Bony Procedures Research Articles

Postsurgical Analysis of Gait, Radiological, and Functional Outcomes in Children with Developmental Dysplasia of the Hip.

Children undergoing DDH correction surgery may experience gait abnormalities following soft tissue releases and bony procedures. The purpose of this study was to compare the residual gait changes, radiological outcomes, and functional outcomes in children who underwent DDH surgery with those in healthy controls. Inertial motion sensors were used to record the gait of 14 children with DDH and 14 healthy children. Pelvic X-ray was performed to determine the Severin classification and the presence of femoral head osteonecrosis (Bucholz-Odgen classification). For functional evaluation, the Children's Hospital Oakland Hip Evaluation Scale (CHOHES) was used. There was no difference in spatial parameters between the two groups. In terms of temporal parameters, the DDH-affected limbs had a shorter stance phase (p < 0.001) and a longer swing phase (p < 0.001) than the control group. The kinematic study showed that the affected limb group had smaller hip adduction angle (p = 0.002) and increased internal rotation (p = 0.006) with reduced upward pelvic tilt (p = 0.020). Osteonecrosis was graded II, III, and IV in five, three, and one patients, respectively. Five patients had no AVN changes. The Severin classification was grade I, II, and III for six, three, and five patients, respectively. Most patients had good functional outcomes on the CHOHES, with a mean total score of 96.64 ± 5.719. Multivariate regression analysis revealed that weight, height, and femoral osteotomy were independent predictors for gait, radiological and functional outcome. Despite good functional scores overall, some children had poor radiological outcomes and gait abnormalities. Our results identified the risk factors for poor outcomes, and we recommend specified rehabilitative strategies for long-term management.

The rheumatoid hand: a review of current medical and surgical management

Rheumatoid arthritis is a chronic inflammatory condition in which immunologically mediated inflammation results in marked synovial joint destruction and functional deterioration in addition to often significant systemic disease. It affects approximately 1% of the population according to the UK National Institute for Health and Care Excellence, presents most commonly in women aged 30–50 years, and has a multifocal aetiology including genetic hormonal and environmental factors. Management of rheumatoid hand disease can be complex and involves excellent multidisciplinary team management from the outset. Early treatment with newer rheumatological biologic drug therapy has largely negated the need for surgical management, however there remains several critical opportunities for hand surgeons to improve quality of life for these patients, including emergencies such as impending tendon rupture and nerve compression, as well as function restoring soft tissue and bony procedures. This article seeks to review the complete management of the patient with rheumatoid hand disease, including medical and surgical. A summary of key learning points for colleagues not specifically involved in this practice, such as biologic drug mechanism of action and key biomechanics where relevant is included.

Correction of neglected post-burn severe calcaneo-valgus deformity of foot with Joshi’s external stabilization system: a one stage surgical procedure

Post burn calcaneovalgus is a complex foot deformity and management becomes increasingly difficult especially if deformity is neglected in growing young child resulting in secondary bony deformity. A simple technique of single stage surgical correction with Joshi’s external stabilization system (JESS) is described using principle of distraction osteogenesis or histogenesis without need of extensive plastic surgical procedure. A functional plantigrade foot is achieved after completion of the procedure without need of any bony procedure and least chances of any neurovascular compromise. JESS is a versatile external fixation device for correction of neglected postburn complex calcaneovalgus deformity.

From second webspace syndrome to second cross over toe: Clinical and radiological findings following Weil osteotomy with no soft tissue procedure

BackgroundThe second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both.The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure. MethodsA retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery. ResultsTwenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001). ConclusionMedial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients. Level of evidenceLevel IV, retrospective case series

Medial Patellofemoral Ligament Reconstruction in Obese Patients Results in Low Complication Rates and Improved Subjective Outcomes

