the SF-36 and the Musculoskeletal Functional but the results as a were to those of a control cohort without deformity. ankle is an to the more anterior procedure. rates using this procedure have to be reported. et reported radiographic in of 86 cases at a mean follow-up of months. Using more CT imaging, et reported lesions in of cases at a mean follow-up of months. rates of are similar to those observed for The to the lateral are to by the same on the same cohort of patients found a rate of early complications and in The results of may be In a retrospective review of patients who underwent hindfoot with an intramedullary et reported an overall hindfoot rate at a mean follow-up of months. A greater nail ratio (p = and hindfoot compression (p = were associated with a higher rate. medial was nonunion (p = and hindfoot (p = and clinical factors including age, and did not rates. and retrospectively reviewed patients (23 feet) who underwent with internal fixation for and At a mean follow-up, the authors reported a 100% rate of with of 23 patients weight-bearing There were 6 The authors for a a and and the of in the Although is as a risk factor for is a of patients age, was associated with a of to and a of The risk was in patients with ratio p = followed by chronic and p < The study the need for improved early and for patients with Orthopaedics The of reviewed a large number of published studies to the system that a higher of In addition to in this relevant to foot and ankle surgery are to this review after the standard with a article to help in an in this Orthopaedics of corticosteroid to therapy for Achilles a randomized clinical JAMA In a randomized controlled trial on the treatment of Achilles et compared corticosteroid and physical therapy with and physical were and were in the tissue anterior to the of the tendon than in the tendon At 6 months, the corticosteroid group had significantly greater improvement in the Victorian Institute of Sport Assessment–Achilles score compared with the group. There was no of improvement at the 2-year follow-up. There were no infections and no ruptures in either group. Although traditional corticosteroid for the treatment of Achilles of corticosteroid the anterior tissue to be a and to physical therapy when Achilles or surgical treatment of acute tendon rupture. In this large randomized controlled et compared open and minimally invasive surgical treatment of acute Achilles tendon ruptures. This is by the study of the The authors reported no significant difference between groups in the mean in the Achilles Tendon Rupture Score from the baseline to and 12 months Although was not reported by the the study was for a of rerupture rates. The rate of rerupture was significantly higher in the nonoperative treatment group of patients) compared with the groups of patients in the open repair group and 1 of patients in the repair were reported in the group, and 5 were reported in the open repair group. Although this study suggested that there was no difference in patient-reported between and operatively treated acute Achilles tendon ruptures at 1 it is important to that the results may have been by the to Achilles Tendon Rupture of patients who a as in the protocol This the likely results from the nonoperative group. A study without data that patient-reported outcomes through the entire of of complications, be required to more the for a surgical procedure. Patients a surgical procedure to an Achilles should be that they similar results for nonoperative management and management as long as they not a but the risk of rerupture is higher with nonoperative management. A, of platelet-rich plasma on ankle and in patients with ankle a randomized clinical 2021 clinical improvement of ankle arthritis after platelet-rich plasma has been by and case et found no to platelet-rich plasma at 26 in a randomized Although the outcome was the AOFAS Hindfoot Score, which has a and is not an patient-reported secondary outcome also their Patients should be that there is no for platelet-rich plasma in ankle C, blood with treatment for chronic plantar a randomized controlled Foot Ankle This double-blinded, randomized controlled trial compared autologous blood patients) and patients) for the treatment of chronic plantar fasciitis. The mean pain scores both groups improved by at a final follow-up. There were no differences in patient-reported or pain scores at time plantar should patients that there is no clear to autologous blood to

Mild cervical dysplasia: Long-term follow-up : Nasiell K, Roger V, Nasiell M: Behavior of mild cervical dysplasia during long-term follow-up. OBSTET Gynecol 67:665, 1986

