Final Postoperative Radiographs Research Articles

Postoperative Maintenance of Sagittal Plane Positioning of the First Metatarsophalangeal Joint After Arthrodesis with an Isolated Dorsal Plate Construct: A Retrospective Review of 43 Feet.

First metatarsophalangeal joint arthrodesis with isolated dorsal plating without a lag screw and without a compressive mechanism incorporated into the plate is not well studied. Although surface area for bony fusion is increased, there is concern for lower fusion rates and progressive loss of sagittal plane positioning. We present fusion rates and progressive sagittal plane deviation with isolated dorsal plate fixation. A retrospective review was performed of 41 patients (43 feet) who underwent first metatarsophalangeal joint arthrodesis with isolated dorsal plate fixation. Patients were excluded if another form of fixation was used, if there was a compressive feature to the dorsal plate, or if a lag screw was used. Preoperative, immediate postoperative, and final postoperative radiographs were reviewed to assess radiographic alignment and fusion about the first metatarsophalangeal joint. Specific attention was placed on hallux dorsiflexion in relation to the first metatarsal. Statistical significance was set at P ≤ .05 a priori. Patients were followed for an average of 55.7 weeks. Overall union rate was 97.62%. The average time to union was 42.55 days. Reoperation rate was 4.65%, with one patient requiring revisional arthrodesis with a lag screw construct. Hallux abduction and first-second intermetatarsal angle correction reached significance (P < .00001). Hallux dorsiflexion increased by 1.05° between initial postoperative and final postoperative radiographs (P = .542). Although fusion rates and progressive loss of sagittal plane position have been concerns for first metatarsophalangeal joint arthrodesis with an isolated dorsal plate construct, these results suggest this to be a stable construct without loss of positioning over time.

The Effects of Interbody Device Design and Placement on Lumbar Lordosis and Disc Height in Transforaminal Lumbar Interbody Fusion

There are a wide variety of interbody devices available for use in transforaminal lumbar interbody fusion (TLIF). While traditionally these interbodies are bullet-shaped, crescent-shaped cages have become increasingly common. There is a paucity of literature comparing the effect of cage geometry with substratification for surgical approach (minimally invasive (MIS) vs. open). The aim of this study was to determine the effect of implant geometry, positioning, and surgical approach on the correction of different spinal alignment parameters in patients undergoing TLIF. A retrospective chart and imaging review was performed on 103 patients with a total of 131 instrumented segments performed by a single surgeon. Preoperative, initial postoperative, and final postoperative standing lateral lumbar radiographs were evaluated for lumbar lordosis (LL), segmental lordosis (SL), anterior disc height (ADH), and posterior disc height (PDH). Anterior-posterior implant positioning was recorded for initial and final postoperative radiographs. These measurements were compared among four groups: open bullet (OB), MIS bullet (MB), open crescent (OC), and MIS crescent (MC). SL increased in all groups by a mean of 2.9° at initial imaging and 2.2° at final imaging. The OC group had greater initial improvement in SL compared to the MB group (p = 0.02), though this effect was lost at final follow-up (p = 0.11). The OB and OC groups conferred greater initial improvement in ADH (p = 0.02; p = 0.04), while the OC group had greater final improvement in ADH compared to the MB and MC groups (p = 0.01; p = 0.01). The OC group had less initial improvement in PDH compared with the other groups (p = 0.03, p = 0.02, p &lt; 0.01). The MB group provided greater final improvement in PDH compared with the MC and OC groups (p = 0.04, p = 0.01). Cage geometry, surgical approach, and implant position all demonstrated a statistically significant but clinically minor impact on segmental alignment for TLIF procedures.

Interstage Imaging in Staged Minimally Invasive Spinal Deformity Surgery

Objective: Spinal surgeons have developed novel minimally invasive (MIS) protocols to correct adult degenerative spinal deformities in well-selected patients. Many surgeons perform these cases in stages: first by an anterior/lateral approach for interbody device placement, and second by a posterior approach for fixation. Imaging is typically obtained in between these 2 stages to reassess the surgical anatomy. We evaluated the utility of interstage imaging by comparing alignment parameters between baseline, interstage, and final postoperative radiographs. Methods: We reviewed MIS deformity cases performed at our institution by 3 expert surgeons, which were staged and had complete preoperative, interstage, and postoperative radiographs. Standard alignment parameters at all timepoints were compared.Results: Thirty-three patients met the criteria for inclusion. There were significant differences between baseline and interstage values for lumbar lordosis (LL, p = 0.004), pelvic tilt (PT, p = 0.002), and pelvic incidence-lumbar lordosis mismatch (PI-LL, p = 0.002). No significant differences existed between interstage and postoperative measurements for these sagittal parameters. Significant differences were found between interstage and postoperative values for the major Cobb angle (p = 0.012) and the lumbar Cobb angle (p = 0.016). Conclusions: In staged cases, our surgeons typically obtain interstage imaging, primarily standing scoliosis films. These studies inform the final levels of instrumentation and the need for additional posterior osteotomies/decompression during stage II. Based on interstage imaging findings, most sagittal correction occurs after stage I, while coronal correction occurs after stage II.

