Proximal Osteotomy Research Articles

Modified Proximal Scarf Osteotomy for Hallux Valgus.

BackgroundWe developed a modified proximal scarf osteotomy technique for moderate to severe hallux valgus in an attempt to obtain better correction of the deformity. In addition, we compared the clinical and radiographic results of this modified technique with those of the classic scarf osteotomy reported in other studies.MethodsBetween December 2004 and July 2009, 44 cases of modified proximal scarf osteotomy was performed in 35 patients with moderate hallux valgus. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, range of motion of the first metatarsophalangeal joint, and radiographic results were evaluated.ResultsThe mean hallux valgus angle and the mean first intermetatarsal angle improved from an average of 32.2° and 14.3°, respectively, to an average of 12.5° and 8.6°, respectively. The distal metatarsal articular angle improved from an average of 18.7° to 12.4°. The preoperative mean AOFAS and VAS scores were 47 points and 7 points, respectively, which improved to 86 points and 1 point, respectively, at the final follow-up. Limited range of motion occurred in two cases postoperatively. The height of the first metatarsal-cuneiform joint, which was an average of 15.9 mm preoperatively, did not change. The first metatarsal-talus angle increased from an average of 4.1° to 7.1°.ConclusionsThe modified proximal scarf osteotomy for the treatment of moderate hallux valgus showed similar results with the classic scarf osteotomy with regard to changes in the first intermetatarsal angle and postoperative satisfaction. Therefore, we suggest the modified proximal scarf osteotomy be considered as well as other proximal osteotomy in the treatment of moderate to severe hallux valgus.

Distances from the deep plantar arch to the lesser metatarsals at risk during osteotomy: a fresh cadaveric study

BackgroundThe deep plantar arch is formed by anastomosis of the lateral and deep plantar arteries. Osteotomy of the lesser metatarsals is often used to treat metatarsalgia and forefoot deformity. Although it is known that some blood vessels supplying the lesser metatarsals are prone to damage during osteotomy, there is little information on the distances between the deep plantar arch and the three lesser metatarsals. The aims of this study were to identify the distances between the deep plantar arch and the lesser metatarsals and to determine how osteotomy could damage the arch.MethodsEnhanced computed tomography scans of 20 fresh cadaveric feet (male, n = 10; female, n = 10; mean age 78.6 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery, and the distance from the deep plantar arch to each lesser metatarsal was measured on axial and sagittal images.ResultsThe shortest distances from the deep plantar arch to the second, third, and fourth metatarsals in the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The shortest distances from the distal epiphysis to a line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal in the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the tarsometatarsal joint were 23.0, 21.0, and 18.6 mm. The deep plantar arch ran at the level of the middle third, within the proximal portion of this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) specimens, respectively, and at the level of the proximal third in 9/20 (45.0%), 13/20 (65.0%), and 11/16 (68.8%).ConclusionsOverpenetration into the medial and plantar aspect of the second metatarsal or the proximal and plantar aspect of the fourth metatarsal during shaft or proximal osteotomy could easily damage the deep plantar arch. Shaft or proximal osteotomy approximately 45–47 mm proximal to the distal epiphysis or 18–23 mm distal to the tarsometatarsal joint on the plantar aspect could interrupt blood flow in the deep plantar arch.

Entry points of nutrient arteries at risk during osteotomy of the lesser metatarsals: a fresh cadaveric study