To compare outcomes, activity scores, and complication rates of obese and non-obese patients undergoing medial patellofemoral ligament (MPFL) reconstruction. A retrospective review identified patients undergoing MPFL reconstruction for recurrent patellofemoral instability. Patients were included if they had undergone MPFL reconstruction and had follow-up for a minimum of 6 months. Patients were excluded if they underwent surgery less than 6 months earlier, had no outcome data recorded, or underwent concomitant bony procedures. Patients were divided into 2 groups based on body mass index (BMI): BMI of 30 or greater and BMI less than 30. Presurgical and postsurgical patient-reported outcomes including Knee Injury and Osteoarthritis Outcome Score (KOOS) domains and the Tegner score were collected. Complications requiring reoperation were recorded. P < .05 was defined as a statistically significant difference. A total of 55 patients (57 knees) were included. There were 26 knees with a BMI of 30 or greater and 31 knees with a BMI less than 30. There were no differences in patient demographic characteristics between the 2 groups. Preoperatively, no significant differences were found in KOOS subscores or Tegner scores (P= .21) between groups. At minimum 6-month follow-up (range, 6.1-70.5 months), patients with a BMI of 30 or greater showed statistically significant improvements in the KOOS Pain, Activities of Daily Living, Symptoms, and Sport/Recreation subscores. Patients with a BMI less than 30 showed a statistically significant improvement in the KOOS Quality of Life subscore. The group with a BMI of 30 or greater had significantly lower KOOS Quality of Life (33.34 ± 19.10 vs 54.47 ± 28.00, P= .03) and Tegner (2.56 ± 1.59 vs 4.78 ± 2.68, P= .05) scores. Complication rates were low, with 2 knees (7.69%) requiring reoperation in the cohort with a BMI of 30 or greater and 4 knees (12.90%) requiring reoperation in the cohort with a BMI less than 30, including 1 reoperation for recurrent patellofemoral instability (P= .68). In this study, MPFL reconstruction in obese patients was safe and effective, with low complication rates and improvements in most patient-reported outcomes. Compared with patients with a BMI less than 30, obese patients had lower quality-of-life and activity scores at final follow-up. Level III, retrospective cohort study.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability.

Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice. A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice. All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss. Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

When Should Bony Correction Be Considered in Addition to Medial Patellofemoral Ligament Reconstruction? Results of a Clinically Derived 2-Group Classification of Lateral Patellar Instability Based on 122 Patients at 2- to 5-Year Follow-up.

The need for concomitant bony procedures to realign pathoanatomic risk factors in addition to medial patellofemoral ligament reconstruction (MPFL-R) remains unclear. To evaluate a clinically derived 2-part classification of lateral patellar instability aimed at identifying patients indicated for a concomitant bony procedure. Cohort study; Level of evidence, 3. The study included 122 patients (42 male, 80 female; mean ± SD age, 22 ± 6 years) who were assigned to a mild instability group (mIG) and a complex instability group (cIG) based on the reversed dynamic patellar apprehension test (ReDPAT) and J-sign. The mIG had a positive ReDPAT result <40° to 50° of knee flexion and an absent or low-grade J-sign (grade 1), and the cIG had a positive ReDPAT result >40° of knee flexion and/or a high-grade J-sign (grade 2 or 3). The mIG underwent isolated MPFL-R, and the cIG underwent MPFL-R and concomitant bony procedures depending on the established risk factor assessment. For evaluation, the BANFF Patellar Instability Instrument 2.0 (BPII 2.0) and numeric analog scale (0-10) for patellofemoral pain and subjective knee function were used. The minimal clinically important difference for the BPII 2.0 was ascertained by calculating half the standard deviation of baseline scores. Radiographic analysis confirmed a significantly more pronounced pathoanatomic risk factor constellation in the cIG regarding severity of trochlear dysplasia, distal malalignment, and patellar height (all P < .05). At final follow-up, no patellar redislocation occurred in either group; 2 patients in the cIG reported patellar subluxation. Within both groups, all outcome scores improved significantly pre- to postoperatively (all P < .0001); no between-group difference was found regarding BPII 2.0 score and numeric analog scale for function. The minimal clinically important difference for the BPII 2.0 was met by 84% (32/38) of the mIG and 90% (76/84) of the cIG (P = .36), but the cIG experienced more patellofemoral pain than the mIG (1.3 ± 1.6 vs 2.1 ± 2.1; P = .036). Patients with a high-grade J-sign and/or a positive ReDPAT finding beyond 40° to 50° of knee flexion exhibited a significantly more pronounced pathoanatomic risk factor constellation; however, the correction of modifiable risk factors led to similarly good outcomes to patients who underwent isolated MPFL-R. A slightly higher level of patellofemoral pain after bony procedures was evident in these patients.

