Bony Deformities Research Articles

RE-INVENTING CYANOACRYLATE RETINOPEXY IN THE 21ST CENTURY: LITERATURE REVIEW AND CASE SERIES.

We report use of cyanoacrylate (N-butyl-Cyanoacrylate) in previously failed retinal reattachment surgeries for chorio-retinal colobomas. We report the surgical technique, its challenges, and long-term outcomes in three patients who underwent the surgery. A chart review of patients with chorio-retinal colobomas and retinal detachment repair with cyanoacrylate at a tertiary eye care center in Nepal. Cyanoacrylate was used to seal colobomatous retinal breaks in eyes which had undergone multiple retinal surgeries with failed outcome. Three eyes that were operated using cyanoacrylate were included. All three patients had attached retina and none of the patients required a long-term tamponading agent. None of the patients underwent head positioning following the surgery. All of the patients had a visual acuity gain of 3/60 or more at the end of 8 months. No adverse or inflammatory reactions were noted. We demonstrate that cyanoacrylate is safe and less resource-demanding without a requirement of second surgery to remove a tamponading agent. It could be helpful in eyes with persistent retinal detachment in colobomatous eyes. Because we were able to achieve favorable outcomes without head positioning, we believe it may also be helpful in patients who are not suitable for positioning because of bodily or bony deformities and in retinal detachment with other coexisting trauma.

Correction of tibial tubercle trochlea groove distance is related to torsional correction in high tibial derotational osteotomy.

High tibial osteotomy with internal tibial derotation (high tibial derotation osteotomy = HTDRO) is a common surgical treatment in patients with patellofemoral malalignment alone or in combination with patellofemoral instability. Operative techniques and theoretical calculations may assume that correction of the tibial tubercle-trochlear groove (TTTG) distance is related to the amount of torsional correction. The purpose of this investigation was to predict the change in TTTG distance in HTDRO through a clinical study. Twenty-one consecutive cases of derotational HTO were evaluated by torsional CT scanning in terms of the pre- and postoperative tibial torsion and TTTG distance. Changes in the TTTG distance were related to the changes in the amount of torsional correction. The change in patellar height was measured pre- and postoperatively, and the Caton-Deschamps Index (CDI) was calculated. The mean change in tibial torsion was 13.9°, and the mean change in the TTTG distance was 6.3mm. A strong relationship (0.90) between the change in torsion and the change in TTTG distance from pre- to postoperative status was found (p < 0.001). No statistically significant change in CDI could be seen between the preoperative [mean value (MV) 1.0] and postoperative (MV 1.1) periods. In patients with patellofemoral instability or patellofemoral maltracking with both a high tibial external torsion and a high TTTG distance, a derotational HTO can correct both bony deformities. Patella height does not change significantly with this surgical technique. With 1° of torsional correction, the TTTG distance decreases 0.45mm with our surgical technique of derotational HTO.

37-Year-Old Man With Headache and Nasal Congestion

37-Year-Old Man With Headache and Nasal Congestion

The Circumferential Femoroplasty: An All-Arthroscopic Technique for Addressing a Challenging Hip Deformity

Femoroacetabular impingement is recognized as a common cause of hip pain. Cam-type femoroacetabular impingement results from abnormal contact between an aspherical femoral head and the acetabular rim during hip range of motion, leading to labral tearing, cartilage damage, and, eventually, osteoarthritis. Arthroscopic correction of this bony deformity has been well described, particularly in the anterolateral quadrant of the femoral neck. Some deformities extend well beyond this quadrant, involving most or all of the circumference of the femoral neck, making arthroscopic decompression a challenge. We present a post-less, all-arthroscopic technique for performing a circumferential cam decompression using 3-dimensional preoperative planning software and interactive fluoroscopy-integrated computer vision interface.

