Additional Soft Tissue Procedures Research Articles

Incidence of Early Adverse Events Following Medial Patellofemoral Ligament Reconstruction.

The current literature lacks data regarding perioperative complications after medial patellofemoral ligament reconstruction (MPFLr). The objective of this study was to identify the incidence and predictors of adverse events in the first 90 days after MPFLr. Patients undergoing primary MPFLr between January 1, 2010, and December 31, 2019, were included. Predictors of readmission for any reason were identified using a multivariable logistic regression analysis. A total of 140 MPFLrs were included in the final analysis. Of these, 17 patients (12.1%) were admitted in the first 90 days after MPFLr. The most common reason for readmission was pain (7/140, 5%), followed by cellulitis (5/140, 3.5%). The only major complication was pulmonary embolism experienced by one patient (1/140, 0.7%). Univariate logistic regression analysis demonstrated that patients who ever smoked were 4.5 times (p = 0.005) more likely to be readmitted in the first 90 days. Although additional soft-tissue procedures increased the readmission rated by 21% (p = 0.810) and additional chondral procedure increased by 35% (p = 0.568), the multivariable analysis did not reveal a significant difference. Surgeons can use this information to counsel patients on what to expect following MPFLr.

Clinical Outcomes of Total Knee Arthroplasty in Patients Who Have Hemophilic Arthropathy: A Prospective Study

BackgroundTotal knee arthroplasty (TKA) is considered the gold standard treatment for patients who have advanced hemophilic knee arthropathy. However, special considerations are required for these patients. This prospective study reports on the need for soft-tissue procedures, implant types, complication rates, mean 53.3 months implant survivorship, and patient-reported outcome measures of TKA in hemophilic patients. MethodsThere were twenty primary TKAs that were performed on 15 hemophilic patients from 2012 to 2023. The mean follow-up was 53.3 months (range, 6 to 128). The necessity for additional soft tissue procedures, implant type, complications, and revision rates were recorded. Knee Injury and Osteoarthritis Outcome Score, Knee Society Score, Hemophilia-specific Quality of Life Questionnaire for Adults, Hemophilia Activities List, and range of motion, were compared preoperatively and at the last follow-up. ResultsAt the last follow-up, implant survivorship was 90%. There were 2 revisions: one for aseptic loosening and one for periprosthetic joint infection. Additional soft tissue procedures included 2 quadriceps snips (10%). Tibial augments, tibial stubby stems, and both tibial and femoral traditional stems were used in one (5%), 4 (20%), and one (5%) TKAs, respectively. A constrained posterior-stabilized bearing was necessary in one case. Clinically and statistically significant improvements were found between the preoperative and final follow-up values of all patient-reported outcome measures, knee flexion (73 versus 108 °, P < 0.001), and flexion contracture (11 versus 4 °, P = 0.002). ConclusionsThis study showed that TKA, in patients who have hemophilic knee arthropathy, is a reliable treatment option that improves knee function and patients’ quality of life with acceptable implant survival rates at midterm follow-up (mean 53.3 months). Standard implants and approaches can be used in most cases. Despite good outcomes, hemophilic patients carry additional risks for complications that require specific considerations. It is paramount for these patients to be treated in specialized centers by experienced surgeons to achieve good results.

An algorithmic approach to total hip arthroplasty in patient with post-polio paralysis and fixed pelvic obliquity.

AimsTotal hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.MethodsIn all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment.ResultsThe mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6o (SD 7.9o) to 1.8o (SD 2.4o; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months.ConclusionSimultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity.Cite this article: Bone Jt Open 2021;2(9):696–704.

A Technique to Correct Troughing in a Z-Osteotomy for Hallux Valgus Correction

A Z-osteotomy is a commonly performed procedure to correct mild-moderate hallux valgus. It is an effective procedure with high patient satisfaction rates. However, it is not without its challenges. One of the most frequently encountered issues during a Z-osteotomy is troughing of the first metatarsal. We present a simple surgical technique to correct troughing if it is encountered without the need for additional soft tissue or bony procedures.