Arthroscopic Latarjet Learning Curve: Operating Time Decreases After 25 Cases

To demonstrate the learning curve associated with the arthroscopic Latarjet procedure and create a timetable to proficiency. Using retrospective data of a single surgeon, consecutive patients who had an arthroscopic Latarjet procedure performed between December 2015 and May 2021 were initially reviewed for inclusion in the study. Patients were excluded if medical data were insufficient for accurate surgical time record, their surgery was transitioned to open or minimally invasive, or if their surgery was performed in conjunction with a second procedure for a separate issue. All surgeries were performed on an outpatient basis and sports participation was the most common reason for initial glenohumeral dislocation. Fifty-five patients were identified. Of these, 51 met the inclusion criteria. Analysis of operative times for all 51 procedures demonstrated that proficiency with the arthroscopic Latarjet procedure was obtained after 25 cases. This number was determined by 2 methods using statistical analysis (P < .05). The average operative time over the course of the first 25 cases was 105.68 minutes and beyond 25 cases was 82.41 minutes. Male gender was seen in 86.3 percent of the patients. The average age of the patients was 28.6 years old. With continued transition towards bony augmentation procedures for addressing glenoid bone deficiency there is an increasing demand for the arthroscopic bony glenoid reconstruction procedures including the Latarjet procedure. It is a challenging procedure with a substantial initial learning curve. For a skilled arthroscopist there is a significant decrease in overall surgical time after the first 25 cases. The arthroscopic Latarjet procedure has advantages over the open Latarjet approach; however, it is controversial because it is technically challenging. It is important for surgeons to understand when they can expect to be proficient with the arthroscopic approach.

Isolated MPFL reconstruction with soft tissue femoral fixation technique in 54 skeletally immature patients: Clinical outcomes at 2 years follow-up. A French multicenter retrospective study

BackgroundMedial patello-femoral ligament (MPFL) reconstruction is one of the therapeutic options to treat patellofemoral instability. Classically, a à la carte treatment of skeletal and ligament abnormalities is described. This option is difficult to achieve in children because bony procedures can damage the femoral and/or tibial growth plate. The objective was to evaluate a strategy for isolated reconstruction of the MPFL in the treatment of objective patellar instabilities in children, in a large cohort. The return to sport, knee function and pain or discomfort were studied as secondary endpoints. MethodsThis French multicenter retrospective study included 54 pediatric patients with objective patellofemoral instability. Patients were included if they had presented at least 2 episodes of objective patella dislocation. A Deie-like technique with gracilis tendon graft, soft tissue femoral fixation and patellar bone tunnels for patellar fixation was used. Recurrence of dislocation was studied as the primary endpoint, and the recurrence rate was compared with the literature. A comparison of functional scores (Kujala, Lille femoro-patellar instability score or LFPI Score and Tegner activity score) and NRS between pre- and postoperative was studied as a secondary objective. ResultsA recurrence of femoro-patellar instability was observed for five patients within 2 years follow up (9%). A significant improvement of the Kujala, LFPI score, Tegner and NRS scores was observed (p<0.001). ConclusionIsolated reconstruction of the MPFL presents a risk of recurrence of 9% at 2years follow-up. This technique significantly improves the functional scores of the knee. This modified Deie technique provides good clinical and functional results, allowing return to sports with an acceptable risk of recurrence of patellar dislocation, similar to those observed in the literature. Isolated MPFL reconstruction as a first-line treatment appears to be a reliable and effective technique in terms of recurrence of dislocation and functional scores. It allows early recovery and rehabilitation and has lower morbidity than procedures requiring bone gestures. Level of evidenceIII, retrospective comparative study.