Pituicytomas are rare neoplasms that typically present as solid, noninfiltrative tumors occupying the sella and/or suprasellar space for which there is no consensus on optimal surgical management. We aimed to define a preferred surgical strategy for these tumors based on our clinical experience and comprehensive review of the world literature. Case series and review of the literature. We documented the clinical, radiographic, and surgical findings of three patients with pituicytoma treated at our institution, as well as complications and long-term outcomes. A comprehensive review of the medical literature identified all cases of pituicytoma for which data regarding surgical approach, outcome and complications could be extracted. We compared our results with published data. All three cases at our institution achieved gross total removal. Two patients underwent an expanded endoscopic endonasal transsphenoidal and transplanum (EETS-TP) approach, while one tumor was removed via craniotomy. Post-operatively all patients developed pan-hypopitutarism. The patient undergoing craniotomy suffered profound visual loss but no other neurological complications were noted. A literature review identified 67 reported cases of pituicytoma. Surgical data was available in 60 cases. Surgical approach was documented in 57 patients. Sixty-three surgeries were performed in which approach and extent of resection was available. Gross total removal was obtained in 33 % of craniotomies, 42 % of transsphenoidal procedures, and 100 % of expanded transsphenoidal procedures. Neurological complications including visual loss, hemiparesis and cranial nerve palsies were reported after craniotomy, but not after transsphenoidal approaches. Overall EETS-TP approaches were associated with the highest rate of gross total removal and no visual or neurological complications. EETS-TP surgery is the preferred strategy for surgical removal of pituicytoma. EETS-TP and transsphenoidal approaches are associated with higher rates of gross total removal and lower rates of neurological complications than craniotomy. Gross total removal should be the intended goal of surgery.

Acute exacerbations (AE) of idiopathic pulmonary fibrosis (IPF) are well recognized in the progression of this uniformly fatal disease. Surgical lung biopsy and lung resection may initiate these acute events leading to a rapid deterioration and permanent decline in lung function. Our aim is to discuss the role of pulmonary and nonpulmonary surgery as a precipitating factor and to review the literature on the nature, course, and outcomes of acute exacerbations in the context of surgical interventions. This study consisted of a retrospective case series of patients at the Johns Hopkins Hospital who experienced acute exacerbation following a surgical procedure. Patients included in the case series suffered from aggravation of dyspnea within 1 month after surgical intervention, with new infiltrates on imaging. There was no other more likely cause after diagnostic evaluation. A comprehensive review of the current literature pertaining to AEs of IPF in the context of a surgical intervention was performed. In a series of four patients from Johns Hopkins Hospital with AE in IPF, two of three patients who underwent video-assisted thoracoscopic surgery (VATS) lung biopsy had a fatal outcome. The fourth patient survived an AE after a total knee replacement but had a fatal outcome after a subsequent coronary artery bypass graft surgery. We found no report in the literature of AE in an IPF patient who underwent nonpulmonary surgery. Acute exacerbations of IPF can occur postoperatively after both pulmonary and nonpulmonary surgery and are associated with a high mortality rate. As a next step, a prospective multicenter clinical study of patients with IPF undergoing both pulmonary and nonpulmonary surgeries would allow the identification of perioperative risk factors in the development of AE of IPF.

Surgical management for chondrosarcoma of the temporomandibular joint (TMJ) is challenging due to the anatomical location involving the facial nerve and the functional joint. The purpose of this case series was to analyze the largest number of TMJ chondrosarcoma cases reported from a single institution and to review the literature about chondrosarcoma involving the TMJ. Ten TMJ chondrosarcoma patients at Seoul National University Dental Hospital were included in this study. Radiographic features, surgical approaches, histopathologic subtypes, and treatment modalities were evaluated. All case reports of TMJ chondrosarcoma published in English from 1954 to 2021 were collected under PRISMA guidelines and comprehensively reviewed. The lesions were surgically resected in all 10 patients with efforts to preserve facial nerve function. Wide excision including margins of normal tissue was performed to ensure adequate resection margins. All TMJs were reconstructed with a metal condyle except one, which was reconstructed with vascularized costal bone. At last follow-up, all patients were still alive, and there had been no recurrence. Among 47 cases (patients from the literature and our cases), recurrence was specified in 43 and occurred in four (9.5%). For surgical management of TMJ chondrosarcoma, wide excision must consider preservation of the facial nerve. Reconstruction using a metal condyle prosthesis and a vascularized free flap is reliable. A more conservative surgical approach correlates with a favorable prognosis for facial nerve recovery. Nevertheless, wide excision is imperative to prevent tumor recurrence. In cases in which the glenoid fossa is unaffected by the tumor, it is deemed unnecessary to reconstruct the glenoid fossa within an oncological setting.

