Preoperative Plain Radiographs Research Articles

Comparison of fusion rate, radiologic and clinical outcome between CaO-SiO2-P2O5-B2O3 bioactive glass-ceramics 7 (BGS-7) spacer and allograft spacer with iliac bone graft in multilevel ACDF.

CaO-SiO2-P2O5-B2O3 bioactive glass-ceramics7 (BGS-7) are known for their strong integration with bone and stability and are commonly used in spinal fusions. This study aimed to compare fusion rates and radiological and clinical outcomes between BGS-7 and allograft spacers with iliac bone grafts (IBG) in multilevel anterior cervical discectomy and fusion (ACDF) surgeries. This retrospective study was conducted at BRM Medical Center. We included patients who underwent multilevel ACDF at BRM Medical Center between January 2012 and December 2023. The patients had symptoms such as cervical radiculopathy and myelopathy due to cervical disc herniation, stenosis, and spondylosis. We evaluated the preoperative and postoperative Japanese Orthopedic Association (JOA) scores, neck disability index (NDI), functional rating index (FRI), and visual analog scale (VAS) scores for the neck, shoulder, and upper extremities at 6 months and 1 year after surgery. Fusion rates were assessed using dynamic radiography and computed tomography (CT) scans at 1 year postoperatively. Radiological measurements were obtained from preoperative and postoperative plain radiographs. At the 1-year follow-up, the fusion rates were 89.5% for BGS-7 and 92.2% for the allograft cage on dynamic radiographs (p=0.156) and 93.4% and 90.4%, respectively, on CT scans (p=0.319), confirming both internal and external osseointegration. Subsidence rates were 4% for BGS-7 and 10% for the allograft spacer group. Both groups showed increased cervical lordosis (CL), segmental lordosis (SL), and segmental height postoperatively, with maintained lower segmental height (LSH) in the BGS-7 group than in the allograft spacer group at postoperatively 1 year. No adjacent segmental disease (ASD) occurred in either group. The JOA, NDI, and FRI showed significant improvements in both groups. The VAS scores decreased significantly in both groups, indicating improved clinical outcomes. In multilevel ACDF, BGS-7 demonstrated fusion rates comparable to those of the allograft spacer with IBG, experiencing fewer instances of subsidence and cage fracture. Therefore, BGS-7 spacer can be safely utilized in multilevel ACDF as a substitute for traditional allograft spacers, without the need for additional IBG.

Closed reduction and internal fixation for tillaux fractures, based on pre-operative three-dimensional computed tomography.

This study aimed to propose treatment protocol and identify patterns of tillaux fractures using three-dimensional (3D) computed tomography (CT) analysis and to describe an effective reduction technique. Forty-two juvenile patients with tillaux fractures were evaluated with 3D-CT scan for fracture displacement pattern and received surgical treatment. Tillaux fragment was reduced by pushing the superomedial quadrant part of the fragment slightly downward towards the ankle joint from anterolateral to posteromedial through 5-mm skin incisions with mosquito forceps. A 4.0 cannulated screw was subsequently inserted from the anterolateral to the posteromedial side parallel to the ankle joint. We analysed the distance and direction of fracture displacement with 3D-CT before the surgery. Pre-operative and post-operative plain radiographs were evaluated. Pre-operative 3D-CT analysis revealed a common fracture pattern, varus tilt, and external rotation of fragment. We achieved satisfactory reduction with residual fracture gaps less than 2mm in 42 cases. Two cases had a 13-mm anterior gap that was reduced by mini-open reduction because of periosteal impingement. No significant clinical complications were found. The closed reduction technique developed based on the fracture pattern identified by 3D-CT anatomical analysis is safe and effective in treating tillaux fractures.