Anatomic Osteochondral Allograft Reconstruction for Concomitant Large Hill–Sachs and Reverse Hill–Sachs Lesions

Glenohumeral instability causing bipolar bone loss is increasingly being recognized and treated to minimize recurrence. Large Hill–Sachs and reverse Hill–Sachs lesions of the humerus must be addressed at the time of surgery to prevent recurrent dislocations and restore the native anatomic track. For patients with epilepsy, locked dislocations may create defects that must be addressed with bony procedures, including osteochondral allograft reconstruction as soft-tissue remplissage may not adequately addresses the magnitude of the bone loss. Osteochondral allografts have been successfully used to address bony defects ranging from 20% to 30% of humeral bone loss whereas shoulder arthroplasty is indicated for larger defects where the native anatomy can no longer be restored. In this Technical Note, we present a technique to address concomitant large Hill–Sachs and reverse Hill–Sachs lesions.

Arthroscopic Latarjet procedure does not lead to loss of clinically significant external rotation at 0° and 90° of shoulder abduction

Several reports have shown that shoulder stabilizing procedures lead to postoperative external rotation (ER) deficits. However, no study on arthroscopic Latarjet procedures has investigated the effect on ER when the arm is abducted at 0° (ER0) and 90° (ER90). This study examined the relationship between the arthroscopic Latarjet procedure and the subsequent effect on ER0 and ER90. Patients who underwent an arthroscopic Latarjet procedure from December 2015 to April 2021 were retrospectively evaluated. Preoperative ER0 and ER90 values were obtained from the contralateral shoulder. ER0 and ER90 values from the operative side were collected at both 3 and 6 months postoperatively. A repeated measures ANOVA was performed to assess the mean preoperative and postoperative values. Forty-six patients met the inclusion criteria. Mean ER0 for the 3- and 6-month time frames measured 44.2° and 54.6°, respectively. Mean ER90 for the 3- and 6-month time frames measured 78.4° and 90.4°, respectively. Comparison to the contralateral arm at the 3-month follow-up period showed a deficit of 14.9° (P=.0001) and 17.2° (P=.0001) for ER0 and ER90, respectively. At the 6-month follow-up period, patients demonstrated an average decline in ER0 and ER90 of 4.57° (P=.063) and 5.11° (P=.008), respectively. A nominal deficit in ER occurred for both ER0 and ER90 status post arthroscopic Latarjet procedure. Despite loss of ER90 at 6 months achieving statistical significance, the clinical impact is arguably inconsequential. Such limited loss of ER provides more information regarding bony procedures being a more definitive treatment for glenohumeral instability and the ability to restore native motion.

Patellar Instability.

Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. The presence of a preoperative J-sign is predictive of recurrent instability after operative management. Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.

Does Revision Surgery Peak after Extensive Joint Surgical Correction of Congenital Talipes Equinovarus?

