Postoperative Radiographic Measurements Research Articles

Surgical technique and outcomes for bilateral humeral lengthening for achondroplasia: 26-year experience.

Elongation in patients with achondroplasia provides better overall skeletal proportionality and significantly improves such individuals' access to their perineal region to self-manage personal hygiene. This paper describes our surgical technique and outcomes for bilateral humeral lengthening in achondroplasia patients over 26years. Ours was a retrospective study of 55 patients with achondroplasia-related short stature, in whom bilateral humeral lengthening was performed from 1990 to 2016. We describe the surgical technique and analyze mean gain in humeral length, days using an external fixator, mean percentage of lengthening, external fixation index, type of callus, and complications. Pre- and postoperative radiographic measurements were obtained. Patients also were contacted by telephone and asked about their ability to perform peri-anal self-hygiene and about their overall satisfaction. In total, 110 humeri were lengthened (28 males and 27 females) with medium elongation of 9.5cm on the right and 9.6cm on the left, while averaging 220days in an external fixator. We observed 14 minor complications. There was no significant association between pin position and type of callus, and elongation most often external and in the presence of a straight callus. Before elongation, 77.1% of patients reported difficulties with perineal hygiene and 85.4% could not put their hands in their pockets. Upon completion of lengthening, 100% could perform both tasks and 94.5% were very satisfied. Bilateral humeral elongation yields significant improvements in patient autonomy, with a relatively low complication rate and very high patient satisfaction.

The impact of age on surgical goals for spinopelvic alignment in minimally invasive surgery for adult spinal deformity.

OBJECTIVEAchieving appropriate spinopelvic alignment in deformity surgery has been correlated with improvement in pain and disability. Minimally invasive surgery (MIS) techniques have been used to treat adult spinal deformity (ASD); however, there is concern for inadequate sagittal plane correction. Because age can influence the degree of sagittal correction required, the purpose of this study was to analyze whether obtaining optimal spinopelvic alignment is required in the elderly to obtain clinical improvement.METHODSA multicenter database of ASD patients was queried. Inclusion criteria were age ≥ 18 years; an MIS component as part of the index procedure; at least one of the following: pelvic tilt (PT) > 20°, sagittal vertical axis (SVA) > 50 mm, pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°, or coronal curve > 20°; and minimum follow-up of 2 years. Patients were stratified into younger (< 65 years) and older (≥ 65 years) cohorts. Within each cohort, patients were categorized into aligned (AL) or mal-aligned (MAL) subgroups based on postoperative radiographic measurements. Mal-alignment was defined as a PI-LL > 10° or SVA > 50 mm. Pre- and postoperative radiographic and clinical outcomes were compared.RESULTSOf the 185 patients, 107 were in the younger cohort and 78 in the older cohort. Based on postoperative radiographs, 36 (33.6%) of the younger patients were in the AL subgroup and 71 (66.4%) were in the MAL subgroup. The older patients were divided into 2 subgroups based on alignment; there were 26 (33.3%) patients in the AL and 52 (66.7%) in the MAL subgroups. Overall, patients within both younger and older cohorts significantly improved with regard to postoperative visual analog scale (VAS) scores for back and leg pain and Oswestry Disability Index (ODI) scores. In the younger cohort, there were no significant differences in postoperative VAS back and leg pain scores between the AL and MAL subgroups. However, the postoperative ODI score of 37.9 in the MAL subgroup was significantly worse than the ODI score of 28.5 in the AL subgroup (p = 0.019). In the older cohort, there were no significant differences in postoperative VAS back and leg pain score or ODI between the AL and MAL subgroups.CONCLUSIONSMIS techniques did not achieve optimal spinopelvic alignment in most cases. However, age appears to impact the degree of sagittal correction required. In older patients, optimal spinopelvic alignment thresholds did not need to be achieved to obtain similar symptomatic improvement. Conversely, in younger patients stricter adherence to optimal spinopelvic alignment thresholds may be needed.https://thejns.org/doi/abs/10.3171/2018.4.SPINE171153.