BackgroundOsteotomies of the lesser (second to fourth) metatarsals are often used to correct forefoot deformities. However, certain areas of the lesser metatarsals where arteries may be prone to damage during surgery, and the resulting nonunion and delayed union could cause serious problems. This study sought to identify the nutrient arteries of the lesser metatarsals and to determine how osteotomy could injure these vessels.MethodsEnhanced computed tomography scans of 21 ft (male, n = 10; female, n = 11; mean age 78.6 years at the time of death) were assessed. Twenty-one lower limbs in 21 cadaveric specimens were injected with barium via the external iliac artery, and the points at which the nutrient arteries entered the lesser metatarsals were identified on axial and coronal images.ResultsEach nutrient artery entered the lateral or medial plantar aspect of the lesser metatarsal in the middle third (just proximal to the middle point of the metatarsal) or proximal third obliquely from a distal direction. The mean ± standard deviation (SD) distances from the dorsal plane of the second, third, and fourth metatarsals to the point of entry of the nutrient artery in the axial plane were 8.2 ± 1.5, 7.6 ± 1.2, and 7.6 ± 1.5 mm, respectively. The mean ± SD distances from the distal epiphysis to the point of entry of the nutrient artery into the second, third, and fourth metatarsals in the coronal plane were 3.3 ± 1.1, 3.1 ± 1.0, and 2.8 ± 1.2 mm, respectively. The mean ± SD distances from the distal epiphysis to the point of entry of the nutrient artery into the second, third, and fourth metatarsals in the coronal plane were 46.0 ± 5.2, 40.9 ± 2.6, and 39.1 ± 3.7 mm, respectively. The mean ± SD distances from the proximal epiphysis to the entry point of the nutrient artery into the second, third, and fourth metatarsals in the coronal plane were 23.8 ± 4.7, 25.8 ± 4.3, and 25.0 ± 3.2 mm, respectively.ConclusionsDistal metatarsal osteotomies might be safer than shaft or proximal osteotomy to avoid disruption of the nutrient artery, leading to delayed consolidation of the osteotomy and nonunion.

Recurrent Hallux Valgus

Category: Bunion Introduction/Purpose: Recurrence of hallux valgus deformity can be a common complication after corrective surgery. The cause of recurrent hallux valgus is usually multifactorial, and includes patient-related factors such as preoperative anatomic predisposition, medical comorbidities, post-operative compliance, as well as surgical factors. This study examines a single surgeon’s consecutive series of corrective surgical cases for recurrent bunion deformity over a 15-year time span. The purpose of the study is to report on common characteristics of patients with symptomatic recurrent hallux valgus deformity, average time to recurrence defined as the time from index surgery to revision surgery, and identify potential associations or risk factors with respect to time to recurrence and revision surgery type. Methods: A single board certified foot and ankle orthopaedic surgeon’s clinical charts and operative findings were compiled in a database over 15 years spanning from 2001 to 2016. 300 patients with recurrent hallux valgus diagnoses were identified and 254 had complete data. Revision surgeries included corrective surgery on the first ray, midfoot, or the forefoot as a result of prior hallux valgus surgery. Patient factors analyzed included diabetes, gender, smoking status, rheumatoid disease, neuromuscular disease, age at index surgery, index surgery, and number of prior surgeries. Preoperative revision surgery radiographic parameters measured included hallux valgus angle (HVA), inter-metatarsal angle (IMA), and sesamoid station. Revision surgery type and number of revision procedures were also logged. Full linear regression models were generated. The first model predicts the time to recurrence in months, while the second produced models that reported odds ratios of revision surgery Results: Average age at index surgery was 43 years old with 90% female and average BMI of 27 in this cohort. Average time to recurrence after index surgery was 14 years. Average radiographic data at presentation for revision surgery were HVA = 28.6, IMA = 12. Index surgeries included 41% distal osteotomy, 32% simple bunionectomy, while revision/corrective procedures included 35% proximal osteotomy, 44% receiving a 1st MTP/midfoot fusion, and 60% forefoot procedures. 32% required 1st MTP fusion at revision. Diabetes and higher HVA were statistically significant and directly associated with longer time to recurrence. Greater number of surgeries, older age, and index proximal osteotomy were associated with a quicker time to recurrence. Index surgery type did not have a significant association with revision surgery type. Conclusion: To our knowledge this is the largest single surgeon series examining recurrent hallux valgus deformity. Most patients with recurrent symptomatic hallux valgus were women in their 6th decade with relatively normal BMI. Average time from index surgery to revision surgery was 14 years. Several factors including diabetes and greater HVA were associated with longer time to revision, while number of surgeries, older age, and proximal osteotomies were associated with earlier time to revision. 44% of patients required a MTP or midfoot fusion at revision. We did not see an association between type of index surgery and type of revision surgery.