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Severe congenital talipes equinovarus (also known as clubfoot) that resists conservative treatments is managed with extensive surgical soft-tissue release and bony procedures. Residual clubfoot deformity, or relapse after a primary intervention may also warrant an open surgery. While the high relapse rate of primary and secondary invasive surgical methods has been widely reported in the literature, the question if this curve will reach a peak in time remains open. This systematic review examines the tendency of required revision surgery in management of talipes equinovarus and statistically extrapolates the result to locate a pivot point. Methods: A comprehensive search was conducted of PubMed, CINAHL, Web of Science, and Cochrane from inception to December 2020 to identify literature on clubfoot. Using PRISMA guidelines, the search terms clubfoot OR clubfeet OR clubbed foot OR clubbed feet OR talipes equinovarus were used. Articles containing more than three human subjects were included. The database was searched for longitudinal studies of clubfoot management by extensive surgical procedures for pediatric, idiopathic, resistant, residual, or relapsed deformity. Retrospective studies of primary and revision surgery performed on children up to ten years old with reported mean follow up of at least one year were included. Outcomes were evaluated according to scoring systems Laaveg-Ponseti, Dimeglio-Bensahel, and Magone based on clinical examination of foot function, radiographic studies, or patient satisfaction questionnaires. Relapse was defined as revision surgery needed to manage residual deformities, mobility, pain, or other complications. Probability of less than 0.05 is considered statistically significant. Results: The initial search yielded 2907 articles, of which 23 relevant articles, were included. The number of treated clubfeet was 1646, and the average age at operation was 13.1 (1 - 120) months. The most common surgical procedures included posterior medial and lateral soft tissue release such as Turco's posteromedial release (PMR), subtalar release, and tibialis anterior tendon transfer. Initial correction outcome was commonly evaluated clinically by physical examination with high satisfaction, evidenced by often long lapses to first revision surgery when needed. The mean follow-up period was 17.2 years (1 - 47). For very long follow- up periods, relapse rate was as high as 89% (mean 37%). There was a strong positive correlation between mean follow-up and rate of relapse (R = 0.5023, p = 0.0073). Conclusion: The high rate of complications that warranted revision surgery (37%) was consistent with the literature, but of more concern was the consistent statistically positive slope that continued to climb even with follow-up periods as long as five decades. The absence of a peak in relapse is most consistent with the postulations that relapse was due to muscle-bone balancing dynamics evolving with growth and activities, damage from repeated surgeries, or severity of deformity at birth that is permanently incurable. Since clinical evidence and statistical assessment indicated persistent high rate of relapse, revision surgery should be limited in managing relapsed clubfoot.

How Does Lateral Column Lengthening Improve the Medial Longitudinal Arch? Now I Started to Understand!

Category: Hindfoot; Other Introduction/Purpose: Since its description by Evan for correction of overcorrected clubfoot cases, lateral column lengthening (LCL) has been widely used for correction of pes planovalgus deformity of any etiology, including flexible flat foot deformity in adolescents and adults, either as a solitary procedure or in combination with other bony or soft tissue procedures. The main indication is correction of forefoot abduction manifested radiologically as talonavicular uncoverage. Different techniques were described including Evan and Hintermann techniques. It was reported by many authors that LCL improved forefoot abduction and talonavicular uncoverage, but it was also noticed that LCL corrects the flattening of medial longitudinal arch. The mechanism by which LCL corrects the medial longitudinal arch is still not clearly understood. It was also reported that LCL is associated with forefoot supination, but the exact mechanism of supination is not understood. This study aimed to try to understand the mechanism by which LCL changes the shape of the foot. Methods: LCL osteotomy using Hintermann technique was performed in ten fresh frozen below knee cadaveric specimens. After completion of the osteotomy, the talus and leg were removed to monitor how the foot moves under the talus with opening of the osteotomy to change the shape of the foot. After that, the whole plantar skin was removed and plantar ligaments were dissected to study the influence of plantar ligaments on the plane of motion of the osteotomy and the effect of the osteotomy on plantar ligaments. Results: With opening of the osteotomy, the distal portion of the foot did not move in pure adduction as might be expected. Instead, it moved medial and plantar, and the osteotomy worked as a dorsolateral opening wedge osteotomy meaning that the osteotomy opened laterally but not medially, and dorsally but not inferiorly. The result was that the distal portion was adducted and plantar flexed, so it can correct the forefoot abduction and the flat arch. Because the osteotomy opens dorsally and laterally only, with no opening medially or inferiorly, the lateral part of the distal portion was plantar flexed more than the medial part, and this is the cause of forefoot supination. After dissection of the plantar ligaments to understand their influence on the osteotomy, it was found that the long and short plantar ligaments prevent the osteotomy from opening inferiorly and force it to work as a dorsolateral opening wedge. It was possible to move the distal portion in pure adduction only after cutting the long and short plantar ligaments. As the osteotomy worked as a dorsolateral opening wedge, the plantar fascia which is plantar and medial was relaxed after opening of the osteotomy. Conclusion: May be this can explain how the LCL osteotomy corrects the flat medial longitudinal arch and how it causes supination and lateral side overload. Based on this study, Cotton osteotomy may be needed to be added to LCL to correct the supination. Also, plantar fascia tightening cannot be the cause of medial longitudinal arch correction as it actually becomes more lax after opening of the osteotomy

Cerebral Palsy: Current Concepts and Practices in Musculoskeletal Care.

