Dorsal Approach Research Articles

Analysis of the effectiveness of two-stage and one-stage surgical treatment for idiopathic scoliosis in children using various methods for deformity mobilization

Introduction. The correction potential of modern systems is limited by the natural mobility of scoliotic deformities, which sometimes require multiple discectomy and osteotomy. Choosing the optimal method of treatment for scoliosis in the thoracic and lumbar regions is difficult due to the variety of approaches and options available for osteotomies. There is no single algorithm for the treatment of idiopathic scoliosis, making it necessary to develop a differentiated approach and treatment strategies. Purpose of the study. To optimize the choice of surgical treatment tactics for children with idiopathic scoliosis based on a compa­rative analysis of the use of one-stage and two-stage surgical treatment. Materials and methods. The study subjects were ninety four patients with idiopathic scoliosis (Lenke type 1–4), operated on between 2017 and 2023. They were divided into three groups: group I (control) — 30 patients underwent one-stage dorsal correction with G1 osteotomy, group II — 31 patients who received two-stage treatment, and group III — 33 patients who underwent a one-stage correction with apical G2 osteotomy. Depending on the initial thoracic kyphotic angle, subgroups were defined as A (hypokyphosis), B (normokyphosis) and C (hyperkyphosis). The minimum follow-up period was 12 months. Results. The frontal balance in all examined patients was in a state of relative compensation, both before surgical treatment and in the postoperative period. When comparing the results in patients from the second and third groups, we found no significant differences (p > 0.05). The second group showed a higher degree of correction of the main arch of spinal deformity (p < 0.05) in the frontal plane compared to the control and third group patients. When analyzing the results of thoracic kyphosis formation, we obtained reliable results in formation more significant indices in patients after surgery in Group II (subgroups A and B), for whom a two-stage applied surgical method was supplemented with anterior release and halo pelvic traction. In Group III (subgroup C), we obtained significant results in thoracic kyphosis indices when using single-stage surgery performed from the dorsal approach supplemented with G2 osteotomy. Conclusion. The condition of the sagittal profile, including the severity of thoracic kyphosis, is an important criterion for choosing the tactics of surgical treatment of scoliotic deformities of the thoracic and lumbar spine. Two-stage treatment, including ventral release and halo-pelvic traction, is recommended for rigid deformities of the thoracic or thoracolumbar spine, under conditions of initial normal kyphosis or hypokyphosis. Severe deformities with initial hyperkyphosis should be corrected preferably in a single stage using posterior surgery, supplemented by G2-osteotomy. The use of G2-osteotomies in patients with initial normal- or hypokyphoses is impractical due to the risk of neurological complications, development of pseudoarthroses, and increase in volume of perioperative bleeding.

Metatarsal sliding osteotomy is effective without altering plantar pressure in Morton's neuroma: Retrospective case series.

Various operative methods for the treatment of Morton's neuroma have been discussed, and osteotomy of the metatarsal bone has been reported recently. However, there has been no report of pedobarographic changes after metatarsal osteotomy. Pedobarographic changes of other metatarsal area after the surgery may cause transfer metatarsalgia, and thorough analysis of the pedobarographic data should be performed peri-operatively. The purpose of this study is to investigate the post-operative pedobarographic changes of sliding osteotomy of the 3rd metatarsal bone for treating Morton's neuroma. Forty patients (45 feet) who underwent metatarsal sliding osteotomy of the 3rd metatarsal bone for treating Morton's neuroma from November 2013 to December 2021 were retrospectively reviewed. Proximal sliding osteotomy was performed at the proximal 3rd metatarsal bone through dorsal approach. Clinical outcomes were evaluated with American Orthopaedic Foot and Ankle Society Lesser Metatarsophalangeal Interphalangeal Scale (AOFAS LMIS), Foot Function Index (FFI), and Visual Analogue Scale (VAS). Plain radiograph and pedobarogram were performed to evaluate the radiologic and pedobarographic outcomes. AOFAS score was improved from 52.8±9.0 (18-62) to 88.8±9.8 (78-100) and FFI was improved from 61.8±4.9 (50-70) to 32.2±5.1 (23-42) on average. The 3rd metatarsal bone was shortened by 3.1±0.8mm and dorsally shifted by 1.5±0.4mm after the surgery. Plantar intermetatarsal distances between 2nd and 3rd and 3rd and 4th metatarsal heads were significantly increased post-operatively. Average forefoot pressure and maximum pressure of the 2nd to 4th metatarsal head were not significantly changed between pre-operatively and post-operatively. Proximal metatarsal sliding osteotomy of the 3rd metatarsal bone shows a satisfactory result in both clinical and pedobarographical evaluations. It could be an effective treatment of permanent indirect decompression of Morton's neuroma with avoiding recurred neuroma, adhesion of tissue, paresthesia, and transfer metatarsalgia.