Dorsal Lunate Facet Fracture Reduction Using a Bone Reduction Forceps.

Background The dorsal lunate facet fragment represents part of a complex articular injury of the distal radius and is challenging to reduce through a standard volar approach. We propose reduction through a standard volar approach and intraoperative dorsal lunate facet reduction using a bone forceps. To evaluate the postoperative reduction, we used computed tomography (CT) scan. Methods We retrospectively included 60 patients with a median follow-up of 44 weeks. Fracture reduction was evaluated using pre- and direct postoperative CT scans of the wrist, measuring the articular gap and step of the sigmoid notch. The range of motion was evaluated clinically by the treating physician. Bivariate analysis was performed to compare pre- and postoperative radiographic measurements and to compare wrist range of motion. Results When comparing the injured with the uninjured wrist, there was a significant difference in flexion, extension, pronation, and supination. In 87% of the patients, there was complete radiographic reduction of the fracture. Conclusion This study shows that dorsal ulnar lunate facet fracture fragments in distal radius fractures can be reduced through a standard volar approach with the help of an intraoperative bone reduction forceps. Using wrist CT, we showed that 87% of the patients with a dorsal ulnar lunate facet fragment had a postoperative articular step or gap of <1 mm. Level of Evidence : This is a level IV, therapeutic study.

Evaluation of surgical treatment of inter-condylar humerus fracture with olecranon osteotomy approach

Background: Inter-condylar fracture distal humerus in adults often pose a challenge to orthopaedic surgeons because of the complex anatomy, fracture pattern and limited bone stock of this region. Adequate exposure of the articular surface of the distal humerus and elbow joint is essential for operative stabilisation of complex distal humerus fracture. Various operative approaches have been recommended to access this difficult region which includes triceps splitting, triceps reflecting and trans-olecranon approaches though each approach has its own advantage & disadvantage. Olecranon osteotomy approach provides better visualization of complex intra-articular fractures, enabling accurate reduction and fixation.Aim of this Study: To assess the functional outcome of intercondylar humerus fracture with olecranon osteotomy approach. Study design: prospective studyMaterial and Methods: Sixty patients of inter-condylar fracture humerus fulfilling the inclusion criteria were treated with internal fixation with various implants with olecranon osteotomy via posterior approach. Preoperative and postoperative radiograph measurements were taken and fractures were classified according to the AO system. All patients were operated through posterior trans-olecranon approach. Elbow exercises were started at third postoperative week. Patients were followed at three weeks and thereafter monthly, with clinical examination and x-rays. Results: The average ROM on follow up after 6 weeks was flexion up to 140o and extension upto 5o of elbow flexion. No cases of olecranon or distal humerus non-union were reported. Conclusions: Posterior surgical approach with olecranon osteotomy provides optimal exposure of the intra articular aspect of distal part of humerus and among them olecranon osteotomy gives the best exposure of the articular surface and there by better reduction and internal fixation which in turn gives better stability and good range of motion as compared to other approaches.

Usefulness of CT-based measurement of volar prominence for evaluation of risk of flexor tendon injury following fixation of a distal radius fracture