Immediate Weight Bearing as Tolerated Is Safe Following Intramedullary Fixation of Extra-articular Metaphyseal Proximal Tibia Fractures (OTA/AO 41-A).

To determine whether immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) results in change of alignment before union. Retrospective Review. Level I and Level II Trauma Center. Thirty-seven patients with 37 proximal tibial fractures, all whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 41-A2, and 19 were OTA/AO 41-A3. Intramedullary nailing of extra-articular proximal tibia fractures. Change in fracture alignment or loss of reduction. The average change in coronal alignment at the final follow-up was 1.22±1.28 degrees of valgus and 1.03 ± 1.05 degrees of extension in the sagittal plane. Twenty-five patients demonstrated excellent initial alignment, 10 patients demonstrated acceptable initial alignment, and 2 patients demonstrated poor initial alignment. Five patients demonstrated a change in alignment from excellent to acceptable at the final follow-up. No patient went from excellent or acceptable initial alignment to poor final alignment. Five patients required unplanned secondary surgical procedures. Two patients required return to the operating room for soft-tissue coverage procedures, 2 patients required surgical debridement of a postoperative infection, and 1 patient underwent debridement and exchange nailing of an infected nonunion. No patient underwent revision for implant failure or loss of reduction. Immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) led to minimal change in alignment at final postoperative radiographs. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stemless and stemmed total shoulder arthroplasty: a comparison of short-term clinical and radiographic outcomes

BackgroundStemless total shoulder arthroplasty could provide benefits over stemmed arthroplasty which has represented the gold standard for decades. Proposed benefits of stemless arthroplasty include better reproduction of anatomy and reduction in stress shielding; however, this does not appear to be confirmed by any study. The hypothesis was there would be no clinical differences between the stemless and the short-stem prosthesis, but the stemless prosthesis would better reproduce coronal radiographic anatomy and have less radiographic evidence of stress shielding. Materials and MethodsA prospectively collected data of patients undergoing primary, anatomic total shoulder arthroplasty for osteoarthritis were retrospectively reviewed. Patient-determined outcomes including the Western Ontario Osteoarthritis Index, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Shoulder Activity Level were recorded preoperatively, at 1 year, and at 2 years. Preoperative and 1-year postoperative range of motion was recorded. Radiographic parameters to assess restoration of proximal humeral anatomy included humeral head height, humeral neck angle, humeral centering on the glenoid, and postoperative restoration of the anatomic center of rotation. Final postoperative radiographs were assessed for evidence of stress shielding. ResultsForty-eight patients had a stemmed humeral prosthesis, and 109 patients had a stemless prosthesis. Patient-determined outcomes were available from 2 years postoperatively in 99.4%. Both groups had significant improvements in all patient-reported outcomes and range-of-motion metrics, but there were no differences between the stemless and stemmed groups in these outcomes. The prosthetic humeral head of the stemmed components was more likely to extend further superior to the humeral osseous margin than that of the stemless group (2.0 ± 2.4 vs. 0.8 ± 1.4 mm; P = .0004). The stemless group had a smaller postoperative deviation from the anatomic center of rotation than the stemmed group (2.5 ± 1.9 vs. 3.2 ± 2.1 mm; P = .04). The humeral neck angle was comparable between the stemmed group and the stemless group (133 ± 7° vs. 131 ± 8°; P = .06). There was similar mean deviation of humeral head centering on the glenoid prosthesis between the stemmed and stemless groups (1.9 ± 1.8 vs. 1.6 ± 1.7 mm; P = .20). There was evidence of stress shielding in 10 patients (21%) with a stemmed prosthesis and in no patients with a stemless prosthesis at 1-year follow-up (P < .0001). ConclusionsThere were no differences in patient-determined outcomes between the groups at 2-year follow-up. Restoration of proximal humeral anatomy was either better or equivalent with the stemless prosthesis compared to the stemmed one. Radiographic evidence of stress shielding was found in the stemmed prosthesis but not in the stemless prosthesis at 1-year follow-up.

