Extra-articular Osteotomy Research Articles

Management of Extra-Articular and Intra-Articular Distal Radius Malunion.

This article presents a comprehensive overview of managing extra-articular and intra-articular distal radius malunions (DRM), discussing the pathoanatomy, clinical, and radiologic evaluation, conservative treatment, and surgical strategies. Corrective osteotomy remains the primary surgical intervention for symptomatic DRM. Surgical planning should consider factors such as timing, approach, correction technique, implant, graft, and associated injuries. The correction of extra-articular malunion necessitates brachioradialis tenotomy, circumferential periosteum release, and intrafocal elevation with grafting to facilitate distal radius realignment following osteotomy. Computer-assisted planning with 3D-printed patient-specific instrumentation (PSI) could help execute extra-articular osteotomy with high precision. As for the management of intra-articular malunion, it may require wrist arthrotomy, arthroscopy, or PSI assistance for precise articular osteotomy and reduction of the joint surface. This review highlights the importance of early intervention, thorough preoperative planning, and appropriate surgical techniques to optimize outcomes and minimize complications. Future research should focus on large-scale randomized controlled trials to compare different surgical methods, particularly for intra-articular DRM.

Extra-articular Osteotomy for the Management of Intra-articular Tibial Plateau Valgus Malunion.

To report a case series of extra-articular osteotomies for the management of intra-articular tibial plateau malunions and to assess the ability to correct deformity and improve knee range of motion (ROM). . Retrospective case series. Academic, tertiary, referral center. Adult patients with tibial plateau fracture malunion treated with extra-articular osteotomy of the femur and/or tibia between 2014 and 2023. Mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), lateral distal femoral angle (LDFA), and posterior proximal tibia angle (PPTA) correction; knee ROM; and time to weight bearing. There were 7 patients included, 6 (85.7%) were female and 1 (14.3%) were male. The median age was 43.5 years (IQR 38.5-51, range 32-62). Four (57.1%) patients were treated with a high tibial osteotomy (HTO), and 3 (42.9%) patients were treated with an HTO and distal femoral osteotomy. One patient had concomitant supramalleolar osteotomy with HTO to address distal tibia procurvatum and valgus. Four were treated with hexapod frames, and 3 were treated with plates and screws. Median follow-up was 22.5 months (IQR 10.5-107 months, range 7-148 months). Surgical intervention corrected median radiographic measures of valgus malalignment preoperatively relative to postoperative values. This included MAD (42.5 mm-0 mm), valgus angle (12.5 degrees-1.5 degrees), MPTA (95 degrees-88.0°), and LDFA (86.0°-87.3 degrees). Surgical intervention increased maximal knee range of motion preoperatively to postoperatively. Median time to full weight bearing was 81.5 days (IQR 46-57 days, range 41-184 days). Two patients were converted to total knee arthroplasty after 5 and 10 years following HTO with hexapod frame. Extra-articular osteotomy is an effective treatment for addressing intra-articular malunion after tibia plateau fractures. It is effective in correcting the MAD, valgus deformity, MPTA, LDFA, PPTA, and improving knee ROM (measured through knee extension and flexion). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lessons Learned – the Learning Curve of Percutaneous Hallux Valgus Correction Using 3rd Generation MICA in 106 Consecutive Cases

