Plate Removal Research Articles

Orthognathic returns to theatre

The objectives of this retrospective study were to determine the unexpected return-to-theatre rate for orthognathic surgery at James Cook University Hospital and describe the reasons for return. A total of 357 consecutive orthognathic cases under two consultants over a 13-year period were included. Patients who had an unexpected return to theatre were identified and their notes analysed for data including preoperative dentofacial discrepancy, surgical movement, and reason for return. Returns to theatre for the removal of plates and planned procedures such as removal of a distractor or delayed genioplasty, were excluded. Thirteen patients required reoperation (3.6%). The commonest reason for return was malocclusion, and the majority returned within four weeks of the initial procedure. Proportionally more men returned to theatre than women, and revision was more likely to involve the mandible than the maxilla.

Factors Associated With Patient Satisfaction After Opening-Wedge High Tibial Osteotomy.

Background:Opening-wedge high tibial osteotomy (OWHTO) is expected to result in higher patient satisfaction compared with knee arthroplasty due to joint preservation. However, patient satisfaction rates as well as factors associated with satisfaction after OWHTO remain unclear.Purpose:To evaluate patient subjective satisfaction after OWHTO and determine factors associated with patient satisfaction after OWHTO.Study Design:Case-control study; Level of evidence, 3.Methods:This study enrolled 123 patients (123 knees) who underwent unilateral OWHTO. Clinical parameters, including range of motion (ROM), visual analog scale (VAS) score for pain, Knee injury and Osteoarthritis Outcome Score (KOOS), weightbearing line ratio (WBLR), and medial proximal tibial angle (MPTA), were assessed before surgery and at the final follow-up at a minimum of 2 years. Patient satisfaction was evaluated using a 5-point scale regarding (1) surgery, (2) pain relief, (3) knee mobility, (4) daily living function, and (5) lower extremity alignment. The mean overall satisfaction scores for the 5 questions were calculated, and the sample was divided into 2 main groups (satisfied or unsatisfied). Preoperative characteristics, physical activity level, patient expectations for surgery, ROM, and KOOS were compared between the groups. Cartilage regeneration was assessed at the time of plate removal, and WBLR and MPTA were also assessed. Factors associated with patient satisfaction were analyzed using multivariable logistic regression analysis.Results:The mean ± SD follow-up was 54.6 ± 20.6 months. The mean WBLR significantly changed from 20.7% ± 11.8% preoperatively to 66.9% ± 10.2% at the final follow-up, and all KOOS subscale scores significantly improved after surgery. Of the 123 patients, 109 (88.6%) were graded as satisfied. Factors associated with patient satisfaction were expectations met (odds ratio, 17.4; P = .026), better postoperative KOOS Pain score (odds ratio, 1.30; P = .001), and better postoperative KOOS Activities of Daily Living score (odds ratio, 1.36; P = .002).Conclusion:OWHTO is an effective treatment in terms of subjective satisfactory outcomes. Patient expectations for surgery have a significant effect on patient satisfaction. Surgeons should consider patient expectations before OWHTO and provide patient education to improve patient satisfaction.

Volar locking plate removal after distal radius fracture: a 10-year retrospective study.

Distal radius fracture (DRF) is the most common upper extremity fracture. After the introduction of volar locking plate (VLP) fixation, treatment has shifted from conservative management to more operative management. The implant removal rate after VLP fixation in patients with DRF varies and the reasons for removal and associated patient characteristics have not been clearly defined. This study aimed to compare the characteristics of patients who underwent VLP with and without subsequent implant removal. Second, the rate of implant removal according to the implant position and type was investigated. Finally, we summarized clinical outcome with implant removal, the reasons for, and complications associated with implant removal. In this retrospective study, patient data were collected between January 1, 2008, and December 31, 2017. The study population was divided into two groups based on subsequent implant removal. Data on patient characteristics, such as age, sex, comorbidities, side of the fractured arm, the AO Foundation and Orthopaedic Trauma Association classification of the DRF, plate position grade based on the Soong classification type, type of inserted plate, insurance coverage, and treatment costs were collected. Furthermore, we investigated the reason for implant removal, clinical outcomes, and post-removal complications. After applying the exclusion criteria, 806 patients with a total of 814 DRFs were included in the study. Among the 806 patients who underwent VLP fixation for DRF, 252 (31.3%) patients underwent implant removal. Among the patients undergoing implant removal, the mean age was 50.8 ± 14.0years, 94 (37.3%) were male. The average time to implant removal from the fracture fixation was 12.1 ± 9.2months (range 1-170months). When comparing groups, patients who underwent implant removal were significantly younger and had fewer cases of diabetes, hypertension, and cancer history. According to the Soong plate position grade, the most common position was G1 in both groups. Although there was no significant difference (p = 0.075), more G2 cases were found in the removal group (15.0%) than in the retention group (10.2%). About 66.5% of the patients with implant removal had other health insurance as well as the national service, compared with 47% of the patients with implant retention. In total, 186 patients (73.8%) underwent implant removal despite being asymptomatic after the bony union. The patient satisfaction scores improved from 4.1 to 4.4 after implant removal, and 93% of the patients answered that they would choose implant removal again. Only 10% of the patients who underwent removal reported minor complications. No major complications were reported. Although the implant removal was conducted without clinical symptoms in the majority of patients, overall patients presented improved functional outcomes with implant removal. The evidence is inconclusive regarding its necessity, however, implant removal after VLP fixation for DRF is not a challenging procedure and is not associated with major complications. Level IV.