Digital protractor as an intraoperative guide to cup anteversion in total hip arthroplasty

IntroductionTo explore if digital protractor could guide the anteversion of acetabular cup during primary THA and make it consistent with preoperative.MethodsWe retrospectively reviewed 172 cases of primary THA with direct anterior approach (DAA) over 2 years. The anteversion of acetabular cup were measured from computed tomography (CT) scan preoperative and de-identified plain radiographs postoperative by two blinded investigators who were not involved in the surgery. The effect of the digital protractor on the anteversion was determined using regression analysis.ResultsThe mean anteversion for the THAs in digital protractor group was 15.5°and 21.4°in control group (P < 0.01). The mean anteversion bias for the THAs in digital protractor group was 1.59° and 6.63° in control group (P < 0.01).Regression analysis identified a 10.7% difference in anteversion due to the use of digital protractor (P < 0.01), and THAs performed without digital protractor were six times more likely to result in anteversion of > 25°. The correlation coefficient for the interobserver reliability of the measurement of the two investigators was 0.94.ConclusionThe digital protractor is a practical tool in the DAA for THA to determine the anteversion of the acetabular prosthesis.

Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study.

The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures. Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups. There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost. Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.

Predictors of Intraoperative and Early Complications in Total Ankle Replacement

Category: Ankle Arthritis; Ankle Introduction/Purpose: Predictors of intra operative and early complications following total ankle replacement (TAR) become more important as the incidence and indications for TAR continue to expand. Talar bone loss whether from avascular necrosis, osteoarthritis, or post traumatic arthritis can be a challenging problem to deal with in TAR. The aim of this study is to report predictors of complications in TAR with talar bone loss. Methods: A retrospective review using CPT codes for four surgeons over a three-year period at an academic institution was performed. A single surgeon reviewed the immediate preoperative plain radiographs for 200 consecutive patients for talar bone loss. The mortise and lateral views were used to calculate talar bone loss and then averaged (Fig 1). 37 patients were identified as having talar bone defects of greater than 20 percent when the two measurements were averaged. Our preoperative variables we looked at were size of talar defect, location, and cause of talar defect and postoperatively, the implant choice. Our primary outcomes were intraoperative fracture, reoperation, subsidence, and revision surgery. Results: The average follow up was 23 months. The average defect size was 54 percent with a range of 20 to 100 percent. Mann U Whitney tests were performed that showed a relationship between the lateral and overall percentage of talar bone loss being predictive of subsidence of the talar component. A Fischer exact test showed a that a chamfered talus cut was protective against subsidence. The mean of the talar bone loss for the chamfered components were 40% versus 58% in flat cut. There were no other significant differences when comparing complications, fracture, reoperation, or wound complications. Conclusion: While TAR for patients with talar bone loss can be a good option for the patient and surgeon it does have a higher complication rate than standard TARs. Careful attention should be given to the percentage of talar bone loss. Flat cut and revision style components were more likely to be used in worse situations, so it is not the authors belief that they are more prone to subsidence. All patients over 20% bone loss need extensive discussion regarding potential complications and additional procedures. Talar bone loss is a difficult problem to deal with but TAR is a viable option.

Hindfoot Alignment and Ankle Stability Following Arthroscopic Lateral Ankle Ligament Repair.

Hindfoot varus deformity is a known risk factor for chronic lateral ankle instability (CLAI). The impact of this deformity on clinical results following arthroscopic lateral ankle ligament repair (ALLR) for CLAI has not been studied. Sixty-three ankles from 62 patients who received ALLR for CLAI were retrospectively examined. Preoperative plain radiographs were used to measure tibial articular surface (TAS) angles, and long axial hindfoot alignment radiographs were used to measure tibiocalcaneal angles (TCAs) pre- and postoperatively. Results included ratings on the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and recurrent ankle instability (respraining of the operated ankle following surgery). Recurrent ankle instability, defined as incidence of any new ankle sprain after surgery reported in the follow-up period, occurred in 13 ankles. The TAS angles of these patients were significantly low, and their preoperative TCA was significantly high. Multivariate analysis showed that preoperative TCA was an independent risk factor for recurrent ankle instability. The threshold values for preoperative TCA for recurrent instability were determined via the receiver operating characteristic curve analysis to be 3.4 degrees. Patients were assigned to a low- or high-TCA group based on the reported average TCA (2.7 degrees) of healthy patients. In the high-TCA group, recurrent instability was significantly more frequent, and the scores on the pain subscale of the postoperative SAFE-Q were significantly lower. Hindfoot varus alignment was associated with pooreroutcomes after ALLR. Level III, retrospective comparative study.

Iliac vein compression syndrome by lumbar degenerative changes is associated with deep vein thrombosis after total knee arthroplasty.