Arthroplasty of the proximal interphalangeal joint of the hand: the current state of the problem

Introduction The proximal interphalangeal joint (PIP joint) plays an important role in ensuring optimal finger dexterity, grip strength and overall hand functionality. Arthroplasty is a promising direction in the surgical treatment of arthritis of the PIP joint of the hand, however, the inconsistency of the results encourages the world scientific community to be restrained and further investigate the problems associated with PIP joint arthroplasty.The purpose of the work was to identify the main problems of PIP joint arthroplasty based on the analysis of foreign and domestic medical literature.Materials and methods In this literature review, an analysis of foreign and domestic scientific publications devoted to the treatment of diseases and injuries of PIP joint was carried out. The purpose of the study was to provide a brief historical background and identify the main problems of PIP joint arthroplasty based on the analysis of foreign and domestic medical literature.Results and discussion The choice of the implant and the surgical aproach used are the two most frequently discussed issues in PIP joint arthroplasty; dorsal, palmar and lateral surgical approaches are described, each with its own advantages and disadvantages. Dorsal approaches are used most often because they are easier to perform; however, the fragile extensor apparatus is damaged with the subsequent development of extensor lag. A number of authors concluded that stiffness and extensor lag were the most common postoperative complications. Several combinations of materials are available: from classic chrome-cobalt/polyethylene to ceramic/ceramic and pyrocarbon/pyrocarbon. Most of them have not stood the test of time yet, and for most implants there is still a lack of real long-term monitoring series for survival of the design.Conclusion The morphology of joints, small bone sizes, complex biomechanics and the load on the hand are a special problem in PIP joint arthroplasty. It is still not possible to restore the full range of motion in this joint, despite the success of colleagues in arthroplasty of large joints.

Outcome of End to Side Nerve Modified Double Oberlin Procedure and End to End Dorsal Approach Spinal Accessory to Suprascapular Nerve in Partial Postganglionic BPI: A Case Report

Introduction: Brachial plexus injury (BPI) is a devastating peripheral nerve injury that mostly affecting young men, often due to motor vehicle accidents. BPIs can be classified into preganglionic and postganglionic lesions, with postganglionic injuries allowing potential nerve regeneration. The Oberlin method, aimed at reinnervating the biceps, and the Mackinnon technique, targeting both biceps and brachialis muscles, have shown promising outcomes in BPI management. Case report: A 45-year-old man presented with right hand weakness and occasional tingling in the upper arm and fingers two months after a motorcycle accident. Motor examination revealed muscle strength of 0/5 in the right trapezius, rhomboids, serratus anterior (positive winging scapula), pectoralis minor and major, latissimus dorsi, deltoid, biceps, and elbow flexion. Wrist and finger functions remained intact. Diagnosed with post-ganglionic BPI, the patient underwent two nerve transfer surgeries: the Mackinnon technique, transferring the spinal accessory nerve to the suprascapular nerve to reinnervate shoulder muscles, and the Double Oberlin procedure, transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve for reinnervation of the biceps and brachialis muscles. Post-surgery, the patient engaged in an aggressive rehabilitation program focusing on strength, range of motion, and sensory re-education. Over nine months, the patient showed significant improvement in elbow flexion (MRC grade 3), wrist extension (MRC grade 5), hand grip strength (MRC grade 3) with improved sensation across the affected limb. He returned to work and daily activities with mild residual weakness and sensory deficits. Discussion: This case illustrates the effectiveness of the Mackinnon and Double Oberlin nerve transfer techniques in restoring function in a patient with total post-ganglionic BPI. The Mackinnon technique enabled shoulder muscle reinnervation, essential for abduction and stabilization, while the Double Oberlin procedure enhanced elbow flexion by reinnervating both the biceps and brachialis muscles. The combined surgical and intensive rehabilitation approach facilitated significant functional recovery. Conclusion: The successful application of the Double Oberlin and Mackinnon techniques in this case demonstrates their potential in managing total post-ganglionic BPI. Early surgical intervention and consistent rehabilitation are crucial for optimizing recovery outcomes. This case highlights the importance of a multidisciplinary approach in treating complex peripheral nerve injuries. Keywords: Double Oberlin, Mackinnon, Brachial Plexus Injury

Dorsal and Volar Approaches for Proximal Interphalangeal Joint Replacement: Comparing Outcomes Through Systematic Review and Meta-Analysis.

