Recurrence Of Deformity Research Articles

Three-step Approach for Facial Reconstruction After Injectable Silicon: Surgical Excision, Fat Grafting, and Hyaluronic Acid Filler.

In facial cosmetic surgery, injectable liquid silicone has been used to augment the cheek and the lips and to camouflage facial wrinkles. However, complications started to arise in 1964 as postoperative silicone granuloma formation. The purpose of this study is to introduce our experience in facial reconstruction after injectable silicon oil with a sequential 3-step approach: transoral surgical excision, full-face fat grafting, and hyaluronic acid filler. A retrospective study was conducted for all patients affected by facial granulomatosis due to liquid silicone injection who underwent surgical treatment between January 2018 and June 2020 at the Unit of Maxillo-Facial Surgery at the Hospital "Policlinico San Martino" (Genoa, Italy). Three female patients completed the entire surgical pathway. The mean age of the patients at the time of surgery was 58.7 years (range, 52-65y). There was no clinical recurrence of the facial deformity during a mean follow-up of 14 months. Apart from the standard postoperative discomforts such as bruising, edema, and pain, the authors did not observe major complications. Our 3-step approach is a safe and viable option that can be offered to motivated patients affected by granulomatous facial reactions. Level 3.

Prevalence and Risk Factors for Leg Length Discrepancy in Children With Idiopathic Clubfoot Treated With Ponseti Method.

Clubfoot is at times associated with other lower extremity abnormalities, such as leg length discrepancy (LLD). Initial studies in patients treated with extensive soft tissue release (STR) have estimated that LLD is prevalent in 9% to 11% of children with idiopathic clubfoot. However, Ponseti-style serial casting has since replaced STR as the preferred clubfoot treatment method. This study aimed to assess the prevalence of LLD, risk factors for LLD, and the required treatment in children with clubfoot deformity after Ponseti casting. A retrospective review of medical records from children ages 0 to 18 treated for clubfoot at a single institution from 2002 to 2023 was conducted. Included patients were initially treated with Ponseti casting and had minimum follow-up until age 3. Patients with nonidiopathic clubfoot or who had LLD noted on physical examination but did not have available radiographs were excluded. LLD was defined as a minimum discrepancy of 0.5cm on bilateral lower extremity radiographs. Two hundred seventy-eight patients (434 feet) met criteria; 73% (203) were male. Forty of the 49 patients with available radiographs had LLD. The prevalence of LLD was 14.4%, with an average discrepancy of 1.1±0.8cm. The prevalence was significantly higher in patients with unilateral than bilateral cases, 27% (33) versus 4.5% (7), P=<0.001. LLD was present in 21.5% (32) of patients with recurrence and 6.2% (8) of patients without recurrence, P=<0.001. Twenty percent (8) of patients with LLD had an epiphysiodesis at an average age of 11.5±1.4 years. This study reported a prevalence of LLD in 14.4% of children with idiopathic clubfoot treated with Ponseti casting. LLD prevalence was higher in children with unilateral and recurrent clubfoot. Up to 20% of children with LLD may require an epiphysiodesis. We recommend that care providers regularly screen children with clubfoot for LLD, particularly those with unilateral and recurrent deformities, and consider obtaining bilateral lower extremity radiographs in patients with clinical LLD. Level III. Therapeutic studies-investigating the results of treatment.

Correction of Ankle Malalignment in Severe Fibular Hemimelia.

Management of ankle joint deformity and instability are challenging issues in congenital fibular hemimelia (FH). This study aims to assess how much the SUPERankle procedure improves ankle alignment and provides durable ankle stability in patients with severe FH. Seventeen children aged 53.4±44.1 months with severe form of FH, equinovalgus foot deformation, ankle instability, and tibial curvature (Paley type IIIC), affecting 19 limbs, underwent the SUPERankle procedure. Foot and ankle position was evaluated clinically and radiologically before surgery, immediately after, and at follow-up of 63.0±19.7 months. Mechanical lateral distal tibial angle (mLDTA), tibiocalcaneal angle (mTCA), and tibiocalcaneal distance (mTCD) were measured on the AP radiograms, while the anterior distal tibial angle (mADTA) and lateral tibiocalcaneal angle (mLTCA) were measured on the lateral radiograms. Recurrences, additional procedures, and complications were documented based on medical records. Quality of life was evaluated with Limb Deformity-SRS questionnaire. On clinical examination, the normal tibia and ankle alignment, along with a plantigrade foot were achieved in all limbs after the first surgery. In 11 limbs (58%) this result was maintained at follow-up. Due to recurrence, additional procedures were necessary to provide durable ankle alignment in 7 limbs (37%), while in 1 limb (5%) the ankle joint remained in equinus at the last follow-up. Significant improvement of radiologic alignment was found in all parameters (preoperative vs. postoperative vs. FU) as follows-mLDTA: 71.4±11.2 versus 88.7±5.6 versus 88.1±2.7 degrees, P=0.0001; mTCA: 41.4±14.9 versus 8.7±8.4 versus 11.6±8.9 degrees, P=0.0001; mTCD: 22.3±7.9 versus 4.0±3.6 versus 7.7±6.5mm, P=0.0001; mADTA: 99.5±19.4 versus 82.3±4.2 versus 81.5±5.9 degrees, P=0.0002; mLTCA: 116.7±23.9 versus 95.8±11.7 versus 93.5±15.1 degrees, P=0.0002. The mean follow-up LD-SRS score was 4.03. In children with severe fibular hemimelia, the SUPERankle procedure provided clinically and radiologically fully corrected ankle joint and plantigrade foot, suitable for further lengthening procedure. The 40% rate of deformity recurrence was managed with additional surgical intervention to achieve a good clinical, radiologic, and functional outcome in 95% of children at 5-year follow-up. Level IV.