74. Risk factors for subsidence following anterior lumbar interbody fusion

<h3>BACKGROUND CONTEXT</h3> Anterior lumbar interbody fusion (ALIF) is a less invasive approach to the lumbar spine when compared to posterior fusion that facilitates stabilization, indirect neural decompression and the option for circumferential fusion. However, ALIF may be complicated by interbody device or graft subsidence contributing to significant morbidity. While several studies have reported the incidence of subsidence in the setting of ALIF, there remains a paucity of literature analyzing specific risk factors that may predispose patients to this complication. <h3>PURPOSE</h3> This study sought to identify patient and procedural risk factors for subsidence in patients undergoing ALIF. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> Patients who underwent ALIF with a minimum of two years clinical and radiographic follow-up. <h3>OUTCOME MEASURES</h3> Subsidence, defined categorically as 2 mm or more interbody device migration into the adjacent vertebra. <h3>METHODS</h3> Preoperative and 6-week postoperative radiographs were used to measure disc space height and cage placement. Cage placement was measured as the center point ratio percentage defined as the distance of the cage midpoint from the posterior edge of the endplate divided by the endplate depth. Final postoperative radiographs were reviewed to measure subsidence and to assess for successful fusion. Patients were then grouped as non-subsidence (NS-ALIF) or cage subsidence (CS-ALIF). Demographic and radiographic variables were evaluated between groups to identify significant predictors on univariate statistics. Multinomial logistic regression was then employed to identify independent predictors of subsidence while retaining variables with a significance of p < .05 on univariate statistics. <h3>RESULTS</h3> A total of 144 patients who underwent ALIF at 170 levels were included for analysis. The average age of the cohort was 47.41±13.04 years, and average follow-up was 50.70±28.44 months (4.23 years). The overall incidence of subsidence was 22.94% (39/170 levels). On univariate statistics, the CS-ALIF group was significantly older (51.44±11.85 vs 46.60±13.13; p=.020), had a significantly higher BMI (31.97±4.38 vs 29.25±5.73; p=.048), worse ASA (p=.001), and a higher prevalence of comorbid osteoporosis (23.08% vs 3.82%; p <.001). Additionally, the interbody device was placed significantly more anteriorly in CS-ALIF patients as measured via the center point ratio (61.28±8.74% vs 56.80±9.76%; p=.005). On multivariate analysis, the center point ratio remained the only significant predictor for subsidence, with more anterior cage placement posing an increased risk (OR: 1.08, 95% CI: 1.03 - 1.14; p=.003). Further, the center point ratio contributed the most to the overall model fit, with a relative contribution of 52.6%, while osteoporosis contributed 14.8%, ASA 14.0%, age 10.9%, and BMI 7.7%. Receiver operating characteristic (ROC) curve analysis was determined a threshold value for the center point ratio of 56.98%, beyond which subsidence risk was increased. <h3>CONCLUSIONS</h3> Subsidence following ALIF occurred at a rate of 22.94%. Significant univariate risk factors for interbody cage subsidence included older age, higher BMI, severe ASA, osteoporosis, and an anteriorly placed cage (increased center point ratio). On multivariate analysis, increased center point ratio remained the only significant predictor of subsidence. Based on these findings, surgical technique should be focused on optimizing placement of the interbody cage and avoiding overstuffing of the disc space. Further investigation should validate these findings in an external cohort. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Evaluation of clinical and radiographic outcomes after total shoulder arthroplasty with inset Trabecular Metal-backed glenoid.

Trabecular Metal (TM)-backed glenoid implants were introduced for their theoretical ability to increase osseointegration while minimizing wear and the risk of loosening in total shoulder arthroplasty (TSA). Initial follow-up studies of TM-backed glenoids demonstrated high rates of metallic debris formation around the implant site, raising concerns about longevity. More recent data suggest that metallic debris formation may be less prevalent than previously reported and that the implants may have positive long-term outcomes regardless of debris. The goal of our study was to assess the clinical and radiographic outcomes at mid-term follow-up of TSA using a TM-backed glenoid implant placed with full backside support using an inset technique. We hypothesized that our clinical and radiographic outcomes would be good using this technique. We retrospectively reviewed the charts of 39 patients who underwent 41 TSA procedures with a Zimmer Biomet TM-backed glenoid component performed by a single surgeon between January 2010 and March 2016. After exclusions for death unrelated to surgery and loss to follow-up, 35 patients (37 shoulders) with minimum 2-year clinical follow-up were included in the study. The glenoids were all placed in an inset fashion with full backside support. Clinical, patient-reported, and radiographic outcomes were analyzed. The average follow-up period was 7.2 years (range, 2-11 years). At final follow-up, average shoulder elevation was 153° ± 22° and average external rotation was 53° ± 12°. The average American Shoulder and Elbow Surgeons score was 86.8 ± 19.0, and the average visual analog scale score was 1.3 ± 2.4. Metallic debris was found in 9 shoulders (27%), and radiolucency was observed around the glenoid components in 13 shoulders (39%) on the final postoperative radiographs. Metallic debris and radiolucency findings were low in severity, with average grades of 0.32 (standard deviation, 0.54) and 0.39 (standard deviation, 0.50), respectively. There were no reoperations. This study of 37 shoulders undergoing TSA with a TM-backed glenoid demonstrated 100% implant survivorship at an average follow-up of 7 years. Clinical outcomes were excellent despite the occurrence of some metallic debris formation. The findings suggest that a TM-backed glenoid component implanted in an inset fashion to achieve full backside support can provide good clinical and patient-reported outcomes in TSA patients at mid-term follow-up and suggest that continued consideration of the role of TM-backed glenoids and the optimal technique for implantation may be warranted.