Category: Bunion; Other Introduction/Purpose: Minimally-invasive Chevron and Akin osteotomy (MICA) represents the third-generation percutaneous hallux valgus surgery which is characterized by an extra-articular osteotomy, stable internal fixation and a high potential for correction. Compared to other percutaneous techniques of the foot, MICA is generally regarded as an advanced and demanding surgical procedure with a prolonged learning curve. The aim of this study is to analyze a single-surgeons learning curve with his first 106 consecutive MICA procedures. Methods: Between May 2018 and November 2022, 106 consecutive MICA procedures performed by the author were prospectively analyzed focusing on surgery duration, number of fluoroscopies, radiological correction results and surgery- associated complications using a modified Clavien-Dindo classification. There were 95 female and 11 male patients with a mean age of 53y (range 16-78y). The mean preoperative intermetatarsal angle I/II (IMA) was 15,7°, the mean hallux valgus angle (HVA) 28,7°. Results: The average amount of radiological correction was 12,6° for IMA and 16,8° for HVA. Overall, the mean surgery duration was 41,6min. (range 27-90min.), the number of fluoroscopies (fs) was 110,8 (range 64-186 fs). Comparing the first 10 MICAS vs. the last 10 procedures, both surgery duration and the amount of fluoro shots decreased significantly (58,8min vs. 32,4min and 165,9 fs vs. 83,1fs). According to the modified Clavien-Dindo classification, there were three grade 1 complications (superficial cellulitis requiring oral antibiotics), four grade 2 complications (1 intraoperative conversion to open surgery, 1 delayed union, 2 symptomatic recurrences) and one grade 3 complication (delayed wound-healing requiring superifical wound revision). Overall screw removal rate was 18 /106 cases, all due to prominent hardware with square headless designed screws (non-beveled). Conclusion: This study represents the largest case series on the learning curve of MICA. Although the learning curve is prolonged requiring specific training and intensive practice, the rate of severe complications is not increased compared to open hallux valgus surgery. The use of bevel-headed screws is strongly advised to reduce the rate of secondary hardware removal. The learning curve manifests itself predominantly in a decreasing operation time and lower number of fluoroscopies. Adherence to the principles of MICA with stable fixation and meticulous intraoperative control of each surgical step helps to reduce complications and allows for adequate correction from the beginning.

Short-Term Complications of Relative Femoral Neck Lengthening Combined with Extra-Articular Osteotomies of the Proximal Femur.

Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO. All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1week, 6weeks, 3months, 6months, 12months and 24months. Seventy two patients (31 males, 41 females, 6-52years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union. RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections. The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.

Nascent Malunion of Distal Radius Fractures Treated with Fixed Angled Volar Plates without Using Bone Grafts.

Malunion of the distal radius is a common complication. Using bone grafts is common to restore the bone to an acceptable level. This study aimed to verify if it is necessary to use bone grafts in nascent malunion of distal radius fractures treated with fixed angled volar plates and which radiographic parameters are essential to obtain satisfactory outcomes. This single-centered prospective study included 11 patients who underwent corrective osteotomy of the radius for malunion. Patients with a metaphyseal, extraarticular osteotomy stabilized by a volar fixed angle plate within 3months after the fracture are included. Patients underwent a standard radiological evaluation at postoperative 1month, 3months, 6months, 1year, and annually thereafter. Radial inclination, radial height, ulnar variance, and palmar tilt were measured. Wrist ranges of motion are measured throughout follow-up with a goniometer. Grip strength is measured using a Jamar Hand Dynamometer. The function is evaluated via the Gartland-Werley (GW) score and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. The mean age of 11 patients, 9 (81.82%) males, included in the study was 41.45 ± 14.89years. The mean post-fracture admission time is 39.3 ± 15.1days. Radial inclination, radial length, and ulnar variance improved significantly after surgery (p = 0.0023, 0.0002, 0.0037). Radial inclination values are within normal limits for all patients at admission. The radial length was in the normal range for 72.73%, the ulnar variance was in the normal range for 72.73%, and palmar tilt was in the normal range for 100% of the patients. Extension 54.55%, flexion 72.73%, radial deviation 81.82%, ulnar deviation 63.64%, pronation 90.91%, and supination 72.73% were achieved after surgery. GW average was 3.09 ± 3.24 DASH score average was 12.24 ± 13.48. The mean grip strength was 29.27 ± 7.21 on the operated side, while it was 34.91 ± 5.32, on the healthy side, with a significant difference (p = 0.0108). It is possible to get good results without using bone grafts in corrective osteotomy of distal radius malunions.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