Is there a relationship between recurrence and obesity in the three-year mid-term follow-up of patients who underwent high tibial osteotomy due to medial gonarthrosis?

This study aimed to radiologically evaluate the possible relationship between the body mass index (BMI) and recurrence of varus deformity during the mid-term follow-up of patients treated for medial gonarthrosis. Fifty-six patients (11 males, 45 females; mean age: 53.8±7.2 years; range, 29 to 64 years) who underwent medial opening wedge osteotomy for the treatment of isolated medial varus gonarthrosis between January 1, 2020, and June 1, 2021, were retrospectively reviewed. Patients were categorized according to BMI values as having a healthy weight (18.5-24.9 kg/m2), being overweight (25.0-29.9 kg/m2), or being obese (≥30 kg/m2). Mechanical medial proximal tibial angle, hip-knee-ankle angle, joint line convergence angle, and knee adduction moment calculations were performed based on radiographs. Among the 56 patients, the mean age of those with healthy weight was 42.5±13.2 years, that of the overweight group was 53.3±6.4 years, and that of the obese group was 54.0±5.8 years. Radiological evaluations were statistically improved postoperatively compared to preoperative scores across BMI groups (p<0.05). There were no correlations between age and radiological scores or BMI (p>0.05). Similarly, no correlation was found between BMI and radiological scores (p>0.05). Body mass index is not of significance in medial opening wedge osteotomy radiological scores in short- and mid-term follow-up.

Modified Technique of Temporal Osteotomy in Fronto-Orbital Advancement in Anterior Plagiocephaly

Background: Nonsyndromic anterior plagiocephaly is one of the most common types of craniosynostosis. In recent years, various surgical techniques have been introduced to correct this deformity, which many surgeons believe have not been associated with adequate clinical and aesthetic results. The aim of the study was to introduce a new surgical technique (modified Z-technique of temporal region osteotomy) and to evaluate the aesthetic and anthropometric outcomes of frontal orbital correction for the management of patients with nonsyndromic anterior plagiocephaly. Methods: In this cohort study, 47 patients with nonsyndromic anterior plagiocephaly who were operated on in 15-Khordad and Mofid Hospital affiliated to Shahid Beheshti University of Medical Sciences during the years 2018 to 2023 with the modified z-technique of temporal region osteotomy, were investigated. Aesthetic outcomes and changes in anthropometric parameters of the skull were evaluated 2 years after surgery. Also, the length of surgery, the mean length of stay in the hospital and ICU, the amount of bleeding and postoperative complications were evaluated. Postoperative recurrence of deformity was evaluated according to the Whitaker classification. Results: The mean age of the patients was 11.1±4.15 months. Twenty-seven (57.44%) patients were female and 20 patients were male. The mean follow-up period of the patients was 19.3±3.54 months. The mean weight of the patients was 13.12±7.45 kg. The mean length of hospital stay and ICU stay were 5.44±0.50 and 1.78±0.63 days, respectively. A significant positive correlation was observed between the duration of surgery and the duration of stay in ICU (r=0.23, P=0.023). According to Whitaker’s classification, 39 (82.97%) patients were classified in class I, 4 (8.51%) in class II, 2 (4.25%) in class III, and 2 (4.25) in class IV. Aesthetically, the surgical results were excellent (class I Whitaker) in 82.97%. No serious complications such as infection, CSF rhinorrhea, hematoma occurrence, skull defect occurrence, fever, bleeding, and postoperative mortality were reported. Conclusion: Our study showed that the modified z-technique of temporal region osteotomy was associated with good and excellent aesthetic and clinical results. Bleeding rate, average length of hospital stay, and average length of ICU stay in patients with nonsyndromic anterior plagiocephaly treated with modified Z-technique of temporal region osteotomy were low and comparable with other with other reported series. No cases of serious complication and death were reported during the follow-up period. Nonsyndromic anterior plagiocephaly can be successfully treated with modified Z-technique of temporal region osteotomy with good results and low complication rates.