Identification and Fixation of Intermetatarsal Coronal Plane Instability Following Modified Lapidus Procedure

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:There are many described techniques to approach surgical correction of bunion deformity and prevention of recurrence is still a topic of interest. Coronal plane instability evidenced by intermetarsal angle (IMA) widening with weight bearing is a cause for concern with respect to recurrence. The identification of patients who are at risk for recurrence intraoperatively is challenging and currently there are few described tests that guide physician treatment. The aim of this study was to demonstrate an intraoperative intermetarsal coronal plane 'squeeze stress test' utilized by the senior surgeon along with the clinical and radiographic outcomes of patients who underwent fixation for their identified instability following the modified Lapidus procedure for hallux valgus correction.Methods:All patients included in this study presented with clinical and radiographic documentation of hallux valgus that was treated by a first tarsometatarsal arthrodesis with additional middle column fixation following widening on intraoperative fluoroscopy 'squeeze stress test' (Figure 1) by a single senior surgeon from 2015-2020. Fixation of the middle column was achieved via endobutton (5), screw (23), or endobutton plus screw (5). Clinical descriptions were reviewed for the presence of symptomatic recurrence and for the need of revision surgery. A single observer measured the HVA and the IMA angle of the preoperative and final post-operative weight-bearing radiographs, respectively. A total of 33 patients were included with an average age of 58.5 (range, 40-80) years of age and a mean follow-up of 8.3(range, 1.5-30) months. Mean BMI was 29 (range, 19- 54). Statistical analysis of this data set utilized the chi-square test and two sample t-test.Results:Pre-operatively, the patients with identified coronal plane instability had a mean HVA and IMA of 33 (range, 16-74) and 14 (range, 7-23) degrees, respectively. At final follow-up, these patients maintained a mean HVA of 9.8 (range, 0-32) and IMA of 4.5 (range, 0-15). No patients sustained clinical recurrence. Two patients underwent elective removal of hardware. One patient sustained a deep infection that required removal of hardware and formal debridement, this subsequently resolved.Conclusion:Coronal plane instability remains one of the unsolved facets of effectively treating symptomatic hallux valgus. Vigilance is the first step in prevention of recurrence in these patients and the 'squeeze stress test' is a simple, quick option for their identification. Our case series demonstrates satisfactory outcomes in terms of clinical recurrence for these patients utilizing this new evaluation technique. We believe further investigation of the squeeze stress test as an instability identifier is warranted in all types of bunion correction procedures.

Recurrence of Hallux Valgus After Modified Lapidus Procedure With Successful Fusion of the Intermetatarsal and Intercuneiform Joints.

BackgroundThe Lapidus procedure has become a popular procedure in correcting hallux valgus deformities and has undergone several modifications in an effort to improve the efficacy of the procedure. The senior author modifies this procedure with the addition of an intermetatarsal and intercuneiform fusion. Our hypothesis is that this will improve the procedure outcomes and decrease deformity recurrence.MethodsWe reviewed patient charts who underwent the procedure between 2014 and 2017 performed by the senior author. This yielded 47 reviewable cases, with 34 meeting study criteria. The cases were analyzed for standard hallux valgus measurements (intermetatarsal angle [IMA], hallux valgus angle [HVA]) and fusion on X-ray.ResultsThe results of the study showed partial intermetatarsal and intercuneiform fusion failure in seven (20%) cases, and one case where the great toe fell into varus. These cases were excluded. In the remaining cases, there was a statistically significant improvement in the HVA and IMA between the preoperative X-ray and first postoperative X-ray. Additionally, there was no significant difference between HVA and IMA between first and final postoperative radiographs. There was a significant increase in IMA for the fusion failure cases (p=0.001).ConclusionClinically, our findings demonstrate that successful union is possible with low recurrence and complication rates when using this modification of the Lapidus procedure in patients with hallux valgus deformity.

