Extra-articular Osteotomy Research Articles

A New Technique for Lesser Metatarsal Osteotomy in the Treatment of Metatarsalgia

Metatarsalgia is a commonly presenting complaint to foot and ankle surgeons and can be a very debilitating condition. It is heralded by the presence of diffuse pain in the area around the metatarsal heads, often times accompanied by intractable plantar keratosis. Causes may include (1) bony (long second metatarsal, posttraumatic deformity, prominent condyle); (2) metatarsophalangeal joint instability with resultant displacement of the plantar fat pad; (3) hypermobility of the first ray leading to lesser metatarsal overload (hallux valgus, generalized ligamentous laxity); (4) iatrogenic (hallux valgus correction, with a shortening of the first metatarsal leading to transfer metatarsalgia); or (5) systemic disease (eg, rheumatoid arthritis, seronegative arthritides). With numerous etiologies, the management of this condition has varied considerably over the years. Nonoperative management is the first line of treatment. This can be accomplished with rest, footwear modification, an orthotic with a metatarsal pad, immobilization in a cast, medication (nonsteroidal anti-inflammatory drugs), or through an intra-articular steroid injection. Only when nonsurgical measures have been exhausted should surgery be contemplated. It is important to determine the cause of pain so that operative treatment can be tailored appropriately. In this study, we will be proposing a new, less technically demanding technique for the shortening of metatarsals in the treatment of metatarsalgia. This technique can be used in isolation or in combination with other procedures depending on the cause of pain and deformity. When a metatarsal requires shortening we recommend an extra-articular metatarsal shaft osteotomy with rigid plate fixation.

Digastric olecranon osteotomy: feasibility study of a new approach to the elbow

None of the multiple posterior approaches to the elbow simultaneously satisfies the following three properties: good articular surface exposure, attention to the extensor apparatus continuity and olecranon vascularization. This study aims to describe a new approach to the elbow: digastric olecranon osteotomy. Nine anatomical subjects were prepared. One-third underwent intra-articular digastric osteotomy, one-third extra-articular osteotomy and one-third a vascularization study using arteriography. Digastric olecranon osteotomy, notably intra-articular, offered excellent articular exposure. After restoration, digastric stability was excellent. Olecranon vascularization was preserved using the two variations of digastric olecranon osteotomy. Digastric olecranon osteotomy preserves the principal vascular supply of the olecranon and the continuity of the extensor apparatus. Articular surface exposure is excellent, and the natural coaptation of the digastric enables immediate mobilization without any theoretical risk of deconstruction.

Simultaneous Femoral and Tibial Osteotomies During Total Knee Arthroplasty for Severe Extra-Articular Deformity

Total knee arthroplasty (TKA) performed in knees with mild or moderate intraarticular deformity often can be resolved with careful ligament balancing and bone resection. However, extra-articular deformity may require an osteotomy to safely create rectangular flexion and extension gap balance. In these challenging situations, restoring the mechanical axis through intra-articular bone resection and soft tissue releases alone can lead to excessive bone loss and ligament instability. We report a case of TKA with combined femoral and tibial osteotomies in a post-polio patient with extra-articular deformities. Although a few small case studies have been previously published in the literature, specific details regarding this procedure are lacking. Our objective is to provide a detailed surgical technique and to review the indications for extra-articular osteotomies performed during TKA.

FasT-Fix versus Inside-Out Suture Meniscal Repair in the Goat Model

Background Recent all-inside meniscal repair devices are available, but in vivo studies with these devices are sparse. Hypothesis The FasT-Fix has inferior meniscal healing compared with the inside-out suture technique in the goat model. Study Design Controlled laboratory study. Methods After Institutional Review Board approval, 73 male castrated goats (Capra hircus) underwent a 2-cm meniscal incision and subsequent repair with the FasT-Fix device on one knee and inside-out meniscal repair on the contralateral knee. Both repairs used a vertical mattress suture technique. Access to the menisci was via an open technique with an extra-articular osteotomy of the medial collateral ligament origin on the femur. The animals were then allowed to ambulate unrestricted in a pasture after a 7-day stay in cages. Necropsy was carried out 6 months postoperatively, and the menisci and articular cartilage were studied with gross and microscopic inspection. Results Nine of the 73 animals were excluded before necropsy. A total of 64 animals underwent necropsy, gross measurement of residual lesions, gross evaluation for chondral damage, histologic evaluation of meniscal repair, histologic evaluation of any adjacent inflammatory reaction to implants, and data analysis. Compared with the inside-out group, the FasT-Fix group had longer residual full-thickness defects (1.2 ± 2.9 mm vs 0.2 ± 1.1 mm; P =. 011) and longer residual partial-thickness defects (8.4 ± 6.3 mm vs 3.6 ± 5.5 mm; P <. 001). A total of 148 FasT-Fix devices were placed for 73 knees. Two devices were replaced for improper deployment. The device deployed and attached correctly 146 of 148 times for a success rate of 98.6%. There was no gross chondral damage and no histologic findings of inflammatory reaction to the implants with either technique. Conclusions The FasT-Fix meniscal repair had inferior meniscal healing results in this animal model. Previous studies using this animal model have paralleled clinical outcomes. Implantation of the FasT-Fix device does not damage adjacent femoral or tibial cartilage. The deployment of the FasT-Fix implant was simple and reproducible. There was no inflammatory reaction to the FasTFix implant. Clinical Relevance The FasT-Fix meniscal repair has inferior meniscal healing results compared with the inside-out meniscal repair technique in the goat model. The clinical significance of this finding is not known. Further clinical study of the FasT-Fix implant is warranted.