This study aimed to identify whether iliac vein compression syndrome(IVCS) is associated with deep vein thrombosis(DVT) after total knee arthroplasty(TKA) and whether lower lumbar degenerative changes were risk factors for IVCS. A total of 259 consecutive patients who underwent TKA from January 2019 to March 2022 was retrospectively reviewed. Preoperative plain radiographs of lumbar spines and CT venography (CTV) for DVT diagnosis at postoperative 7days were performed in all patients. Imaging findings of lower lumbar degenerative changes were analyzed on plain radiograph including lateral osteophytes, scoliosis, lateralolisthesis, retrolisthesis, anterolisthesis, and lower lumbar lordosis angle (LLLA). Percent compression at the left common iliac vein (LCIV) and right common iliac vein (RCIV) as well as DVT were evaluated on CTV. Moreover, IVCS was defined as greater than 50% of compression of the iliac vein on CTV. DVT occurred in 79 patients (30.5%) after TKA. The overall occurrence of DVT was significantly higher in patients with IVCS of LCIV (52.8%) than those without (18.8%, P < 0.001). When DVT was further subdivided, compared to non-IVCS, IVCS of LCIV was significantly associated with bilateral DVT (P < 0.001, both), especially distal DVT (P < 0.001, both), and IVCS of RCIV was significantly associated with right-side DVT (P = 0.031), especially popliteal (P = 0.008) and distal DVT(P = 0.011). Female patients (OR: 3.945, P = 0.039), presence of left osteophyte (OR: 2.348, P = 0.006), and higher LLLA (OR: 1.082, P < 0.001) were significantly associated with IVCS of LCIV, and presence of right osteophyte (OR: 3.494, P = 0.017) was significantly associated with IVCS of RCIV. IVCS was significantly associated with DVT after TKA and lumbar degenerative changes with lateral osteophytes and hyperlordosis were significant risk factors for IVCS.

Scoliosis in osteogenesis imperfecta: results of posterior spinal fusion in 39 patients.

To evaluate the outcomes of scoliosis corrective surgery in Osteogenesis Imperfecta (OI) patients with primarily pedicles screw fixation in terms of correcting and maintaining the correction of the spinal deformity, and to assess for several peri-operative parameters and complications associated with this surgical treatment. Retrospective case series of 39 consecutive patients with OI treated surgically for scoliosis. The surgeries were performed between 2002 and 2020 by three different surgeons. All patients' medical peri-operative and post-operative charts were evaluated. Radiological assessment was performed by evaluation of the pre-operative, immediate post-operative and last follow-up plain radiographs. There were 20 females and 19 males included in this review with a mean age of 14years (range, 6-20years) at the time of surgery. The median follow-up time was 7.9years. The mean pre-operative cobb angle (CA) of the major curve was 76.5 degrees (SD ± 18.9), decreasing to 42.6 (SD ± 17.4) in the long-term post-operative follow-up (P < 0.001). A total of 21 adverse events in 16 patients were noted. Only 4 patients required subsequent invasive surgical treatment or prolonged hospital stay. All other patients were treated conservatively with no lasting complication. Scoliosis surgical correction in OI patients seems to yield acceptable results, with maintained coronal plane surgical correction in the long-term follow-up. Even though a high peri-operative complications rate is observed in this series, there were no long-term sequelae or lasting complications. Level IV, Case series.

A Demographic Survey of Pertrochanteric Fractures Based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification Using 3D CT Scan Images.