Open reduction and internal fixation is the gold standard treatment for tibial plateau fractures. However, the procedure is not free of complications such as knee stiffness, acute infection, chronic infection (osteomyelitis), malunion, non-union, and post-traumatic osteoarthritis.The treatment options for knee stiffness are mobilisation under anaesthesia (MUA) when the duration is less than 3 months, arthroscopic release when the duration is between 3 and 6 months, and open release for refractory cases or cases lasting more than 6 months. Early arthroscopic release can be associated with MUA.Regarding treatment of acute infection, if the fracture has healed, the hardware can be removed, and lavage and debridement can be performed along with antibiotic therapy. If the fracture has not healed, the hardware is retained, and lavage, debridement, and antibiotic therapy are performed (sometimes more than once until the fracture heals). Fracture stability is important not only for healing but also for resolving the infection.In cases of osteomyelitis, treatment should be performed in stages: aggressive debridement of devitalised tissue and bone, antibiotic spacing and temporary external fixation until the infection is resolved (first stage), followed by definitive surgery with grafting or soft tissue coverage depending on the bone defect (second stage).Intra-articular or extra-articular osteotomy is a good option to correct malunion in young, active patients without significant joint damage. When malunion is associated with extensive joint involvement or the initial cartilage damage has resulted in knee osteoarthritis, the surgical option is total knee arthroplasty.

The percutaneous learning curve of 3rd generation minimally-invasive Chevron and Akin osteotomy (MICA)

BackgroundMinimally-invasive Chevron and Akin osteotomy (MICA) represents the third-generation percutaneous hallux valgus surgery which is characterized by an extra-articular osteotomy, stable internal fixation and a high potential for correction. Compared to other percutaneous techniques of the foot, MICA is generally regarded as an advanced and demanding surgical procedure with a flat learning curve. The aim of this study is to analyze a single-surgeons experience with his first 50 consecutive MICA procedures. MethodsBetween May 2018 and February 2021, 50 consecutive MICA procedures performed by the author with the "K-wires-First technique" were prospectively analyzed focusing on surgery duration, number of fluoroscopies, correction results and surgery-associated complications. A modification of the original MICA technique as described by its inaugurators Redfern and Vernois allows the use of a standard-sized C-arm and aims to reduce revison rates and conversion to open surgery by placing the guidewires prior to performing the osteotomy. ResultsThe average surgery time for all MICA procedures was 46.8 min (SD 12.1, range 31–90 min). The average amount of fluoro shots required to perform MICA was n = 126.6 (SD 40.8, range 65–231). Comparing the preoperative and 6-week postoperative radiographs, the IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°. One case required intraoperative conversion to open hallux correction. There were 4 feet in three patients with secondary screw removal of the Chevron fixation due to prominent proximal screw tips. ConclusionsAlthough the learning curve of 3rd generation MICA is flat and requires specific training and intensive practice, the rate of complications is not elevated compared to other percutaneous hallux valgus techniques. Strict adherence to the principles of 3rd generation MICA with stable fixation and meticulous intraoperative control of each surgical step helps to reduce surgery-associated complications. The learning curve showed a continous improvement in regard to surgery time and use of fluoroscopy. After 40 procedures, the surgery time consistently dropped under 45 min and required less than 100 fluoro-shots. The modified surgical technique may help reduce Chevron screw mal-positioning when using large C-arm fluoroscopy for this procedure.

Late Outcomes of Triple Arthrodesis in Patients with Flat Foot

Summary. Triple arthrodesis (TA) is a final surgical decision in treatment of the acquired flat foot (FF).
 Objective: to study late outcomes of TA in the acquired FF; to establish factors influencing functional outcome of treatment.
 Materials and Methods. The study included 51 patients (56 feet) with acquired FF at the age 32 – 77 years (54.7±1.2 years). Vertical and horizontal talometatarsal angles (TMA), as well as calcaneal inclination angle were determined by standing radiographs of the foot. The severity of osteoarthritis of the ankle joint (AJ) was assessed according to the Kellgren-Lawrence classification; range of motion in the AJ was determined according to the 0-pass method. Foot function was assessed by the dynamics of indicators: AOFAS scale (hindfoot and ankle joint), FFI (Italian version), quality of life (Roles and Maudsley scale), and VAS (pain). Establishment of factors influencing the outcome of treatment was performed using regression-correlation and factor analysis.
 Results. Long-term results were studied in 32 cases. Cases of non-unions were registered at the following levels: talonavicular (2) and calcaneocuboidea (2). The dynamics of skiological indicators was significantly positive (p˂0.05; unpaired t-test). According to the AOFAS scale, 2 excellent, 19 good and 11 satisfactory results of treatment were obtained. Significant influence of pain level (inverse dependence) and range of foot extension (direct dependence) on the result (regression analysis) were determined, as well as significant effect of ankle osteoarthritis on the function of the foot (Fisher’s exact test; 0.002).
 Conclusions. TA in the treatment of acquired FF is an effective surgery that provides favorable results in cases of severe deformity, degenerative changes in the joints, and contraindications to extra-articular corrective osteotomies.