Hypertrophic nonunion management with distraction osteogenesis: a scoping review of the literature

Abstract Introduction: Traditionally, stiff hypertrophic nonunions have been managed with open preparation of the nonunion site, which is then secured with internal fixation. Alternative surgical options are available including distraction osteogenesis with an external fixator. There is currently a limited amount of literature pertaining to the use of distraction osteogenesis in the management of hypertrophic nonunion. The aim of this systematic review was to collate and assess the effectiveness of distraction osteogenesis (DO) in the management of hypertrophic nonunions and to evaluate the complications that are commonly reported in the literature. Methods: We searched for articles pertaining to the treatment of hypertrophic nonunion using distraction osteogenesis. Several electronic bibliographic databases and clinical trial registries were searched using the MeSH terms “hypertrophic non-union,” “distraction osteogenesis,” “stiff non-union,” and “External Fixation” in various combinations to return the maximal number of studies for review. We performed a systematic review and identified a total of 11 studies eligible for review. Results: The review of the literature demonstrated that this technique is highly effective in achieving bony union with minimal complications. The most common complication is mild superficial pin site infections, usually managed with oral antibiotics and effective wound hygiene. Other complications reported were deep pin tract infections, broken hardware, and deformity recurrence due to collapse of regenerate bone. Conclusion: The use of distraction osteogenesis with external fixator devices is an effective and safe method for producing bony union in hypertrophic nonunions. There were minimal associated complications.

Lateral soft tissue release with distal chevron metatarsal osteotomy in moderate and severe hallux valgus.

The purpose of this study was to evaluate the radiographic outcomes of distal chevron metatarsal osteotomy associated with lateral joint capsule split as only lateral soft tissue release in patients with symptomatic moderate and severe hallux valgus (HV) deformity. Ninety patients (103 feet) at our institution between January 2014 and December 2019 were included in the present retrospective study. Each patient was evaluated preoperatively and at final follow-up by means of weight bearing radiographs lateral and dorsoplantar views. We analyzed hallux valgus angle (HVA), first-second intermetatarsal angle (IMA) and medial sesamoid position (MSP). The mean follow-up time was 21.8 months (range 6-69.4). The mean of the HVA improved, from 36.6 to 24.3º, the IMA from 13.05 to 9.93º and the MSP from 2 to 1. Our study demonstrates that the deformity recurrence rate after surgery is 69.9%. Radiologic HV recurrence was defined by a final HVA equal or more than 20 degrees at final follow-up. Level of Evidence, IV.

Association Between Postoperative Medial-Middle Intercuneiform Joint Widening and Recurrence Rates in Hallux Valgus Treated With Modified Lapidus Procedure.

Although an association between intercuneiform (C1-C2) joint instability and the recurrence of hallux valgus (HV) deformity after the modified Lapidus procedure has been suggested, there is currently no radiographic evidence to support it. This study aims to investigate radiographic changes in the C1-C2 joint after the modified Lapidus procedure for HV correction, using weightbearing computed tomography (WBCT). This retrospective cohort study included 52 feet (50 patients) with HV who underwent modified Lapidus procedure and had preoperative and postoperative WBCT. Patients who had an additional transfixation screw between the first and second ray were excluded. The preoperative and average 6.5 months postoperative C1-C2 distance, C1-C2 angle, and C1-ground angle were measured on coronal multiplanar reconstructed WBCT images. Radiographic parameters between the recurrence group (n = 9) and nonrecurrence group (n = 43) were compared. Recurrence of HV deformity was characterized by a postoperative hallux valgus angle (HVA) greater than 20 degrees. Nine of 52 patients (17.3%) had recurrence of their HV deformity. The recurrence group had greater changes in the C1-C2 distance; the median widening in the recurrence group was 0.7 mm (IQR, 0.6-0.8), whereas the nonrecurrence group was 0.3 mm (IQR, 0.1-0.4, P < .001). Regression analysis showed that increase in the C1-C2 distance were significantly associated with recurrence (odds ratio, 1.79; 95% CI, 1.18-3.77; P = .0015). Although no preoperative imaging parameters were associated with a change in the C1-C2 distance, increasing postoperative sesamoid position (r = 0.32, P = .022) and HVA (r = 0.28, P = .046) were correlated with a greater change in the C1-C2 joint gapping. Our study results suggest a possible association between early postoperative widening of the C1-C2 joint and the recurrence of the HV deformity following a modified Lapidus procedure. This raises, but does not answer, the question as to whether the routine stabilization of intercuneiform joint directly or indirectly may help reduce the rate of hallux valgus recurrence when performing the modified Lapidus procedure.

Congenital Radioulnar Synostosis Review: Recommendations and Treatment Outcomes.