BackgroundAlthough some radiographic evaluations of the risk of flexor tendon injury following fixation of a distal radius fracture are useful, these radiographic measurements are limited because of their inability to obtain three-dimensional measurements. We hypothesized that CT-based measurements would be more sensitive indicators for risk estimation than radiography. MethodsWe retrospectively evaluated the relationship between plate positioning and the incidence of flexor tendon symptoms based on postoperative radiographic and CT-based measurements in 99 hands that were followed up for more than 12 months. We also compared the reproducibility, diagnostic accuracy, and ability to detect the plate-bone gap between radiographic and CT-based measurements. We also assessed the correlation between the volar prominence and plate-bone gap using CT. Multivariable analysis using stepwise logistic regression was performed to identify factors independently associated with tendon rupture or irritation. ResultsIn single variable analysis, we found that the volar tilt was significantly smaller and the radiographic plate-to-critical line distance (PCL), CT-PCL, and CT-gap were significantly greater in the group with tendon irritation or rupture. Multivariable logistic regression analysis indicated that the CT-based measurement of the volar prominence is a significantly positive independent predictor of tendon rupture or irritation. ConclusionCT-based measurement of the volar prominence may be one of the best radiographic predictors of the risk of flexor tendon injury following fixation of a distal radius fracture regardless of the plate type and distal prominence and the extent of rotation. This measurement may assist surgeons when deciding on the need for removal of hardware to decrease the long-term risk of flexor tendon rupture.

Chronic Scapholunate Interosseous Ligament Disruption: A Systematic Review and Meta-Analysis of Surgical Treatments.

Background: Although many techniques have been described, there is no clear optimal surgical treatment for chronic scapholunate interosseous ligament (SLIL) disruption. Methods: We identified 255 articles reporting outcomes of SLIL reconstruction. Of these, 40 studies (978 wrists) met eligibility requirements and reported sufficient data on radiographic outcomes to be included in the study. The mean and standard deviation of preoperative and follow-up assessments including scapholunate gap (SLG) and scapholunate angle (SLA) were used to calculate pooled standardized mean differences (SMD) with 95% confidence intervals (CIs). For other radiographic or clinical outcomes, there were not enough reported data to calculate a pooled effect size, and pooled nonstandardized comparisons were made. Results: The SMD between preoperative and postoperative SLA in tenodesis reconstruction was 0.7 (CI, 0.29 to 1.11, P = .001) and 0.04 (CI, -0.27 to 0.38, P = .8) for capsulodesis reconstruction. For SLG, tenodesis demonstrated an SMD of 1.1 (CI, 0.6 to 1.55, P < .001) compared with 0.1 (CI, -0.36 to 0.59, P = .6) for capsulodesis reconstruction. Tenodesis had a significant improvement compared with capsulodesis in SLA (P = .01) and SLG (P = .005). Tenodesis also showed improvement in grip strength and Disabilities of the Arm, Shoulder and Hand scores. Conclusions: Comparing preoperative and postoperative radiographic measurements, tenodesis reconstruction demonstrated significantly improved SLG and SLA relative to capsulodesis. Interpreted in the context of the limitations, existing data demonstrates some benefit of tenodesis reconstruction.

Should 15° of Valgus Coronal-Plane Deformity Be the Upper Limit for a Total Ankle Replacement?

Category: Ankle Arthritis Introduction/Purpose: Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with &lt;15°. Methods: Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° (“valgus” group) and 50 ankles with valgus deformity of &lt;15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected. Results: The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up. Conclusion: Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed.

The Importance of Comprehensive Cam Correction: Radiographic Parameters Are Predictive of Patient-Reported Outcome Measures at 2 Years After Hip Arthroscopy