Outcomes Following Surgical Treatment of Hallux Valgus Deformity

Category: Bunion Introduction/Purpose: Hallux valgus (HV) deformity is one of the most common chronic disorders. Surgical correction plays a central role in the treatment of painful HV deformity with over 100 different surgical techniques described in the current literature. In this report we performed a systematic literature review on studies that addressed clinical outcomes following surgical treatment of hallux valgus. The objectives of our study were to (1) describe available study characteristics on surgical HV deformity treatment; (2) determine patients’ postoperative satisfaction including postoperative pain and recurrence of HV deformity; (3) determine rate of postoperative complications by surgery type; and (4) analyze the relationship between radiographic HV deformity parameters and postoperative complication rate. Methods: We reviewed the literature using common data bases. All searches were unlimited. Study demographics were collected and analyzed. Gender distribution was estimated using an inverse-variance weighting method and patient age and follow-up time were summarized using a simple weighted average due to an absence of reporting variance in the majority of studies. A chi- squared Q test, or heterogeneity test, was used to test for differences across surgery types for patient dissatisfaction, deformity recurrence, removal of hardware, reoperation, nonunion, hallux varus, nerve injury, infection, metatarsalgia, and VAS>5. Outcome estimates and 95% confidence intervals (CIs) for each surgery type were pooled across studies using the inverse-variance weighting method. A random effects model was used when study variance was estimated using the DerSimonian-Laird method. Results: In total, 269 studies with 13,112 patients and 16,594 feet were included. Patients treated by simple buniectomy had the highest dissatisfaction rate with 25.5% (95%CI 17.5-35.6). Deformity recurrence was highest in patients treated by proximal osteotomy with 10.5% (95%CI 5.6-18.7). The highest rate of secondary surgery was in patients treated by simple buniectomy with 6.1% (95%CI 2.4-14.7). In the same patient group the highest rate of hallux varus deformity was observed with 9.1% (95%CI 2.9- 24.9). Patients treated by hemi-joint resection had the highest rate of postoperative metatarsalgia with 16.2% (95%CI 11.3-22.8) and persisting pain VAS>5 with 6.5% (95%CI 3.3-12.3). Conclusion: Patients with buniectomy and hemi-joint resection demonstrated the highest rates of postoperative complications including dissatisfaction, need for secondary surgery, postoperative metatarsalgia, and persisting pain.

MIS hallux valgus correction with proximal osteotomy and internal bracing

Most studies of hallux valgus surgery focus on the radiological findings or on medium-term clinical follow-up. The results obtained using various osteotomy techniques do not differ greatly. However, patient comfort and the need for postoperative care do appear to present differences.In the Kramer technique, the osteotomy is secured with a wire extruding from the skin of the foot. In this situation, patients may well experience problems (or at least discomfort) in the immediate postoperative period. Previous studies of the Kramer technique (also known as SERI, or percutaneous distal metatarsal osteotomy) do not report an increased number of complications. Early complications may not influence the outcome in the medium to long term, and patient discomfort during the postoperative period is rarely reflected in the analysis of one-year results obtained with standard scales such as AOFAS; in our experience, however, patient discomfort, the care burden (i.e., the number of visits and emergency service consultations) and the economic cost of immediate postoperative care are all aspects that should be borne in mind when assessing the merits of different surgical techniques.In this study we compare the care burden and economic cost of two surgical approaches to hallux valgus correction – the Kramer and the scarf techniques – during the first postoperative year.Retrospective review of two independent patient cohorts. Sixty-nine feet underwent Kramer osteotomy and 133 the scarf technique. Care burden was assessed by the number of visits each patient required and the complications. The follow-up and costs of each were assessed and compared independently.Both techniques obtain satisfactory clinical results at one year. However, comparison of clinical progression showed AOFAS score increases of 34.7 points for Kramer and 41.1 points for the scarf technique (p-value < 0.05). Patients in the Kramer group required a higher number of visits, especially postoperative emergency department visits (p < 0.05), and had a significantly higher number of complications (27.5% vs. 6.7%, p < 0.05). The mean cost of follow-up was significantly higher in the Kramer group (€ 218.97 vs. € 171.41, p < 0.05).Kramer osteotomy presented significantly higher care burdens, complication rates and associated costs during the first year of follow-up. It is therefore a less cost-effective technique. Thus, even though according to the results of AOFAS we would not have changed our clinical practice, the analysis of these data has made us change our treatment strategy for hallux valgus and practically abandoned the use of the Kramer osteotomies.