Background/Objectives: Congenital radioulnar synostosis (CRS) is a rare congenital disorder of the elbow joint caused by the abnormal fusion of the radius and ulna during fetal development, leading to limited forearm rotation and functional impairment. This narrative review aims to summarize the key aspects of diagnostic suspicion, treatment options, and lifestyle management strategies for individuals affected by CRS. Relevant sections: While CRS often occurs sporadically, there are familial cases with an autosomal dominant inheritance pattern. The diagnosis is established through a combination of clinical evaluation and radiological imaging, which confirms the presence and extent of the synostosis. Identifying the specific type and severity of CRS is critical for management decisions. Surgical interventions are considered based on factors such as the patient's age, level of functional limitation, and symptom severity, while conservative treatment may be appropriate for cases with mild impairment. Discussion: Various surgical techniques have been described, but derotation osteotomy has emerged as a preferred option due to its predictable improvement in forearm function. Nevertheless, surgical treatment poses challenges, including potential complications like nerve injury and recurrence of deformity. Cultural and individual considerations, such as the desired forearm position, must be addressed to achieve optimal outcomes aligned with the patient's lifestyle and needs. Conclusions: Managing CRS requires a nuanced and individualized approach, recognizing the unique challenges each patient presents. This review highlights the importance of continuous research to refine diagnostic and therapeutic strategies, ultimately aiming to enhance functional outcomes and quality of life for CRS patients.

Caregiver Impressions of Bracing and Its Association With Unsuccessful Outcomes Throughout the Ponseti Treatment.

Clubfoot is a common congenital foot deformity, occurring in about 1 in 1000 live births. The Ponseti method consists of weeks of manipulation and serial casting, followed by years of orthotic wear. Recurrent or relapse deformity following the Ponseti method remains a challenging problem for many patients. Many studies have attributed relapse to noncompliance with the treatment plan, particularly during the maintenance phase. Many patient risk factors have been studied and attributed to recurrent deformity, but less emphasis has been placed on aspects of the treatment method from the caregiver's perspective. From 2010 to 2014, 127 patients between 1 and 354 days old who had been diagnosed with clubfoot were recruited for the parent study. At the initial visit, and each subsequent follow-up, the primary caregiver was given a questionnaire that included 21 binary belief questions exploring his or her experience with the Ponseti method. Univariate analyses were performed to find any relationship with caregiver responses and either clinical recurrence of the deformity or overall failure of treatment. Of the recruited patients, 126 were enrolled in the parent study and 100 were able to complete the full 3-year follow-up. Patient demographics and characteristics (sex, race, family history of clubfoot, laterality, and severity of deformity) were similar. Statistical analysis of the questionnaire responses found that choosing "yes" for either "I don't feel the braces are necessary" or "I am not comfortable with applying and removing the braces" was associated with significantly increased risk of overall failure. Gathering insight from the caregiver's perspective can help identify barriers to treatment not recognized by the provider. Lack of comfortability with the orthosis and lack of understanding are associated with increased risk of overall failure. A better understanding of the caregiver's perspective on barriers to treatment could help guide the Ponseti method provider's educational efforts. Level III.

Total knee replacement in severe genu recurvatum. High prosthetic survival rate without deformity recurrence, using rotating hinge prosthesis

IntroductionGenu recurvatum can originate from neurological and non-neurological causes. Its presence associated with knee osteoarthritis represents 1 % of the causes of total knee replacement (TKR). The aim of this retrospective study was to show the functional outcomes, recurrence rate and prosthetic survival in patients with genu recurvatum treated with articulated rotating hinge prostheses. Methodsbetween January of 2008 and December of 2021, we performed 3224 primary TKR, of which 34 (1 %) had recurvatum. This was defined as hyperextension ≥10°. Inclusion crirteria were patients with primary TKR and recurvatum that were treated with a rotating hinge prosthesis (Endo Model, Walderman Link, Ham, Germany), and completed a minimum follow-up of 24 months. Final series consisted in 23 patients with 25 TKR with 15 (65.22 %) females and a mean age of 66.8 ± 14.2 years old. The median follow-up was 5.0 (range 2.11–11.5). Clinical analysis was performed with the use of Knee Society Score (KSS) and Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC). Prosthetic survival rate was calculated with a Kaplan-Meier curve considering as the endpoint of the analysis revision due to any reason. Recurrence was defined as the presence of hyperextension ≥ 5° after surgery. Resultsof the 23 patients, 9 (39.13 %) had history of neurological disorders. Median recurvatum observed was 20.12° (range 13.0° - 30.2°). A median of 19.6° (range 10.1° - 55.4°) valgus misalignment was observed in 19 patients and 10.7° (range 2.0–23.5°) of varus was observed in 6 (24 %) patients. Clinical and functional KSS improved significantly after 12 months (from 34.2 ± 9.8 and 40.1 ± 12.6 to 82.1 ± 7.5 and 89.2 ± 6.8 respectively; p < 0.01) and at the end of the study (84.3 ± 7.5 and 90.0 ± 11.3; p < 0.01). Final mean WOMAC value was 24.1 ± 9.6. One (4.0 %) complication was registered after surgery (superficial infection). Four (16.0 %) patients had demarcation. Prosthetic survival rate was 100 % at the end of the study. ConclusionThe rotating hinge prosthesis restores joint function in patients with severe knee osteoarthritis with and without neurological disorders, without recurrence of misalignment and with excellent survival rates.