Radiological Findings More Important and Reliable in the Diagnosis of Skeletal Fluorosis

Skeletal fluorosis is the resultant of prolonged chronic fluoride exposure through fluoride containing water and food and /or industrial fluoride emission. In this disease, due to pathological changes in various bones of the body, many types of physical deformities develop which are more painful and unbearable. These bony deformities remain in man throughout his life. There is no cure available for these fluoride-induced disorders yet. Among these deformities, the most common bone deformities in humans are bending at the waist (kyphosis) and curvature of the lower extremities (genu-varum and genu-valgum). In severe state of skeletal fluorosis, neurological complications such as paraplegia and quadriplegia are also prevalent in human population. In fact, these are the crippling deformities and can be easily recognised by necked eyes. But many times mistakes are made in identifying skeletal fluorosis in its early stages. However, radiological study makes the diagnosis of skeletal fluorosis easier, which is also more important and reliable. Because even mild fluorideborne effects, such as periosteal exostosis, osteosclerosis, osteoporosis, and osteophytosis can be easily detected in X-rays of diverse bones of skeletal. However, the presence of fluoride-induced calcification of the interosseous membrane between radius and ulna bones of upper limbs or forearms is the most ideal or correct diagnostic feature or sign of skeletal fluorosis. In present editorial, besides the different forms of crippling deformities, various fluorideinduced radiological changes in diverse bones of subjects afflicted with mild to severe skeletal fluorosis have also been focussed which are more important, useful, and reliable in the diagnosis of skeletal fluorosis in humans.

Tessier cleft numbers 3 and 4: Presentation of soft tissue and bony deformities in a select South African population

BackgroundTessier cleft numbers 3 and 4 are rare congenital craniofacial malformations. Tessier cleft number 3 runs from the philtrum of the superior lip, traverses the ala of the nose and ends at the medial canthus of the eye. Tessier cleft number 4 commences between the philtrum and oral commissure in the superior lip, and ascends into the orbit, remaining medial to the infraorbital foramen. The associated clinical manifestation of each cleft type varies amongst patients. This study documented the soft tissue and bony deformities of Tessier cleft numbers 3 and 4 in a select South African population. MethodsThe study group was selected from retrospectively reviewed computed tomography (CT) scan records, which were made available via the repository of the Department of Clinical Anatomy at higher education institution in South Africa. Seven out of fifty CT scans that met the inclusion criteria were assessed and analysed. The patient records associated with the selected scans were reviewed. The soft tissue and bony deformities characteristic of Tessier cleft numbers 3 and 4 were documented [Ethical approval number: BE363/19]. Descriptive statistics were used to summarise the results. ResultsThe bony deformities presented in the cases of this study included alveolar clefts, nasal septum deviation, hypertelorism and maxillary bone defects. The soft tissue deformities included cleft lip, nasolacrimal abnormalities, eye dystopia, anophthalmia and nasal ala defects. ConclusionsThe extent of the associated deformities of each case varied; however, the primarily affected regions remained constant i.e., the orbital, nasal and oral regions. The variation in soft tissue and bony presentation warranted the need to document these clefts. This study will contribute to the anatomical interpretation of Tessier cleft numbers 3 and 4 in South Africa, and aid medical professionals in the evaluation, differentiation, and treatment of such clefts.

Hunchback with “S” Shape Spine: Cadaveric Case series

Introduction: Kyphosis is a sharp posterior angulation due to localized collapse or wedging of one or more vertebrae and scoliosis is the lateral curvature of the spine. These may occur due to a congenital defect, fracture, and sometimes pathological or spinal tuberculosis. Materials and Methods: During routine cadaver dissection, four cases of kyphoscoliosis were identified. In the first case, a protrusion on the posterior surface of the trunk of the cadaver at L1 level was observed in a 60-year-old male. The lungs were collapsed and adherent with the pleura and thoracic wall. The posterior wall of the stomach was adherent to the pancreas and a depression was noted on the anterior surface of abdominal aorta. The T12 and L1 vertebrae were fused, and the spine was deviated to the left side. The anterior aspect of the body of L1 vertebrae was marginally eroded. The second case of kyphoscoliosis was from 80-year-old female cadaver. The descending and abdominal aorta had an abnormal course along the vertebral column, third and fourth cases were observed with slight protrusion and scoliosis but not much changes in the vertebral column. Results: The cause of the deformity was confirmed by pathological examination of the tissues showed inter vertebral disc degeneration with calcification and ossification and osteopenia. The underlying etiology can be tuberculosis, injuries, or infections. Conclusion: Severe kyphoscoliosis can affect wide range of systems in the body. It will affect not only the respiratory system also pressure on great vessels as a consequence of bony deformity. KEY WORDS: Kyphosis, Cadaver Dissection, Kyphoscoliosis, Deformity, Calcification, Ossification.