Alternative and additive arthroscopic soft-tissue procedures for anterior shoulder instability

AbstractAnterior glenohumeral instability is a widespread pathological condition, not only in athletes but also in the general population. The variations in the lesions (soft tissue and bone defects) that occur after traumatic dislocation or recurrence, combined with the degree of ligamentous laxity and activity, have led to numerous surgical techniques. Following the introduction of arthroscopy in the treatment of shoulder pathology, several new procedures and modifications of old methods were introduced to treat anterior instability. Despite this, there is still controversy regarding the proper management of instability cases combined with bone loss or insufficient anterior soft tissue wall or laxity. Additional soft tissue procedures, along with the simple Bankart repair, strengthen the stability of the repair and can fill the gap in the transition from the classic Bankart repair to the potential overtreatment of bony procedures. This literature review attempts to summarize all the critical studies referring to soft tissue techniques and highlight the most crucial points of their conclusions.

Computer-Aided Rhinoplasty Using a Novel “navigated” Nasal Osteotomy Technique: A Pilot Study

To describe the surgical technique of navigation-guided nasal osteotomies and assess feasibility of this technique for treating complex nasal bone deformities in reconstructive rhinoplasty. A retrospective chart review was performed in order to identify patients who underwent computer-aided rhinoplasty from August 2014 to February 2017. Inclusion criteria were nasal bone deformities on computed-tomography (CT) that correlated with specific nasal complaints. All patients underwent computer-aided rhinoplasty with navigation-guided nasal osteotomies using a standard navigation system. Osteotomies were performed using real-time visualization on the navigation screen. Additional soft tissue procedures were performed as needed. Medical records were reviewed for presenting symptoms, radiologic and operative findings, and postoperative course. Cosmetic outcomes were subjectively based on patients' standard 6-view photo-documentation from pre- and post-operative timepoints. Twenty-one patients were included in the study; 8 were revision cases and 3 had mild-to-moderate hemifacial microsomia. Fifteen were completely closed procedures. No cases were opened because of inadequate visualization or difficulty accessing bony pathology. Mean (range) follow up was 98.6 (6-559) days. There were no intra-operative complications, unplanned admissions or re-admissions, or iatrogenic cosmetic complications (ie, "inverted V" or "saddle nose" deformities). Two patients required revision. One was after suffering nasal trauma within 4 weeks of initial rhinoplasty. The second underwent further correction of a deformity that required a costochondral graft. Both experienced good final results. Computer-aided rhinoplasty is safe and feasible for treating complex nasal deformities using standard navigation systems.

Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity.

There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Level V, consensus, expert opinion.

Long term outcomes of abdominal wall reconstruction using open component separation and biologic mesh in the liver, kidney, and small bowel transplant population.

The aim of this study is to critically examine the multidisciplinary approach to abdominal wall reconstruction (AWR) in the solid organ transplant (SOT) population at our institution, MedStar Georgetown University Hospital, using a modified component separation technique (CST). A retrospective review of AWR utilizing modified open CST with biologic mesh in SOT patients was performed from January 2010 to June 2018. Patient demographics, comorbidities, operative details, complications, and outcomes were recorded. Descriptive statistics, logistic and linear regression analyses were performed to appraise outcomes. Thirty-five patients were included; mean age was 53years. Patient demographics and comorbidities were: 82.9% male, 45.7% history of tobacco use, and 28.6% diabetes. Fifty-one percent had undergone prior hernia repair. Transplant types were: kidney (9), liver (16), liver/kidney (1), small bowel (7), multivisceral (2). All were on an immunosuppressive regimen at time of surgery; 22.9% included steroids. Average defect size was 361cm2. Additional soft tissue procedures were performed in 65.7% (n = 23) of patients. Median time to healing was 29.0days. Complication rate was 31.4% (n = 11); six patients required reoperation within 90days. Recurrence rate was 5.7% (n = 2) at mean of follow up of 3.0years. Additional soft tissue procedures were statistically significant for healing time (p = 0.037). Steroid use was statistically significant for reoperation within 90days (OR = 12.500; 95% CI 1.694-92.250); however, steroid use was not significant after correction for confounders. Modified open CST with biologic mesh is a safe, efficacious approach to complex AWR in the SOT population with recurrence rates comparable to the general population.

Effect of Intravenous Aminocaproid Acid on Blood Loss and Transfusion Requirements After Bilateral Varus Rotational Osteotomy: A Double-blind, Placebo-controlled Randomized Trial.