Role of Sesamoid Position and Recurrence of Hallux Valgus Deformity

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: One of the most important complications of hallux valgus surgery (when performed either through an open or minimally invasive technique) is recurrence of deformity. Recurrence is often multifactorial due to patient factors such as anatomy, pre-operative deformity, soft tissues, comorbidities and compliance with instructions and surgical factors such as choice of surgical technique, implant and technical competency. The aim of this study was to investigate the role of sesamoid position and impact on recurrence of hallux valgus deformity following percutaneous minimally invasive hallux valgus surgery. Methods: A prospectively maintained research registry of fourth-generation percutaneous metatarsal extra-capsular transverse osteotomy (META) for hallux valgus between 2017-2023 was retrospectively analysed to identify feet that had recurrence of hallux valgus deformity (defined as HVA&gt;20°). Comparative analysis was then performed to assess the impact of pre-operative deformity and sesamoid position on recurrence. Radiographic deformity and sesamoid position (including ‘Round sign’) were assessed according to AOFAS guidelines. Secondary outcomes included clinical patient reported outcome measures including the Manchester-Oxford Foot Questionnaire (MOXFQ) and Visual Analogue Scale for Pain. All p-values &lt; 0.05 were considered significant. Results: Between November 2017 and January 2023, 729 feet underwent META with minimum 12-month radiographic follow up (mean 2.6±1.3 years). There were 33 cases with HVA&gt;20° at final radiographic follow up (4.5%). There was a statistically significant difference in sesamoid position between feet which had recurrence with higher rates of Grade 2 and 3 compared to those which didn’t (p &lt; 0.05). There was no significant difference in Round sign assessment between cases which recurred and those that did not (p=0.27). The mean pre-operative deformity in cases which underwent recurrence was significantly greater than those which did not recur (p &lt; 0.05), (HVA:44.3±6.5, IMA:15.6±3.7° compared to HVA:28.8±8.0°, IMA:12.8±3.3°). Of the 33 cases which had recurrence, 13 demonstrated HVA&gt;20° at 6 month XR suggesting incomplete deformity reduction. Conclusion: Incomplete reduction of sesamoids appears to be a risk factor for recurrence. Incomplete deformity reduction at the time of surgery, particularly in cases of severe deformity (HVA&gt;40°) is an important factor to acknowledge when considering risk of recurrence. The deformity correction achieved through bony correction (using the fourth-generation META technique) appears to be maintained from 6-months to final radiographic follow up suggesting that recurrence is predominantly linked to incomplete deformity reduction and sesamoid position at the time of surgery.

Modern Percutaneous Hallux Valgus Surgery for Revision of Recurrent Hallux Valgus

Category: Bunion; Other Introduction/Purpose: Hallux valgus is the most common foot deformity, and recurrent deformity is the most common complication after primary hallux valgus correction. The principles of HV revision surgery do not differ from the initial goal of hallux valgus correction, which is to restore physiologic alignment and alleviate symptoms. Choosing the appropriate procedure to address the given deformity pattern and the technical competence to perform the corrective procedure are the keys to success. To date, no 3rd or 4th generation minimally-invasive technique for the correction of recurrent hallux valgus has been described in the literature. The aim of this multicenter analysis is to evaluate the use of modern percutaneous bunion surgery techniques in the revision of recurrent hallux valgus. Methods: A total of 100 cases operated between 2013 and 2023 and contributed by 7 surgeons from 6 countries, all performing percutaneous 3rd and 4th generation Minimally-Invasive Chevron Akin (MICA) / Percutaneous Chevron Akin (PECA) / Minimally Invasive Extra-articular Transverse and Akin (META), were retrospectively evaluated. Minimum follow-up was 12 months (range 12-104). Radiological correction (HVA, IMA, tibial sesamoid position), surgery associated complications using the modified Clavien-Dindo-Sink classification and functional outcome (MOXFQ) were evaluated. Results: The complication rate was 21%. Most complications could be managed non-surgically. The most common complication was screw prominence leading to revision surgery with hardware removal in 8.5% of all cases. Major complications such as deep infection requiring revision surgery were extremely rare. HVA was corrected from a mean of 33.5° to 10.3° at 6 weeks and 9.0° at 12 months, IMA from a mean of 13.9° to 4.8° and 5.1°, respectively. The mean Clapham-Hardy tibial sesamoid position was classified as type 6 preoperatively and improved to type 2 postoperatively. PROMs using the MOXFQ score improved from a preoperative index score of 46.0 to 8.9. Conclusion: Modern percutaneous hallux valgus techniques have proven to be a reliable tool in the primary correction of hallux valgus and metatarsus primus varus, aiming to minimize surgical morbidity and maximize surgical efficiency without compromising safety. To date, there have been no reports of these procedures for recurrent hallux valgus. With adequate training and experience, the use of 3rd and 4th generation MICA/PECA/META is a safe procedure for the revision of recurrent hallux valgus resulting in significant improvements in radiographic parameters, functional outcome and patient satisfaction. The rate of relevant complications is not increased compared to traditional open surgical techniques.