MALUNION AND NONUNION OF THE METACARPALS AND PHALANGES

The management of nonunion and malunion in the metacarpals and phalanges is influenced by the multiple gliding structures and the propensity for stiffness, the ability of adjacent digits to substitute functionally for compromised digits, the small size of the bones, and associated complications. Amputation and arthrodesis are useful treatment options for nonunions in the hand because they are nearly always atrophic, are frequently associated with joint stiffness and tendon adhesions, and often occur in digits with poor nerve function, vascularity, or skin cover. Surgical fixation with autogenous bone grafts and stable internal fixation has a high union rate with resultant restoration of alignment and stability, but achieves modest improvements in motion. Slightly larger implants than one would use for a fracture at the same size and structural (corticocancellous) bone grafts are useful for obtaining adequate stability to initiate immediate exercises in order to limit the potential for stiffness. Malunion is treated only when doing so offers useful functional advantages. The optimal timing and site of intervention are debatable; however, it is usually easiest to restore alignment when operating at the site of the original fracture and prior to complete consolidation of the fracture. This is particularly true for articular fractures. Once these fractures are mature, it may be preferable to perform an extra-articular osteotomy. If a late intra-articular osteotomy is performed, it should be done in such a way as to create large fragments that are easier to repair and more likely to retain their blood supply.

Extra-Articular Osteotomy for Malunited Unicondylar Fractures of the Proximal Phalanx

To evaluate an extra-articular osteotomy rather than an intra-articular osteotomy in the treatment of malunited unicondylar fractures of the proximal phalanx. An extra-articular osteotomy was used to correct the deformity resulting from a malunion of a unicondylar fracture of the proximal phalanx in 5 patients. A closing wedge osteotomy that was stabilized with tension band fixation accomplished realignment of the joint. Each patient was evaluated at a minimum of 1 year after surgery for radiographic healing, correction of angulation, digital motion, postoperative complications, current level of pain with motion, and overall satisfaction with the procedure. All of the osteotomies healed by 10 to 12 weeks after surgery with an average angular correction from 25 degrees to 1 degrees . The average proximal interphalangeal joint motion improved to 86 degrees from the preoperative average of 40 degrees , whereas the average total digital motion improved from 154 degrees before surgery to 204 degrees at follow-up evaluation. This method of extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx is highly reproducible, avoids the risks of intra-articular surgery, and leads to a predictable outcome.

CONDYLAR ADVANCEMENT OSTEOTOMY FOR CORRECTING CONDYLAR MALUNION OF THE FINGER

Unicondylar fractures of proximal and middle phalanges of the finger can unite with intra-articular malunion, which may result in joint pain, stiffness and deformity. There is currently no satisfactory technique of corrective osteotomy for these fractures. Extra-articular osteotomies often do not give good results and existing techniques of intra-articular osteotomy through the healed fracture site are technically difficult due to the small bone fragment, difficulty achieving stable fixation and the risk of avascular necrosis. We propose a different method of intra-articular correction with a longitudinal osteotomy and advancement of the malunited condyle. The “condylar advancement osteotomy” can overcome problems encountered with the other techniques. Excellent results were obtained in six patients.

Wedge osteotomies of the radius for Kienböck's disease: a biomechanical analysis.

We compared changes in lunate cortical strain with an applied physiologic load by altering radial inclination to simulate opening and closing wedge osteotomies of the distal radius. Nineteen fresh-frozen cadaver arms were mounted in neutral position and tested under axial compression at a physiologic load by means of a repeated-measures design. Principal compressive strains were measured with rosette strain gauges mounted on the lunate's palmar and dorsal cortices. Distal radius osteotomy and custom external fixator allowed for altering radial inclination in progressive 3 degrees increments both by increasing and decreasing radial inclination in each specimen. Maximum principal strain was recorded for each inclination increment and compared with control. Comparison of all data showed a 26% decrease on lunate cortical strain for the radial opening wedge osteotomy and a 24% increase for the radial closing wedge osteotomy. This difference was statistically significant. No significant differences were found between individual angular increments (3 degrees to 15 degrees). The radial opening wedge osteotomy was more effective than the radial closing wedge osteotomy at diminishing lunate strain. The results validate the biomechanical effectiveness of this extra-articular osteotomy, which is intended to minimize alteration of ulnar variation.

