Joint-preserving Osteotomies Research Articles

Prediction of time to prosthesis implantation as a function of joint anatomy in patients with developmental dysplasia of the hip

BackgroundDevelopmental dysplasia of the hip (DDH) can lead to pain and premature secondary osteoarthritis at an early stage. Joint-preserving osteotomy is an established solution to this problem. In contrast, a conservative approach would result in pain persistence, ultimately raising the patients question for a possible date of expected prosthesis implantation.The aim of the study was to identify the relationship between the dysplastic hip anatomy and the time of prosthesis implantation in order to enable prognostic predictions in younger patients with symptomatic DDH.Materials and methodsData from 129 hips who received THA due to secondary DDH osteoarthritis were evaluated. The preoperative hip anatomy was evaluated for AI and LCE angle. Multiple linear regression analyses were then used to correlate the influence of these parameters with the patient’s age at the time of surgery. In addition, a graphical relationship was derived by the method of power least squares curve fitting with second-degree polynomials.ResultsThe mean age for THA was 54.3 ± 11 years. The time of surgery correlated significantly with LCE (0.37) and AI (− 0.3) (p < 0.001). The mean age of patients with LCE angle ≤ 10° was 41.9 ± 14.0 years, for LCE 11–20° 52.7 ± 9.5 years, and for LCE 21–30° 57.0 ± 10.3 years. The following formula could then be determined for the calculation of the potential patient age at the time of THA as a function of LCE angle: age pTHA = 40.2 + 0.8 × LCE angle − 0.01 × (LCE angle)2.ConclusionA significant correlation between the extent of dysplasia and the time of prosthesis implantation was identified. In particular, the LCE and the AI correlated strongly with the time of implantation. The more dysplastic the angles were, the sooner the THA was necessary. Using the calculations presented in this study, the probable age of prosthesis implantation can be prognosticated and included in a counseling session about treatment options for DDH.

Computer-assisted virtual surgical technology in pre-operative design for the reconstruction of calcaneal fracture malunion.

No computer-assisted pre-operative design for calcaneal fracture malunions has been presented. The aim of the study is to evaluate the intra-operative realization of computer-assisted pre-operative planning (CAPP) and the clinical outcomes based on computer-assisted virtual surgical technology for calcaneal malunions. Between 2010 and 2016, 20 patients with 21 calcaneal fracture malunions were retrospectively reviewed with the average follow-up time of 22.3months (range, 12 to 43months), which were operatively treated with the help of CAPP. The CAPP steps included the image segmentation, exostectomy of lateral wall, simulated reconstruction of calcaneal thalamus, morphological evaluation, and the implantation of internal fixation devices. Post-operative outcomes were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) score, SF-36 physical component summary (PCS), VAS for pain, range of motion of ankle, and the morphological parameters of the calcaneus including the axial length of the calcaneus, the height of the posterior facet, the talocalcaneal angle, Böhler's angle, and Gissane's angle. The mean time required for CAPP was 41.8minutes. All the surgical processes were carried out according to CAPP. Six patients (6feet) were treated with the joint-preserving osteotomy. Fourteen patients (15feet) underwent the subtalar distraction bone block arthrodesis, among which the medial displacement calcaneal osteotomy was additionally performed in six patients (6feet). At the final follow-up, the average AOFAS, SF-36 PCS, and VAS scores were significantly improved to 77.4, 64.3, and 1.4, respectively (P < 0.001). The postoperative calcaneal morphological parameters and the range of motion of ankle were significantly restored (P < 0.05). CAPP can assist surgeons in understanding calcaneal malunions, thereby improving intraoperative correction and reconstruction. The satisfying clinical and radiographic outcomes could be provided after treating calcaneal malunions aided by the computer-assisted virtual surgical technology.

