Joint-sparing Procedures Research Articles

Radiographic Assessment of Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are a result of imbalance between static and dynamic stabilizers of the lesser toes. Flexor-to-extensor tendon transfer and PIP joint arthrodesis/arthroplasty are the gold standards of treatment. Tendon transfers are associated with stiffness, edema and recurrence. PIP arthrodesis/arthroplasty sacrifices the PIP joint producing loss of both motion and toe grip. Phalangeal sustraction osteotomies have been proposed for correcting these deformities by theoretically relaxing the surrounding soft tissue structures and correcting the hammertoe deformity at the PIP joint. We present the results of a new joint sparing procedure consisting on a Diaphyseal Proximal Phalangeal Shortening Osteotomy (DPPSO) with resection of a 3-4 mm cilindrical bone section. Methods: Retrospective study. Review of medical records of patients who underwent phalangeal shortening osteotomy for hammer toe correction from 2010 to 2016 by the senior author (L.S.). Patients with previous surgery on the toe were excluded of the study as well as patients with incomplete radiological follow-up. Demographic and comorbidities data were noted as well as postoperative complications and secondary procedures. We performed a radiographic analysis of preoperative and postoperative x-rays-Union was defined as the existence of brigding of at least 3 cortices on the osteotomy site. Preoperatively and 6 months follow up x-rays were additionally analyzed to obtain the following measurements (Figure 1): Frontal anatomic angle (medial) FAAm Lateral anatomic angle (plantar) LAAp Frontal proximal interphalangeal angle (medial) mFPIA Lateral interphalangeal angle (plantar) pLIPP Statistical analysis: t-test for paired samples to compare preoperative and postoperative angles. Results: Forty-five toes (31 patients) were included in the study. The mean age of the patients was 59,5 years and the mean follow-up was 27.9 months (range:12-52). Concomitant procedures were performed on 29 patients, most commonly Hallux Valgus correction. All patients evolved with radiographic union at an average 11,2 weeks. Two patients presented with delayed healing (15 and 19 weeks). Complications were present on 4 toes corresponding to Superficial infection (3 patients) and a symptomatic floating toe (1 patient). There were not recurrences in this group. Radiographic measurements showed no significant differences between the preoperative and postoperative mFFA (p:0,43), pLAA (p:0,239) and mFIA (p:0,239). In the other hand, the Plantar lateral interphalangeal angle (pLIA) that corresponds with the hammertoe deformity, was significantly corrected (p<0,05). Conclusion: DPPSO is a safe and reproducible procedure with a low rate of complications. This procedure has a corrective effect on the PIP joint on the sagittal plane, reducing significantly the plantar lateral interphalangeal angle and consequently the hammertoe deformity. There was no significant effect on the PIP joint on the coronal plane and neither on the anatomical axis of the proximal phalanx in the frontal and lateral planes, therefore not producing secondary deformities of the toe.The location of the osteotomy improves bone contact and anatomical alignment of the toe while obtaining a significant correction power of the deformity.

Minimally invasive correction of lesser toe deformities and treatment of metatarsalgia

Atraumatic and joint-sparing procedure for the correction of lesser toe deformities by using alinear or perpendicular osteotomy of the proximal and/or middle phalanx of the lesser toes with additional capsulotomies or tendon dissection for soft tissue realignment. Metatarsalgia is addressed via an extracapsular distal metaphyseal crescentic-like metatarsal osteotomy. Symptomatic lesser toe deformities, painful pseudoexostosis, metatarsalgia, symptomatic metatarsal malalignment, metatarsus adductus. Infection or malperfusion of the forefoot, dislocation at metatarsophalangeal joint level, noncompliance. Correction of lesser toe deformities via fluoroscopy-guided minimally invasive surgical technique. Osteotomy of the proximal and middle phalanx is combined with aplantar capsulotomy of the proximal interphalangeal joint. Condylectomy of the head of the proximal phalanx, tenotomy of the extensor digitorum longus tendon proximal to the joint line in combination with tenotomy of the short flexor tendons at the level of proximal interphalangeal joint can be necessary. Distal metatarsal osteotomies are performed with amicro-burr starting from plantar-medial parallel to the metatarsal shaft axis ending dorsally perpendicular to the metatarsal shaft axis. Taping for external stabilization of the lesser toes as well as self-adhesive bandage to stabilize the metatarsals for 6weeks; early weight-bearing is possible. Aprospective study of minimally invasive distal metaphyseal metatarsal osteotomies (DMMO; 30patients, n = 73osteotomies) and Weil osteotomies (30patients, n = 45osteotomies) showed similar results after amean follow-up of 13months. The surgery time was significantly shorter for the minimally invasive technique, but radiation exposure for the surgeon and patient were higher.