Cerebral palsy is a neurologic disorder characterized by a spectrum of motor and cognitive deficits resulting from insults to the developing brain. The etiologies are numerous and likely multifactorial; an increasing portion of cases may be attributable to genetic causes, although the exact mechanisms responsible remain poorly understood. Major risk factors include intrauterine stroke and prematurity and neonatal infection, trauma, and hypoxia, which may occur in the prenatal, perinatal, or postnatal period. The Gross Motor Function Classification System (GMFCS) is a widely used tool to establish a child's level of function and to guide treatment; however, additional metrics are necessary to formulate long-term prognoses. Goals of care are to maximize function and independence, which directly correlate with overall quality of life, and family participation is key to establishing goals early in treatment. Nonpharmaceutical treatments include physical, occupational, and speech therapy, as well as bracing, equipment, and technology. There is a breadth of medical interventions for managing hypertonia, including medications, botulinum toxin injections, intrathecal baclofen pumps, and selective dorsal rhizotomy. Orthopedic interventions are indicated for symptomatic or progressive musculoskeletal sequelae. Treatments for dysplastic hips and/or hip instability range from soft tissue releases to bony procedures. Neuromuscular scoliosis is managed with posterior spinal fusion because bracing is ineffective against these rapidly progressive curves. The degree of care varies considerably depending on the child's baseline GMFCS level and functional capabilities, and early screening, diagnosis, and appropriate referrals are paramount to initiating early care and maximizing the child's quality of life.

3D Analysis of the Hindfoot Following Total Ankle Replacement for Varus Ankle Osteoarthritis

Category: Hindfoot; Ankle; Ankle Arthritis Introduction/Purpose: In advanced stages of varus ankle osteoarthritis (OA) progressive destabilization of the peritalar structures is common. Total ankle replacement (TAR) is a viable treatment option although data, particularly on changes in the subtalar joint position following TAR, is scarce. Therefore, we evaluated the subtalar joint using semi-automated measurements based on weightbearing cone-beam CT scans (WBCT) before and after TAR. Methods: 14 patients (15 ankles) who received TAR without additional bony procedures for varus ankle OA were analyzed using semi-automated measurements of the hindfoot based on pre-and postoperative WBCT. Pain on visual analog scale (VAS) and American Orthopedic Foot and Ankle Society Hindfoot Score (AOFAS) were assessed. Results: Five of 6 measurements showed a significant improvement including sagittal and axial talocalcaneal angle, talar horizontal inclination angle, hindfoot angle, and talar tilt. Conclusion: Besides ankle joint realignment, TAR for varus ankle OA without additional bony procedures achieved significant correction of the subtalar joint based on WBCT.

Surgical Correction of Peritalar Subluxation and Subtalar Joint Articular Coverage Improves Patient- Reported Outcomes in Progressive Collapsing Foot Deformity