The 2 primary surgical approaches for proximal interphalangeal joint (PIPJ) arthroplasty, dorsal or volar, have been extensively described in the literature. However, the ongoing debate regarding which approach offers superior results or is associated with fewer complications persists. This systematic review aims to compare the outcomes of PIPJ arthroplasty between the dorsal and volar approaches. A comprehensive search of multiple databases was conducted, and studies meeting predetermined criteria were included. Data extraction, assessment of bias risk, and statistical analysis were performed to compare treatment modalities. Outcome measures included range of motion (ROM), patient-reported outcome measures (PROMs), revisions, and reported complications. Among 368 screened articles, 5 studies involving 302 patients (310 implants) were eligible for final review. No significant differences were observed between the 2 approaches regarding postoperative ROM (mean difference [MD] 2.24; 95% confidence interval [CI] -3.83, 8.32; P = .47) and PROMs (standardized mean difference [SMD] 0.18; 95% CI -0.12, 0.48; P = .25). Complication rates, including revision/fusion, persistent pain, stiffness, infection, and dislocation, did not significantly differ between the approaches. Notably, dorsal approach was associated with higher risk of swan-neck deformity (9 out of 82 implants), while no such cases were reported in the volar approach (0 out of 101 implants). Despite limitations and heterogeneity in the literature, both dorsal and volar approaches for PIPJ arthroplasty appear to yield equivalent outcomes for patients. II, therapeutic.

Our Experience with Surgical Treatment of Scaphoid Fractures with Headless Compression Screw

BACKGROUND: Fractures of the scaphoid bone are quite common, and they come with their own set of challenges due to the specific shape of the fractures and the delicate blood supply to the scaphoid bone. Failing to diagnose and treat acute scaphoid fractures promptly can result in failure of the bone to heal and subsequent development of wrist arthritis. Advances in diagnosis, surgery, and implant materials have led to a growing inclination towards early surgical fixation, even for non-displaced scaphoid fractures that could potentially be treated without surgery. AIM: The study's goal was to assess the effectiveness of headless compression screws for treating acute scaphoid fractures and, in two cases, nonunion following previous conservative therapy. METHODS: Between January 2022 and March 2024 ten patients with scaphoid fractures were surgically treated at the University Clinic of Traumatology Skopje, within twelve months follow-up. All of them were male with mean age of 27,3 years. All were diagnosed with X-rays and CT scans. Six of the fractures were on the right hand and four on the left. RESULTS: All the patients were surgically treated with open reduction and internal fixation with headless compression screw. Volar approach was used in 9 cases and dorsal approach in only one of them. Six of the patients were surgically treated within 4-14 days after injury and four of them were surgically treated due to non union after previous conservative treatment, two of them after three and two of them after seven months of injury. All fractures united after a mean time of 9,5 weeks, without secondary displacement. Throughout the follow-up period, there were no incidences of developing osteoarthritis of the wrist. CONCLUSIONS: It is crucial to understand that achieving a positive result is not guaranteed for every patient and relies on selecting the right patients and fractures. However, our study shows favorable results in sooner surgical treatment with the headless compression screw, rather than delayed treatment of scaphoid fractures. Surgical treatment with headless compression screw showed both functional and radiographic results. While it is beneficial for the screw to be positioned in the subchondral area, it is important to be cautious to avoid cortical penetration, as this will require the screw to be removed later.

Is endoscopic decompression for Morton's neuroma a safe technique?