Treatment of hallux deformities in adolescents with cerebral palsy.

This commentary is on the original article by van de Velde et al. on pages 624–628 of this issue.

Hallux rigidus.

An estimated 40% of the US population have foot problems.Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed ‘hallux rigidus’. First MTP osteoarthritis is the most common arthritic condition in the foot.Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal headMultiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results. Cite this article: EFORT Open Rev 2017;2:13–20. DOI: 10.1302/2058-5241.2.160031

Osteoarthritis of the ankle

Ankle arthritis is a debilitating condition. Primary ankle joint osteoarthritis is much rarer than hip or knee arthritis. The majority of cases are post-traumatic secondary to previous articular trauma or ligamentous instability. Treatment methods available are guided by disease severity and the patient's functional demands. Weight loss, activity modification, the wearing of an ankle brace or high topped-lace up boots and orthoses should be the first line of treatment. Joint sparing procedures such as arthroscopic debridement, supramalleolar osteotomy and distraction arthroplasty have been trialed with low levels of supporting evidence. The demand for joint preservation has led to the development of total ankle allografting procedures, but these have fallen out of favour. Despite advancements, the gold standard for end stage arthritis remains arthrodesis, although evidence for total ankle arthroplasty in certain groups of patients is increasing. The current third generation implants have improved survivorship although their results remain inferior to arthroplasty of the hip and knee. There are currently two prospective randomized control trials of ankle replacement versus arthrodesis under way as well as several national joint registries, which will hopefully better define those patients who will gain most benefit from replacement as opposed to fusion.

Knee osteoarthritis: a review of management options.

Osteoarthritis of the knee is a complex peripheral joint disorder with multiple risk factors. The molecular basis of osteoarthritis has been generally accepted; however, the exact pathogenesis is still not known. Management of patients with osteoarthritis involves a comprehensive history, thorough physical examination and appropriate radiological investigation. The relative slow progress in the disease allows a stepwise algorithmic approach in treatment. Non-surgical treatment involves patient education, lifestyle modification and the use of orthotic devises. These can be achieved in the community. Surgical options include joint sparing procedures such as arthroscopyando osteotomy or joint-replacing procedures. Joint-replacing procedures can be isolated to a single compartment such as patellofemoral arthroplasty or unicompartmental knee replacement or total knee arthroplasty. The key to a successful long-term outcome is optimal patient selection, preoperative counselling and good surgical technique.

Joint sparing treatments in early ankle osteoarthritis: current procedures and future perspectives.

Ankle osteoarthritis (AOA) is a severe pathology, mostly affecting a post-traumatic young population. Arthroscopic debridement, arthrodiastasis, osteotomy are the current joint sparing procedures, but, in the available studies, controversial results were achieved, with better outcomes in case of limited degeneration. Only osteotomy in case of malalignment is universally accepted as a joint sparing procedure in case of partial AOA. Recently, the biological mechanism of osteoarthritis has been intensively studied: it is a whole joint pathology, affecting cartilage, bone and synovial membrane. In particular, the first stage is characterized by a reversible catabolic activity with a state of chondropenia. Thus, biological procedures for early AOA were proposed in order to delay or to avoid end stage procedures. Mesenchymal stem cells (MSCs) may be a good solution to prevent or reverse degeneration, due to their immunomodulatory features (able to control the catabolic joint environment) and their regenerative osteochondral capabilities (able to treat the chondral defects). In fact, MSCs may regulate the cytokine cascade and the metalloproteinases release, restoring the osteochondral tissue as well. After interesting reports of mesenchymal stem cells seeded on scaffold and applied to cartilage defects in non-degenerated joints, bone marrow derived cells transplantation appears to be a promising technique in order to control the degenerative pathway and restore the osteochondral defects.

Surgical management of hallux valgus and hallux rigidus: an email survey among Swiss orthopaedic surgeons regarding their current practice.