Surgical treatment of femoroacetabular impingement syndrome : Arthroscopy-mini-open-surgical hip dislocation

Femoroacetabular impingement syndrome (FAIS) is one of the most common prearthritic hip deformities. Since FAIS is amechanical pathology, surgical correction of the underlying deformity is the sole causal treatment. If surgery is indicated, a surgical technique that results in complete deformity correction with least morbidity should be selected. Due to advancements in techniques and instruments, most pathologies in FAIS can nowadays be addressed arthroscopically. Hip arthroscopy can be successfully performed if the locations of the pathologies are anterior and lateral. In special cases and indications-like periarticular pathologies, pathologies of the hip capsule and large labral reconstructions and transplantations, acombination of arthroscopy with amini-open approach is advantageous. Furthermore, the learning curve of hip arthroscopy can be improved with an additional open approach. Global and circumferential pathologies still have to be addressed in surgical hip dislocation to avoid residual deformities. Finally, extraarticular osteotomies have to be considered in cases with significant rotational deformities.

3rd generation MICA with the \u201cK-wires-first technique\u201d - a step-by-step instruction and preliminary results

BackgroundMinimally-invasive techniques for hallux valgus correction are becoming increasingly popular. In the last decades, multiple techniques for minimally-invasive hallux valgus correction have been described. MICA (Minimally-invasive Chevron & Akin), representing the 3rd generation of minimally-invasive hallux valgus correction, combines the advantages of an extraarticular osteotomy, stable internal fixation, and high potential for correction.This report aims to provide a step-by-step instruction of the surgical technique with the “K-wires-first” MICA modification, illustrated by detailed imaging of both intraoperative fluoroscopy and clinical imaging as well as corresponding sawbone models for each step. Preliminary results including radiological outcome and complications of the first 50 cases will be discussed.MethodsBetween May 2018 and May 2021, 50 consecutive MICAs in 47 patients were performed with the K-wires-first technique. There were 40 women and 7 men with an average of 57.4y (range 25–78). The mean preoperative IMA was 16.2° (range 11.0–21.5), the HVA 30.6° (range 21.8–42.1).ResultsThere was one intraoperative conversion to an open surgical bunion correction corresponding to a 2% conversion rate respectively (1/50). On 3 feet (2 patients), removal of the Chevron screws was performed after 7, 9, and 12 months due to prominent and disturbing screw heads at the level of the medial cortex, accounting for a revision rate of 6% (3/50). There were no other secondary revision surgeries. The IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°, demonstrating MICA’s high potential for correction.ConclusionsCompared to other MICA techniques, the K-wires-first modification helps to reduce hardware malpositioning and the risk of conversion to open surgery. Furthermore, our preliminary results demonstrate a high potential for correction even for severe hallux deformities.Trial registrationRetrospectively registered, swissethics BASEC-ID 2021–01537, July 16th, 2021 (www.raps.swissethics.ch).

Intra-articular osteotomies for medial compartment osteoarthritis: Is adding an extra-articular osteotomy worthwhile?