Introduction A demographic survey of femoral pertrochanteric fractures provides several important information for the healthcare system of a country since this fracture is commonly seen in the elderly and has a poor postoperative functional prognosis that is a burden on society. The importance of accurately classifying pertrochanteric fractures as stable or unstable cannot be understated. However, the use of plain radiograph images alone is known to underestimate fracture severity with low inter- or intra-observer agreement. Computedtomography (CT) images offer information for a more accurate classification of pertrochanteric fractures. With this three-dimensional (3D) CT-based study using the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, the purpose of this study is to elucidate the epidemiological demography of patients with pertrochanteric fractures. Material and methods We retrospectively collected 808 patients from five hospitals, classified into two groups: stable (A1) or unstable (A2). Age, gender, fracture laterality, and surgerytiming were identified as epidemiological variables. Patients with both preoperative plain radiographs and 3D CT scans were included in the study. The exclusion criteria were AO/OTA A3 type fractures, pathological fractures, previous ipsilateral surgery, 60 years old or younger, and conservatively treated patients. The primary outcome involved detailing the total number of fractures based on classification (A1 or A2) and variables. The secondary outcome involved a comparison between the A1 and A2 groups. Results The mean age of patients at the time of surgery was 85 years (range: 61-103 years). There were 637 female and 171 male patients. There were 463 left-sided fractures and 345 right-sided fractures. Of the 808 patients, 371 (45.9%) were classified to have A1 fractures, and 437 (54.1%) had A2 fractures. The age at surgery, gender, fracture laterality, and surgerytiming between the A1 and A2 groups were compared. The mean and standard deviation of the age at surgery for patients in the A1 and A2 groups were 84.9±7.7 and 86.9±6.8, respectively. The number of patients for each age distribution of 61-69, 70-74, 75-79, 80-84, 85-89, 90-94, and 95 or older for the A1 and A2 groups was 18 and 7, 18 and 12, 43 and 44, 76 and 82, 107 and 132, 79 and 110, and 30 and 50, respectively, showing that the difference in categorial distribution was statistically significant (p=0.002). Overall, 278 females and 93 males were classified to have A1 fractures compared with 359 females and 78 males with A2 fractures (p=0.01). There were 166 right-sided and 205 left-sided stable A1 fractures and 179 right-sidedand 258 left-sided A2 fractures (not significant (NS)). Among the total number of A1 and A2 surgeries by month, the most were in December with 77 surgeries(37 and 40, respectively), and the least was in June with 37 (18 and 19, respectively). The seasonal classification for A1 and A2 surgeries is as follows: spring with 172 (74 and 98, respectively), summer with 150 (70 and 80, respectively), autumn with 193 (90 and 103, respectively), and winter with 208 (97 and 111, respectively) (NS). Conclusion In this demographic study of 808 patients with pertrochanteric fractures classified by 3D CT images, 371 had A1 fractures and 437 had A2 fractures. A2 fractures were significantly more in females with an age peak of 85-89 years.

Microscopic Unilateral Approach for Bilateral Decompression of Lumbar Spinal Stenosis.

This is a study based on single-surgeon data on spinal stenosis surgery via microscopic approach. The aim is to evaluate the effectiveness of the unilateral approach to bilateral decompression and the usage of Taylor retractors and brain spatula in patients with spinal stenosis. This is a retrospective study on bilateral decompression for lumbar spinal stenosis using a microscopic unilateral approach by a single surgeon, between April 2015 and March 2018. In total, 50 patients were operated due to single level lumbar spinal stenosis. All patients were evaluated by preoperative and postoperative plain radiographs and magnetic resonance (MR) images. Walking distance (WD), visual analog scale (VAS) for pain and Odom's criteria were evaluated for follow-up. One level of the lumbar spine was surgically decompressed in all patients. The median age of patients was 64.6 (51- 82). Of the patients, 72% (36) were women, and 28% (14) were men. Most patients had refractory low back pain (96%) after conservative treatment. The stenotic levels of the cases were as follows: L3-4, 23(46%); L4-5, 24(48%); and L5-S1, 3 (6%). VAS scores decreased in all patients after surgery. According to Odom's criteria, an excellent or good score was found in 43 patients at the 12th follow-up examination. WDs increased up to 1000 meters for 41 patients. The microscopic unilateral approach to bilateral decompression is an effective method for decompression in spinal stenosis. Via this approach, surgical trauma is reduced and surgically induced instability is avoided as much as possible.

Does Sesamoid Pathology Adversely Impact Outcomes of Cheilectomy in the Treatment of Hallux Rigidus?