Background:This study aimed to assess the arthroscopic treatment, one of the surgical treatment options, for early grade focal osteochondral lesions of the first MTP joint, and to determine the impact of the arthroscopic microdrill hole surgery on foot function and daily life in a patient group with failed conservative treatment.Materials-Methods:This prospective study reviewed 27 patients having hallux rigidus with osteochondral injury of the first MTP joint who were operated with first MTP joint arthroscopy. Six patients had Coughlin-Shurnas grade 4 hallux rigidus and were excluded from the study; 5 patients were excluded due to having an arthroscopic kissing lesion, and 3 patients were excluded for not having attended regular follow-up after third month. After excluding the above patients, the study was completed with 14 patientsResults:The mean hallux vagus angle was 13.29⁰ (±1.93 SD) and the mean intermetatarsal angle was 9.14⁰ (±0.86 SD). Apart from joint arthroscopy, no soft tissue procedure and/or any procedure requiring osteotomy was intended in any patient. The median operative duration was 27.8 (19-56) minutes.The patients had mean preoperative VPS and AOFAS-Hallux scores of 8.14±0.86 SD and 48.64±4.27, respectively; the corresponding postoperative values of both scores were 1.86±0.66 SD and 87.00±3.70. Both VPS and AOFAS-Hallux scores changed significantly (p<0.01)Discussion:In this prospective study we explored the impact of arthroscopic microdrill hole surgery on foot functions and daily life activities in patients with focal osteochondral lesions of the first MTP joint. Our results indicated significant improvements in VAS and AOFAS scores with this treatment. The micro drill technique we applied in this study is based on the principle of opening 4-6-mm long tunnels to enable stem cells to migrate to the defected area and achieve cure by differentiation in full-thickness chondral injuries with exposed subchondral bone.In conclusion, arthroscopic microhole drill technique can be applied with impressive functional scores and without any complication in persons who failed conservative therapy for hallux rigidus with focal chordal injury, a common foot problem. There is a need for comparative studies with long follow-up period in this field.