Radiographic and Patient-Reported Outcomes for First Tarsometatarsal Arthrodesis Using An Intramedullary Nail for Hallux Valgus Deformity: A Consecutive Case Series

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: First tarsometatarsal (TMT) arthrodesis is one of the most common procedures performed each year for the correction of hallux valgus deformity (HVD) and there are currently over 100 different techniques that have been described. Non-union rates for first TMT arthrodesis are commonly reported to be between 5-15%. A systematic review found that 10.6% of patients reported dissatisfaction following their surgery to correct HVD and 4.9% had recurrent deformity. Multiple techniques featuring an intramedullary nail for first TMT arthrodesis have been described with promising early results in biomechanical studies and studies involving small numbers of patients. The purpose of this study was to evaluate radiographic and patient-reported outcomes of an intramedullary nail system in patients requiring first TMT arthrodesis for HVD. Methods: An ambispective, multi-surgeon, consecutive case series was conducted, with retrospective and prospective collection of patient-reported outcome measure (PROM) data (Foot and Ankle Ability Measure (FAAM), Pain Interference, Pain Score (scale of 0-10), and Neuro-Quality-of-Life Mobility Lower Extremity (Neuro QOL)) and subsequent radiographic measures (intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), Meary’s angle (MA), 1st metatarsal declination angle, tibial sesamoid position, and relative metatarsal length). Patients who underwent first TMT arthrodesis from July 2019–July 2022 for HVD with a Phantom® Small Bone Intramedullary Nail system and had adequate records for a minimum of three months post-operation (±4 weeks) were included. The indication for surgery was a painful HVD with failure of conservative treatment options. A patient chart review was conducted to collect basic demographic data, surgical data, and patient comorbidities. Results: 70 patients were included in the final analysis (N =68 for radiographic measures), with a median prospective PROM follow-up of 1.6 years. There was an overall union rate of 91.4% (64/70 patients), with 92.4% (61/66) of primary hallux valgus surgeries achieving union. Nine patients required secondary procedures; two experienced migration of the proximal peg and two experienced irritation from the index device. Hardware was completely removed in the 5 primary nonunions, and it was broken in 3 of these 5 patients. PROMs demonstrated significant improvement in FAAM, Pain Interference, overall pain, and Neuro-QOL scores; IMA, HVA, DMAA, MA, and tibial sesamoid position showed significant improvement at follow-up (P&lt; 0.05) (Table 1). 1st Metatarsal Declination angle was not significantly altered and there was minimal (2.4 mm) metatarsal shortening. Conclusion: In the current sample of 70 feet, there were 6 non-unions, resulting in an overall union rate of 91.4%. The overall nonunion rate for first TMT arthrodesis is commonly reported to be between 5 and 15%. Similarly, PROMs and radiographic measurements collected showed significant improvement post-surgery. The results suggest that this system parallels other procedures for first TMT arthrodesis in terms of nonunion, complication rate, and various PROMs. With over 100 different surgical techniques for TMT arthrodesis, the results of this case series support that the intramedullary nail system can be considered as an option for surgeons.

Concurrent Calcaneal Osteotomy with Hindfoot Arthrodesis for Pes Planovalgus: Outcomes and Alignment

Category: Hindfoot; Other Introduction/Purpose: Severe, rigid deformities of the hindfoot related to pes planovalgus are commonly treated with hindfoot arthrodesis. Deformity recurrence and ankle valgus deformity can occur due to attenuated and often incompetent medial soft tissues. While the addition of a medial displacing calcaneal osteotomy (MDCO) to a hindfoot arthrodesis has been described, the complication profile and the effect on alignment parameters including ankle alignment has not been well elucidated. There is biomechanical data to suggest that the addition of MDCO to a triple arthrodesis will reduce the force on the deltoid ligament by 56% (Okereke et al). The purpose of this study is to evaluate the clinical and radiographic outcomes of combined calcaneal osteotomy with hindfoot arthrodesis, and compare to a group that had hindfoot arthrodesis alone. Methods: We performed an IRB-approved single institution retrospective review of all patients who had undergone double or triple arthrodesis for pes planovalgus over a 6-year period from 1/1/2016 to 12/31/2021, and comparing those who had concurrent MDCO and those with arthrodesis alone, via CPT code. We included those who were &gt;/= age 18 and had undergone double or triple arthrodesis, and had a minimum of 3 months follow up with radiographs. Patients were excluded if they had prior hindfoot arthrodesis surgery, charcot arthropathy, or documented neuropathy. We collected basic demographic data, surgical data including length of surgery, type of implant(s) and grafting used, pre-operative and post-operative radiographic parameters, complications, reoperations and presence of union of any and all arthrodesis and osteotomy sites. The primary outcome variable was successful arthrodesis of the subtalar (ST) joint, with secondary outcomes including successful union of the remaining sites. Results: A total of 22 patients (26 surgeries) had undergone concurrent hindfoot arthrodesis and MDCO versus 145 patients (150 surgeries) for hindfoot arthrodesis alone. Follow up was 10.6 and 10.8 months on average, respectively. The MDCO cohort surgical duration was 27 minutes longer than the control group (p=0.0079). Pre-operative and post-operative talonavicular (TN) coverage, AP and lateral Meary’s angle, cuboid height, calcaneal pitch, and post-operative AP ankle alignment were not significantly different between the groups. There were no failures of the MDCO or wound issues with the MDCO incision. The nonunion rate for the ST joint was 3.8% and 4.7%, respectively with TN nonunion rate of 15.4% and 16.7%, respectively (p&gt;0.99). Reoperation rates were 23.1% and 20.7%, respectively. Conclusion: In conclusion, this study has demonstrated that when deemed appropriate based on intraoperative or preoperative findings, the addition of an MDCO to either a double or triple arthrodesis is a safe and effective adjunct. There is a slightly longer surgical time, without any additional surgical complication risks. Longer term radiographic follow up is needed to determine if this helps to protect against late ankle valgus collapse.