Background and Aims: Medial compartment osteoarthritis (MCOA) of the knee presents with varus deformity arising from the upper tibia or lower femur. High tibial osteotomies relieve pain by correcting the varus and improving the mechanical axis deviation (MAD). Closing wedge, opening wedge, and dome osteotomies are popular choices in the upper tibial metaphysis. These are all extra-articular osteotomies (EAO). Recently, attention has turned to detection and treatment of intra articular deformity arising from the knee to treat MCOA. Tibial condylar valgus osteotomy (TCVO) is an intra-articular osteotomy (IAO) which corrects the varus malalignment by elevating the medial tibial condyle and is usually fixed with a plate (Tibial condylar valgus osteotomy-plating [TCVO-P]). A second distal extra articular osteotomy, fixed with an Ilizarov fixator (tibial condylar valgus osteotomy-Ilizarov [TCVO-I]) is performed in some patients for better correction of the mechanical axis. The two groups were treated with different surgical approaches based on preoperative analysis of deformity. Hence this is a level IV study. We aimed to study the improvement in radiological parameters after TCVO in MCOA. We also compared the results between TCVO-P and TCVO-I. Patients and Methods: We performed 64 osteotomies in 55 patients over the last 7 years. 30 (33 tibiae) had a TCVO-P. 25 (31 tibiae) had a TCVO-I. The mean age in TCVO-P was 55 years, and in TCVO-I was 48 years. Results: The mean preoperative (bo) MAD was more in TCVO-I at –37.4% and improved to a mean postoperative MAD of 53.8%. TCVO-P had a lesser mean bo MAD of –7.4%, which corrected to 46.4%. MAD was better corrected by TCVO-I (P = 0.0058). Correction of medial proximal tibial angle, hip knee ankle angle, ankle joint line orientation improved significantly in both groups. The knee joint line orientation was improved by TCVO-I (P = 0.001), but not by TCVO-P (P = 0.075). Joint line convergence angle (JLCA), spine edge angle, and spine vertical distance were all significantly improved in both groups. Condylar plateau angle was not changed significantly in either group. Conclusion: TCVO is an Intra articular osteotomy which effectively corrects the varus deformity arising from the knee joint in MCOA. An isolated TCVO-P slightly under-corrects the mechanical axis. TCVO-I is better at restoring mechanical axis to beyond neutral and is better for younger patients and with intorsion deformities.

Percutaneous Distal Metatarsal Mini-Invasive Osteotomy: Comparison Between Standard vs Modified Intraosseous Approach: A Cadaveric Study

Category:Midfoot/ForefootIntroduction/Purpose:Minimally invasive surgery (MIS) of the forefoot has gained popularity as an alternative to traditional open procedures for the treatment of metatarsalgia and hammertoe deformity. Distal metatarsal mini-invasive osteotomy (DMMO) is an extraarticular osteotomy done in a percutaneous manner, with minimal soft tissue dissection that permits elevation as well as shortening. However, there is concern for damage to vital structures due to lack of direct visualization. The objective of the study was to evaluate the structures at risk in standard versus modified DMMO.Methods:11 thawed fresh-frozen cadaveric specimens underwent minimally invasive DMMO using both the standard and modified approach. The standard technique was performed by moving the burr in a circular motion with an angle of 45° (right- handed surgeon), which cut sequentially the left, plantar, right and dorsal cortices. It was compared to a modified intraosseous technique requiring less wrist supination while remaining intraosseous. After completion of the procedures, the cadavers were fully dissected and analysed to identify unintentional injury to soft tissue structures and to verify if cuts were completely extraarticular and performed with proper angulation.Results:In the standard group the most commonly injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group demonstrated injury to the EDL (27%), while MJC (0%) and EDB (0%) were not damaged. Distances between osteotomies and structures were 6.08 +- 3.99 mm from the dorsal metatarsal head articular surface (DMHAS), 4.85 +- 2.45 mm from EDB and 0.76 +- 1.72 mm from the EDL in the standard group and 9.92 +- 3.42 mm from the DMHAS, 4.71 +- 3.24 mm from EDB and 1.24 +- 1.84 mm from the EDL in the modified group. Statistically significant difference was found among osteotomy site and DMHAS (p=0.02).Conclusion:The most frequently injured structure was the EDL tendon with both DMMO techniques used. Intra-articular positioning of the osteotomy was more frequently observed in the standard technique. There was also a statistically significant difference between the distance of the osteotomy site and the dorsal metatarsal head articular surface when comparing the standard group and the modified group. Overall, it appears that the modified method could be a safer, less complex alternative to the standard DMMO technique, especially for the inexperienced surgeons.