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is the most common degenerative pathology of the foot, marked by degenerative osteoarthritis of the first metatarsophalangeal joint (MTPJ) and reduced sagittal motion. Cheilectomy remains the standard of treatment, with satisfactory pain relief and increases in MTPJ range of motion (ROM). While the majority of these patients have satisfactory outcomes, a subset remains dissatisfied with persistent pain and poor ROM. In this study, we aim to assess the effect of sesamoid pathology on the functional outcomes of those undergoing cheilectomy for hallux rigidus. Methods: Electronic medical records were retrospectively reviewed to identify patients who underwent cheilectomy, with or without a corrective osteotomy (Moberg or Akin) for a diagnosis of HR, identified through CPT code 28289. The data referenced was from November 2019 through November 2021, belonging to three fellowship-trained foot and ankle specialists at a single high volume orthopedic practice. Exclusion criteria included revision procedures, loss of follow-up prior to one year, and prior sesamoidectomy. Our assessment included the presence of sesamoid arthritis or degeneration, demographic data, stage of HR according to the Coughlin and Shurnas classification on preoperative plain radiographs, a patient-reported pain scale, postoperative satisfaction, ROM, and return to activity. Patients were followed at 6 weeks, 3 months, 6 months, and 1 year. Complications were recorded. Statistical analysis was performed using Pearson's chi-square analysis and a two-sample t-test with significance set at alpha &lt;0.05. Results: In this retrospective study, 74 patients who underwent cheilectomy for the treatment of hallux rigidus were examined; 1 with grade 0 HR, 7 with grade 1 HR, 51 with grade 2 HR, and 15 with grade 3 HR. There were 33 with radiographic evidence of sesamoid arthritis, 41 without. Those with sesamoid arthritis trended towards having less pain relief over the course of our study (p=0.290) and more restricted postoperative ROM (p=0.385), though neither reached significance. There was no difference in complication rates between the two groups (p=0.661). Conclusion: The presence of sesamoid pathology appears to trend towards worse outcomes after cheilectomy for the treatment of hallux rigidus. Patients with sesamoid pathology may go unrecognized and may warrant consideration for modalities of treatment beyond cheilectomy for hallux rigidus for more satisfactory outcomes. This study is limited in its power and would benefit from greater sample sizes and more objective parameters of measurement. Nonetheless, this data allows for recognition of these patients in whom cheilectomy does not result in pain relief with the goal of identifying factors to improve care and provide sufficient treatment.

Plain Radiographs are Insufficient for Evaluation of First Metatarsal Pronation in Patients Undergoing Surgery for Hallux Valgus

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Previous studies using weight-bearing CT (WBCT) have suggested that up to 30% of patients with hallux valgus may have excessive pronation of the first metatarsal when defined as a metatarsal pronation angle (MPA) of greater than 16 degrees (Najefi et al.). The MPA is calculated on coronal slices of a CT or MRI, but axial imaging is not the norm in the assessment of these patients. It is however unclear how accurate radiographs are at determining pronation. This study aimed to assess the degree of pre-operative first metatarsal pronation in patients undergoing surgery for hallux valgus using radiographs and WBCT. Methods: This was a retrospective review of patients undergoing scarf osteotomy for hallux valgus correction. Patients were included if they had both plain radiographs and WBCT. Patients were excluded if they had any prior surgery to the foot in question. Pre-operative weightbearing plain radiographs of the foot were analyzed and the classification by Okuda et al. was used to determine if pronation was present using the shape of the lateral edge of first metatarsal head. Pre-operative WBCTs were reviewed and MPA calculated. Twenty-two feet were included. Results: In total 10 feet (45.5%) had an ‘angular’ first metatarsal head, 9 (40.9%) had an ‘intermediate’ head shape, and 3 (13.6%) had a ‘round’ head on plain radiographic assessment. The overall mean MPA was 16.25 degrees (range 2.1-30), and 12 (54.5%) feet had an MPA of greater than 16 degrees (excessively pronated). There was a strong correlation between increasing MPA and increasing roundness of the metatarsal head (Eta = 0.952). The mean MPA was 14.4 degrees in the angular head group, 17.0 degrees in the intermediate group, and 20.1 degrees in the round head group. In the intermediate and round groups 9 feet (75%) had greater pronation than the normal range. By contrast, only 3 (30%) of feet in the round head group had pronation greater than 16 degrees. Conclusion: In this surgical population of hallux valgus patients, the overall prevalence of excessive first metatarsal pronation was greater than in general cohorts of hallux valgus patients. Patients with intermediate and round shaped heads on plain radiographs tended to have greater first metatarsal pronation than those with angular shaped heads, although the correlation was not perfect. This suggests that plain radiographic assessment of metatarsal rotation may not be accurate as there may be discrepancies due to changes in foot position or angle of beam while acquiring the radiographs. Although further work is still required to determine whether there is clinical benefit from addressing the pronation, axial imaging (such as with WBCT) may be useful in the intermediate and round groups for accurate assessment of pronation and to determine if it is significant. This may be especially relevant in surgical candidates in whom osteotomies such as a scarf are being considered, where pronation cannot be addressed.