IntroductionMorton's neuroma is predominantly attributed to chronic nerve entrapment within third space adjacent metatarsals, the deep transverse metatarsal ligament (DTML), and the plantar skin. While conservative treatments are of election, failures require alternative interventions such as ultrasound-guided injections and various surgical procedures, including minimally invasive neurectomy and DTML release. This study aimed to anatomically assess the risks associated with the endoscopic dorsal surgical decompression of Morton's neuroma. Materials and methodsTwenty feet from ten fresh-frozen cadaveric specimens underwent a dorsal percutaneous approach for endoscopic access. Surgical procedures were monitored by three foot and ankle surgeons. Post-surgical anatomical dissections were conducted to evaluate potential risks to surrounding structures. ResultsThe endoscopic technique successfully sectioned the DMTL in all specimens (100%) without iatrogenic injury of tendons, nerves, or arteries, while lumbricals may be at risk. ConclusionEndoscopic dorsal decompression of Morton's neuroma presents as an accessible minimally invasive surgical option with low risk of collateral associated injuries.

How to Find Correct Transection Plane in Laparoscopic Right Hepatectomy Extended to S1 for Bismuth IIIa Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (pCCA) is one of the most challenging tumours for hepatic surgeons. To reach radical resection, it is mandatory to extend the hepatectomy to segment 1 and biliary tract. With the advent of minimally invasive techniques, an increasing number of centres have begun to treat this tumour using robotic or laparoscopic approaches, demonstrating the ability to maintain oncological standards as well as morbidity and mortality criteria. This video presents a case of a 79-year-old man with pCCA Bismuth type IIIa, undergoing right hepatectomy extended to segment 1 and biliary tract after preoperative optimization including biliary drainage and portal vein and right hepatic vein embolization. Unlike conventional right hepatectomy, extending transection to include segment 1 requires identifying the plane defined by the Arantius duct. To reach this plane, we suggest using three approaches, previously described in other hepatectomies, were employed: dorsal and caudal approaches to the middle hepatic vein (MHV) and an extraglissonian intrahepatic approach to the left portal pedicle. With this method, we achieved oncologically radical resection of pCCA using minimally invasive surgical techniques.

Tarans-Scaphoid Lunate Fracture Dislocation: A Case Report of a Rare Injury

Trans-scaphoid lunate dislocation is an uncommon injury but can be devastating, causing loss of wrist joint movement and function, and compromising grip strength. In this report, we present a case of a 48-year-old man with a history of psychiatric disorder who attempted suicide by jumping from the second floor. He sustained a volar lunate dislocation and scaphoid fracture, with migration of the proximal part of the scaphoid to the volar aspect of the forearm. Open surgical reduction was planned through a dorsal approach: first, the lunate was reduced, then the proximal part of the scaphoid was retrieved from the volar aspect of the forearm and anatomically fixed with a 2.5 mm headless screw. The scapholunate relationship was reduced and fixed with two wires through the scapholunate and scaphocapitate joints. The wound was closed in layers, and the wrist joint was immobilized with a dorsal splint for six weeks. Six weeks postoperatively, the K wires were removed, and the patient started physiotherapy. At three months postoperative follow-up, the wrist joint function was good, with good grip strength and a good range of motion. The gold standard treatment option is open reduction and fixation of the fractured bone and stabilization of the carpal bones in anatomical alignment to reduce possible complications such as median nerve compression, chronic carpal instability, chronic wrist pain, loss of grip strength, wrist arthritis, and carpal collapse.

Robot-assisted hemihepatectomy is superior to laparoscopic hemihepatectomy through dorsal approach: A propensity score-matched study (with videos)

BackgroundDorsal approach is the potentially effective strategy for minimally invasive liver resection. This study aimed to compare the outcomes between robot-assisted and laparoscopic hemihepatectomy through dorsal approach. MethodsWe compared the patients who underwent robot-assisted hemihepatectomy (Rob-HH) and who had laparoscopic hemihepatectomy (Lap-HH) through dorsal approach between January 2020 and December 2022. A 1:1 propensity score-matching (PSM) analysis was performed to minimize bias and confounding factors. ResultsNinety-six patients were included, 41 with Rob-HH and 55 with Lap-HH. Among them, 58 underwent left hemihepatectomy (LHH) and 38 underwent right hemihepatectomy (RHH). Compared with Lap-HH group, patients with Rob-HH had less estimated blood loss (median: 100.0 vs. 300.0 mL, P = 0.016), lower blood transfusion rates (4.9% vs. 29.1%, P= 0.003) and postoperative complication rates (26.8% vs. 54.5%, P = 0.016). These significant differences consistently existed after PSM and in the LHH subgroups. Furthermore, robot-assisted LHH was associated with decreased Pringle duration (45 vs. 60 min, P = 0.047). RHH subgroup analysis showed that compared with Lap-RHH, Rob-RHH was associated with less estimated blood loss (200 vs. 400 mL, P = 0.013). No significant differences were found in other perioperative outcomes among pre- and post-PSM cohorts, such as Pringle duration, operative time, and hospital stay. ConclusionsThe dorsal approach was a safe and feasible strategy for hemi-hepatectomy with favorable outcomes under robot-assisted system in reducing intraoperative blood loss, transfusion, and postoperative complications.