Comparison between proximal chevron and distal chevron osteotomy in moderate to severe hallux valgus patients undergoing simultaneous bilateral correction

Comparison between proximal chevron and distal chevron osteotomy in moderate to severe hallux valgus patients undergoing simultaneous bilateral correction

Proximal rotational metatarsal osteotomy for hallux valgus. Case series of a novel technique

Proximal rotational metatarsal osteotomy for hallux valgus. Case series of a novel technique

Is double metatarsal osteotomy superior to proximal chevron osteotomy in the treatment of hallux valgus with increased DMMA

Is double metatarsal osteotomy superior to proximal chevron osteotomy in the treatment of hallux valgus with increased DMMA

Effect of incomplete sesamoid reduction on outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

Effect of incomplete sesamoid reduction on outcomes of proximal chevron osteotomy for moderate to severe hallux valgus deformity

Recurrence after proximal medial opening wedge osteotomy for correction of hallux valgus

Recurrence after proximal medial opening wedge osteotomy for correction of hallux valgus

Outcomes of First Metatarsophalangeal Joint Fusion in Patients with Greater Than Fifteen Percent Intermetatarsal Angle. Is Lag Screw Essential?

Category: Midfoot/Forefoot Introduction/Purpose: Metatarsophalangeal arthrodesis has usually been performed using a dorsal plate to immobilize the MTP joint with or without lag screw fixation. Data in the literature is sparse on outcomes of dorsal plate plus lag screw fixation, especially in patients with IMA greater than 15 percent. Our objective was to compare IMA correction outcomes and union rates between dorsal plate only fusions and dorsal plate plus lag screw fixation in patients with IMA greater than 15 percent. Methods: We retrospectively reviewed the charts of 36 patients (39 feet) who underwent first MTP joint arthrodesis for moderate to severe HV deformity between 2011 and 2015. Average age was 61 (range, 39 to 84) years. There were 24 females and 12 males. A single surgeon performed all operations. Joints were immobilized postoperatively using either dorsal locking plate alone or dorsal locking plate with a lag screw. Union (at least 3 bridging cortices) was determined radiographically at 6 weeks, 3 months, 6 months and yearly. All suspect nonunions were examined with CT. Other radiographic parameters examined included preoperative and postoperative hallux valgus, intermetatarsal, and dorsiflexion angles (HVA, IMA, and DFA respectively). Student’s t test was used to compare group means while Pearson’s Chi square test was used to compare group rates. Results: Overall union rate was 82.1% (32/39). There was no significant difference in union rates between the two groups (dorsal plate only = 81.5% (22/27), dorsal plate plus lag screw group = 83.3% (10/12)) (P &gt; 0.05). Average follow-up was 9 (range 7 to 35) months. Overall, the average IMA correction was 4.7 (preoperative = 17.8, postoperative = 13.1) degrees. Average IMA corrections were 4.7 and 4.54 degrees in the dorsal plate only group and dorsal plate plus lag screw groups respectively. Overall, average HVA correction was 21 (preoperative = 39.5, postoperative = 18.5) degrees. Conclusion: Our findings indicate that there is no difference in the fusion rates between both patient groups with IMA greater than fifteen percent. Because other published studies have a wide range of IMAs preoperatively, our study represents more attainable goals in patients with severe (IMA greater than 15%) deformities. In addition, our findings suggest that in such patients, MTP arthrodesis may not be sufficient as a standalone procedure for correction of IMA. Additional proximal osteotomy may be required for correction of the IMA.

Primary outcomes of femoral head reduction osteotomy for coxa magna or coxa plana