Does Implant Density Impact Three-Dimensional Deformity Correction in Adolescent Idiopathic Scoliosis with Lenke 1 and 2 Curves Treated by Posterior Spinal Fusion without Ponte Osteotomies?

Study DesignRetrospective cohort study.PurposeTo determine whether implant density impact three-dimensional deformity correction in posterior spinal fusion (PSF) without Ponte osteotomies (POs) for patients with Lenke 1 and 2 adolescent idiopathic scoliosis (AIS).Overview of LiteratureCurrently, the optimal pedicle screw (PS) density for flexible moderate-sized thoracic AIS curve correction is still controversial. There are limited data regarding the impact of implant density on three-dimensional correction in PSF without the use of PO for thoracic AIS surgery.MethodsA database of patients with AIS with Lenke 1 and 2 curves treated with PSF without PO and instrumented with PSs and ≥2-year follow-up was reviewed. The preoperative, immediate, and final follow-up postoperative radiographs were analyzed. The correlation between PS density and the following factors were determined: major curve correction (MCC), correction index (CI; MCC/curve flexibility), kyphosis angle change, and rib index (RI) correction. Then, patients were divided into low-density (LD) and high-density (HD) groups according to mean PS density for the entire cohort (1.5 PS per level). Demographics and radiographic and clinical outcomes were compared between groups.ResultsThe study included 99 patients with Lenke 1 and 23 patients with Lenke 2 AIS. The average MCC was 67.2%. There was no correlation between screw density and these parameters: MCC (r=0.10, p=0.26), CI (r=0.16, p=0.07), change in T2–T12 kyphosis angle (r=−0.13, p=0.14), and RI correction (r=−0.09, p=0.37). Demographic and preoperative radiographic parameters were similar between the LD and HD groups. At the latest follow-up, there were no differences between the two groups in regard to MCC, CI, change in T2–T12 kyphosis angle, RI correction, and Scoliosis Research Society-30 scores (all p>0.05).ConclusionsThis study revealed no significant correlation between screw density and curve correction in any planes. HD construct may not provide better deformity correction in patients with flexible and moderate thoracic AIS undergoing PSF without PO.

Clinical and Radiographic Outcomes of Lateral Interbody Fusion for Adjacent Segment Degeneration.

Retrospective cohort study. Assessment of outcomes in patients undergoing lateral interbody fusion as part of the surgical treatment of adjacent segment deterioration after previous lumbar spine fusion. Adult patients with previous lumbar posterior spinal fusion who presented with adjacent segment degeneration and stenosis refractory to nonoperative treatment and who underwent lateral lumbar interbody fusion were retrospectively analyzed. Clinical and radiographic outcomes were assessed and comparisons made between preoperative baseline and postoperative values. Thirty-six patients with symptomatic adjacent segment degeneration at 46 motion segments were included. Thirty (83.3%) of the 36 patients had complete relief of both preoperative lower extremity pain and back pain at the time of final follow-up. Six (16.7%) of the 36 patients had persistent pain, though in all 6 cases, the pain was less postoperatively than preoperatively. Oswestry Disability Index scores were improved significantly at final follow-up (P = .001). Compared with preoperative baseline parameters, initial and final postoperative radiographs had an increase in segmental lordosis (P < .001 and P < .001, respectively), increase in overall lumbar lordosis (P < .05 and P = .094, respectively), decrease in segmental coronal angulation (P = .63 and P < .01, respectively), decrease in overall coronal angulation (P = .063 and P = .009, respectively), and increase in intervertebral height (P < .001 and P < .001, respectively). Lateral lumbar interbody fusion achieves favorable clinical and radiographic outcomes for the treatment of adjacent segment degeneration after previous lumbar fusion. 4.

Continued vertebral body growth in patients with juvenile idiopathic scoliosis following vertebral body stapling.