Background: The specific influence of preoperative and postoperative radiographic measurements on patient-reported outcome measures after hip arthroscopy for femoroacetabular impingement (FAI) remains unclear. Purpose: To investigate the relationship between radiographic measurements and 2-year outcomes after hip arthroscopy for the treatment of FAI. Study Design: Case series; Level of evidence, 4. Methods: A clinical registry of patients undergoing primary hip arthroscopy for FAI between January 1, 2012, and December 31, 2014, was queried. Outcome measures included the Hip Outcome Score (HOS) Activities of Daily Living (ADL), HOS Sport-Specific Subscale (SSS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction. Preoperative and postoperative radiographic measurements were recorded. Univariate analysis was conducted to identify relationships between all radiographic and demographic variables and outcome scores. A multivariate regression analysis, controlling for demographic factors, was used to identify independent associations between radiographic measurements on plain radiographs and patient-reported outcomes. Results: The authors identified 707 patients who underwent primary hip arthroscopic management for FAI who were included for analysis. Two-year outcome surveys were completed for 78% to 84% of patients. The mean age of the patients was 33.2 ± 12.3 years, and 64.4% of the patients (n = 456) were female. The mean anteroposterior (AP) alpha angle decreased by 34.3° (P < .0001), false profile alpha angle by 25.2° (P < .0001), Dunn lateral alpha angle by 28.9° (P < .0001), lateral center edge angle by 2.6° (P < .0001), and anterior center edge angle by 3.4° (P < .0001). The HOS-ADL score increased from 65.7 ± 18.7 preoperatively to 85.9 ± 16.7 postoperatively (P < .0001), HOS-SSS increased from 43.4 ± 23.1 to 72.6 ± 27.2 (P < .0001), and mHHS increased from 57.7 ± 14.0 to 79.1 ± 17.2 (P < .0001). With multivariate analysis, independent predictors of the postoperative HOS-ADL score included the preoperative false profile alpha angle (beta = −0.16, P = .028). Independent predictors of HOS-SSS score were preoperative AP alpha angle (beta = −0.33, P = .032) and preoperative false profile alpha angle (beta = –0.28, P = .041). For the postoperative mHHS score, independent predictors included preoperative AP alpha angle (beta = −0.18, P = .046), preoperative false profile alpha angle (beta = −0.20, P = .014), and postoperative false profile alpha angle (beta = –0.48, P = .035). The preoperative AP alpha angle (beta = 0.28, P = .024) was a significant predictor for the postoperative VAS pain score. The preoperative false profile alpha angle (beta = −0.34, P = .040) was a significant predictor for the postoperative VAS satisfaction score. Conclusion: The authors observed that radiographic measurements, specifically the preoperative false profile alpha angle, AP alpha angle, and postoperative false profile alpha angle, are independent predictors of 2-year clinical outcomes. The femoral-side measurements were the strongest independent predictors of outcomes, especially measurements of the anterior and lateral-based CAM lesion.

Does overstuffing of the patellofemoral joint in total knee arthroplasty have a significant effect on postoperative outcomes?

BackgroundThere is ongoing debate in the literature as to whether or not patellofemoral joint overstuffing has a clinically significant effect on postoperative outcomes following total knee arthroplasty (TKA). This study investigates the effect of patellofemoral joint overstuffing on patient-reported outcomes using novel methods of radiographic measurement. MethodsThe study population consisted of a prospective cohort of 266 patients receiving a Triathlon® (Stryker, Kalamazoo, MI, USA) TKA between 2006 and 2009. Participants completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire preoperatively and at 12 months postoperatively. Pre- and postoperative radiographic measurements were taken according to a defined protocol to assess for patellofemoral overstuffing. Measurement reproducibility was assessed using inter-observer intraclass correlation coefficients. Associations between radiographic measurements and patient-reported outcomes were analysed using linear regression analysis. ResultsA total of 107 patients had adequate images and were included in the analysis for this study. Three different radiographic measurements were used to identify patellofemoral overstuffing all with good intra- and inter-observer reliability. There was no association identified between combined (patella and trochlea) patellofemoral overstuffing measurements and WOMAC scores. However, a statistically significant association was identified between an increase in anterior trochlear offset and worse knee pain and function scores (P < 0.05). ConclusionsThere is no identifiable association between true patellofemoral overstuffing and clinical outcome; however, there is a small association with the anterior trochlear offset though further studies are warranted to confirm the clinical significance of this finding.