Patterns of osteoarthritis in long finger joints: an observational cadaveric study with potential biomechanical considerations

PurposeTo explore the distribution and prevalence of osteoarthritis in metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints in long fingers in a cadaveric study, and to discuss potential biomechanical influences on these patterns. MethodsThis cadaveric study evaluated 144 metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints from 12 embalmed cadaver hands. A dorsal dissection approach was used to expose the joints, which were then marked with color-coded pegs for consistent orientation during imaging. High-resolution digital images of the distal articular surfaces were captured for analysis. The images were analyzed using custom software to quantify osteoarthritic areas, distinguishing between radial and ulnar aspects. Percentage affected joint surface was calculated using pixel-based measurements. Statistical analysis was used the Student t-test and ANOVA, with the significance threshold set at p < 0.05 and 95% confidence intervals ResultsThe ulnar side of the proximal interphalangeal joint in digits 2 and 3 showed higher prevalence of osteoarthritis (59.31% ± 15.48%) than the radial side (40.68% ± 15.48%), p = 0.007; in contrast, for digits 4 and 5, prevalence was greater on the radial (54.3% ± 10.99%) than the ulnar side (45.7% ± 10.99%), p = 0.007. No significant differences were noted in osteoarthritis distribution between the radial and ulnar aspects of the metacarpophalangeal and distal interphalangeal joints. ConclusionsThis study identified distinct patterns of osteoarthritis distribution in long-finger joints, with greater prevalence in the proximal interphalangeal joints. Although there were differences between stable (digits 2 and 3) and mobile (digits 4 and 5) fingers, further research is necessary to conclusively determine the role of biomechanical forces in the development of osteoarthritis. These findings lay the groundwork for future studies of the pathophysiology of osteoarthritis in the hand, and could guide the development of preventive and therapeutic interventions.

ASO Author Reflections: Dorsal Approach Combined with In Situ Split for Laparoscopic Segment 7 Resection.

ASO Author Reflections: Dorsal Approach Combined with In Situ Split for Laparoscopic Segment 7 Resection.

Treatment of Fourth Metatarsal Brachymetatarsia Using Distraction Osteogenesis with External Fixator: Surgical Techniques, Outcomes and Complications.

Surgical technique in distraction osteogenesis for the treatment of brachymetatarsia can influence the final prognosis. However, there are currently no standardized guidelines for surgical procedures and complication management. The aim of this study is to investigate the effect of bone lengthening with external fixation by minimally invasive osteotomy based on Ilizarov technique in the treatment of congenital brachymetatarsia. A retrospective study was conducted on patients with congenital brachymetatarsia treated by metatarsal lengthening, from June 2017 to December 2020. There were 11 patients with 17 shorted fourth metatarsals, including 10 females and 1 male, with age of 24.6 ± 4.5 years (16-31 years). Six patients were bilaterally involved. Orthofix external fixator mini track was installed through dorsal approach and the fourth MTP joints were temporarily fixed by Kirschner wire. Bone lengthening was performed after a minimally invasive osteotomy at the proximal metatarsals. American Orthopedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal (MTP-IP) scores, metatarsal length, complications were recorded. Statistical comparison was performed using the paired t-student test for pre- and postoperative AOFAS MTP-IP scores. Patients were followed up for 55 ± 10.8 months. The mean length of the fourth metatarsal bone was 49.9 ± 2.9 mm preoperatively. The mean metatarsal shortage was 18.8 ± 3.1 mm. The mean lengthening achieved was 19.8 ± 3.3 mm, with a lengthening ratio of 39.7% ± 6.6%. The lengthened callus ossified completely at 3-4 months after operation. All patients were satisfied with the results of lengthening. The AOFAS scores were improved significantly from 83.7 ± 4.2 preoperatively to 93.2 ± 2.7 postoperatively (t = -10.27, p < 0.001). One patient with traumatic metatarsophalangeal joint subluxation was treated by joint reduction and Kirschner wire fixation. One patient had metatarsophalangeal joint release and Kirschner wire fixation due to flexion contracture. Pin tract infections were controlled by wound care and antibiotics in 6 patients. All patients had no nonunion, necrosis of toes, and sensory disturbance of toes. Metatarsal lengthening by minimally invasive osteotomy with external fixator had satisfactory results in the treatment of congenital brachymetatarsia.