Polymethylmethacrylate (PMMA) Augmentation Increases the Strength of Midfoot Beam Constructs in Charcot Neuroarthropathy Model: A Biomechanical Study

Category: Basic Sciences/Biologics; Diabetes Introduction/Purpose: Even with the best conservative care, patients with Charcot Neuroarthropathy (CN) of the foot and ankle often ulcerate, increasing their risk of infection, amputation, and death. Surgical fixation has a 30% risk of recurrent ulceration, likely due to poor host bone quality which is prone to deformity recurrence and subsequent ulceration. We propose midfoot beam reconstruction with PMMA augmentation as a novel means of improving fixation. Methods: A protocol was developed to create the characteristic CN midfoot fragmentation both visually and fluoroscopically in each of tweleve matched-pair cadaveric feet. Afterward, the pairs were divided into two groups (1) Midfoot beam fusion alone, and (2) Midfoot beam fusion augmented with PMMA. In both groups, a solid 7.0 mm beam was placed into the medial column and a solid, 5.5 mm beam was placed across the lateral column. In the PMMA group, 8-10 mL of PMMA was inserted into the medial column. The hindfoot of each specimen was potted and the metatarsal heads were cyclically loaded for 1800 cycles, followed by load to failure while load and displacement were continually recorded. Results: One specimen in the beam only group failed before reaching the 1800th cycle and therefore was not included in the failure analysis. The midfoot beam only group demonstrated greater mean displacement during cycle testing compared to the PMMA group, p&lt; 0.05. The maximum force (N), stiffness (N/mm) and toughness (Nmm) were all significantly greater in group augmented with PMMA, p&lt; 0.05. Conclusion: In a CN cadaveric model, PMMA augmentation significantly decreased gapping during cyclic loading and nearly doubled the load to failure compared to midfoot beams alone. Clinical Relevance: The results of this biomechanical study demonstrate that augmentation of midfoot beams with PMMA increases the strength and stiffness of the fusion construct, which may reduce the risk of nonunion and infection in patients with neuropathic midfoot collapse.

Fourth-Generation Metatarsal Extra-Capsular Transverse Akin (META) Osteotomies for Percutaneous Hallux Valgus Correction: A Series of 729 Consecutive Feet

Category: Bunion; Lesser Toes Introduction/Purpose: Fourth-generation percutaneous or minimally invasive hallux valgus surgery utilises a transverse osteotomy to achieve deformity correction. There are only a small number of series reporting the clinical and radiological outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow up or use of non-validated outcome measures. The aim of this study was to provide a methodological robust investigation into percutaneous transverse osteotomies for hallux valgus deformity. Methods: A prospective case series of consecutive patients undergoing fourth generation metatarsal extra-capsular transverse osteotomy (META) performed by a single surgeon (PL) between November 2017 and January 2023. The primary outcomes were radiographic deformity correction and clinical foot function assessed using the Manchester-Oxford Foot questionnaire (MOXFQ-a validated patient reported outcome measure). Radiographic deformity (Hallux valgus angle (HVA) and 1-2 Intermetatarsal angle(IMA), sesamoid position) was assessed according to AOFAS guidelines. Secondary outcomes included Visual Analogue Scale for Pain and radiographic deformity recurrence (defined as HVA &gt;20° at final radiographic follow up). All p-values &lt; 0.05 were considered significant. Results: 729 feet from 483 patients (456 Female, 27 Male, mean age 57.9±11.9 years) underwent META. Radiographic data (minimum 12 months post-surgery) was available for all feet with mean follow up of 2.6±1.3 years (range 1.0-5.7). There was a statistically significant improvement (p&lt; 0.05) in both HVA; 29.5±8.5° to 7.3±6.7°, and IMA, 12.9±3.4° to 4.6±2.5°. All MOXFQ domains showed significant improvement (p&lt; 0.05); Index 36.6±19.1 to 11.8±13.8, Pain 40.1±22.1 to 15.6±16.4, Walking/Standing 32.2±23.2 to 10.2±15.8 and Social Interaction 40.0±20.6 to 9.7±14.0. The recurrence rate was 4.6% (n=33) with a significantly higher proportion of sesamoids in Grade 2 and 3 in the recurrence group (p&lt; 0.05). There was 1 non-union, 1 deep infection and 20 cases of superficial infection. No avascular necrosis of the first metatarsal head occurred. Conclusion: This is the largest consecutive series of any percutaneous osteotomy technique to correct hallux valgus deformity. This study demonstrates that the technique leads to significant improvement in clinical and radiographic outcomes with a low rate of recurrence. Recurrence may be linked to incomplete sesamoid reduction at the time of surgery.