Controllable Risk Factors for Neurologic Complications in Posterior Lumbar Interbody Fusion as Revision Surgery

The main concern with revision lumbar surgery is the possibility of neurologic complications. This retrospective study was conducted to clarify the risk factors, especially the effects of nerve stretching, for postoperative neurologic complications in posterior lumbar interbody fusion (PLIF) without excessive nerve retraction by bilateral total facetectomy as revision surgery. Between 2005 and 2015, 50 consecutive patients underwent revision PLIF for recurrent stenosis or recurrent disc herniation. The patients were divided into two groups: patients with neurological complications (NC group) and patients without neurological complications (non-NC group). Radiological examinations to evaluate the magnitude of nerve stretching included the following pre- and postoperative plain radiograph measurements: anterolisthesis at flexion, intervertebral lordosis in the neutral position, and posterior disc height in the neutral position. Sixteen patients (32%) had neurological complications. The decrease in intervertebral lordosis was significantly greater in the NC group than that in the non-NC group (0.8° vs.-1.5°, P<0.05). Distraction of the posterior disc height was significantly greater in the NC group than that in the non-NC group (5.0 mm vs. 2.6 mm, P < 0.01). Neurological complications were seen in all patients with a decrease in intervertebral lordosis >3° and distraction of the posterior disc height >3 mm. Decreased intervertebral lordosis, and distraction of the posterior disc height, which can be controlled by surgeons, appear to be risk factors for neurological complications following revision PLIF. In revision PLIF, surgeons should create segmental lordosis without excessive disc height distraction.

Metal on Metal Hip Resurfacing in Patients 45 Years of Age and Younger at Minimum 5-Year Follow-Up

BackgroundMetal on metal hip resurfacing (MoM-HR) is an alternative to total hip arthroplasty in young and active patients. The purpose was to determine the survivorship of MoM-HR procedures performed in patients aged 45 years and younger assessing patient-reported outcome measures (PROMs) at minimum 5-year follow-up. MethodsAll 217 patients equal to or younger than 45 years of age at the time of surgical intervention presenting to our center with MoM-HR between May 2002 and May 2011 were prospectively followed. Baseline demographic data, preoperative and postoperative radiographic measurements, and validated PROMs were obtained (Hip Disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles Activity Score). Survivorship was calculated using Kaplan-Meier analysis, and risk factors for failure were identified using multivariate regression analysis. ResultsThe overall survivorship excluding septic failures was 94.6% and 93.8% at 5 and 10 years, respectively. Aseptic loosening of the acetabular component was the most common mode of failure (11/20 cases). Gender, head size, and acetabular abduction angle had no significant effect on survivorship. Significant improvements in PROMs were seen for Hip Disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles Activity Scale (P < .001). ConclusionThis study indicates that MoM-HR is a suitable option for young individuals, as demonstrated through improved functional scores and low revision rates. The survivorship of HR in the younger than 45 age-group was similar to that of total hip arthroplasty, as well as HR in older patients. Given the proposed benefits of HR, this procedure may be viewed as a viable option in patients aged younger than 45 years.

Patterns in Outcomes Reporting of Operatively Managed Pediatric Patellofemoral Instability: A Systematic Review and Meta-analysis