Objective To investigate the clinical efficiency and safety of femoral head reduction osteotomy for young patients with coxa magna or coxa plana. Methods Between June 2012 and September 2015, the clinical characteristics of 12 patients (13 hips) with coxa magna or coxa plana who underwent femoral head reduction osteotomy were analyzed retrospectively. There were 6 males (7 hips) and 6 females (6 hips) with average age 18.1 years (range, 10-25 years). The etiology of the femoral head deformity was multiple epiphyseal dysplasia in 6 hips and Legg-Calve-Perthes sequela in 7 hips. The head reduction osteotomy was conducted through the surgical hip dislocation approach combined with extended retinacular soft-tissue flap extending technique. All patients underwent simultaneous periacetabular osteotomy and relative lengthening of the femoral neck, of which four also underwent proximal femur derotational osteotomy. All patients received the standardized rehabilitation procedures. The postoperative complications, gaits, the range of motion (ROM) of the hip, Harris hip scores, iHOT scores and VAS were analyzed postoperatively. In addition, the lateral center-edge (LCE) angle, sphericity index and coverage rate of femoral head were assessed as well. Results The average follow-up duration was 28.8 months (range, 12-45 months). All patients achieved osteotomy healing of the femoral head and greater trochanter with average healing time 3.7 months (range, 3-7 months). Nine of 12 patients had significant gaits improvement. The Harris hip scores (81.08±12.36 vs. 88.38±8.96, t=2.41, P=0.033), iHOT score (51.90±15.07 vs. 67.69±8.70, t=3.63, P=0.003), LCE angle (-1.82°±16.57° vs. 36.02°±7.72°, t=10.52, P=0.000), sphericity index of anteroposterior pelvic radiographs (71.08%±10.32% vs. 81.22%±8.61%, t=7.17, P=0.000) and the coverage index (48.79%±11.85% vs. 87.46%±10.44%, t=8.56, P=0.000) were all significantly improved when compared to those preoperatively. The VAS score (4.46±2.37 vs. 1.23±0.93, t=4.25, P=0.001) was significantly decreased when compared with that preoperatively. However, for the sphericity index of 65° false profile (78.96%±10.39% vs. 80.36%±8.42%, t=0.411, P=0.688) and the average hip ROM (264.62°±32.05° vs. 255.00°±40.31°, t=0.89, P=0.391), they did not achieve statistical significant difference. One case of femoral head necrosis site was localized at the lateral-superior part of femoral head, and there was no progression after 3 years follow-up. Moreover, no revision or total hip arthroplasty were observed due to other complications (osteoarthritis, hip pain or non-union). Conclusion The femoral head reduction osteotomy can correct deformity, improve femoral head sphericity, relieve pain and improve gaits and hip function. This procedure leads to satisfied clinical outcomes for patients with coxa magna or coxa plana in early follow-up. Key words: Osteochondrodysplasias; Legg-Calve-Perthes disease; Reconstructive surgical procedures; Hip dislocation, congenital

Scarf osteotomy without internal fixation for correction of hallux valgus: A clinical and radiographic review of 148 cases

BackgroundHallux valgus is a common condition with in excess of 120 procedures described in the literature for its correction. Traditionally, distal metatarsal osteotomies have been employed in the treatment of mild deformities, with proximal osteotomies being reserved for more severe presentations. The Scarf osteotomy without internal fixation allows large translations which can successfully correct severe hallux valgus deformities, without limitations related to screw placement. MethodsThis is a retrospective single surgeon case series performed over a three year period. One hundred and forty-eight cases were identified, with an average follow up time of 16.5 months. Visual analogue scales were used to obtain preoperative and postoperative pain and cosmetic scores, with the Foot and Ankle Disability Index (FADI) index used to assess functional status. The hallux valgus angle (HVA) and intermetatarsal angle (IMA) were assessed on preoperative and postoperative AP weight-bearing foot X-rays. ResultsThe mean pain score improved from 7.04/10 preoperatively to 0.29/10 postoperatively. The mean cosmetic score improved from 2.1/10 to 9.1/10 postoperatively. The mean preoperative HVA and IMA were 35.04° and 15.04°, respectively. The mean postoperative HVA and IMA were 11.54° and 4.83°, respectively. The mean postoperative FADI score was 103.4/104. We report a loss of correction in two cases. One revision surgery was performed. ConclusionsWe report a large series of cases of the modified Scarf osteotomy as described by Maestro—a versatile, cost-effective, safe and reliable technique with the potential for three dimensional correction. Whilst this is a technically demanding procedure, we recommend the use of the modified Scarf osteotomy in the treatment of a wide range of hallux valgus deformities.

The effect of valgus and varus femoral osteotomies on measures of anteversion in the dog

To determine whether femoral osteotomies that change frontal plane alignment without affecting torsion influence anteversion and inclination. Femurs without deformity were scanned to create three-dimensional reconstructions. The femoral head-neck axis was identified by placement of a virtual intramedullary pin. A proximal osteotomy was simulated to create three conditions while keeping torsion constant: Normal, Coxa Valga (neck-shaft angle increased by 12°), and Coxa Vara (neck-shaft angle decreased by 12°). Femoral anteversion was measured from an axial image in all three conditions. Femoral inclination was calculated for all conditions using the neck-shaft and anteversion angles. Changes in anteversion and inclination were calculated and compared using a one-way repeated measures analysis of variance. Distal femoral osteotomies were then simulated with the native femurs, inducing 18° of distal varus with no change to torsion. Changes in anteversion and inclination for the Normal and Distal Varus conditions were calculated and compared by a paired t-test. Version changed by a mean of 13.9° (± 1.5; p <0.0001) from the Coxa Valga to Coxa Vara conditions while inclination changed by a mean of 1.3° (± 0.39; p <0.01). Version changed by a mean of 6.6° (± 0.7; p <0.0001) between the Distal Varus and Normal conditions while inclination changed by a mean of -3.8° (± 0.75; p <0.001). Femoral version changes with changing frontal plane alignment even when torsion is constant. This should be considered when correcting femoral deformities.