Category: Hindfoot; Ankle; Midfoot/Forefoot Introduction/Purpose: Optimization of articular joint coverage has been shown to decrease the progression of arthritic degeneration and to improve outcomes in patients with hip and shoulder pathologies. Progressive Collapsing Foot Deformity (PCFD), previously known as Adult-Acquired Flatfoot Deformity, has been demonstrated to advance with peritalar subluxation (PTS), progressively decreased articular coverage of the subtalar joint articular facets (anterior, middle, and posterior), as well as the development of sinus tarsi and subfibular impingements. Outcome assessment in PCFD has focused on improving conventional radiographic measurements such as the talus-first metatarsal angle and the hindfoot moment arm. This study aimed to evaluate improvements of PTS, subtalar joint articular coverage, and extra-articular impingement following PCFD joint-sparing surgical treatment, as well as the influence of these improvements in patient-reported outcomes. Methods: IRB-approved prospective comparative study. Adult PCFD patients that failed conservative treatment for three-months and underwent hindfoot joint-sparing surgical procedures by a single-surgeon were enrolled. Realignment soft-tissue and bony procedures performed were recorded. All patients underwent Weight Bearing CT (WBCT) preoperatively, and at the 3- and 12- months follow-up. Two observers performed traditional WBCT PCFD measurements. The foot bones were segmented, and distance measurements were performed along the entire 3D superior surface of the calcaneus, including the subtalar joint (SJ) articular facets (anterior, middle, and posterior), sinus tarsi and subfibular area. Color-coded coverage maps (CM) were calculated to grade the amount of articular joint coverage and extra-articular impingement. Patient Reported Outcomes (PROs) were recorded at all follow-up time-points. Pre- and postoperative measurements were compared by paired T-Tests/Wilcoxon and a Multivariate regression analysis was utilized to assess the influence of improvements of articular coverage and impingement in PROs. Results: Twenty patients were included (15F/5M), mean age, BMI, and follow-up of respectively 48.1 (22 to 72) years, 33.88 (23.8 to 46.8) kg/m2, and 13.2 (4 to 27) months. Significant improvements in all traditional PCFD WBCT measurements were noted postoperatively. Articular coverage (CM) of the SJ middle and anterior facets improved postoperatively by respectively 13.5% (p=0.02) and 78% (p=0.001). Similarly, improvement in sinus tarsi impingement, with a 69% decrease in sinus tarsi coverage was observed (p&lt;0.001). Significant PROs improvements were also noted, with Pain Catastrophizing Score (PCS) improving from 13.4 to 5.2 (p=0.0032) and the European Foot and Ankle Score (EFAS) from 6 to 8.5 (p=0.036). Improvements in PROs for PCS and EFAS were explained its majority by improvement in SJ articular coverage and sinus tarsi impingement, with R2 values of respectively 84% and 92% for PCS and EFAS. Conclusion: Peritalar subluxation (PTS) is an important marker of Progressive Collapsing Foot Deformity (PCFD). To the author's knowledge, this is the first time that 3D articular coverage maps were utilized to assess deformity correction following surgical treatment in PCFD. We found significant improvements in the subtalar joint (SJ) anterior and middle facet articular coverage as well as significantly decreased sinus tarsi and subfibular impingement. Most importantly, we found that PTS and SJ articular coverage improvements were the most important variables to influence Patient-Reported Outcomes. Three-dimensional evaluation of PTS and joint coverage can hopefully optimize treatment and improve outcomes in PCFD.

Management of Hallux Valgus in adults by Chveron Corrective Osteotomy

Background: Hallux valgus is a complex deformity and although not common but difficult to treat .It started from first row and then involve the entire foot. There are many surgical techniques to treat this problem. Both soft tissue procedures and bony osteotomies are mentioned in literatures but still there is no any gold standard. We used soft tissues procedure and cheveron osteotomy for treatment. Coughlin classification was used to assess the outcome Aim: To assess the outcome of cheveron corrective osteotomy to treat hallux valgus deformity in adult by using Coughlin’s classification. Methods: We operated 15 adults patients with hallus valgus in Mayo hospital Lahore between 1-6-19 to 31-12-19 .Both soft tissues and bony procedure were done, Coughlin's classification used to assess the pre operative and post operative deformity. Results: From total 15 patients 5 were male (27.3%) and 10 were female (72.7%). The mean age was 31.63 years (SD =1,689), ranging from 20 to 50 years old. Right side was involved in 4 (26.66%) patients foot affected, left side was involved in 5(33.33%) patients and both sides were involved in 6(40%) patients. Postoperatively, 12 patients (72.7%) showed the first ray angles within acceptable values. All patients had cosmetic correction and 13 patients (90.9%) had relief of pain and suitability for footwear. Conclusion: Chevron osteotomy is effective safe and treatment of choice in adults . Key words: Soft tissues, Hallux Valgus, Chevron osteotomy