Retrospective case series. To quantitatively measure the rate of growth of vertebral bodies in juvenile idiopathic scoliosis (JIS) treated with vertebral body stapling (VBS). VBS has been suggested to be a safe and effective method for modulating the growth of the young scoliotic spine, but few long-term studies have examined its efficacy. Seven patients with JIS 11years of age or younger underwent VBS with a minimum 6-year follow-up. Vertebral body height on the unstapled and stapled aspects of the curve was measured from initial and final postoperative radiographs and converted into rate of growth per year. Known staple dimensions were used to standardize the measurements between radiographs. Interstaple distance was measured to demonstrate continued growth of the spine. Adjacent vertebral bodies without instrumentation served as an internal control of growth. Each vertebral body (n = 35) was analyzed as an individual experimental unit. The average rate of growth was 0.86mm/year (standard deviation [SD] 0.44, 95% confidence interval [CI] 0.71-1.0) per vertebral body on the stapled side and 0.83mm/year (SD 0.46, 95% CI 0.67-0.98) per vertebral body on the unstapled side of the vertebral body. The adjacent vertebral body segments grew at a rate of 0.91mm/year (SD 0.42, 95% CI 0.66-1.15) on the stapled side and 0.99mm/year (SD 0.66, 95% CI 0.61-1.37) on the unstapled side, p < 0.01. The distance between staples increased significantly from 3.0mm (SD 2.0, 95% CI 2.3-3.6) to 8.4mm (SD 2.4, 95% CI 7.7-9.3). Vertebral body growth in the presence of VBS occurred at a similar rate on the stapled and unstapled sides of the curve. The high standard deviation of instrumented segment growth further supports the conclusion that VBS is not a reliable method of growth modulation in the young scoliotic spine. IV.

The Development of Heterotopic Ossification Following Ankle Fracture Syndesmotic Screw Fixation

Category:Ankle, TraumaIntroduction/Purpose:Syndesmotic fixation with screws is commonly used for ankle fractures with syndesmotic disruption. Few studies have reported the development of heterotopic ossification (HO) within the syndesmosis following ankle injuries, which may lead to abnormal joint kinematics and even joint synostosis. However, there is little data on the prevalence and on the risk factors associated with the development of HO. The purpose of this study is to determine the (1) prevalence and (2) risk factors associated with the development of HO within the distal tibiofibular syndesmosis following ankle fractures requiring syndesmotic fixation. We hypothesized that screws within the syndesmosis articulation and broken screws would be associated with a higher incidence of HO than extraarticular and intact screws, respectively.Methods:A retrospective review was conducted for patients who sustained an ankle fracture with syndesmotic disruption. Inclusion criteria: age between 18 and 65 years old, a closed ankle fracture treated operatively with syndesmotic screw fixation. Exclusion criteria: additional lower extremity injury, history of prior ankle fracture, lack of radiographic follow-up and fixation other than 1 or 2 syndesmosis screws.Medical records were reviewed for: age, sex, high or low energy injury mechanism, smoking status, diabetes, BMI, perioperative complications, and further procedures. Fractures were classified by Lauge-Hansen and Weber systems. Immediate postoperative radiographs were reviewed for the number of syndesmotic screws, whether screws were intraarticular or extraarticular and the number of cortices each screw crossed. Final postoperative radiographs were reviewed for retention or screw removal and the presence of HO. The presence of HO was defined as new or increased bone formation within the syndesmosis compared to immediate postoperative radiographs.Results:Included were 264 patients, mean radiographic follow-up of 10.5+/-10.2 months. The mean age was 39.2+/-12.6 years (38.7% female) with a mean BMI of 32.1+/-7.8. Current smokers made up 39.4% of patients and 10.6% were diabetic. The mean time to fracture fixation was 12.6+/-3.2 days and 198 patients (75%) had a low energy injury. There was no significant difference in HO formation for demographics, injury mechanism or time to fixation. Overall, HO developed in 160 patients (60.6%). There was no difference, additionally for fracture pattern, number screws or fixation construct (Table 1). HO developed in 92% of broken, 75% of loose and 44% of intact screws (P<0.001). Screws were removed in 107 patients (40.5%) with no difference in HO formation compared to patients with intact screws.Conclusion:Heterotopic ossification is commonplace following screw fixation for syndesmotic injuries with a prevalence of 60.6%. Broken screws and loosened screws are a significant risk factor for the development of HO. However, no other risk factors in this study were found to be associated with the development of HO, including intraarticular syndesmotic screw placement. Patients should be counseled on the prevalence although further research is needed to determine the effect on ankle motion and progression of post-traumatic osteoarthritis.

Medial Cuneiform Opening-Wedge Osteotomy for the Treatment of Hallux Valgus.

Background:While proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyper-obliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus.Methods:Fourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively.Results:A mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions—one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear.Conclusion:Medial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint.Level of Evidence:Level IV, case series.