외이도 연골부 및 골부의 변형을 동반한 이구선종 1예

Ceruminous adenoma is a well-circumscribed tumor that originates from apocrine glands located in the external auditory canal (EAC). It is a rare disease that accounts for 5.7% of all EAC and auricular tumors. It usually presents as slow-growing tumor accompanying several ear symptoms; mass, fullness, hearing loss, pruritus and otorrhea. If the detection of the tumor is delayed, the tumor can obstruct the EAC completely and its further growth may lead to deformation of surrounding structures such as the cartilaginous or bony portion of EAC. The wide local excision is the treatment of choice for benign ceruminous gland tumors and thorough histopathologic review is essential in that there is possibility of recurrence and malignant transformation. Herein, we present a case of ceruminous adenoma with cartilage and bony deformation in the EAC with a literature review.

A RARE CASE OF DORV IN ADULTHOOD

Background: Double outlet right ventricle (DORV) is a rare cardiac malformation in children and even more rare when it comes to adulthood. Clinical Presentation: We report a boy with DORV with Mitral atresia and hypoplastic Left Ventricle who presented to us with breathlessness on climbing 2 flight of stairs at the age of 22 years.He was not seriously limited when he came to our hospital with complaint of breathlessness on exertion. The mother first noticed him getting breathless on climbing 2 flight of stairs at 5 years of age.The patient had history of recurrent infections in the past with failure to gain weight since childhood.On Examination the Pulse was 90 beats per minute,Spo2 was 85% on Room Air in all four limbs, BP was 90/60 mmhg, no tachypnea.There was Grade 2 clubbing present with cyanosis on the nails of all four limbs. Patient had cleft lip and cleft palate with pes cavus in left foot. On inspection, precordial bulge seen on left side with bony cage deformity and apex impulse in left 5th intercostal space lateral to midclavicular line and visible pulsations in 3rd intercostal space. On palpation, Diastolic thrill present in 2nd left intercostal space with grade 3 parasternal heave. On Auscultation, Grade 3/6 loud harsh diastolic murmur heard over the left precordium and interscapular and infrascapular area with diaphragm of stethoscope in supine position.Soft high pitched early diastolic murmur heard best at left upper sternal border and increased during inspiration. 2D echo suggestive of Double outlet Right ventricle with mitral atresia with hypoplastic left ventricle with pulmonary arterial hypertension and severe pulmonary regurgitation. Discussion: To our knowledge very few cases of DORV survives upto this age without any serious limitation that have been reported.DORV if diagnosed early and operated between the age of 1 year to 3 years have satisfactory results. Some cases that remain asymptomatic or are diagnosed late leads to development of pulmonary hypertension which makes them poor candidates of surgery.It was surprising as this patient have survived till now without any serious limitation or symptoms.

The Increased Tibiofemoral Rotation: A Potential Contributing Factor for Patellar Maltracking in Patients with Recurrent Patellar Dislocation.