Ostéotomie tibiale et arthroplastie totale de genou en un temps pour cal vicieux fémoro-tibial et arthrose

Extraarticular tibiofemoral malunion causing malalignment and osteoarthritis of the knee can be managed by an extraarticular osteotomy, or by compensatory distal femoral or proximal tibial wedge resection along with total knee replacement, to achieve limb alignment and improve knee function.We operated on 6 knees with tibiofemoral malunion with osteoarthritis of the knee. All knees had an extraarticular osteotomy either at the site of malunion (3 knees) or away from the malunion site (3 knees). There were 4 femoral deformities and 2 tibial malunions. In one patient a femoral osteotomy was done as a part of revision knee replacement for loosening with supracondylar malunion.5 of these patients had a press fit stemmed superstabiliser total knee replacement. In the remaining patient with tibial malunion, a conventional total condylar total knee replacement was done along with a high tibial osteotomy.At a mean follow-up of 45 months (range 24 to 84), one osteotomy had not healed inspite of bone grafting and one patient had an above knee amputation for infection. The HSS (Hospital for Special Surgery) scores revealed a good result in 4 knees, fair in 1 and poor in 1 patient. None of the surviving knee replacement has required a revision to date for clinical or radiological loosening. All patients had a good mechanical alignment of the lower limb, with no ligamentous imbalance following surgery.Single stage osteotomy and total knee arthroplasty is a technically demanding surgery associated with complications and should be reserved for large deformities. Minor deformities should be corrected by intraarticular distal femoral or proximal tibial wedge resection taking due care that ligament balance is not compromised and a satisfactory alignment is restored.

Complications Following Distal Radial Fractures

Union with deformity is the most common complication following a distal radial fracture1-5. The deformity may be extra-articular, characterized by loss of length and metaphyseal angulation; it may be intra-articular, involving either the radiocarpal or the radioulnar joint, or both; or it may be a combination of the two. Surgical treatment of a symptomatic malunion of the distal part of the radius has been recognized for more than 200 years. Resection of the distal aspect of the ulna for the management of pain at the distal radioulnar joint after a distal radial fracture, a procedure attributed to Darrach after his description in 19136, had been suggested by Desault in 17917 and again by Moore in 18808. In 1937, Campbell described a corrective osteotomy of the distal part of the radius with use of an interpositional bone graft obtained from the distal part of the ulna9. In 1945, Merle d’Aubigne and Joussement described a multiple-facet curved osteotomy without the need for an interpositional bone graft10. This concept is currently being revisited and will be described. A deformity following fracture of the distal part of the radius is not necessarily symptomatic. In fact, it is not uncommon for an older patient to have acceptable wrist and forearm function without pain even when there is an apparent deformity. Therefore, impairment of function rather than radiographic deformity is the reason to treat a distal radial malunion, and, consequently, the patient’s wrist and forearm function must be assessed. The most common deformity following a malunited extra-articular Colles type of fracture is the loss of the normal volar tilt of the articular surface in the sagittal plane, loss of ulnar inclination in the frontal plane, loss of length relative to the ulna, and …

Corrective Osteotomy of Malunited Fractures of Phalanges and Metacarpals

We have retrospectively reviewed our experience of corrective osteotomies for phalangeal and metacarpal malunions in eleven patients over a 5-year period. Rotational metacarpal malunion treated by metacarpal osteotomy and AO plate fixation can be performed with confidence of achieving a good or excellent result. Phalangeal osteotomy remains a daunting undertaking for most hand surgeons. Our indifferent results are probably due to the inclusion of three intraarticular malunions treated by extraarticular osteotomy. An alternative approach to these malunions may be appropriate.

Corrective osteotomy of malunited fractures of phalanges and metacarpals

We have retrospectively reviewed our experience of corrective osteotomies for phalangeal and metacarpal malunions in eleven patients over a 5-year period. Rotational metacarpal malunion treated by metacarpal osteotomy and AO plate fixation can be performed with confidence of achieving a good or excellent result. Phalangeal osteotomy remains a daunting undertaking for most hand surgeons. Our indifferent results are probably due to the inclusion of three intraarticular malunions treated by extraarticular osteotomy. An alternative approach to these malunions may be appropriate.

Bilateral Spontaneous Arthrodesis of the Hip After Combined Shelf Acetabular Augmentation and Femoral Varus Osteotomies

Spontaneous arthrodesis occurred after bilateral, extraarticular shelf augmentation and femoral varus osteotomies in a child with dislocated hips secondary to muscle imbalance from cerebral palsy. The proposed cause is heterotopic bone formation in the hip abductors in the face of insufficient range of motion exercise.