BackgroundVarious clinical and radiological criteria have been suggested to choose one of the numerous techniques in surgical treatment of hallux valgus and rigidus. We hypothesized that the surgeons' professional background will influence that choice depending on specialization, age, type and institution of training as well as his orthopaedic cultural orientation. Since Switzerland is characterized by regional languages (the most important being German and French), we were interested to learn if the linguistic differences had an influence on the orientation of the surgeons towards e.g. Anglo-American or French surgical traditions and/or sources of literature on the subject.MethodsA survey was e-mailed to all members of the Swiss Orthopaedic Society (SGOT-SSOT). Questions were asked regarding respondents’ demographics as well as their preferred treatment for 3 separate cases of (1) moderate and (2) severe hallux valgus and (3) hallux rigidus. The responses were collected and statistically analyzed.ResultsTwo hundred thirty of 322 respondents completed the survey(response rate 46 %). as they perform foot surgery on a regular base; 39 % were members of the Swiss Orthopaedic Foot and Ankle Society (SFAS). Selected surgical treatments differed as follows: in joint sparing procedures older and busier surgeons were more likely to use Chevron osteotomies, however more than 50 % preferred a Scarf-type of osteotomy. Along the so-called "Rösti-Graben" separating the French from the German speaking part of Switzerland no significant difference was found in the choice of operation technique.Nevertheless the fact being a member of SFAS showed significant differences in technical choice in case 2 and 3.ConclusionsThere are significant associations between the surgeons’ age, expertise and training and their preferred operative intervention. Considerable differences in the surgical management were found in the practice of the general orthopaedic surgeons 72 and the foot and ankle specialists. The cultural background and training is not mirroring the classical Swiss east west discrepancy. Despite the large number of surgical options available for hallux valgus, only a small number were preferred by the majority of surgeons.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-015-0751-7) contains supplementary material, which is available to authorized users.

Surgical Management of Freiberg's Infraction: A Systematic Review.

Avascular necrosis of the second metatarsal head was first described by Freiberg in 1913. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. Should conservative treatment fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown. This systematic review was undertaken to determine which surgical procedure allows for the best resolution of symptoms and return to activity. Included studies were restricted to articles published in English language peer-reviewed journals that consecutively enrolled patients of all ages, with Freiberg's infraction of any stage, who underwent operative treatment, and had a mean follow-up of greater than or equal to 12 months duration. Eighty-five publications were identified, of which 38 (44.7%) met all the inclusion criteria. Surgical techniques and outcomes were grouped into joint sparing and joint destructive procedures. A total of 70 joint destructive procedures were performed with a combined mean follow-up time of 15.0 months. A greater than 70% resolution of pain and full return to activity was reported. A total of 257 joint sparing procedures were performed with a combined mean follow-up of 30.4 months. A greater than 90% resolution of pain and full return to activity was reported. Results of this systematic review reveal that the results of joint sparing procedures are reported more often and appear to have a better prognosis for symptom resolution and return to activity. Smillie stage was not consistently reported, making it difficult to determine its effect on procedure selection. Therapeutic, Level IV: Systematic review of Level IV studies.

Calcaneus osteotomy

Calcaneal osteotomy is an extra-articular, joint-sparing procedure that is used in the correction of cavovarus and planovalgus foot deformity. Careful indications and contraindications for the procedure, with meticulous surgical technique, should be followed to avoid complications and to achieve optimal outcomes. Multiple options of osteotomies exist, including translational (medializing and lateralizing calcaneal osteotomy, with ability to slide proximally or distally, closing wedge (Dwyer), and rotational type osteotomies (Evans, Z-osteotomy). Future directions for innovation include developments of both implants and surgical techniques.

Foot and ankle tuberculosis: Case series and literature review

Foot and ankle tuberculosis (TB) is a rare presentation of skeletal TB. The uncommon site along with low index of clinical suspicion in the western world leads to delays in the diagnosis and treatment. This can make joint sparing procedures less successful, especially in the midfoot where the joints can often be interconnected. Plain radiographs have low sensitivity and specificity and cross sectional imaging in the form of MRI or CT is more reliable. Treatment involves the use of multiple anti-tuberculous drugs in the first instance, followed by surgery to address any symptomatic deformity and/or secondary degenerative changes. We present our experience on the management of this rare problem and review the literature on the clinical presentation, diagnosis, imaging modalities and treatment.

Augmented Deltoid Reconstruction Techniques

Joint-sparing procedures for stage IV-A adult acquired flatfoot deformity have garnered attention because they represent the opportunity to avoid TTC or pantalar fusion and the functional limitations that these arthrodeses engender. The role and technique of augmented deltoid reconstruction as a component of joint preservation procedures in the patient with adult acquired flatfoot deformity will be discussed here.