ObjectiveThe purpose of this study was to analyze the relationship between tibiofemoral rotation and patellar maltracking in patients with recurrent patellar dislocation.MethodsA total of 143 consecutive knees (118 patients) with clinically diagnosed recurrent patellar dislocation from January 2018 to December 2019 were retrospectively analyzed. Patellar tilt angle and bisect offset index were recorded on axial CT to assesses the severity of patellar maltracking. Tibiofemoral rotation angle is measured by comparing the angle between the posterior femoral and tibial condylar lines on three‐dimensional CT. The Pearson correlation was calculated to investigate the association between tibiofemoral rotation angle and patellar maltracking. Patients were divided into the rotation group (≥15°) and control group (<15°) based on the value of tibiofemoral rotation and a further comparison was performed. To further clarify the complicated relationship among tibial tubercle‐trochlear groove (TT‐TG), tibial tubercle‐posterior cruciate ligament distance (TT‐PCL), tibiofemoral rotation, and patellar maltracking, patients were divided into four subgroups according to the value of TT‐TG and TT‐PCL.ResultsThe mean preoperative tibiofemoral rotation angle was 12° ± 6° (range, 0°–31°). Pearson correlation between patellar maltracking parameters (bisect offset index, patellar tilt angle) and various bony deformities found that the tibiofemoral rotation angle was moderately correlated with bisect offset index (r = 0.451, p < 0.001) and patellar tilt angle (r = 0.462, p < 0.001). Further results demonstrated that bisect offset index (152.1 vs 121.2, p < 0.001) and patellar tilt angle (41.2° vs 33.5°, p < 0.001) were significantly higher in the rotation group than that in control group. For patients with a TT‐TG distance of >20 mm, the increased TT‐TG distance was mainly caused by tibiofemoral rotation angle in group C (TT‐TG > 20 mm, TT‐PCL < 24 mm) and predominantly induced by tibial tubercle lateralization in group D (TT‐TG > 20 mm, TT‐PCL > 24 mm). Bisect offset index and patellar tilt angle were significantly higher in the group C than group D.ConclusionThe increased tibiofemoral rotation angle is associated with patellar maltracking in patients with recurrent patellar dislocation. Patients with increased tibiofemoral rotation angle usually have more severe patellar maltracking.

The coronoid opening angle: a novel radiographic technique to assess bone loss in coronoid trauma.

Elbow fracture dislocations are complex injuries that often require surgical treatment in order to obtain a stable and congruent elbow joint. The coronoid plays a key role in the stability of this joint. Accurately identifying the degree of coronoid bone loss in the setting of traumatic elbow injuries is challenging. The purpose of this study is to describe a newradiographic measure, the coronoid opening angle (COA), to assist in estimating bone loss in these challenging fractures. Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were determined by 3 reviewers. A total of 120 subjects were included. The normal coronoid opening angle was 34° (95% CI 32.9°-34.0°) and the coronoid height, 18.8 mm (18.1-19.6). Ninety-five percent of the population had an opening angle greater than 29° (95% CI 27.2°-29°). The COA limit was calculated at 20%, 33%, and 50% of baseline coronoid height corresponding to degree of bone loss. Coronoid opening angles of 24°, 20°, and 16°, respectively, indicate the minimum bone loss of interest in 95% of the population. The intraclass correlation coefficient was found to be 0.89 or higher. In the setting of elbow trauma, it is often challenging to predict the amount of coronoid bone loss. The coronoid opening angle is a newtechnique and an adjunct for lateral elbow radiographs to predict the minimum coronoid bone loss. This can be used to guide clinical decision making, aid in predicting instability, and guide treatment. Future research will aim to validate this tool in the clinical trauma setting.

Persistent or recurrent symptoms after surgery for femoroacetabular impingement syndrome (FAIS) : Pathology, diagnostics and therapy

Femoroacetabular impingement syndrome (FAIS) has gained vast importance in the last two decades. Multiple studies have shown that if untreated, early osteoarthritis of the hip joint may result. Hip arthroscopy is one of the fastest growing procedures in the orthopedic cosmos, having already replaced the majority of (mini) open techniques in FAIS surgery. However, with the recent remarkable increase in the volume of hip arthroscopies performed worldwide, the number of patients with persistent or recurrent symptoms after FAIS surgery is also growing. Potential underlying pathologies are misresection of the bony deformity, insufficiency fracture of the femoral head neck junction or the femoral subchondral head itself (SIFFH), adhesions, failed chondrolabral or capsular treatment, septic arthritis, heterotopic ossification or awrong indication in the case of osteoarthritis that is already too advanced. Most of these occur more often during the extensive learning curve for hip arthroscopy. High-quality imaging plays akey role in determining the need for revision surgery vs. further conservative treatment. Therapeutical avenues are shown with the common goal of proper detection and correction of the underlying pathology to address unsatisfactory FAIS treatment outcomes and ensure long-term survival of the native hip joint.

Newly repairing technique of deformed hand by a posterior interosseous flap in an infant: A case report.