Management, Complications, and Radiographic Follow-Up of Total Ankle Arthroplasty in the Setting of Talar Bone Loss

Category: Ankle Arthritis; Ankle Introduction/Purpose: As the incidence and indications for total ankle arthroplasty (TAA) continue to expand the need to better understand the properative risk factors becomes increasingly important. Talar bone loss whether from avascular necrosis, osteoarthritis, or post traumatic arthritis can be a challenging problem to deal with in TAA. The aim of this study is to report the operative characteristics, clinical complications, and radiographic changes in patients’ status post TAA in the setting of talar bone loss. Methods: A retrospective review using CPT codes for four surgeons over a three year period at an academic institution was performed. A single surgeon reviewed the immediate preoperative plain radiographs for 200 consecutive patients captured by the CPT codes for talar bone loss. The mortise and lateral views were used to measure the lesions and an example measurement is shown in Figure 1. 38 patients were identified as having talar bone defects of greater than 20 percent when the two measurements were averaged and the depth of the penetrance was categorized by dividing the talus into thirds. A chart review was then performed that included demographic information, additional procedures at the primary procedure, use of adjuvants, reoperation rates and, subsidence rates. Results: The average patient age and follow up were 59 years and 23 months respectively. The average defect was 44 percent with a range of 20 to 100 percent. 16 out of 38 defects were contained to the upper third of the talus and 17 had a corresponding tibial lesion. Overall the reoperation rate was 34 percent with the plurality being I&amp;Ds of both superficial and deep infections. Two patients ended up with below knee amputations. Subsidence of talar components occurred at a rate of 43 percent with about half of these having a reoperation. 68 percent of the patients had additional procedures such as tendo achilles lengthening, lateral ligament reconstruction, and various osteotomies. 35 percent of talar components were cemented and there was an intra operative complication rate of 14 percent with the most common being intra operative fracture. Conclusion: While TAA for patients with talar bone loss can be a good option for both the patient and surgeon it has a higher complication rate in our series than previously described. Careful surgical strategy including implant choice is paramount and the need for additional procedures should be considered.

Delayed Repair of a Lesser Tuberosity Avulsion Fracture in an Adolescent 3 Years After Initial Injury.

This case study examines an adolescent athlete who had an avulsion fracture of the lesser tuberosity of the humerus. This is a relatively rare injury, although a collection of case studies have identified an increase in this type of injury in the past 15 years. Uniquely, the patient experienced a delay in appropriate diagnosis for approximately 3 years from the time of his initial injury. This is one of the most significant delays in diagnosis and treatment in the current body of literature regarding lesser tuberosity fractures. The authors include a detailed series of imaging studies, including preoperative plain radiographs, preoperative computed tomography, intraoperative arthroscopic images, and postoperative plain radiographs. In addition, a thorough description of the patient's surgery is presented. The degree of scarring to the axillary nerve present in this patient required conversion to a full open reduction. The authors' aim is that this case can be used as a reference for future surgical decision making, particularly in pediatric patients whose injuries are highly chronic or who are actively involved in athletic physical training programs. [Orthopedics. 2023;46(3):e189-e192.].

Reliability improvement in Hallux Valgus measurement using weight-Bearing CT scan.

Background: Radiographic assessment of hallux valgus is an essential process. Residual rotational deformity was shown associated with higher recurrent rate. This study aims to comprehensively assess reliability of measurement of various parameters from plain films and weight-bearing CT scan. Methods: A total of 40 pre-operative plain radiographs, 40 post-operative plain radiographs, and 37 weight-bearing CT scan were evaluated to determine reliability of hallux valgus parameters. Results: TSP and head shape representing coronal plane deformity showed lower inter-observer reliability compared to other parameters using for transverse plane evaluation especially in post-operative period. (post-op TSP amongst 3 assessors: κ = 0.386, 0.520, 0.340; post-op head shape: κ = 0.374, 0.375, 0.295) Using α angle for evaluation 1st metatarsal rotation in weight-bearing CT scan demonstrated very good reliability for inter-observer (ICC = 0.853 (95% CI = 0.715-0.925)) and intra-observer (ICC = 0.902 (95% CI = 0.844-0.939)). Conclusion: Weight-bearing CT scan can improve reliability in post-operative coronal plane assessment.