Среднесрочные результаты внесуставной корригирующей остеотомии бедра при юношеском эпифизеолизе головки бедренной кости

Despite the diversity of surgical options for slipped capital femoral epiphysis (SCFE), there is an ongoing search for the technique that would ensure a satisfactory outcome, stable fixation of bone fragments and a low rate of complications. The aim of this study was to improve the surgical technique for SCFE in patients with moderate and severe SCFE. The study included 52 children (16 girls and 36 boys) aged 10-15 years (the mean age was 13.2 years) with chronic severe (Krechmar’s stage III) stable (according to Loder’s classification) SCFE. The control group (n = 16) underwent a classic Imhauser procedure; the main group (n = 36) underwent a triplane osteotomy proposed by the authors of the study. The patients were examined prior to surgery and in the late follow-up period (the mean follow-up time was 4.7 years, ranging from 1 to 10 years). The procedure included a clinical examination, history taking, radiography to measure the slip angle and the severity of the slip, and the Harris hip score to assess hip function. After 4.7 years, both groups demonstrated an increase in the range of motion, in comparison with their preoperative results (p ≤ 0.05), good Harris hip scores (94 points in the main group and 81 points in the control group. Postoperative radiographs showed consolidation of the bone, recovery of the proximal femur anatomy. Leg length discrepancy improved significantly in both groups. The proposed technique for extraarticular osteotomy allows recovering the length of the affected leg, the anatomy and physiology of the hip joint, is simple and less traumatic.

Risk Factors for Nonunion in Pediatric Lateral Column Lengthening (Mosca) Procedures

Category:HindfootIntroduction/Purpose:The Evans/Mosca procedure remains the most utilized extra-articular osteotomies for correction of pes planus. This desired lengthening is created by inserting a graft in the anterior aspect of the calcaneus through a complete transverse osteotomy. Failure of conservative methods, particularly for rigid pes planus, is a primary consideration for surgical management. Complications of the Evans procedure include delayed union, nonunion, malunion, subluxation of the calcaneocuboid joint, and persistent lateral column pain. Our study analyzes risk factors for development of non-union.Methods:After IRB approval 120 patients charts and 157 feet were analyzed for incidence of non-union which was defined by clinical and radiographic evidence of absence of union >6 months. Delayed union was diagnosed if there was clinical evidence of healing without complete union at >6 months. Exclusion criteria included age >18 and revision lateral column lengthening. Patients' medical records were reviewed for basic demographics, complications, and surgical technique.Results:The cohort consisted of 75 females (47.8%) and 82 males (52.2%). The median age was 12 with an interquartile range (IQR) of 3. A total of 6 patients (3.7%) had wound complications or nerve injury. Nonunion occurred in 7 of 157 feet (4.5%) with 2 of 157 feet (1.3%) experiencing delayed union. The median age for patients with nonunion was significantly higher than those who achieved union (13.2 (IQR 2.75) vs. 11.2 (IQR 3) respectively). The fixation construct used was associated with increased risk of nonunion. Patients with screw fixation had the highest rate of nonunion at 50% (2/2) compared to pin and/or staple fixation at 6.8% (5/73), no fixation at 4% (3/75), and plate fixation at 0% (0/2). Both delayed union patients were treated with ultrasound bone stimulation, both patients were able to achieve complete union. Revision was attempted in 5/7 nonunions with all operative patients achieving union.Conclusion:Our study analyzed risk factors for developing non-union in patients undergoing calcaneal lengthening osteotomy for pediatric pes planus. We found age at time of surgery and graft fixation method to be significant risk factors for development of non-union. Our study highlighted that those patients who had non-union was on average >2yrs older at time of surgery. Overall, lateral column lengthening is a well-tolerated procedure with a complication rate, including non-and delayed union, of 10.8%. Surgeons should be aware, in the largest cohort of pediatric Evans/Mosca procedures to date, patient age and type of fixation were associated with nonunion.