Ludloff’s diaphyseal osteotomy in the treatment of hallux valgus

Background Proximal first metatarsal osteotomy combined with distal soft tissue procedure is recommended for the surgical treatment of moderate to severe hallux valgus (HV) deformity with increased intermetatarsal (IM) angle. Materials and methods This is a retrospective study evaluating the results of the Ludloff’s osteotomy, stabilized with two lag screws, for the management of HV cases with HV angle greater than 40° and IM angle greater than 13°. The procedures were undertaken from January 2011 and August 2015 and were done by the authors. The study included 16 female patients. All patients were assessed using the American Orthopedic Foot and Ankle Society Score preoperatively and postoperatively. Results There was a mean correction of HV angle of 30.6° and of IM angle of 7.9°. The average American Orthopedic Foot and Ankle Society Score improved from 48 preoperatively to 92 postoperatively. The average first metatarsal shortening noted was 1.4 mm. One case experienced transfer metatarsalgia. One case had nonunion, which was managed with revision fixation and bone graft. Conclusion Ludloff’s osteotomy is a valuable operative management technique for moderate and severe HV, with low rate of complications.

OUTCOMES OF PALLIATIVE ORTHOPEDIC SURGERY FOR HIP DISLOCATION IN PATIENTS WITH CEREBRAL PALSY

Introduction. Hip dislocation is the key problem in patients with severe cerebral palsy (GMFCS IV, V) older than 10 years that affects life quality and limits functional capabilities. In the present study the authors evaluated the efficiency of the proximal femoral resection arthroplasty (pfra) and valgus proximal osteotomy of the femur (VPOF) associated with femoral head resection for pain control, improvement of postural management, hygiene and verticalization with total weight-bearing and correction of accompanying orthopaedic deformities. Material and мethods. A retrospective study compared two groups of patients where PFRA (7 cases, 13 hips) or VPOF (14 patients, 23 hips) were performed. Level V of GMFCS was reported in 10 patients, and level IV of GMFCS – in 11 patients. The mean age at time of surgery was 15.3±3.9 y.o. PFRA was performed in 7 cases (13 joints) and VPOF – in 14 patients (23 joints). Results. The authors did not observe any difference between the methods in respect of pain control, postural management, comfortable sitting position and hygiene. The verticalization with total weight-bearing and life quality improvement was achieved only after PVOF with femoral head resection associated with simultaneous knee and foot deformity correction performed according to the principles of Single-Event Multilevel Orthopedic Surgery. Conclusion. Both palliative methods allow to control pain syndrome, to achieve satisfactory postural management, comfortable sitting position and hygiene. But only VPOF with simultaneous knee and foot deformity correction provides possibility to verticalize the patient with weight-bearing using different orthopedic devices.

What's New in Primary Bone Tumors.

This Update provides a review of work published in the area of primary musculoskeletal tumors between May 2015 and June 2016. The studies are largely Level III and IV, in part due to the rarity and varied nature of such tumors. The articles were identified by searching PubMed and reviewing prominent journals. Margins and local recurrence were the focus of several osteosarcoma studies. Bertrand et al. reviewed 51 high-grade extremity sarcomas with localized disease at presentation and found that a positive margin compared with a negative margin of >1 mm was the only factor that independently predicted local recurrence1. They confirmed that patients with a positive surgical margin had an increased risk of death from disease compared with those with negative margins. In another study, no local recurrences were noted among 11 patients followed for a minimum of 37 months who had undergone joint-sparing surgery for proximal tibial osteosarcoma that invaded the physis2. The proximal edge of the tumors was treated with intraoperative microwave ablation prior to tumor resection. The proximal osteotomies were planned at the edge of the tumor, but there were no positive margins. As Ewing sarcoma survival has improved, the factors influencing long-term outcomes have become more important. Stish et al. analyzed scores of the Toronto Extremity Salvage Score (TESS) and Pediatric Quality of Life Inventory (PedsQL) for 74 patients at an average duration of follow-up of 17.8 years3. They found that TESS results were better for those diagnosed at <18 years of age and that PedsQL scores were better for male patients than for female patients. Pelvic tumors were associated with decreased functional outcomes but not lower quality-of-life scores compared with tumors from other sites. The authors were not able to measure an effect of local therapy modality. Survival among …