The Efficiency and Reliability of Minimally Invasive Anterior Corpectomy and Percutaneous Posterior Stabilization for the Treatment of Unstable Thoracolumbar Burst Fractures

The purpose of this study was to evaluate the radiological and clinical outcomes of minimally invasive anterior corpectomy and percutaneous posterior stabilization for treating unstable thoracolumbar burst fractures. Patients with unstable thoracolumbar burst fractures who underwent minimally invasive anterior corpectomy and percutaneous posterior stabilization between 2012 and 2019 at a tertiary hospital were enrolled. Radiological outcomes such as endplate subsidence and fusion status were identified on preoperative and postoperative plain radiographs and computed tomography images. Preoperative and postoperative neurological statuses were evaluated using the American Spinal Injury Association impairment scale. Furthermore, operation-related parameters were analyzed. In total, 21 patients (mean follow-up period, 21.7months) were included in this study. Of them, 17 (80.95%) patients exhibited complete fusion according to the Bridwell's criteria at the final follow-up, and only 1 patient exhibited nonunion at the surgical level. Endplate subsidence was observed in 6 (28.57%) patients; however, there were no definite symptoms that would have necessitated a revision surgery. Of 15 patients with preoperative neurological impairment, 7 exhibited neurological improvement during follow-up. None of the patients experienced postoperative neurological deterioration. Regarding operation-related parameters, the mean operative time and intraoperative blood loss were 266.19±51.54min and 520.71±190.86ml, respectively. The mean length of hospital stays and days to postoperative ambulation were 12.14 and 4.20days, respectively. Minimally invasive anterolateral corpectomy with percutaneous pedicle screw fixation is a reliable surgical treatment option for unstable thoracolumbar burst fractures.

Results of the osteochondral autologous transplantation for treatment of osteochondral lesions of the talus with harvesting from the ipsilateral talar articular facets.

There are few studies on the clinical outcomes of osteochondral autologous transplantation (OAT) harvesting from local talar non-weight-bearing articular facets for the treatment of osteochondral lesions of the talus (OLTs). The purpose of this study was to review the short- to midterm outcomes of our patients who were treated with OAT harvesting from ipsilateral talar articular facets for OLTs. Between December 2010 and November 2018, 24 patients were enrolled in this study. There were 16 males and eight females with an average age of 39.1years and a follow-up period of 50.9months. The clinical results were evaluated according to the American Orthopedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS) score. Pre-operative plain radiographs and magnetic resonance imaging (MRI) scans, post-operative radiographs, and X-ray and computed tomography (CT) scans at the last follow-up were observed. There was a significant improvement in the AOFAS score from 61.3 ± 19.0 pre-operatively to 84.9 ± 9.2 post-operatively (P < 0.001). The VAS score improved from 6.1 ± 2.3 to 2.0 ± 1.4 at the last follow-up (P < 0.001). Twenty-one patients (87.5%) were satisfied with their clinical results. By the last follow-up CT scan, there was bone cyst formation at the donor sites in three patients, at the recipient sites in five patients and at both sites in five patients. Two patients (8.3%) underwent re-operation with arthroscopic debridement because of medial gutter hypertrophic soft tissue impingement. OAT harvesting from the ipsilateral talar articular facet showed satisfactory results. The mean post-operative VAS score and AOFAS ankle-hindfoot score improved significantly. Post-operative impingement around the osteotomy site was the main complication and reason for re-operation after the index procedure. In addition, bone cysts at the recipient and/or donor site(s) were found with a large percentage under CT. Therefore, longer follow-up is necessary to determine the long-term clinical results for this technique.

Relationship between the Hamada Grade and underlying pathological conditions in the rotator cuff and long head of biceps in symptomatic patients with rotator cuff tears.