IntroductionMany non-surgical methods were performed to repair the deformities in the skeletal system to avoid severe complications post-open surgery, especially within the childhood stage or below. We aim, in this case, to present a new technique for repairing bony deformities in the childhood stage, which fewer studies have to instigate its efficacy versus open surgery.Case presentationWe present a 14-months-old infant with wrist extravasation injury at the neonatal stage (day 1), end with a right wrist volar contraction and complete loss of brain homunculus of the right hand.DiscussionWe used a reverse posterior interosseous flap to reconstruct the soft tissue and release the flexor tendons of the hand. The flap was conducted entirely and was rapidly adapted to the recipient beds to achieve good color and texture harmonies. Within following up for 12 weeks, the patient restored hand function.ConclusionMore global cohort studies are required to compare precisely the efficacy between surgical options and the used technique in our case for salvaging deformities in childhood.

A Comparison of Arc of Motion, Radiological Parameters of the Wrist and Patient Rated Wrist Evaluation between Adult Transfusion Dependent Thalassemics and Normal Subjects.

Background: Bony deformities and arthropathies have been noticed in thalassemia patients. The aim of this study is to compare the arc of motion and radiological parameters of the wrist and patient rated wrist evaluation (PRWE) between adult transfusion-dependent thalassemics and normal subjects. Methods: An observational cross-sectional study was done in the department of orthopaedics over a period of 2 years where a total of 30 skeletally mature thalassemia major patients (group A) were assessed. The data was then compared with the data of demographically matched 30 healthy adults (group B). Arc of motion of the dominant wrist that included flexion, extension, radial and ulnar deviation, pronation and supination was measured using a handheld goniometer for both groups. Radiographs of the dominant wrist were obtained in both groups and used to determine the radial height, radial articular angle and carpal slip. PRWE was used to assess the function of the wrist. A p-value of <0.05 was considered statistically significant. Results: Clinical abnormalities at the wrist joint were found in 80% of thalassaemia patients. There was a statistically significant increase in ulnar deviation, wrist extension and decrease in wrist flexion in group A compared to group B. Radiological abnormalities were found in 100% of thalassaemia patients. All the radiological parameters were significantly increased in group A compared to group B. There were no differences in PRWE scores between both groups. Conclusion: Clinical and radiological changes of wrist joint occur in skeletally mature thalassaemia major patients due to shortened ulna compared to healthy adults. This may be due to disease itself, bone marrow expansion, osteopenia, drug (chelating agent) or iron toxicity. Understanding the changes at the wrist in patients with thalassemia major is important to increasing the life expectancy of these patients. Level of Evidence: Level IV (Diagnostic).

A Case of Patellar Instability and Lateral Facet Cartilage Defect

Background: Concomitant cartilage injury is commonly associated with patellofemoral instability. While nonoperative treatment remains the gold standard for first time dislocators, there has been an increased trend toward addressing patellar instability when symptomatic cartilage disease is present. Indications: A healthy active 29-year-old woman &gt;2 years of patellar instability and pain symptoms in the right knee. Imaging revealed tibial tubercle to trochlear groove (TT-TG) distance of 19.8 mm, and a Caton Deschamps Ratio of 1.54. Initial staging arthroscopy demonstrated a near full thickness cartilage defect of the lateral patellar facet measuring 2x2 cm. Technique Description: In the index procedure, a staging diagnostic arthroscopy is performed to evaluate the extent of the cartilage defect. Given the size of the lesion, a matrix-induced autologous chondrocyte implantation (MACI) biopsy is performed for later implantation. At the second stage procedure, a midline approach to the patella and tibial tubercle is performed. A 45° osteotomy is initiated with a cutting jig. The osteotomy is detached distally to allow for both anteromedialization and distalization to offload the cartilage defect and improve patellar articulation. The lateral patellar facet cartilage defect is prepared, and a combination of fibrin sealant and digital pressure is used to implant the pre-shaped MACI transplant. The osteotomy is then secured with 2 bicortical screws. A semitendinosus allograft is secured to the upper half of the medial border of the patellar and secured to its anatomometric point on the femur to reconstruct the medial patellofemoral ligament (MPFL). Results: Patient successfully returned to running and is currently working on return to other sports with no anterior knee pain or instability. Recent studies have demonstrated overall good clinical outcomes following MACI for patellofemoral lesions. Addressing underlying bony deformity and offloading patellofemoral cartilage lesions with tibial tubercle osteotomy in combination with MPFL reconstruction has improved patellar stability and good patient satisfaction. Discussion/Conclusion: Combined tibial tubercle osteotomy, MPFL reconstruction, and MACI in a comprehensive approach can successfully address symptomatic patellofemoral cartilage disease in the setting of patellar instability with underlying bony abnormalities.