Background:ε-Aminocaproic acid (EACA) is an antifibrinolytic agent that has been shown to decrease blood loss and transfusion requirements in several populations undergoing various surgical procedures. However, the efficacy of EACA has not been assessed in pediatric patients with cerebral palsy undergoing bilateral varus rotational femoral osteotomies. The purpose of this study was to assess the efficacy of intravenous EACA in reducing calculated intraoperative blood loss and transfusions in this population.Methods:Patients aged 18 years or younger were eligible. Patients were randomized to receive EACA or placebo (saline), and randomization was stratified based on sex and whether or not additional soft tissue or osseous procedures were performed. On the basis of retrospective data, the calculated sample size was 12 patients per arm to detect a difference of 250-mL blood loss. The primary outcome was calculated intraoperative blood loss. Secondary outcomes included transfusion requirements, 24-hour drain output, length of stay, and incidence of complications.Results:The mean age of patients in this study was 8 years (SD: 2.4 y). There were no differences in age, sex, height, weight, type of anesthesia, operative time, and associated procedures between the EACA and placebo groups (P>0.05). Preoperative hematocrit was lower in the EACA group (37.1 vs. 40.0, P=0.04). Calculated intraoperative blood loss was 536 mL in the EACA group and 628 mL in the placebo group (P=0.45). Transfusions were required in 62% of patients in the EACA group and 67% of patients in the placebo group (P=0.68). Total 24-hour drain output was 72.5 mL in the EACA group and 103.3 mL in the placebo group (P=0.37). Length of stay was similar between both groups, and there were no drug or placebo-related complications in either group.Conclusions:There was no difference in blood loss or transfusion requirements associated with EACA compared with placebo; however, this study is underpowered to detect smaller differences in blood loss. Additional studies with larger sample sizes are needed to confirm these findings and further elucidate the indications for antifibrinolytic agents in pediatric patients.Level of EvidenceLevel I.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

Category:HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of soft tissue involvement.Methods:This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant.Results:We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04).Conclusion:This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

ACL Reconstruction with Augmentation: a Scoping Review.

We reviewed the recent literature to identify and summarize new research surrounding anterior cruciate ligament reconstruction (ACLR) with augmentation in the form of additional soft tissue procedures or biologic augmentation. Specifically, we wanted to review the failure rates of these procedures in both the primary and revision settings. The databases Embase, PubMed, and Medline were searched on August 13, 2018, for English-language studies that reported on the use of anterior cruciate ligament reconstruction (primary and revision) in conjunction with either soft tissue or biologic augmentation. The studies were systematically screened and data abstracted in duplicates. Advancements in ACLR surgery, including soft tissue augmentation, may decrease primary and revision surgery failure rates for high-risk patients. The use of biological augmentation has shown histologic and radiographic improvements. These differences, however, have failed to be statistically significant and have not resulted in clinically significant improvements in outcome. The limited body of evidence has shown that the addition of soft tissue procedures may in fact lower the risk of graft re-rupture rates particularly in revision or in patients wishing to return to high-risk sports and activities. The use of biologic augmentation although promising in laboratory studies has yet to show any significant clinical results and therefore will require further studies to prove any efficacy.

One-Stage Metatarsal Interposition Lengthening With an Autologous Fibula Graft for Treatment of Brachymetatarsia

Objective: Brachymetatarsia is defined as the pathological shortening of a metatarsal bone, which can cause cosmetic problems and pain in the forefoot. The main surgical treatment options are: extension osteotomy, interposition of a bone graft, and callus distraction. Usually, a bone graft from the iliac crest is used for the interposition osteotomy. The operative technique of graft extraction from the fibula has not been described in the literature yet. Methods: Eight feet with brachymetatarsia in 5 patients were evaluated retrospectively. The minimum follow-up period was 2 years. Via a dorsal V/Y skin incision, a central osteotomy on the metatarsal bone was done. A graft was obtained from the anterior fibula. The graft was inserted and fixed by a locking plate. Additional soft tissue procedures were done. Results: We had bony consolidation in all cases. The mean extension was 9.01 mm (5.49 to 12.54 mm). This corresponded to a mean 20.3% extension of the entire metatarsal. High patient satisfaction as well as high satisfaction regarding the cosmetic results were achieved. There were no postoperative complications. The range of motion of the metatarsal-phalangeal joint IV was 20% less preoperative in terms of plantar flexion. Standing up on tiptoes was possible in all patients postoperatively. One patient reported mild symptoms after sports activities. Conclusions: Because of its anatomy the graft adapts to the metatarsal IV bone. As our study showed, harvesting from the distal fibula causes no functional restriction. In terms of wound and bone healing as well as pain symptoms, this method should be considered as an alternative to the standard iliac graft.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p&lt;0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p&lt;0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04). Conclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Role of the anterolateral complex in rotatory instability of the anterior cruciate ligament deficient knee