Joint-preserving osteotomy for calcanean malunions

Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis. Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint. While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects. In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

Joint-Preserving Osteotomy for Malunited Intra-articular Calcaneal Fractures

Displaced intra-articular fractures of the calcaneus can lead to severe pain and disability if not treated appropriately. Failure to treat may require fusion of the subtalar joint, supplemented by additional osteotomies. Occasionally, these fractures are seen after the fracture has just healed, and the decision to treat can be a difficult one. Over the course of 10 years, 5 patients were treated with a corrective osteotomy along the primary fracture line, joint realignment, soft tissue balancing, and secondary internal fixation at a mean of 2.9 months after the injury. At a mean of 4.1 years (range, 2-10 years), all patients were satisfied with their result. Two patients underwent implant removal and subtalar arthrolysis 1 year after correction. No secondary fusions were required. The mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 19.0 preoperatively to 81.2 at follow-up (P < 0.001). The radiographic parameters (the Böhler angle, talocalcaneal height, and heel width) were substantially corrected. A joint-preserving osteotomy with axial realignment can be a treatment option for malunited intra-articular calcaneal fractures encountered early on, before the development of subtalar arthrosis.

Joint-preserving osteotomy of malunited ankle and pilon fractures

Malunion and nonunion after ankle and pilon fractures regularly lead to the development of painful functional impairment even in cases of only mild axial deviation or residual joint incongruity. Involvement of the tibial pilon results in rapid progression of posttraumatic ankle arthritis. Corrective osteotomy with joint preservation aims at secondary anatomical reconstruction with functional rehabilitation. This requires a careful preoperative analysis and will be possible in carefully selected cases only. Prerequisites for successful reconstruction are intact cartilage, sufficient bone quality, residual joint function and good patient compliance. Since the works of B. G. Weber, joint-sparing osteotomy is an established treatment option for malunited malleolar fractures with reliable long-term results and low rates of complications and secondary fusions. Key to success is the re-establishment of the length of the distal fibula and repositioning into the tibial incisura in cases of syndesmotic instability. Corrections of the medial malleolus and posterior tibial fragment are less frequent. Corrective intra-articular osteotomies for malunited pilon fractures are rarely feasible because of manifest arthritis at the time of patient presentation in most cases. Besides case reports there is only one series of 14 patients available in the literature. At 5-year follow-up, a good to excellent result was seen in 10 cases and secondary ankle fusion was done in 2 patients with a poor result. Anatomical reconstruction of malunited tibial pilon fractures appears to be a viable treatment option besides arthroplasty and fusion in carefully selected patients.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

Triple pelvic osteotomy as treatment for osteoarthritis secondary to developmental dysplasia of the hip

Joint-preserving osteotomies are an established treatment for adult hip pain secondary to developmental dysplasia of the hip. However, their value for advanced osteoarthritis is unclear. Therefore this study addresses the question of long-term results of triple pelvic osteotomy in patients with second grade osteoarthritis. Thirty-two patients with second grade osteoarthritis secondary to developmental dysplasia of the hip before triple pelvic osteotomy were clinically and radiographically assessed 11.5 years postoperatively. Five patients required conversion to total hip replacement. Kaplan-Meier survivorship analysis predicted a survival rate of 85.3%. The mean Harris hip score increased significantly with more than 56% good or very good results. A preoperative BMI > 25 and Harris hip score < 70 resulted in worse outcome or early conversion into total hip arthroplasty. The results indicate that developmental dysplasia of the hip even in second grade osteoarthritis can be treated with triple pelvic osteotomy.

Surgical approaches for osteoarthritis.

Patients with osteoarthritis (OA) often benefit from properly performed surgical procedures. However, the scientific database from studies investigating appropriate timing of surgery, patient morbidity, quality of life before and after the intervention, and cost utility of different procedures is insufficient. In order to allow a fair allocation of resources in future health care systems, randomized controlled trials (RCTs) with defined entry criteria, sufficient number of patients, and valid outcome measures should be performed for different surgical approaches. They should especially include control groups with conservative treatment in order to allow an evidence based comparison between different therapeutic approaches. At present, however, optimal management of OA as a dynamic disease process must include a combination of conservative as well as operative treatment modalities. In case of malalignment, instability and intra-articular causes of mechanical dysfunction, correction of these abnormalities and relief of symptoms can be achieved with properly indicated and performed osteotomies. Debridement by arthroscopy and arthotomy probably does not alter the natural history of OA and true clinical outcomes are difficult to determine, but it can provide transient relief of symptoms. Joint replacement has to be considered for refractory pain associated with disability and radiological deterioration. As the pre-operative functional status seems to influence the outcome not only in joint replacement but also in joint-preserving osteotomies, the indication for these procedures might be expanded in the future.