BackgroundThis study aimed to investigate the relationship between Hamada Grade and rotator cuff and long head of the biceps (LHB) pathologies in symptomatic patients with rotator cuff tears (RCTs).MethodsWe retrospectively reviewed 376 patients (156 men and 220 women; mean age, 68.4 years) who had undergone surgery for complete RCTs. Preoperative plain radiography, magnetic resonance imaging, and intraoperative findings were assessed. All cases were allocated to the Hamada Grade 1, 2, 3, and 4-5 groups to investigate the correlation between Hamada Grade severity and underlying rotator cuff and LHB pathologies.ResultsThe rate of RCTs involving the infraspinatus was significantly higher in Grade 2 than in Grade 1 (P < .0001). The tear size and fatty muscle degeneration of the subscapularis in Hamada Grade 3 were significantly more severe than those in Grade 2 (P = .01 and P < .0001, respectively). The tear size and fatty muscle degeneration of the rotator cuff in Grade 4-5 were significantly more severe than those in Grade 3 (all P < .05). The complete LHB rupture rate was significantly higher in Hamada Grade 4-5 than in Grades 1, 2, and 3 (all P < .001).ConclusionRotator cuff tears involving the infraspinatus were associated with Hamada Grade 2. The rate of concomitant subscapularis tears with posterosuperior RCTs was significantly higher in Hamada Grade 3 than in Hamada Grade 2. RCT enlargement, progression of fatty muscle degeneration of the subscapularis and posterosuperior rotator cuff muscles, and the increase in complete LHB rupture were associated with Hamada Grade 4-5.

Acetabular retroversion is prevalent and proportional to the severity of slipped upper femoral epiphysis.

AimsSlipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes’ disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements.MethodsA retrospective review of all SUFE surgical cases presenting to the Royal Children’s Hospital, Melbourne, Australia, from 2012 to 2019 were evaluated. Preoperative plain radiographs were assessed for slip angle, validated radiological signs of retroversion, and standardized postoperative CT scans were used to assess cranial and mid-acetabular version.ResultsIn all, 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 (52%) were male, with a mean age of 12.7 years (7.5 to 16.6). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. Overall, 82 patients (82%) underwent pinning in situ (PIS), with subcapital realignment surgery (SRS) performed in 17 patients (18%) (slip angles > 75°). Contralateral prophylactic PIS was performed in 72 patients (87%). On the slip side, 62 patients (68%) had one or more radiological sign of retroversion. Tomographical acetabular retroversion was more pronounced cranially than caudally of the acetabulum on both the affected side and the contralateral side (p < 0.001) as expected in the normal population. Increasing severity of the slip was found to be directly proportional to the degree of reduction in cranial and central acetabular version (p < 0.05) in the SUFE hips.ConclusionAcetabular retroversion is more prevalent in patients with SUFE than previously reported, and have been shown be correlated to the severity of the slip presentation. The presence of radiological signs of acetabular retroversion could be used to justify prophylactic contralateral pinning.Cite this article: Bone Jt Open 2022;3(2):158–164.

Differences in knee joint degeneration between primary hip osteoarthritis and hip osteoarthritis secondary to hip developmental dysplasia: A propensity score-based analysis

Objectives This study aimed to investigate differences in lower limb alignment and the prevalence of knee osteoarthritis (OA) among patients with primary hip osteoarthritis (PHOA) versus those with hip osteoarthritis secondary to developmental dysplasia of the hip (DDH-OA). Methods We compared 83 patients who underwent primary total hip arthroplasty for unilateral PHOA or DDH-OA after performing propensity score matching. The prevalence of knee OA and lower limb alignment were evaluated on preoperative plain radiographs. Results The prevalence of knee OA on the ipsilateral side was significantly higher in the PHOA group than in the DDH-OA group (p =.019), whereas there was no difference between the groups on the contralateral side (p = .631). Lower-limb alignment was more valgus on the ipsilateral side in the DDH-OA group than the PHOA group, whereas it was not significantly different on the contralateral side between groups. Conclusion The prevalence of knee OA and lower-limb malalignment on the ipsilateral side of hip OA were different for PHOA and DDH-OA patients. Shifting the mechanical axis of lower limbs might be associated with the prevalence of knee OA and lower limb malalignment in the presence of unilateral hip OA.