Modification of proximal row carpectomy (PRC) technique for adaptive wrist collapse (pilot study)

Introduction Proximal carpal row resection has been used for many decades as a “salvage procedure” for progressive wrist collapse. Improving the technique of its implementation, as well as introducing various modifications of the technique into practice are an important area for achieving better results of surgical treatment.The purpose of this work was to demonstrate aspects of the modified proximal row carpectomy (PRC) technique and the immediate results of its use.Materials and methods Eight patients aged from 24 to 57 years (seven men and one woman) were treated with the modified PRC technique. Treatment results were assessed using an adapted QuickDASH questionnaire, a visual analogue scale (VAS), based on patient satisfaction and radiographic results.Results The average duration of surgical intervention was (149.0 ± 35.5) minutes. In the postoperative period, six patients (75 %) underwent fixation with an Ilizarov apparatus, the rest with a plaster splint. The average range of motion of flexion and extension was (67.5 ± 18.3)°, range: 40–95°. The patients had an average of (35.6 ± 16.13)° extension, range: 10–65° and (31.87 ± 10.9)° flexion, range: 10–45°. Patients reported decreased grip strength after surgery. Pain syndrome according to VAS at rest was equal to 0–1 points and 3–4 points when the affected limb was loaded. Six patients completed the QuickDASH survey, with a mean score of (14.83 ± 4.25) points. All patients are satisfied with the result of treatment and the absence of pain at rest. Patients returned to their usual work.Discussion Unlike the conventional dorsal approach through the III–IV tendon canals, the use of two mini-approaches provides a better cosmetic effect and makes it easier to restore the integrity of the tendon canals, which are important for the prevention of desmogenic contractures. The use of the Ilizarov apparatus has proven to be the method of choice, providing absolute stability and reduction of pain in the postoperative period. For patients under 45 years of age with increased functional demands, a balanced approach is required when choosing PRC or intercarpal arthrodesis, depending on which functional parameters are more important to the patient.Conclusion The analysis of short-term results of using the modified PRC technique shows that it reduces the invasiveness of the operation, improves its esthetic result, provides pain relief and a satisfactory range of motion and grip strength.

A safe zone of dorsal scaphoid approach: an anatomic study of proximal dorsal vessel foramina.

The dorsal approach to the scaphoid carries a risk of injuring its nutrient vessels. This cadaveric study identified a safe zone dorsally, which extends from the proximal pole to 11.3 mm distally along the scaphoid axis.Level of evidence: Level V.

Intra-articular fracture reduction: a comparative observational study of clinical results after the surgical treatment of distal radius fractures

Purpose: This study compared the outcomes of intra-articular fracture reduction for distal radius fractures. Methods: Among 180 patients who underwent open reduction and plate fixation, the exclusion criteria were as follows: non-acute fracture (&gt;1 month), an accompanying ulnar neck fracture, a distal ulnar fracture requiring fixation, fixation through the dorsal approach, other accompanying hand fractures, the absence of preoperative or postoperative computed tomography (CT), and follow-up for &lt;1 year. Intra-articular fractures were evaluated through CT. Forty-eight patients with intra-articular fractures were studied. Displaced intra-articular fractures were defined as: (1) articular step-off ≥1 mm, (2) fracture gap ≥2 mm, or (3) gross incongruence. Reduction was classified as good (n=23) or poor (n=25) based on postoperative CT. The pain visual analogue scale (pVAS), the quick Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and range of motion of the wrist joint were compared between both groups.Results: No significant between-group differences were found in the preoperative demographic data and the postoperative pVAS and quick DASH scores (pVAS: 0.6 vs. 0.8 and quick DASH: 9.4 vs. 10.2 in the good vs. poor reduction groups, respectively). However, the flexion-extension arc was significantly restricted in the poor reduction group (162° in the good reduction group vs. 146° in the poor reduction group, p&lt;0.001).Conclusion: The reduction of the articular surface was not related to pain and functional results at the mid-term follow-up after the surgical treatment of intra-articular distal radius fractures. However, insufficient fracture reduction affected the postoperative range of motion.