Background: Traumatic patellofemoral dislocation is a common injury in pediatric patients, and surgical treatment is often recommended. Increasingly, it has been recognized that clinical studies need to report age-appropriate treatment outcomes. However, the variability and appropriateness of outcomes reporting in the youth patellar instability literature are unknown. Purpose: To analyze the patterns of outcomes reporting in studies published in high-impact orthopaedic journals after operative management of pediatric patellar instability. Study Design: Systematic review; Level of evidence, 4. Methods: Six high-impact orthopaedic journals were searched using PubMed and EMBASE to identify studies reporting outcomes of operative management of pediatric patellar instability. Studies containing adults were excluded. Clinical and radiographic outcomes were recorded from included articles. Descriptive statistics were calculated for overall instability recurrence rates, return-to-activity rates, and changes in Kujala and Tegner scores. Results: Of 545 identified articles, 8 studies met the inclusion criteria. These studies encompassed 213 patients and 230 knees (mean age, 13.2 years; range, 4.5-18.3 years). Seven of 8 studies reported patients’ physeal status, but only 4 studies limited their outcomes reporting to patients with open physes. Two studies reported postoperative radiographic measures, and 5 studies reported preoperative radiographic findings. Six studies reported patient-reported outcome measures (PROMs). Seven unique PROMs were reported. All but one study reported complication rates and types of complications. The mean postoperative change in Tegner scores was −0.07 (range, −0.6 to 1.0). Among studies examining medial patellofemoral ligament reconstruction with adequate data, the mean return-to-activity rate was 86% (range, 81%-92%), the instability recurrence rate was 3% ± 20%, and the mean improvement in Kujala scores postoperatively was 22.1 (range, 19.9-26). Conclusion: There is a need for more pediatric-specific outcomes studies regarding operatively managed traumatic patellofemoral instability. Of the outcomes reported, both radiographic outcomes and PROMs should be standardized. Among radiographic outcomes, there is a need for more studies that report tibial tubercle–trochlear groove distances and use Caton-Deschamps and/or Blackburne-Peel indices to assess patellar height. Among PROMs, there is a need for studies that use PROMs validated in pediatric populations, such as the International Knee Documentation Committee Pediatric Form or the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Complications of treating distal radius fractures with external fixation: A community experience

Objective: To analyze the immediate postoperative complications associated with treating distal radius fractures with external fixation. Design: A retrospective chart review of data obtained from 24 consecutive patients who were treated with small AO external fixators in 1997. Setting: Two community medical centers. Intervention: Preoperative and postoperative radiograph measurements were taken of radial inclination, radial tilt, and radial length, and fractures were classified according to the AO system. Patient charts were reviewed to document demographics, type of fixator used, open or percutaneous technique for pin placement, use of augmentation, additional operations, and complications. Main outcome measurements: Complications associated with treating distal radius fractures with one type of external fixator. Results: Sixteen of the 24 patients had complications: 5 with neuropathies of the median or superficial radial nerve, 9 with pin track infections, 2 with pin loosening, one with a nonunion, 2 with malunion, and 4 patients each with radial shortening, loss of radial tilt, collapse of ulnar border or volar intercalated segment instability (VISI) of the lunate and rotatory subluxation of the scaphoid. Conclusions: Postoperative complications following distal radius fractures treated with external fixation are common. Their effect, however, on long term functional results and patient satisfaction is negligible, with the exception of those patients with complications intrinsic to the fracture itself, i.e., nonunion, malunion or carpal malalignment.

A Novel 4-Rod Technique Offers Potential to Reduce Rod Breakage and Pseudarthrosis in Pedicle Subtraction Osteotomies for Adult Spinal Deformity Correction.

Pedicle subtraction osteotomy (PSO) can be used to treat rigid sagittal plane deformities. Nonunions and rod breakages are known complications of PSO. To assess outcomes of 2 methods of posterior instrumentation for PSO, traditional 2 rods vs a novel 4-rod technique in which 2 additional rods span only the osteotomy level. This study was a retrospective, radiographic review of consecutive PSOs performed at 2 centers. The primary difference in technique between the centers was the use of 4 rods including 2 independent rods attached only to the vertebral levels immediately adjacent to the PSO (group 1, n =29 patients) vs the traditional 2-rod technique (group 2, n =20 patients). Demographics and preoperative to postoperative radiographic measurements were similar between the study groups, including the PSO wedge resection angle (P= .56). The rod breakage rate was 25% with 2 rods and 0% with 4 rods (P= .008), and the pseudarthrosis rate with 2 rods was 25% and with 4 rods was 3.4% (P= .035). The patient with pseudarthrosis from group 1 had an infection and developed pseudarthrosis only after instrumentation removal. Rates of other complications did not differ significantly between the study groups. This study provides a comparison between 2 techniques for rod placement across a PSO and suggests that the described novel 4-rod technique may help to reduce the rates of pseudarthrosis and rod failure. It will be important to confirm these findings in a prospectively designed study with multiple institutions in order to better control for potentially confounding factors.