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Psychiatric comorbidity has been shown to significantly impact postoperative course, leading to increasingly complicated hospitalizations, increased pain, and worse overall patient outcomes. Achieving adequate pain management is paramount in restoring mobility and ultimately reaching treatment goals, making an understanding of the interplay between psychiatric conditions and orthopedics vitally important. Specifically, deformity of the first MTP joint has been associated with increased psychiatric symptoms preoperatively. However, despite this particular population's vulnerability to depressive symptoms, the effects of surgical correction on mental function outcomes have not been well observed. The purpose of this study was to assess the association of psychotropic medication use in patients with diagnoses of hallux rigidus and hallux valgus undergoing first MTP fusion and differences in patient-reported pain and functionality scores.Methods:A retrospective analysis of prospectively collected patient outcomes for those undergoing MTP fusion for hallux valgus and hallux rigidus between August 1, 2015, and July 1, 2018, was conducted. A total of 95 patients were included in the study.Demographics and surgical data were collected from a review of the electronic medical record, and patients were grouped based on chronic use of psychotropic medications at the time of surgery. Patient-reported VAS, SF-36 Mental Component Scores (MCS), and Physical Component Scores (PCS) scores were collected at preoperative and routine 6-month and 12-month postoperative follow-up clinic appointments. Categorical variables were compared using Pearson's chi-squared test. For normally distributed data outcome scores were compared using the independent sample t-test while non-normal data comparisons were made with the Mann-Whitney U test. For all statistical tests, assumptions of α <.05 and β =.8 were made.Results:The average age of the patients in our cohort was 63.3 (range, 39 - 83), with 42 patients in the psychotropic medication (MED) and 53 patients non-psychotropic medication (NO MED) cohorts. Mean time to final follow-up was similar between NO MED and MED groups (p=.987). No differences in mean VAS scores were detected at preoperative (p=.455), 6-month (p=.505), nor 1-year (p=.269) visits. Similarly, no differences in SF-36 PCS were detected at preoperative (p=.087), 6-month (p=.314), nor 1- year (p=.103) postoperative visits. Patients taking psychotropic medications had significantly lower mean SF-36 MCS at preoperative and 6-month postoperative visits (p=.004, p=.033, respectively). No difference in mean mental component score was detected at the 1-year postoperative visit (p=.184).Conclusion:This study is the first to examine the surgical outcomes of patients undergoing 1st MTP fusion for hallux rigidus and hallux valgus while concurrently taking psychotropic medications. SF-36 mental component scores were depressed at preoperative baseline in the psychotropic medication cohort and improved postoperatively to a level similar to that of their non- psychotropically medicated peers. These findings suggest that psychiatric diagnoses should be considered in the discussion of conservative vs. surgical management of hallux valgus and rigidus, as a secondary benefit of surgical correction may be partial relief of depressive symptoms.

Due to the missing bony integration of the ceramic Moje prosthesis for replacing the first metatarsophalangeal joint (MTPI) in hallux rigidus, the mid-term results were bad so far. In case of revision, the distraction arthrodesis with autologous bone taken from the iliac crest as a salvage procedure is the method of choice. In our prospective case series, the short-term results after revision of the Moje prosthesis with the ToeFit Plus prosthesis were investigated. The clinical and radiological investigations were done in six MTPI over a 24-month period using AOFAS score and visual analogue scale. There were no radiological signs of loosening or implant migration of the ToeFit Plus 24 months, postoperatively. There was one fissure at the first proximal phalanx necessitating a wire stabilisation. No other complications could be observed. A significant improvement of the AOFAS score and the range of motion were observed 6 weeks postoperatively. We could show good and very good short-term results after the replacement of a loosened MTPI prosthesis with a ToeFit Plus. Due to the conic screw anchorage, ToeFit Plus is excellently suited for prosthesis replacement at the MTPI. With sufficient bony anchorage prerequisites, it is possible to preserve and improve the range of motion by changing the loosened MTPI prosthesis in the ToeFit Plus, thereby avoiding the morbidity of gaining autologous bone from the iliac crest.

Sinonasal osteoblastoma is a rare benign tumor that can involve critical structures like the skull base and orbit. This study presents a case series and literature review to describe clinical features, surgical management, and outcomes. Five patients with sinonasal osteoblastoma were treated endoscopically between 2020 and 2025. Clinical data, imaging, surgical approach, histopathology, and follow-up outcomes were reviewed. A PubMed search was conducted to identify previously reported cases. Patients ranged from 12 to 57 years old. Tumors most commonly involved the ethmoid sinus and presented with nasal obstruction, headache, or epistaxis. Four underwent total endoscopic resection; one had subtotal removal due to frontal sinus involvement. Histopathology revealed three conventional and two aggressive osteoblastomas. No recurrences or major complications occurred over a follow-up of two to five years. Endoscopic resection appears to be a safe and effective approach for sinonasal osteoblastomas, even in cases with skull base or orbital extension. This series supports the growing role of minimally invasive surgery in managing these uncommon tumors.