Management of metacarpophalangeal bone defects after hand trauma by distraction osteogenesis with mini external fixation

Objective To evaluate the outcomes of distraction osteogenesis with mini external fixation in management of metacarpophalangeal bone defects after hand trauma. Methods From June 2010 to December 2015, 16 patients with metacarpophalangeal bone defects after hand trauma received distraction osteogenesis at our department. They were 11 men and 5 women, from 20 to 45 years of age (average, 32.5 years). There were altogether 20 bone defects: 8 cases had single metacarpal bone defect, 2 unilateral second and third metacarpal bone defects and 6 phalangeal shortening after repair of digital stump (involving thumb in 4 cases, index finger in one and index and middle fingers in one). The metacarpophalangeal bone defects averaged 1.8 cm (from 1.0 to 3.1 cm). Under the fluoroscopic guide, 4 or 6 mini half-pins in one line were directly drilled into the dorsal aspect of the involved metacarpophalangeal bone before the Orthofix fixator was mounted. The proximal (18 digits) or distal (2 digits) osteotomy between the second and third pinholes was performed via the dorsal approach. The external fixator and pins were removed without anesthesia after callus maturation. Results Average follow-up period was 12.2 months (range, from 9 to 26 months). All the metacarpal bone defects were reconstructed and all the phalangeal shortenings were lengthened; the bony callus was completely calcified at the lengthened part. The mean lengthening was 1.9 cm (from 1.0 to 3.1 cm); the percentage of lengthening ranged from 26% to 51% (average, 34%). The bone lengthening index (time cost by average 1 cm) was 70.9 d/cm (from 60.0 to 87.1 d/cm). According to the Tentative Assessment Criteria for Upper Extremity Function by Hand Surgery Society, Chinese Medical Association, the total activity of motion (TAM) was excellent in 13 cases, good in 4, fair in 2, and poor in one, yielding an excellent to good rate of 85.0%. Conclusion Distraction lengthening using mini external fixation is a valid option with a minor rate of complications which allows for early functional exercise to help restore the appearance and function of the affected fingers. Key words: Hand; Injury; External fixators; Bone lengthening; Bone defect

First Metatarsophalangeal Contact Properties Following Proximal Opening Wedge and Scarf Osteotomies for Hallux Valgus Correction: A Biomechanical Study.

Proximal opening wedge osteotomy (POWO) is an established procedure for moderate to severe hallux valgus. A common concern of this procedure is that it results in lengthening of the first metatarsal, which could cause increased intra-articular pressure of the first metatarsophalangeal joint (MTP) and may ultimately lead to arthritis because of these altered mechanics. The purpose of this study was to use a cadaveric model to compare intra-articular pressures and articulating contact properties of the MTP joint following either scarf osteotomy or POWO. Fresh-frozen cadaveric below-knee specimens with pre-existing hallux valgus (n = 12) and specimens without hallux valgus (n = 6, control group) were used. The hallux valgus specimens were stratified into 2 groups (n = 6 each): POWO or scarf osteotomy. The groups were matched based on the degree of deformity. Peak intra-articular pressure, force, and area were measured in all normal, preoperative, and postoperative specimens with a simulated weightbearing model. These measurements were made with a pressure transducer placed within the first MTP joint. Postoperatively POWO group had slightly higher contact forces and pressures compared to the scarf group and lower contact forces and pressures than those of the normal group but were not statistically significant ( P > .05). Normal specimens had higher intra-articular force, pressure, and area than postoperative specimens but the difference was not found to be significant. First metatarsal lengthening was found in both the scarf and POWO specimens; however, neither increase was found to be significant ( P > .05). The results from this study show that after operative correction, contact properties of the fist MTP joint among normal, POWO, and scarf osteotomy groups revealed no significant differences. First MTP joints in those with hallux valgus had significantly lower contact force and pressure compared to those without hallux valgus. With little long-term outcomes of proximal opening wedge osteotomy, this study will help predict the possibility of future MTP joint arthritis.