The anterolateral complex (ALC) of the knee plays an important role in rotatory knee stability, especially in anterior cruciate ligament (ACL)-deficient patients. There is considerable awareness of anterolateral rotatory instability secondary to reported high failure rates after ACL reconstruction. As such, there has been a renewed interest in lateral extra-articular reconstruction procedures to stabilize the ALC. The concept of lateral extra-articular tenodesis (EAT) as the sole treatment of ACL injuries was popular in the 1970s, but fell out of favor due to unacceptably poor long-term outcomes. However, as greater understanding of rotatory knee instability has evolved, lateral stabilization procedures similar to those described in the 1970s have emerged to augment ACL reconstruction. These additional soft tissue techniques are not without risk, as many studies have demonstrated knee over-constraint after these procedures. Therefore, it is prudent to take an individualized approach to ACL reconstruction and to assess the value of additional soft tissue procedures in the face of persistent rotatory laxity. This review will address the role of the ALC in rotatory knee injury, the difficulty in diagnosing these injuries, and provide an objective review of additional stabilizing procedures after ACL reconstruction.

A mid-term follow-up of Koutsogiannis' osteotomy in adult-acquired flatfoot stage II and "early stage III".

Introduction: Koutsogiannis’ osteotomy has been widely described to treat adult-acquired flatfoot. However, few articles describe its midterm follow-up. Our aim was to study clinical and radiological outcomes at least one year after surgery and to analyze whether a combined procedure on the medial soft tissue affected these outcomes. Methods: We performed a retrospective study of 30 feet of patients who underwent a Koutsogiannis’ osteotomy due to adult-acquired flatfoot stage II and “early stage III”: a stage III acquired flatfoot without any important structural deformities. The parameters studied were additional medial soft tissue procedures, clinical outcome through the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and midfoot score as well as complications and radiological measurements. Results: Sixteen cases were “early stage III” and 14 stage II. Thirteen patients underwent an associated posterior tibial tendon (PTT) revision: in three cases an end-to-end suture was possible, seven cases needed a FDL transposition, and three underwent synovectomy. Statistically significant improvement was found in the AOFAS score although no significant changes were seen radiologically. No additional benefit was found with the revision of the posterior tibial tendon. As to clinical and radiological results, no differences were found between stage II and “early stage III”. Five cases presented a mild dysesthesia but only one patient needed neurolysis. Conclusions: We consider the Koutsogiannis’ osteotomy to be a safe and effective procedure to reduce pain in patients with stage II and “early stage III” adult-acquired flatfoot.

Comparison of the Calcaneo-Cuboid-Cuneiform Osteotomies and the Calcaneal Lengthening Osteotomy in the Surgical Treatment of Symptomatic Flexible Flatfoot

Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot. The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated. Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group. Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results. Level III, retrospective comparative study.

Revision of Total Ankle Replacements

We discuss the medium-term and long-term complications of total ankle replacements (TARs) requiring revision surgery. TAR failures include the following reasons: stiffness, periprosthetic ossification and malleolar impingement, medial or lateral hindfoot instability, loosening and/or subsidence of the components, and infections. Before performing any revision surgery, the etiology of the failure must be established. The analysis must not focus solely on the ankle but should also consider the overall biomechanics of the lower limb and the interrelationship between the knee joints, the subtalar joint, and the midfoot. All the factors responsible (malalignment, instability, stiffness, and problems with joints above or below the ankle) should be analyzed. Non–prosthetic-related and periprosthetic pathologies can be addressed by additional osseous or soft tissue procedures without revision of metallic prosthesis components. Bony cysts, whose frequency is underestimated in most reported series, without affecting the stability of the implant, may require an autograft or additional bone substitutes. There is only limited literature addressing the long-term viability of graft, and therefore, no valid evidence-based recommendation can be made. The causes of dislocation of the mobile component, an inherent complication of 3-component prostheses, must be investigated. In addition to any ligament (supplementary arthrolysis, iterative ligamentoplasty) and/or bone procedures, the polyethylene inlay must be replaced systematically. For late-onset chronic infections, revision in 1-stage or 2-stage procedures requires the initial removal of the implant followed by an extensive debridement of all the infected tissues. A revision in the 2-stage procedure can include the use of a spacer and/or an external fixator, especially if skin problems are present. If there is a non–prosthetic-related reason for the failure, the prosthesis will only be replaced after correcting the non–prosthetic-related conditions that caused the prosthesis to fail. Any replacement is also dependent on the remaining bone capital after the removal of the prosthesis. The greater the amount of bone loss, the more uncertain the replacement of the prosthesis and, if necessary, an arthrodesis will then be discussed. The revision rates of ankle replacements without replacing the prosthesis remain high in the literature. TAR is one of the surgical procedures that can be considered in treating degenerative ankle disorders.