Hindfoot Fusions in the Flatfoot Deformity

Classically, the patient presenting with a stage II posterior tibial tendon rupture is distinguished from the stage III patient by the presence of hindfoot stiffness. As with all deformities, there are certainly shades of gray between the 2 stages and a “one-size-fits-all” approach is inappropriate. Typically, the more longstanding the deformity, the greater the likelihood of progression of arthritis and hindfoot rigidity, but this is not always the case. Some patients may have only partial loss of hindfoot motion and the surgeon may be tempted to “push the limits” for joint-sparing procedures, or conversely, to perform a triple arthrodesis in a patient who does not have a completely rigid deformity. In the following pages we will discuss the evaluation of the “late” stage II and stage III posterior tibial tendon rupture and present a variety of arthrodesis techniques that successfully address these conditions.

Osteonecrosis of the femoral head: An update in year 2012

Osteonecrosis is a phenomenon involving disruption to the vascular supply to the femoral head, resulting in articular surface collapse and eventual osteoarthritis. Although alcoholism, steroid use, and hip trauma remain the most common causes, several other etiologies for osteonecrosis have been identified. Basic science research utilizing animal models and stem cell applications continue to further elucidate the pathophysiology of osteonecrosis and promise novel treatment options in the future. Clinical studies evaluating modern joint-sparing procedures have demonstrated significant improvements in outcomes, but hip arthroplasty is still the most common procedure performed in these affected younger adults. Further advances in joint-preserving procedures are required and will be widely studied in the coming decade.

Minimally Invasive Deltoid Ligament Reconstruction for Stage IV Flatfoot Deformity

Stage IV is the most advanced form of acquired adult flatfoot deformity (AAFD). It is present when valgus tibiotalar angulation occurs with foot deformities associated with AAFD. Tibiotalocalcaneal or pantalar fusion has been the gold standard for treatment of Stage IV AAFD. However, in some of these patients the tibiotalar deformity is correctable. We sought to determine whether minimally invasive deltoid ligament reconstruction in conjunction with triple arthrodesis (MIDLR/Triple) allows tibiotalar joint sparing surgical therapy in Stage IV-A AAFD patients. Patients diagnosed with Stage IV-A AAFD were given the option of undergoing ankle joint sparing surgery with the MIDLR/Triple technique. Those that chose this option were followed longitudinally. Eight patients underwent the ankle joint sparing procedure. Average followup was 36 months. Radiographic and functional outcome measures were obtained. Success was defined as maintenance of 3 degrees or less of valgus tibiotalar angulation and greater than 2 mm of lateral joint space remaining at final followup. At final followup, five were judged to have a successful outcome. In those, tibiotalar valgus angulation was reduced from 6.4±2.9 degrees to 2.0±2.0 degrees, lateral ankle joint space was maintained at preoperative levels and SF-12 functional scores were equal to age matched normative scores. The only parameter found to be predictive of successful outcome was the magnitude of preoperative tibiotalar tilt. MIDLR/triple is a new treatment option that requires significant care in patient selection and surgical execution. It is a choice that allows for preservation of ankle motion in patients diagnosed with Stage IV-A AAFD who have less than 10 degrees of valgus tibiotalar tilt on preoperative standing ankle radiographs.

Single-Screw Fixation for Subtalar Joint Fusion Does Not Increase Nonunion Rate

A philosophical shift toward more joint-sparing procedures has led to increased use of isolated subtalar joint (STJ) versus triple arthrodesis. Union rates for STJ fusion range from 47% to 100%, leading to controversy regarding the optimal type, orientation, and amount of internal fixation. The purpose of this study was to determine if single-screw fixation is a predisposing factor to nonunion. Single-screw fixation is parallel to the STJ axis and may result in motion. It is hypothesized that higher nonunion rates will be observed in single-screw versus 2-screw fusions. Isolated STJ arthrodeses performed in 113 patients were retrospectively reviewed. Single screws were used in 89 (78.8%) fusions; 2 screws were used in 24 (21.2%) fusions. The mean follow-up was 11 months (range, 9-17 months). Nonunion occurred in 13 (14.6%) single-screw and 6 (25.0%) 2-screw fusions. Twenty (22.5%) single-screw and 3 (12.5%) 2-screw fusions required hardware removal. Revision surgery was performed in 6 (6.7%) single-screw and 3 (12.5%) 2-screw fusions. No significant differences in demographics were calculated between single and 2-screw fusions. Furthermore, no significant differences were observed in nonunion rate, postoperative complication incidence, or subsequent surgeries. The results from this study do not support the contention that single-screw fixation predisposes STJ fusions to nonunion. Comparable nonunion and complication incidences were observed between single and 2-screw fusions. These data suggest that the motion occurring from single-screw fixation may not be significant enough to directly affect the rate of union.