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PurposeThe authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization. MethodsThe preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied. ResultsAccording to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from −1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from −7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws. ConclusionFlexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury’s key features, which may facilitate exposure and enhance fixation strength.

Factors Associated With Failure of Hip Arthroscopy in Patients With Hip Dysplasia.

The purpose of this study was to compare a group of dysplastic hips treated successfully with hip arthroscopy with a group of dysplastic hips treated unsuccessfully with hip arthroscopy to determine (1) preoperative patient characteristics and radiographic parameters and (2) intraoperative findings and treatment associated with outcome. The authors retrospectively reviewed a prospective database of 20 adult patients (17 female, 3 male) with hip dysplasia who underwent primary hip arthroscopy between January 2009 and February 2013. Modified Beck scores to quantify cartilage damage as well as preoperative and postoperative radiographic measurements (including alpha, Tonnis, and lateral center edge angles [LCEAs]) were compared between patients who failed hip arthroscopy (11 patients) and those who did not (9 patients). Failure after hip arthroscopy was defined as a modified Harris hip score of less than 80 or the need for subsequent hip arthroscopy, arthroplasty, or periacetabular osteotomy. The mean follow-up for the successful patients was 58 months (range, 37-82 months), with an average modified Harris hip score of 93 at most recent follow-up. Preoperative radiographs showed a lower mean LCEA (18.0° vs 21.3°; P=.02) in the failure group, and all successes occurred with a LCEA of 17° or greater. The failure group was more likely to have rim resection of greater than 3 mm performed (hazard ratio, 3.53; P=.04). Among the hips with dysplasia undergoing arthroscopic treatment, patients with a poor outcome were more likely to have an LCEA of less than 17° and intraoperative rim resection of greater than 3 mm. Furthermore, the labral repair group did substantially better than the labral debridement group. [Orthopedics. 2018; 41(2):e234-e239.].

The Use of Fluoroscopy During Direct Anterior Hip Arthroplasty: Powerful or Misleading?

BackgroundDirect anterior approach total hip arthroplasty (THA) with fluoroscopic assistance is growing in popularity. Variables such as pelvic tilt, c-arm technique, and patient positioning can affect the perceived fluoroscopic view. This study evaluates the effect of these variables on the position of the acetabular component. MethodsForty-one hips in 40 patients undergoing direct anterior arthroplasty THA with fluoroscopic assistance underwent routine postoperative radiographs and postoperative pelvic computed tomography scan. The acetabular component position as defined by a 3-dimensional reconstruction was compared to the surgeon's intraoperative perception of the component's position and compared to routine postoperative plain radiograph measurements. ResultsAlthough fluoroscopy was used to create an anteroposterior pelvic radiograph utilizing the coccyx to pubis symphysis distance, a 3D reconstruction created in the same pelvic orientation as the fluoroscopic images confirmed that 39/41 hips were placed with unrecognized excess of anteversion and inclination secondary to imaging the pelvis in extension. ConclusionIntraoperative imaging during supine direct anterior arthroplasty THA confirms appropriate component placement. Pelvic tilt can greatly affect the perceived position of the acetabular component and cannot be accurately compensated for by assessing the relationship between the coccyx and pubic symphysis due to morphologic variation and orientation. We recommend positioning the c-arm so that the size and shape of the obturator foramen matches the standing preoperative anteroposterior pelvis image. This technique allows for the native standing pelvic tilt to be accounted for intraoperatively and will result in the least variation in intraoperative and postoperative standing acetabular component orientation.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 2: Radiographic Predictors of Early Graft Failure.