Advances in treatment of basal joint arthritis of the thumb

Purpose of review Various forms of surgery have been successfully used to treat trapeziometacarpal osteoarthritis. However, no conclusive evidence is available to recommend one form of surgery over another. This is a review of recent surgical techniques and current concepts in the treatment of this common condition. Recent findings Early disease (stages 1 and 2) treated with ligament reconstruction or metacarpal extension osteotomy produces good results. Advanced disease (stages 3 and 4) continues to be treated successfully with trapezial excision, with or without additional soft-tissue procedures. Trapeziometacarpal joint replacement provides adequate pain relief, but loosening remains a concern. Satisfactory short-term results have been obtained using trapeziometacarpal arthroscopic procedures in stages 1 to 3 disease. Summary The initial management of basal joint arthritis should be nonsurgical. If this fails, surgery is recommended. Joint preserving procedures produce good outcomes in early disease. In advanced disease, some form of trapezial excision is required, and present evidence suggests that simple trapezial excision produces functional results equivalent to the more complex reconstructive procedures. Arthroscopy offers all the advantages of minimally invasive surgery, and early results are encouraging. There is a need for further comparative studies to determine if any procedure is superior to the others.

Correction of Anteversion in Skeletally Immature Patients

There has been reluctance by some surgeons to accept antegrade femoral nailing in children and adolescents due to concerns about producing iatrogenic osteonecrosis or growth disturbance of the femoral neck. Others believe that with the recent advent of pediatric transtrochanteric intramedullary nails, femoral fracture and osteotomy fixation may now safely be accomplished using these devices. Extrapolating from experience treating mature patients, the senior author (P.S.) has adopted the technique of percutaneous femoral osteotomy and transtrochanteric intramedullary fixation in skeletally immature patients as a standard approach for the correction of anteversion, combining this with concomitant surgery as indicated. With the institutional review board approval, we reviewed our experience using the Phillips intramedullary rod (EBI/Biomet, Inc, Warsaw, Ind), to secure femoral osteotomies in a series of 30 patients with 40 femoral osteotomies (10 bilateral). The etiologies of anteversion included idiopathic and neuromuscular. There were 10 boys and 20 girls, ranging in age from 8 to 16 years and in weight from 32 to 60 kg. Additional surgical bony and soft tissue procedures were combined as indicated. These included supramalleolar osteotomy, hindfoot stabilization, tendon lengthening or transfers, and hemiepiphysiodesis in select patients. Two of the femoral rotational corrections were combined with shortening. Despite early mobilization without casts, each osteotomy healed primarily in an average of 3 months, and the complication rate was exceedingly low. One patient had removal of a loose distal interlocking screw at 6 weeks postinsertion. By that time, he had formed good callus and had rotational stability; thus, the outcome was not compromised. Importantly, we have not observed osteonecrosis, growth disturbance of the femoral neck, or limb length discrepancy resulting from this treatment method. In the skeletally immature patient, femoral anteversion can safely be corrected using the Phillips/Biomet antegrade locked intramedullary rod, placed through a transtrochanteric approach; growth disturbance has not been encountered. This device is well tolerated, with a low complication rate. Compared with alternative techniques, recuperation is rapid and fixation problems seen with plates or crossed pins/spica are largely circumvented. The advantages include quadriceps sparing, minimal blood loss, and the use of a load-sharing, low-profile implant. IV (retrospective, clinical).

Functional and Aesthetic Endpoints in Orthognathic Surgery

Although facial deformity can accurately be described and classified, the treatment goal can be more difficult to define. Functional and esthetic endpoints calibrated to a set of normal facial proportions may achieve a "normal" face but one that is not necessarily beautiful. Results of orthognathic surgery can dramatically be improved by adding an aesthetic concept to the surgical plan. We can achieve a face with both stable occlusion and a beautiful look each time. Additional soft tissue procedures may be required to perfect the final balance and harmony of the face.