Outcomes of Open Reduction and Internal Fixation of Bilateral Fractures of the Distal Radius

Background Bilateral distal radius fracture (DRF) is an uncommon injury. We described the outcomes of 10 consecutive cases of bilateral DRF treated with open reduction and internal fixation (ORIF) at our institution.Materials and Methods We retrospectively searched our electronic medical records data for all patients 18 years of age or older treated surgically for bilateral DRF over a 6-year period (2011–2016). Patient demographics, fracture classification, fixation method, postoperative complications, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) questionnaire scores, wrist range of motion (ROM), and radiographic measurements of X-rays at final follow-up were collected and analyzed.Results Ten patients (8 women; 2 men; mean age: 63 years) with 20 fractures were assessed. A volar approach for ORIF was used in 90% of cases. Six of 20 (30%) wrists experienced postoperative complications and required hardware removal. Mean QuickDASH score was 24.8 at final follow-up. On average, ROM reached 58-degree extension, 52-degree flexion, 75-degree pronation, and 75-degree supination. Mean measurements of radial shortening, radial inclination, and volar tilt taken from final postoperative radiographs were 1.3 mm, 21.2 degrees, and 7.8 degrees, respectively.Conclusion In bilateral DRF treated with concomitant ORIF, functional outcomes, recovery of wrist ROM, and restoration of radiographic parameters are comparable to those seen in patients with ipsilateral DRF.

Extra Articular Distal Femoral Fractures in the Elderly Treated with Retrograde Nailing Using a Spiral-Locking Blade System.

Background:The number of elderly patients sustaining long bone fractures is increasing with the rise of elderly population in the western world. Management of distal femur fractures is particularly difficult due to osteoporosis and other associated comorbidities. The key to management would be by surgical stabilization, which allows early mobilization. This study was devised to look into the radiological outcome and complication rate in a series of elderly patients who were treated with retrograde nail using spiral locking blade system for extra articular distal femur fractures.Materials and Methods:This is a retrospective study of patients who have undergone retrograde nailing with spiral-locking blade for distal femoral fractures (extra articular) above the age of 70 years in a major trauma center from 2001 to 2015. Notes were assessed for postoperative complications; time to union and final postoperative followup radiographs were assessed for alignment using a scoring system.Results:Forty one patients with an average age of 80 years and an average followup period of 9 months were included. The mean radiological score at final followup was 10.34 (range 8–12), with no significant shortening in any of the patients. Thirty patients had excellent radiological score (>10) and 11 patients scored good (8–9). The difference in time to union between Group 1 – simple fracture pattern (3.42 months) and Group 2 – complex comminuted fracture pattern (4.74 months) was not statistically significant (P = 0.072). There were five delayed unions but no cutout or metal work failure.Conclusion:The retrograde femoral nail with distal spiral-locking blade system can be a good surgical option for the treatment of extra articular distal femoral fractures in the elderly with the possibility of early weightbearing.

Midfoot Charcot Reconstruction with Intramedullary Beaming

Category: Midfoot/Forefoot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients (Median Age: 60; Median BMI: 32.5; Diabetic: 79%; Insulin Dependent: 74%) were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer- free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, post-operative infection, and amputation. Results: The lateral Meary’s angle median improved from -29° preoperatively to -21° on final postoperative radiographs (p&lt;0.001). Likewise, the AP Meary’s angle median improved from 17° to 2° (p&lt;0.001). 43% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.04); all six deep infections occurred in patients with preoperative ulceration. 63% of patients required reoperation. Three (13%) patients progressed to amputation at a median nine postoperative months, all for deep infection. The final postoperative median FAAM score was 21. The VR-12 median score was also 21 (PCS: 32, MCS: 67). Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with ADLs, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in both the lateral and AP Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.

Functional and Radiographic Outcomes After Allograft Anatomic Coracoclavicular Ligament Reconstruction.

To analyze the functional and radiographic outcomes of anatomic coracoclavicular ligament reconstruction (ACCR) using allograft tendon without interference screw fixation. Retrospective nonrandomized study. Level I trauma center (University Hospital). Seventeen patients (mean age of 44 years) with Rockwood III through V acromioclavicular joint disruptions. Twelve of 17 patients had a primary reconstruction, including 4 patients sustaining their injuries as part of a polytrauma incident. Five of 17 patients were revisions of a previously failed acromioclavicular reconstruction procedure. Open ACCR using hamstring allograft with high-strength suture augmentation and knotted graft fixation without interference screws. Clinical and patient reported outcome measures including Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and visual analog scale scores for pain and radiographic outcomes. The average final postoperative Simple Shoulder Test and American Shoulder and Elbow Surgeons scores were 10.8 and 80.5, respectively. The average final postoperative visual analog scale pain was 1.8. All patients demonstrated clavicle tunnel widening on final postoperative radiographs compared with immediate postoperative radiographs. The overall complication rate was 36%, with no clavicle or coracoid fractures. Open ACCR using hamstring allograft tendon secured with a square knot and high-strength suture augmentation yields equivalent outcomes to those repairs requiring an additional interference screw. Clavicle tunnel widening predictably occurs, but the clinical significance is undetermined. It appears therefore that an interference screw is not needed. Larger comparison studies are needed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Midfoot Charcot Reconstruction with Intramedullary Beaming