This case series and literature review evaluated the baseline variables, clinical symptoms, pathological characteristics, and prognosis of patients with orbital oncocytic carcinoma. This retrospective case series collected the medical histories and other related data from 13 patients pathologically diagnosed with oncocytic carcinoma. The average age of patients with orbital oncocytic carcinoma was 64.8 years, with a significantly higher rate of males than females. Furthermore, unilateral disease was more common than bilateral disease. All patients had surrounding tissue invasion, most commonly to extraocular muscles (69.2%) and bones (53.8%). The clinical manifestations were proptosis (30.8%), swelling of the lesion area (23.1%), vision loss (23.1%), diplopia (23.1%), periocular mass (23.1%), tears (15.4%), eye pain (7.7%), ptosis (7.7%), and visual field loss (7.7%). Microscopic examination revealed many large eosinophilic cells. There were obvious nuclei and abundant mitotic figures. The cancer cells expressed cytokeratin, but not P63 or S-100. The follow-up duration was 2-53 months, and the metastasis rate was 16.7%. The patients exhibited a good prognosis. The main treatment methods included surgical resection, surgery combined with radiotherapy, and the enucleation of ocular contents. Orbital oncocytic carcinoma has the immunohistochemical characteristics of eosinophilic tumor cells, with expression of cytokeratin but not P63 or S-100. The prognosis is favorable. Surgical resection, surgery combined with radiotherapy, and enucleation of intraocular material are effective treatment options. Nevertheless, long-term follow-up and close observation for metastases are required.

Granulomatous mastitis (GM) presents as a tender and firm breast mass that can be accompanied by erythema, pustular drainage, and ulceration. It can be either unilater or bilateral. This condition occurs most commonly in Latina and Asian women.1 Most clinicians perform a breast biopsy to exclude malignancy or infection.2 The diagnosis of GM is best established through a core biopsy that demonstrates non-caseating granuloma, multinucleated giant cells, and epithelioid histiocytes within breast lobules.2 Corynebacterium is frequently isolated from tissue culture and has been postulated to be involved in the pathogenesis of this condition.3 Given the rarity of GM with an incidence of only 2.4 per 100 000 women,4 clinicians often misdiagnose this condition as being an infective process or surgical condition and patients often have a significant delay in diagnosis by up to 4–5 months.5 There is a spectrum of management of GM, and this can include conservative treatment with a watch-and-wait strategy; a medical approach with antibiotics and immunosuppression; a surgical approach with either drainage or excision; or a combination of the above.6 Unfortunately, there is no consensus regarding the ideal management6 and this condition is often treated by various specialists including surgeons, infectious disease physicians, rheumatologists, and immunologists. In particular, the overall evidence in the literature to support the use of methotrexate currently remains weak.7 Given the uncertainty with immunosuppressive therapies, we decided to review the efficacy of immunosuppression in a case series of GM in a large quaternary referral hospital. This retrospective case series included GM patients reviewed at the Department of Clinical Immunology and Allergy at Westmead Hospital (Sydney, Australia) over 9 years (from 2014 to 2022). Clinical data were collected by chart review. Patients included in this case series were required to have biopsy-proven GM showing non-caseating granulomas and needed to have had other differential diagnoses excluded such as mycobacterial infections. All patients were referred from the same hospital's breast surgery clinics. "Complete remission" was defined as complete resolution of symptoms and healing of the lesion. "Partial remission" was defined as a measurable improvement in the patient's condition (lesion and/or symptoms) without complete remission. "Observation" was defined as expectant management without the use of systemic immunosuppression. Twenty-two patients were identified in the specified timeframe, and three patients were excluded because they were lost to follow-up and had insufficient/incomplete medical records. Hence, a total of 19 patients (86%) were included in this analysis. Table 1 summarizes the patient characteristics of our cohort and Table 2 summarizes the treatment results of this case series. Two of the five patients (40%) (Patients 8 and 16) being observed without receiving immunosuppression developed recurrence/flare of disease requiring further treatment. Prednisone was typically used