Acute Phase Peyronie's Disease: Where Do We Stand?

Peyronie's disease (PD) is a common benign condition characterized by superficial fibrosis and scar formation at the tunica albuginea of the penis, eventually leading to penile curvature. It is believed that penile micro-traumas during intercourse and subsequent activation of inflammatory processes constitute the pathogenetic basis of the disease. Routinely, PD is divided into acute and chronic phases, with pain during erection or flaccid state being the hallmark of the former. Surgical intervention should be avoided during the acute phase, as the risk of recurrence or progression of penile deformity during this stage might affect the optimal outcomes of the procedure. During this stage, many conservative treatment options have been suggested, including oral, topical, and intralesional therapies, extracorporeal shock wave therapy (ESWT), and penile traction therapy (PTT). Currently, the optimal treatment consists of a combined treatment strategy with phosphodiesterase type 5 inhibitors (PDE5Is), ESWT for pain management, PTT, and intralesional therapies. Large, well-designed randomized controlled trials (RCTs) are necessary to further elucidate the most efficient treatment option for acute phase PD.

Features of the formation of bone regenerate and metabolism of bone formation markers in a patient with type 1 diabetes mellitus and diabetic neuroosteoarthropathy (Charcot foot)

Background: Surgical treatment of diabetic neuroosteoarthropathy is a complex area in traumatology — orthopedics not only because of severe biomechanical disorders and gross deformations of the distal segment of the lower limb, but also because these phenomena are accompanied by many disorders of the somatic status. Of particular importance is a pronounced decrease in bone mineral density. This case is intended to illustrate the features of the treatment of this pathology. Clinical case description: A clinical case of treatment of a 34-year-old young female patient with type 1 diabetes mellitus, development of diabetic neuroosteoarthropathy (Charcot foot), and aseptic necrosis of the talus of the right foot is presented. From 2019–2020 conservative and surgical treatment was carried out aimed at stopping the active stage of Charcot foot, correcting deformity and stabilizing the distal segment of the limb (calcaneotibial arthrodesis). A satisfactory treatment result was achieved, complete activation 8 months after the operation. However, in 2021 The patient suffered a closed low-energy fracture of the distal metaphysis of the right tibia. Regarding this episode, the patient comes in at the stage of consolidation of a displaced fracture and complaints of recurrence of varus deformity, even greater shortening of the limb, and swelling of the ankle joint. The fact of injury is denied, which allows us to regard the existing fracture of the tibia as pathological. In this regard, an operation was performed: osteotomy of the fibula and tibia in the area of consolidation of the pathological fracture in order to correct the deformity and compensate for the existing shortening of the limb due to the formation of a distraction regenerate. During the treatment, malnutrition and delayed formation of bone regenerate were noted, which required prolonged use of an external fixation device and specific drug therapy aimed at stimulating osteogenesis and improving bone mineral density. At the end of the course, there was an increase in the mineral density of the tissue, the density of the regenerate radiologically and laboratory (control of bone formation markers) and a satisfactory functional result. CONCLUSION: A successful result in this clinical case was achieved by combining orthopedic surgical and conservative treatment with specific drug therapy in a comorbid patient with reduced bone mineral density and a high probability of complications in a multidisciplinary approach.

Percutaneous removal of hardware after orthopedic surgery: Is it safe? and What are patients saying?

To analyze our patient's complication profile and rate after removal of hardware (ROH) surgery, and survey our patients to ask their overall status and improvement in symptomatology post-operatively. Retrospective chart review and survey. Academic, tertiary referral center. 173 patients with 314 pieces of hardware. Seventy-six patients (43.9%) responded to our survey. ROH surgery. Patient demographics and complications were recorded. All patients were sent a brief 3-question survey which asked: (1) Why did you get your hardware removed? (2) How did your overall status change after ROH? (3) How did the ROH affect your stiffness, pain, swelling, and mobility? There were 10 complications (5.5%): 5 infections, 2 with unresolved pain, 1 hematoma, 1 chronic regional pain syndrome exacerbation, and 1 recurrent deformity. All infections were treated with oral antibiotics and improved. All other complications resolved with treatment except for the patient who developed recurrent deformity. Patients underwent ROH surgery because their doctor suggested it (76.3%) and to improve mobility (39.5%). 86.9% reported their overall status improved after ROH. They improved regarding stiffness (73.7%), pain (73.6%), swelling (61.8%), and mobility (76.3%). Similar results were seen among different implants removed. The majority of patients who underwent percutaneous ROH were satisfied. They reported improvement in stiffness, pain, swelling and mobility (greatest improvement). The complication rate was low (5.5%). ROH can be a meaningful operation to patients allowing them to improve their quality of life with a low complication rate. Level IV.