Novel TBXAS1 variants in two Indian children with Ghosal hematodiaphyseal dysplasia: A concise report

Ghosal hematodiaphyseal dysplasia (GHDD) is a rare, autosomal recessive condition characterised by diaphyseal dysplasia of long bones with defective haematopoiesis. We describe 2 such cases with clinical and radiological evidence of GHDD. Molecular analysis revealed novel variants in TBXAS1 gene in both of them. Suspicion and confirmation of this entity is crucial in cases of refractory anemia with bony deformities, as the clinical manifestations in this entity are usually well responsive to corticosteroids.

Anatomical variations of human sphenoid sinus in terms of volume and septation pattern in a subset of Pakistani population using computed tomographic images.

To compare the sphenoid volume between the genders and to analyse variations in septal insertions on bony wall of optic nerve and internal carotid artery. The prospective study was conducted from October 2020 to February 2021 at the Radiology Department of Dow University of Health Sciences, Karachi, and comprised paranasal sinus patients of either gender aged 20-60 without any bony deformity of sphenoid sinus who were analysed for sphenoid volume, number of septa and variable septal insertions using computed tomography of paranasal sinus. On the basis of septal insertions, the scans were categorised into Group 1 with no risky septal insertion, Group 2 with septal insertion on bony wall of optic nerve, Group 3 with septal insertion of internal carotid artery, and Group 4 with septal insertion on both optic nerve and internal carotid artery. Differences in sphenoid volume were analysed between males and females and among the four groups. Data was analysed using Graph Pad Prism 9. Of the 300 patients, 171(57%) were males and 129(43%) were females. The overall mean age was 39.28±10.9 years. Multiple septa were found in 208(69.3%) of the sinuses. There were 129(43.7%) patients in Group 1, 34(11.3%) in Group 2, 119(39%) in Group 3 and 18(6%) in Group 4. Significant difference was found between volume and gender as well as among the four groups (p<0.001). The sphenoid volume between the genders and the variations in septal insertions on bony wall of optic nerve and internal carotid artery were significantly different.

Mechanical Axis Method to Determine First Intermetatarsal Angle and Tibial Sesamoid Position

Utilizing the mechanical axis can decrease load on the joint and be beneficial when analyzing bony deformities and planning surgical correction with osteotomies. The aim of this study was to identify the normal mechanical axes of the first and second metatarsals and use them to obtain the first/second mechanical intermetatarsal angle (mIMA). The mechanical axis of the first metatarsal was used to obtain the mechanical tibial sesamoid position (mTSP), which provides a mechanical relationship with the sesamoid apparatus. The angular difference between the anatomic and mechanical axis lines (anatomic-mechanical angle [AMA]) was determined for the first metatarsal and for the second metatarsal. The commonly used first/second anatomic intermetatarsal angle (aIMA) and anatomic tibial sesamoid position (aTSP) were also obtained and compared with the first/second mIMA and mTSP. In this retrospective analysis, radiographs of 50 normal feet (40 patients) were assessed. Pearson's correlation coefficients were used to measure reliability between obtained measurements. Mean first/second aIMA was 8.6 ± 3.0 degrees, and first/second mIMA was 8.6 ± 2.6 degrees. First metatarsal AMA was 1.1 ± 1.0 degrees; second metatarsal AMA was 2.0 ± 1.6 degrees. The mTSP was 2.8 ± 1.1, and aTSP was 2.9 ± 1.0. The TSP median was 3 (range, 1-5). Using the mechanical axis method to obtain the first/second mIMA and the mTSP is reproducible and not affected by anatomic changes to the shape of the metatarsal. Unlike the anatomical axis, the mechanical axis does not change, therefore we recommend using the mechanical axis during surgical planning and when obtaining preoperative and postoperative measurements for the long bones of the foot, particularly for forefoot conditions such as hallux valgus.