Role of the Ilizarov fixator in high tibial osteotomy

Role of the Ilizarov fixator in high tibial osteotomy

Choice of surgical treatment for slipped capital femoral epiphysis with severe chronic displacement of the epiphysis

Background. The spatial relationship between the epiphysis and the acetabulum in slipped capital femoral epiphysis (SCFE) with severe chronic epiphysis displacement is restored by different corrective extra-articular femoral osteotomies and a standard Dunn procedure. Severe residual deformity of the femoral component of the joint with symptoms of femoroacetabular impingement and a large number of severe ischemic complications forced the surgeons to improve the technique of these surgical interventions. In particular, a modified Dunn procedure was proposed using a low traumatic surgical hip dislocation. However, the selection of surgical treatment in these patients remains a subject of discussion.
 Aim. This study aimed to improve the results of treatment in children with SCFE with severe chronic epiphysis displacement.
 Materials and methods. Data of preoperative and postoperative clinical and radiological studies of 40 patients (24 male and 16 female) aged 1215 years who were suffering from SCFE with severe chronic epiphysis displacement were analyzed. In all cases, on the lesion side, displacement was found in typical directions (posterior-downward or only posterior), and in the contralateral joint, the disease was still at its initial stage (pre-slip). In group 1 (n = 20 children), a corrective extra-articular femoral (anterior-rotational or rotational-valgus) osteotomy was performed according to the method we have proposed in 2011 [22], and in group 2 (n = 20 children), the modified Dunn procedure that strictly followed our technique was performed. The follow-up period after surgery in both groups ranged from 1 month to 2.5 years.
 Results. At 2.5 years after surgery, good anatomical and functional outcomes were observed only in 1 (12.5%) of 8 patients in group 1, while they were observed in 7 (87.5%) of 8 patients in group 2. Poor results were determined by residual epiphyseal displacement (from 22 to 28) and/or step-like transition of the anterior femoral neck surface to the head in 5 (62.5%) children in group 1 and by femoral head avascular necrosis (diagnosed in 6 months after surgery) in 1 (12.5%) child in group 2.
 Conclusion. The results allow us to make a preliminary conclusion about the high efficiency of the modified Dunn procedure and the low efficiency of the corrective extra-articular femoral osteotomy in SCFE with severe chronic displacement of the epiphysis. The modified Dunn procedure corrects the pronounced deformity of the femoral component of the affected joint and femoroacetabular impingement in the above-mentioned anatomical situations.

New measurements to determine changes after intra-articular high tibial osteotomy

Background: Most high tibial osteotomies (HTO), performed for medial compartment osteoarthritis of the knee (MCOA) are extra-articular osteotomies of the upper tibia. Recently, attention has turned to detecting and treating intra-articular deformities of the upper tibia causing MCOA. Chiba introduced the tibial condylar valgus osteotomy (TCVO) in Japan and few English language articles have described indications, surgical techniques of results of these osteotomies. Two angles commonly measure and detect the intra-articular deformity and measure the difference between preoperative and postoperative parameters: Joint line convergence angle (JLCA) and condylar plateau angle (CPA). Aims and Objectives: JLCA is relatively easy to measure as it uses clearly visible landmarks to draw tangents to femoral and tibial condyles to subtend the angle. CPA is a little difficult to measure and we found it to be less reliable in intra-observer as well as interobserver readings. Materials and Methods: We decided to measure the intra-articular deformity by using spine edge angle (SEA) and spine vertical distance (SVD) as two new measurements. These have proved to be reliable in intra as well as interobserver measurements. We compared readings of SEA and SVD in 57 patients each who had an intra-articular TCVO and also an extraarticular medial open wedge HTO (OWHTO). Results: We found a significant change between preoperative and postoperative measurements of SEA and SVD in patients who underwent TCVO, but no change in patients who underwent OWHTO. Conclusions: The two new measurements of SEA and SVD accurately measure the change in intra-articular deformity parameters in patients who undergo TCVO and are more reliable than CPA.

Alignment of the hindfoot in total knee arthroplasty: a systematic review of clinical and radiological outcomes.