Background:Accumulating evidence suggests that long-term anterior cruciate ligament (ACL) deficiency can give rise to an abnormal tibiofemoral relationship and subsequent intra-articular lesions. However, the effects of chronic ACL deficiency (ACLD) on early graft failure after anatomic reconstruction remain unclear.Hypothesis:We hypothesized that patients with long-term ACLD lasting more than 5 years would have a greater rate of early graft failure due to insufficient intraoperative reduction of the tibia and that the preoperative and immediately postoperative abnormal tibiofemoral relationship in the sagittal plane, such as anterior tibial subluxation (ATS), would correlate with the graft status on postoperative magnetic resonance imaging (MRI).Study Design:Cohort study; Level of evidence, 3.Methods:A total of 358 patients who had undergone anatomic ACL reconstruction with hamstring grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken in all patients to evaluate the tibiofemoral relationship, specifically with regard to ATS, space for the ACL (sACL), and extension angle. All patients underwent MRI at 6 months to reveal graft status. Groups with a high rate of graft failure were further analyzed to compare demographic and radiographic factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors.Results:Graft failure without trauma was observed in 4 (1.8%), 0 (0%), 1 (3.7%), 3 (9.7%), and 8 patients (17.7%) in groups 1, 2, 3, 4, and 5, respectively. Of the 76 patients in groups 4 and 5, significant differences were noted between the failure and intact subgroups in preoperative ATS (4.9 vs 2.4 mm, respectively; P < .01), side-to-side differences in sACL (sACL-SSD) (4.7 vs 1.9 mm, respectively; P < .01), extension deficit (4.4° vs 1.3°, respectively; P < .01), and chondral lesions (P = .02), while postoperative ATS and sACL-SSD showed no differences. Multivariate logistic regression analysis revealed that of these factors, preoperative sACL-SSD could be a risk factor for early graft failure (odds ratio, 3.2; 95% CI, 1.37-7.46).ConclusionEarly graft failure at 6 months increased in patients with ACLD longer than 2 years. In this population, preoperative sACL-SSD was the most significant risk factor for early graft failure on MRI. However, immediately postoperative radiographic measurements had no effect on graft failure rates.

Influence of screw density on thoracic kyphosis restoration in hypokyphotic adolescent idiopathic scoliosis

BackgroundPrevious studies have reported that rod composition and diameter, as well as the correction technique are key factors associated with thoracic kyphosis (TK) restoration. However, few study has analyzed the correlation between screw density and TK restoration in hypokyphotic adolescent idiopathic scoliosis (AIS).MethodsFifty-seven thoracic AIS patients with preoperative TK < 10° treated with all pedicle screw fixation with a minimum 2-year follow-up were recruited. Preoperative and postoperative radiographic measurements, and information of posterior instrumentation were reviewed. Pearson and Spearman correlation coefficient analysis were used to assess relationships between change in TK and number of variables. Then, the included patients were classified into two groups (Group 1: postoperative TK ≥ 20°; Group 2: postoperative TK < 20°) to evaluate the influence factors of TK restoration.ResultsThe average preoperative TK was 4.75°, which was significantly restored to 17.30° (P < 0.001). Significant correlations were found between change in TK and flexibility of major thoracic curve (r = 0.357, P = 0.006), preoperative TK (r = −0.408, P = 0.002), and screw density of concave side (r = 0.306, P = 0.021), respectively. In the subgroup comparison, 17 patients (29.8%) maintain the postoperative TK ≥ 20°, increased flexibility of major thoracic curve (P < 0.001), screw number of concave side (P = 0. 029), and cobalt chromium rods (P = 0.041) were found in the group of postoperative TK ≥ 20°.ConclusionsTK restoration remains a challenge for AIS patients with hypokyphosis, especially for the poor flexibility ones. Except for thicker and cobalt chromium rods, screw density of concave side might be another positive predictor of restoring normal kyphosis, which provides a stronger corrective force on the sagittal plane with more pedicle screws.

Patient specific instrumentation in total knee arthroplasty.

The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. The percentage of knees that had a HKA within ±3° of the desired value was 92.2. the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.