A description and outcome evaluation of sacrococcygeal joint radiofrequency neurotomy for treatment of chronic coccydynia – A dorsal approach

BackgroundCoccydynia is a condition characterized by pain and tenderness in the coccyx region of the spine. Chronic coccydynia (≥3-months) management remains a clinical challenge. Radiofrequency neurotomy (RFN) targeting the sacrococcygeal joint (SCJ) and/or 1st intercoccygeal joint (ICJ) margins has emerged as an alternative, minimally invasive intervention for refractory coccydynia. ObjectiveThe objective of this study was to evaluate the safety and effectiveness of an RFN technique targeting the dorsal aspect of SCJ and/or 1st ICJ for treatment of patients with chronic coccydynia. MethodsRetrospective analysis of prospective outcomes for patients with chronic coccydynia (≥3-months) who underwent RFN to dorsal SCJ and/or 1st ICJ between 2009 - 2023. RFN technique was a dorsal approach targeting the distal sacrum and proximal coccyx, which form the SCJ or 1st ICJ margins. Numerical rating scale (NRS) and Pain Disability Quality-of-Life Questionnaire-Spine (PDQQ-S) scores were completed pre- and 3-months post-RFN. Successful RFN was defined as ≥50% reduction or minimal clinical important difference (MCID) in PDQQ-S and NRS pain scores. The primary outcome measures were the proportion of patients achieving ≥50% reduction in NRS pain and PDDQ-S scores following primary and repeat RFN to SCJ and/or 1st ICJ. Secondary outcomes included the proportion of patients achieving MCID on NRS pain and PDQQ-S scores following RFN, as well as mean NRS and PDQQ-S scores pre- and 3-months post-RFN, and magnitude of improvement for patients following successful RFN procedures. ResultsA total of 52 RFN procedures (n = 30 primary, and n = 22 repeat procedures) were performed on 30 patients (female = 25, male = 5, mean age 55.1 ± 13.0yrs). Ten patients (33.3%; 95% CI = 17.3–52.8) reported ≥50% pain reduction as measured by NRS pain and PDQQ-S scores following primary SCJ and/or 1st ICJ RFN at 3-months follow-up. Fifteen patients (50%; 95% CI = 31.3–68.7) reported MCID NRS pain reduction and 12 patients (40.0%; 95% CI = 22.7–59.4) reported MCID PDQQ-S scores at 3-months following primary RFN. The mean magnitude of improvement for patients with primary successful RFN, as defined as ≥50% reduction in either NRS pain or PDQQ-S scores, was 77.4% (±SD 21.4%) and 74.9% (±SD = 19.9%), respectively. Similarly, the mean magnitude of improvement for patients with successful RFN, as defined by MCID reduction in NRS pain or PDQQ-S scores, was 62.6% (±SD = 28.2%) and 69.3% (±SD = 22.3%), respectively. At 3-months follow-up, 14 patients (63.6%; 95% CI = 40.7–82.8) reported ≥50% pain reduction as measured by either NRS pain and PDQQ-S scores following repeat RFN. Nineteen patients (86.4%; 95% CI = 65.1–97.1) reported MCID NRS pain reduction and 16 patients (72.7%; 95% CI = 49.8–89.3) reported MCID PDQQ-S scores at 3-months following repeat RFN. Statistically significant differences were observed between pre- and post-RFN NRS pain and PDQQ-S scores (p < 0.005) in both primary and repeat procedures. Discussion/conclusionThis study represents an introductory step in evaluating the efficacy of a dorsal approach RFN technique targeting the SCJ and/or 1st ICJ as a treatment option for chronic coccydynia. Primary RFN demonstrated pain reduction and improvement in function at 3-months in 33.3% of patients. Several limitations remain, including heterogeneity in patient population, small sample size, and no control groups. Future detailed investigations include cadaveric studies to clarify sensory innervation and enhance reliability of our targets during RFN. Larger prospective studies of long-term outcomes, including comparison with control groups, are required to further evaluate the efficacy of our dorsal RFN approach.

Early Functional Outcomes and Complications of Tibial and/or Peroneal Sesamoidectomy Utilizing a Burr Through a Medial Approach.