Patients with a deformity of the hindfoot present a particular challenge when performing total knee arthroplasty (TKA). The literature contains little information about the relationship between TKA and hindfoot alignment. This systematic review aimed to determine from both clinical and radiological studies whether TKA would alter a preoperative hindfoot deformity and whether the outcome of TKA is affected by the presence of a postoperative hindfoot deformity. A systematic literature search was performed in the databases PubMed, EMBASE, Cochrane Library, and Web of Science. Search terms consisted of "total knee arthroplasty/replacement" combined with "hindfoot/ankle alignment". Inclusion criteria were all English language studies analyzing the association between TKA and the alignment of the hindfoot, including the clinical or radiological outcomes. Exclusion criteria consisted of TKA performed with a concomitant extra-articular osteotomy and case reports or expert opinions. An assessment of quality was conducted using the modified Methodological Index for Non-Randomized Studies (MINORS). The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered in the PROSPERO database (CRD42019106980). A total of 17 studies were found to be eligible for review. They included six prospective and ten retrospective studies, and one case-control study. The effects of TKA showed a clinical improvement in the hindfoot deformity in three studies, but did not if there was osteoarthritis (OA) of the ankle (one study) or a persistent deformity of the knee (one study). The radiological alignment of the hindfoot corrected in 11 studies, but did not in the presence of a rigid hindfoot varus deformity (in two studies). The effects of a hindfoot deformity on TKA included a clinical association with instability of the knee in one study, and a shift in the radiological weightbearing axis in two studies. The mean MINORS score was 9.4 out of 16 (7 to 12). TKA improves both the function and alignment of the hindfoot in patients with a preoperative deformity of the hindfoot. This may not apply if there is a persistent deformity of the knee, a rigid hindfoot varus deformity, or OA of the ankle. Moreover, a persistent deformity of the hindfoot may adversely affect the stability and longevity of a TKA. These findings should be interpreted with caution due to the moderate methodological quality of the studies which were included. Therefore, further prospective studies are needed in order to determine at which stage correction of a hindfoot deformity is required to optimize the outcome of a TKA. Cite this article: Bone Joint J 2021;103-B(1):87-97.

Comparison of unilateral rostral, middle and caudal segmental mandibulectomies as an alternative treatment for unilateral temporomandibular joint ankylosis in cats: an ex vivo study.

Temporomandibular joint ankylosis (TMJA) is the partial or complete inability to open the mouth due to intra- or extra-articular fibrous, bony or fibro-osseous tissue proliferation. Surgical procedures such as gap arthroplasty, condylectomy or wide extra-articular osteotomy have been recommended to treat this condition; these techniques are challenging, time-consuming and have been occasionally associated with postoperative recurrence, severe periarticular neurovascular iatrogenic trauma and death. Segmental mandibulectomy had previously been recommended as an alternative option for unilateral TMJA, but the location of mandibulectomy and extent of bone removal from the mandible region have not been mentioned in the literature. This study aimed to validate the area of the mandibular body (rostral, middle or caudal) and amount of bony tissue that should be osteotomized during a segmental mandibulectomy for treatment of unilateral TMJA in cats. In this block study, 30 cadaver heads of domestic shorthair cats were randomly divided into three groups of 10 specimens each based on the mandibular region that would undergo segmental mandibulectomy (rostral, middle and caudal). The size of the removed mandibular segment and pre- and postoperative vertical range of mandibular motion were compared for statistical purposes. A significant statistical difference was observed between the pre- and postoperative vertical range of mandibular motion between the rostral, middle and caudal segmental mandibulectomies (P <0.001). The mean postoperative recovered range of mandibular motion for the rostral, middle and caudal segmental mandibulectomies was 50.4%, 81.9% and 90.4%, respectively. The caudal segmental mandibulectomy showed the highest postoperative vertical range of mandibular motion. The removal of a minimum of 1.2 cm of the caudal mandibular body was required to achieve nearly full recovery of presurgical mouth opening in the specimens of this study. The caudal segmental mandibulectomy may eliminate the risk of iatrogenic periarticular neurovascular damage inherent to more invasive surgeries performed at the temporomandibular joint area. When performed unilaterally, the caudal segmental mandibulectomy is a viable surgical alternative that may show a similar outcome to other surgical techniques.

Lateral Column Lengthening Revisited: A Simple Intraoperative Approach to Ensure a True Extra-Articular Osteotomy

Lateral column lengthening is a common method for treatment of patients with symptomatic flat feet. Although variations of the technique have been described by many authors, there is a lack of agreement about the exact location of the osteotomy. Most authors tried to find the interval between the anterior and middle talocalcaneal facets but did not offer a reproducible method to achieve this purpose. The use of a plantarflexion anteroposterior view of the foot provides better visualization of the anatomic landmarks and helps to precisely perform the osteotomy anterior to the sustentaculum tali, with protection of the anterior and middle talocalcaneal facets.