at a starting dose of 0.5 mg/kg daily before tapering over several weeks or months. Methotrexate was used in nine patients either as initial therapy, after the use of prednisone, or with prednisone and was commenced at 7.5 mg per week and titrated up to 25 mg per week. Seven of the nine patients (78%) treated with methotrexate achieved either complete or partial resolution of symptoms with five patients (56%) achieving complete resolution of symptoms. The median time to resolution after use of methotrexate was 6 months. Four of the nine patients (44%) receiving methotrexate encountered adverse effects, including alopecia (33%, 3/9), metallic taste (11%, 1/9), liver function test (LFT) derangement (11%, 1/9), and miscarriage (11%, 1/9). Prednisone 5 months Prednisone Prednisone: Steroid-induced myopathy, emotional lability, steroid-induced hyperglycemia, weight gain, reflux MTX: nausea, fatigue, alopecia, miscarriage MMF: diarrhea Sirolimus: headaches Five patients were treated with other immunosuppressants/immunomodulators including hydroxychloroquine and mycophenolate. Two patients received hydroxychloroquine and both patients achieved complete resolution of symptoms after 6 months without adverse effects. This approach with hydroxychloroquine has been used successfully in other case series.8 Mycophenolate mofetil was used in three patients of which two patients (66%) achieved complete or near complete resolution of symptoms following 12 months of therapy. One patient (33%, 1/3) did not tolerate this therapy because of diarrhea. GM is a rare diagnosis that requires a multidisciplinary approach to investigation and management. This case series reflects the heterogenous management of patients who have had refractory GM and required systemic immunosuppression. These patients had undergone unsuccessful therapy including observation, antibiotics, or surgery. In our department, we found that systemic immunosuppression was widely used and effective in the treatment of GM. All patients in this case series were premenopausal women, a finding also established in the literature.9 From our experience, an observation approach can be considered, although this was associated with a high recurrence of disease in 40% of patients. Patients with milder disease tended to favor expectant management in our review. However, a conservative approach has been associated with a high relapse rate.10 Indeed, 74% of patients (14/19) received a trial of antibiotics before a formal diagnosis of GM in our case series. This is consistent with another case series that identified frequent antibiotic use with variable success.11 However, aspirates of the inflammatory reaction are generally sterile.11 Many patients (58%) also received surgical treatment with either aspiration, incision or intralesional corticosteroids which did not produce sustained relief of symptoms. In the literature, the surgical approaches to treating this condition have ranged from drainage, wide surgical excision, and mastectomy in some cases.12 The approach with abscess drainage was associated with a low success rate of 29% in one study.13 On the other hand, another study demonstrated that wide excision offered superior clinical response compared with steroid treatment, and has been advocated to be the best and fastest way to achieve complete response.10 However, this approach can be associated with surgical complications such as infection, bleeding, and scarring. The use of oral steroids has been highlighted as part of the initial management in multiple case series.10 The clinical response rate with oral steroid therapy ranged from 42% to 71% in some studies.5, 14 Topical steroids have also been used successfully in a case series of 11 patients.15 We did not examine the efficacy of prednisone monotherapy because most of our patients received further immunosuppression with disease-modifying anti-rheumatic drugs (DMARDs) as steroid-sparing therapy. This combination therapy practice was adopted to minimize the long-term effects of high-dose prednisone, particularly in otherwise medically well young women. One of the more commonly used DMARDs within our department was methotrexate. We found that methotrexate is an appropriate second-line therapy and achieved high efficacy, producing either complete resolution or significant improvement of symptoms in our patients (78%). Its use allowed the prednisone dose to be tapered more quickly, minimizing steroid-induced adverse effects with the median time to resolution of 6 months. A short course of methotrexate could also result in a significant improvement in symptoms in some patients, although other patients required a longer course of 12 months or more. This finding is comparable to findings in the literature, where a