Sesamoid pathology can lead to significant pain and disability both with activities of daily living and high-impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain, but complications were reported. A proposed alternative medial approach using a burr may provide many advantages compared with traditional approaches. This study presents patient outcomes and complications for this technique. This was a retrospective chart review of patients undergoing sesamoidectomy (tibial, peroneal, or both) using a burr through a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Twenty-seven patients (29 feet) were included. The mean age was 38.4 years followed up for a mean of 30.9 months. VR-12 physical component improved from 35.98 ± 7.86 to 51.34 ± 8.01 (P < .001), FAAM ADL and sport improved from 58.33 ± 16.61 to 83.27 ± 18.28 (P < .001) and 26.37 ± 20.31 to 63.75 ± 29.74 (P < .001), respectively. Patient satisfaction with the treatment was 80.59% ± 27.06%. The overall complication rate was 11 (37.9%) whereas the overall reoperation rate was 4 (13.7%) of 29 feet. Complications included 1 arthrofibrosis, 1 flexor hallucis longus subacute rupture, and 1 asymptomatic hallux valgus. There were no sesamoid excision revisions. Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, with a relatively acceptable complications rate including 20% persistent pain. The medial approach is familiar to orthopaedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar scar while avoiding disruption of the plantar plate, flexor hallucis brevis tendon, and ligamentous structures attached to the sesamoids. Larger studies with long-term follow-up from other centers are needed.

Perilunate Fracture-Dislocation: Results at Mean Follow-Up of 7 Years after ORIF.

Background: Perilunate fracture-dislocations are frequently associated with a high risk of developing post-traumatic arthritis. Current studies indicate that during mid-term follow-ups, radiological signs of arthritis do not appear to correspond with functional score. The aim of this study was to assess the occurrence of posttraumatic arthritis and the wrist function after perilunate dislocations (PLD) and fracture dislocations at a mid-term follow-up of 7 years. Methods: We report the clinical and radiological outcomes of 17 wrists treated for PLD or fracture-dislocation by open reduction and internal fixation through a dorsal approach with dorsal ligament repair. Functional outcomes were evaluated using the short version of the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the Patient-Rated Wrist Evaluation questionnaire (PRWE) and the Mayo Wrist Score (MWS). Results of radiographs were assessed using the Herzberg Radiological Scoring Chart. Results: The MWS showed five excellent, five good, five fair and two poor results with an average score of 81%. Radiological analysis using the Herzberg classification revealed midcarpal and/or radiocarpal arthritis in 65% of cases, lunate collapse in 59% and an increase in the mean ulnar translocation ratio in 53% of the cases. Complications included one case of lunate osteonecrosis and one case of stage 3 scapholunate advanced collapse that required revision surgery. Conclusions: Although the clinical and functional outcomes are favourable at mid-term follow-up, radiological evaluation shows a progression towards osteoarthritis (OA). Further research is warranted to refine treatment strategies and investigate factors influencing the development of OA. Level of Evidence: Level IV (Therapeutic).

Preservation of the native urethral plate and corpus spongiosum combined with buccal mucosa graft plus Orandi's penile skin flap as an alternative to staged urethroplasty for narrow penile strictures.

In narrow anterior urethral strictures, the combined buccal mucosa graft (BMG) with pedicled penile skin flap (PSF) represents a well-known effective alternative to staged urethroplasty. We hypothesized that if the native urethral plate and adjacent corpus spongiosum were preserved, a narrower flap would be needed, and reinforced ventral stability could be achieved without compromising the surgical outcome. Twelve patients with narrow penile urethral strictures underwent single-stage augmentation urethroplasty using a combined technique. A BMG was quilted to the corpora cavernosa in a dorsal onlay approach, and a longitudinal ventral PSF was transposed ventrally and sutured to the scarred native urethral mucosa on one side and to the BMG on the other side to form a neourethra of triangular form. The preserved corpus spongiosum was wrapped and fixed around the flap ventrally. The median age was 47 years (IQR 35-59), and the median stricture length was 5 cm (IQR 3, 8-7). The median surgical time was 205 min (IQR 172-236). The overall success rate (SR) was 91.7% without sacculation or diverticula formation after a median follow-up period of 38 months (IQR 33-40). Three transient fistulas healed through prolonged urinary diversion. Five patients (41.7%) reported postvoid dribbling following urethroplasty. Preservation of the native urethral plate is a valuable adjunct to the combination of graft and flap for single-stage augmentation urethroplasty for narrow urethral strictures, with satisfactory mid-term success and an acceptable complication rate.