Treating posteriorly eroded glenoids with augmented baseplate or bony increased-offset reverse shoulder arthroplasty: a finite element comparison

BackgroundAugmented reverse shoulder arthroplasty (RSA) implants restore glenohumeral joint alignment in cases of asymmetric glenoid wear. However, no consensus has been reached on whether the use of metallic augmented RSA baseplates and bone graft reconstruction are equivalent in terms of implant fixation and risk of implant loosening. Therefore, the purpose of this study was to compare 2 augmented RSA designs by assessing the amount of interfacial micromotion generated under realistic physiological loading. MethodsFinite element analysis models of 9 scapulae with Walch-type B2 or B3 glenoid morphology were virtually implanted with both a metallic augmented baseplate (AUG-RSA) and using the angled bony increased-offset RSA procedure (BIO-RSA). Simulation of physiological loading was performed on each of the 18 finite element analysis models. The relative tangential and normal micromotion at the implant-to-glenoid interface was compared in each anatomical quadrant. ResultsThe AUG-RSA and angled BIO-RSA showed similar magnitudes of micromotion in most anatomical quadrants of the glenoid. Within the superior quadrant, AUG-RSA displayed a higher magnitude of mean and maximum tangential micromotion (mean: 16.6 ± 2.4 μm, P < .000; maximum: 35.1 ± 5.3 μm, P < .000). The proportion of the posterior quadrant experiencing >50 microns of micromotion was also statistically greater with AUG-RSA (5.8 ± 2.5 %, P = .047). ConclusionBecause of its statistically greater micromotion and portions of contact exceeding the accepted 50-micron threshold, the AUG-RSA may be more likely to have inhibited bone on-growth. However, the clinical importance of these differences remains unclear.

At 10-Year Minimum Follow-Up, One-Third of Patients Have Patellofemoral Arthritis After Isolated Medial Patellofemoral Ligament Reconstruction Using Gracilis Tendon Autograft

To report the long-term clinical outcomes after isolated medial patellofemoral ligament reconstruction (MPFLr) to treat recurrent patellar instability. This was a single-center study of patients undergoing an isolated MPFLr between 2000 and 2011. All patients underwent reconstruction using hamstring autograft. The inclusion criteria were a minimum 10-year follow-up period and skeletally mature patients with more than 1 episode of patellar dislocation who underwent MPFLr without an associated bony procedure. A total of 54 knees were available for final analysis. The mean follow-up period was 12.3 years (range, 10-14 year). The mean age at surgery was 25 years. No patients had patellofemoral arthritis (PFA) prior to surgery. Preoperatively, the mean Caton-Deschamps index was 1.1 and the mean tibial tubercle-trochlear groove distance was 14.9 ± 2 mm (range, 7-17 mm). All patients had trochlear dysplasia according to the Dejour classification. At final follow-up, the mean Kujala score was 82.9 ± 15.3; mean International Knee Documentation Committee score, 78.3 ± 18.5; and mean Tegner score, 4.0 ± 1.7. Patients with an unsatisfactory outcome as determined by a Kujala score lower than 80 had a higher Caton-Deschamps index preoperatively and were more likely to be female patients; however, neither factor reached significance. Of the patients, 33 (66%) had no radiographic evidence of PFA whereas 15 (30%) had Iwano stage 1 and 2 had Iwano stage 2 (4%). At final follow-up, 4 patients (7.4%) had recurrent instability requiring revision surgery. Isolated MPFLr with gracilis tendon autograft in appropriately selected patients is an effective long-term treatment for recurrent patellofemoral instability with low rates of recurrence. One-third of patients exhibit radiographic evidence of PFA more than 10 years after isolated MPFLr. Level IV, case series.