Category: Diabetes, Midfoot/Forefoot, Charcot Introduction/Purpose: Midfoot Charcot osteoarthropathy is characterized by non-infectious osteolysis that often leads to midfoot collapse and resultant ulceration. Deformity and ulceration often lead to deep infection and amputation. Midfoot reconstruction with intramedullary screws (beams) is a recently described technique that provides deformity correction and a stable construct without the extensive exposure required for plate fixation. The purpose of this study is to examine the clinical outcomes and complications of patients with midfoot Charcot managed with midfoot osteotomy, realignment arthrodesis, and stabilization using intramedullary beams. Methods: A surgical database query of a tertiary-care foot and ankle center was performed from January 2013 to July 2016 to identify patients with midfoot Charcot who underwent corrective osteotomy with internal beam fixation. 24 patients were identified and included in the final analysis. Patients with minimum one-year follow-up were evaluated with physical examination, weight-bearing radiographs, and patient-reported outcome measures (FAAM and VR-12). The primary outcome measure was defined as restoration of a stable, plantigrade, ulcer-free foot. Secondary outcome measures include quantitative angular correction, rates of reoperation, postoperative infection, and amputation. Results: Median age was 60 years, median BMI was 32.5, and 79% were diabetic. The lateral Meary’s angle median improved from -29° preoperatively to -20° on final postoperative radiographs (p=0.007). 39% of midfoot osteotomies were united on final radiographs. An ulcer-free, stable, plantigrade foot was obtained in 83% of patients. Deep infection developed in six (25%) patients. The presence of a preoperative ulcer was found to be predictive of postoperative infection (p=0.05); all six deep infections occurred in patients with preoperative ulceration. 62.5% of patients required reoperation. Three (12.5%) patients progressed to amputation at a median nine postoperative months. The final postoperative median FAAM scores was 19. The VR-12 median score was also 19 with the following breakdown: Physical Component – 30, Mental Component – 67. Conclusion: Results from the FAAM indicate that patients with midfoot Charcot are severely disabled overall, moderately disabled with activities of daily living, and mostly unable to participate in sport. Results from the VR-12 indicate that patients continue to have poor healthcare quality of life, even following Charcot reconstruction. Midfoot Charcot reconstruction with intramedullary beaming allows for restoration of an ulcer-free, plantigrade foot in most patients, but the complication rates are high, especially in patients with pre-operative ulceration. Despite a low bony union rate, improvement in the lateral Meary’s angle and clinical success is often obtainable with a relatively low amputation rate.

Retrospective Assessment of Healing Outcome of Endodontic Treatment for Mandibular Molars with C-shaped Root Canal.

A thorough knowledge of the anatomic morphology of the root canal system is necessary for the long-term success of the root canal therapy. The occurrence of C-shaped root canal configuration is one such variation. Achievement of favorable prognosis after commencing root canal therapy in such teeth is one of the challenges imposed on the endodontist. Hence, we evaluated the healing occurring after endodontic therapy in patients with C-shaped root canals in mandibular molars. The present study was conducted in the Department of Conservative Dentistry of the institution and included assessment of all the patients who underwent root canal treatment of the mandibular first and second molars. Endodontic therapy was performed in all the cases by experienced endodontist. Final postoperative radiographs were taken. Recording of the data of the personal and clinical details of a total of 250 patients was done. All the clinical and radiographic details of the patients, such as tooth location in the jaw, presence or absence of C-shaped canals, status of the pulp tissue, presence or absence of the fractures, and other details of the patients were recorded. Radiographic and clinical examination of the tooth of the patients was done during the baseline visit and further during the follow-up visits. The presence of C-shaped root canals was confirmed using the radiographs. Periapical index (PI) scoring system was used. Categories defined for enlisting the healing after the root canal treatment with the assessment of the PI score. All the results were analyzed by Statistical Package for the Social Sciences software. Vital pulp tissue was encountered in majority of the cases. C-shaped root canal configuration was observed in 40% of the cases included in the present study. After completion of the endodontic therapy, complete crown placement was done in only 22% of the cases. In cases of vital teeth with C-shaped root canals configuration, most of the teeth showed complete healing. Significant results were obtained while comparing the complete coverage crown parameter in relation to the healing process in teeth with C-shaped root canals. In the present study, no significant effect of the C-shaped root canal configuration was found on the healing rate of the endodontic therapy in mandibular molars. Meticulous endodontic therapy with special techniques should be done while preparing teeth with C-shaped root canals.