clinical efficacy rate of up to 94% was noted in one case series with 19 patients, and up to 75% of patients had remained in remission after 15 months of treatment.4 Other case series have suggested a relapse-free remission of virtually 100% using typical maximal doses of 10–15 mg weekly.14 However, with limited patients and reliance on case series, the overall evidence for methotrexate is weak.7 Furthermore, methotrexate can be associated with significant adverse effects that result in its early cessation. The adverse effects experienced by four of nine patients in our study included nausea, alopecia, LFT derangement, dysgeusia, and miscarriage. Therefore, it is important to monitor for these, including routine monitoring of LFTs and hematology profiles. Methotrexate is also teratogenic, so effective contraception is mandatory for women with child-bearing potential, and risks should be discussed with the patient. Unfortunately, there is less experience and evidence for other DMARDs. Azathioprine and anti-tumor necrosis factor biologic therapy have been trialed with success.14 Some of our patients trialed hydroxychloroquine and mycophenolate as alternatives to methotrexate. Indeed, more cases are required to establish the effectiveness of these approaches given that the literature currently consists of a limited number of case reports and case series. GM is a rare condition. The cases in this study were retrieved from a single quaternary referral center where patients were more likely to have persistent or severe symptoms of GM. As such, 19 patients over several years represent a small fraction of the actual cases of GM, which may confer a selection bias to our case series. There was a limited amount of follow up after treatment given that the nature of this case series is limited to a chart review. Therefore, the sustained benefits of treatment cannot be confirmed. We also do not have data on patients who were managed with conservative therapy and not referred to our department for comparison. In summary, regardless of the selected approach, immunosuppression with DMARDs was highly effective in treating refractory GM in our case series and in inducing remission. We also found that other DMARDs such as hydroxychloroquine and mycophenolate could be considered depending on the patient context with similar efficacy rates in our case series; however, further data and case series are required to explore these. The decision to introduce systemic immunosuppression would need to consider the patient's individual circumstances, such as the desire for pregnancy. Ian Liang was involved in study conception, data collection and analyses and drafted the manuscript. Lucinda Berglund, David Brown, Dan Suan, and Farid Meybodi were involved in data collection and analyses. Adrian Lee and Sanjay Swaminathan were involved in study conception, data collection and analyses, supervision, and contributed to the manuscript draft. All authors reviewed the manuscript, edited it for intellectual content, and approved the final version. None. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Introduction: The anterior cruciate ligament (ACL) is a crucial ligament structure of the knee that plays a significant role in knee joint stability and competitive sports performance. In order to reestablish knee stability, ACL reconstruction (ACLR) in the presence of rupture has been recognized as the most common surgical management procedure. Case: This study reported six cases of chronic ACL rupture reconstruction using peroneus longus tendon graft. All patients underwent an arthroscopic ACL repair procedure in Sanglah Hospital Bali. In terms of functional outcome, all patients were assessed using the scoring of AOFAS for the ankle and IKDC for the knee. Result: The functional outcomes of the IKDC and AOFAS score were good from all six patients who already underwent ACL reconstruction using peroneus longus graft with a minimum follow-up of one year. Discussion: Chronic ACL ruptures were successfully treated using the peroneus longus tendon graft. Intraoperatively, there were no significant problems from the harvested peroneus longus tendon graft and ACL reconstruction with the graft. All patients showed no complications, including the local infection following the operation. Rehabilitation procedure post-ACL reconstruction was performed at the Rehabilitation Unit in Sanglah General Hospital. Conclusion: Peroneus longus tendon graft is considered a suitable choice of graft for ACL reconstruction. It presented satisfactory results, effectiveness, and safety based on the AOFAS and IKDC scores.

Surgical repair of symptomatic chronic achilles tendon rupture using synthetic graft augmentation.

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