Functional Outcomes after Treatment of Aggressive Tumors in the Distal Radius

We aimed to determine whether wide excision and radiocarpal arthrodesis in patients with aggressive tumors of the distal radius resulted in more significant functional deficit than joint salvage procedures. We compared functional outcomes, surgical complications, and local tumor relapse in 33 consecutive patients. Fourteen patients initially had joint-sparing procedures, whereas 19 underwent wide resection and arthrodesis. At minimum final followup of 18 months (mean, 96 months; range, 18-204 months), local tumor relapse occurred in five of 14 patients after joint salvage versus zero of 19 after arthrodesis. Two of five patients with tumor recurrence retained their native joints, whereas three underwent resection and arthrodesis. Six of 19 patients had complications, including one nonunion, for which we performed additional surgery after arthrodesis. All patients remained disease-free at followup and none developed metastases. Disabilities of the Arm, Shoulder and Hand score, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society scores all indicated more disability after arthrodesis. Persistent pain, radiographic wrist arthritis, and weaker grip strength was seen in some patients following joint salvage. Whenever possible, joint preservation is preferable for the result of better extremity function, but weaker grip, higher local tumor relapse, and late arthritis remain concerns.

NONTRAUMATIC OSTEONECROSIS OF THE FEMORAL HEAD

The etiology of osteonecrosis of the hip may have a genetic basis. The interaction between certain risk factors and a genetic predisposition may determine whether this disease will develop in a particular individual. The rationale for use of joint-sparing procedures in the treatment of this disease is based on radiographic measurements and findings with other imaging modalities. Early diagnosis and intervention prior to collapse of the femoral head is key to a successful outcome of joint-preserving procedures. The results of joint-preserving procedures are less satisfactory than the results of total hip arthroplasty for femoral heads that have already collapsed. New pharmacological measures as well as the use of growth and differentiation factors for the prevention and treatment of this disease may eventually alter our treatment approach, but it is necessary to await results of clinical research with long-term follow-up of these patients.

Nontraumatic Osteonecrosis of the Femoral Head

The etiology of osteonecrosis of the hip may have a genetic basis. The interaction between certain risk factors and a genetic predisposition may determine whether this disease will develop in a particular individual. The rationale for use of joint-sparing procedures in the treatment of this disease is based on radiographic measurements and findings with other imaging modalities. Early diagnosis and intervention prior to collapse of the femoral head is key to a successful outcome of joint-preserving procedures. The results of joint-preserving procedures are less satisfactory than the results of total hip arthroplasty for femoral heads that have already collapsed. New pharmacological measures as well as the use of growth and differentiation factors for the prevention and treatment of this disease may eventually alter our treatment approach, but it is necessary to await results of clinical research with long-term follow-up of these patients.

Pelvic osteotomies for hip dysplasia

Purpose of review The purpose of this paper is to discuss the current trends in pelvic osteotomies for the treatment of developmental dysplasia of the hip. Recent findings The recent literature reports on midterm to long-term results of three types of pelvic osteotomies for hip dysplasia. The Chiari osteotomy has been shown to be effective in delaying the need for total hip arthroplasty in patients with dysplasia, hip inconguity, and osteoarthritis. Spherical osteotomies, which are mostly performed in the centers in which they were developed, have good results but are limited by the inability to medialize the acetabular fragment. The Bernese periacetabular osteotomy shows good midterm results even in patients with severe dysplasia who have not been considered surgical candidates for an acetabular reorientation in the past. Summary Patients with hip dysplasia are at increased risk for the development of osteoarthritis because of joint overload. A variety of pelvic osteotomies to redistribute the forces have been developed. Reports of long-term follow-up of the Chiari osteotomy are reasonable for young patients with an incongruent hip joint and arthritis who desire a joint-sparing procedure. The current trend for the treatment of acetabular dysplasia in the skeletally mature patient with a congruent hip joint is the Bernese periacetabular osteotomy. Although it is technically challenging, significant reorientation of the acetabulum can be achieved in all planes, including anterolateral coverage, restoration of acetabular version, and hip joint medialization.