Return to Physical Activity following Flatfoot Reconstruction

Category:Hindfoot; Midfoot/Forefoot; SportsIntroduction/Purpose:Progressive collapsing foot deformity (PCFD) is a condition encompassing multiple interrelated, progressive bony and soft tissue deformities, often requiring surgical correction. Patients are often debilitated, with postoperative goals commonly cited as walking and low-impact activities without pain. However, some patients engage in sports and more rigorous activities. Surgeons may struggle to set expectations after surgery since few studies investigate returns to activity following flatfoot reconstruction and every patient is different. Existing studies are limited by small sample sizes, lack of data of activity-specific data, and cohorts confined to one or two of the many possible concomitant procedures in flatfoot reconstruction. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible PCFD.Methods:Patients who underwent reconstructive surgery from February 2016-May 2019 for flexible-stage PCFD were identified by registry review and contacted with IRB approval. 70/119 patients (72/121 feet, 60%) were reached at mean 3.1 (range, 2.0 to 5.4) years post-operatively with mean age 43.5 (range, 18 to 59) years at surgery. Concomitant procedures were noted. Physical activity was evaluated with a previously published questionnaire that assessed participation in 15 sports and activities, allowed patients to list additional activities, and classified activities as high or low-impact. Patients specified postoperative number of sessions per week, session duration, return times to participation and maximal activity, relative pre/postoperative difficulty, and satisfaction with outcome regarding sports. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Multivariable regressions assessed associations between PROMIS domain changes and survey responses and linear models measured association of sports participation with the most performed procedures, controlling for concomitant procedures.Results:Patients experienced significant improvements in all PROMIS domains except Depression and surpassed previously reported minimal clinically important differences for PCFD in Physical Function and Pain Interference scores. Patients reported participation in 21 specific sports and activities (Table 1). Compared to preoperatively, patients rated 16.7% (45/270) of activities as more difficult postoperatively, 33.3% (90/270) as equally difficult, and 50% (135/270) as less difficult. Median return times were 6-9 months for participation in activities and 13-18 months to reach maximum preoperative participation. Patients spent a median 7.6 (range, 0-29.8) hours/week engaged in physical activity. 3% of patients (2/72) were sedentary, 31% (22/72) were moderately active, 28% (20/72), were highly active and 36% (26/72) were extremely active. Improvements in Physical Function (P=.021), Pain Interference (P=.001), and Global Physical Health (P=.001) were associated with increased outcome satisfaction regarding physical activities. No associations were found between procedures performed and any PROMIS domains or return parameters.Conclusion:This is the largest and most comprehensive analysis of patient participation in sports and physical activities following flatfoot reconstruction. Results suggest that flatfoot reconstruction surgery generally results in good returns to physical activity in terms of return time, pre-postoperative difficulty changes, and satisfaction. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to some athletic limitations. However, ninety percent of patients reported satisfaction with their surgical outcomes with respect to returns to physical activity, indicating that, for most patients, flatfoot reconstruction provides meaningful relief from debilitation.

Tibial Condylar Valgus Osteotomy Combined With Medial Open-Wedge Distal Tuberosity Tibial Osteotomy

Severe varus deformity in osteoarthritic knees is attributed not only to bony deformity but also to intra-articular deformity as a result of medial joint space narrowing with lateral joint space widening (increased joint line convergence angle). In such knees, correction of bony deformity by high tibial osteotomy (HTO) alone may not be capable of restoring physiological joint geometry and biomechanics. Tibial condylar valgus osteotomy (TCVO), an L-shaped osteotomy in the medial tibial condyle, has been proposed to improve articular stability and congruity by elevating the medial tibial joint line and addressing the articular component of the deformity; however, its surgical efficacy for correction of the valgus deformity is limited. Therefore a procedure combining HTO and TCVO can be a reasonable option to achieve restoration of the knee joint physiology in such situations. In our current practice, medial open-wedge distal tuberosity tibial osteotomy (MOW-DTO) has been the procedure of primary option among the HTO procedures to avoid patellofemoral overload which could be an inherent problem in medial open-wedge HTO. In this article, the surgical rationale and the combined procedure of TCVO and MOW-DTO are described.