Hook plate with or without coracoclavicular ligament augmentation in the treatment of acute acromioclavicular separation

BackgroundAcromioclavicular (AC) separation can be treated with the use of a hook plate. Some studies have reported that coracoclavicular (CC) ligament augmentation is necessary to reduce the complications of hook plate fixation, whereas others recommend hook plate fixation alone without augmentation. The aim of this study was to compare the results and complications between these two groups.MethodsThis was an observational case-control study. Patients with acute (less than 2 weeks) Rockwood type V AC separation were treated with a hook plate at our hospital. A total of 105 cases received hook plate fixation with CC ligament augmentation (group I), and 112 cases received hook plate fixation without augmentation (group II). Constant-Murley scores were used to evaluate the function before and after implant removal, and radiographs were taken to evaluate the complications. The results and complications were compared between groups.ResultsBefore removal, the Constant-Murley score was significantly higher in group I (mean, 50.1) than in group II (mean, 42.6) (p = 0.004); however, there was no significant difference between groups at 3 and 6 months after removal. The incidence of significant acromion osteolysis was higher in group II (65/112) than in group I (25/105). Before removal, the patients with significant acromion osteolysis had worse Constant-Murley scores than those of the patients without osteolysis in both groups. The incidence of peri-implant fracture of the hook plate was higher in group II (8/112) than in group I (1/105).ConclusionThe patients without CC ligament augmentation had worse functional results before hook plate removal, a higher incidence of radiographic acromion osteolysis, and a higher incidence of peri-implant fractures than those patients with CC ligament augmentation. Therefore, CC ligament augmentation is highly recommended to improve short-term outcomes and decrease complications for Rockwood type V AC separation treated by hook plate.

Tronco-conical locking plate in distal radius fractures

IntroductionVolar locked plates represent the most popular fixation technique for distal radius fracture (DRF). However, threaded screw-hole angular stability mechanism has some issues. The purpose of our study is to evaluate clinical and radiological outcome of a tronco-conical locking mechanism for volar plating of DRF. Materials and methodsEighty patients with DRF treated with tronco-conical locking volar plates between May 2013 to December 2017 in two institutions were collected. We analysed clinical and radiological outcomes and peri-operative complications, like loss of reduction, fragment displacement, deformation or implant-related problems and surgical and other general complications. Results78 patients were available for at final follow-up. The average follow-up period was 11.4 months (range, 6-18 months). All fractures healed within three months. Five cases of final reductions were defined unsatisfying. According to Gartland and Werley's scoring system at final follow up, 36 patients had excellent results, 40 patients had good results, one patient had fair and one patient had poor results. Five complications were observed. No complications were observed during surgical plate removal. ConclusionComplications found in our study are not related to tronco-conical locking mechanism and are like those found in the literature. Further studies are needed to evaluate functional results or radiographic parameters of this new type of angular stability mechanism. Tronco-conical locking plate is an attractive alternative threaded screw-hole angular stability mechanism.

Pterygopalatine Fossa: Microsurgical Anatomy and its Relevance for Skull Base Surgery

Abstract Introduction The purpose of this study was to define the anatomical relationships of the pterygopalatine fossa (PPF) and its operative implications in skull base surgical approaches. Methods Ten cadaveric heads were dissected at the Dianne and M Gazi Yasargil Educational Center MicrosurgicaLaboratory, in Little Rock, AK, USA. The PPF was exposed through an extended dissection with mandible and pterygoid plate removal. Results The PPF has the shape of an inverted cone. Its boundaries are the pterygomaxillary fissure; the maxilla, anteriorly; the medial plate of the pterygoid process, and greater wing of the sphenoid process, posteriorly; the palatine bone, medially; and the body of the sphenoid process, superiorly. Its contents are the maxillary division of the trigeminal nerve and its branches; the pterygopalatine ganglion; the pterygopalatine portion of the maxillary artery (MA) and its branches; and the venous network. Differential diagnosis of PPF masses includes perineural tumoral extension along the maxillary nerve, schwannomas, neurofibromas, angiofibromas, hemangiomas, and ectopic salivary gland tissue. Transmaxillary and transpalatal approaches require extensive resection of bony structures and are narrow in the deeper part of the approach, impairing the surgical vision and maneuverability. Endoscopic surgery solves this problem, bringing the light source to the center of the surgical field, allowing proper visualization of the surgical field, extreme close-ups, and different view angles. Conclusion We provide detailed information on the fossa's boundaries, intercommunications with adjacent structures, anatomy of the maxillary artery, and its variations. It is discussed in the context of clinical affections and surgical approaches of this specific region, including pterygomaxillary disjunction and skull base tumors.

Preoperative flexion contracture is a predisposing factor for cartilage degeneration at the patellofemoral joint after open wedge high tibial osteotomy

PurposeThe purpose of the study was to determine the effect of cartilage degeneration at the patellofemoral joint on clinical outcomes after open wedge high tibial osteotomy and to investigate the predisposing factors for progressive patellofemoral cartilage degeneration.MethodsSeventy-two knees were evaluated on second-look arthroscopy in patients who opted for plate and screw removal at an average of 20.1 months after osteotomy. Cartilage degeneration at the patellofemoral joint was evaluated using the International Cartilage Repair Society grading system, with cases divided into progression and nonprogression groups. Radiographic parameters of the patellofemoral anatomy, knee range of motion, and clinical outcomes were evaluated from the preoperative baseline to the final follow up, on average 50 months after osteotomy. A contracture > 5° was considered a flexion contracture.ResultsCartilage degeneration progressed in 31 knees, and preoperative knee flexion contracture was significantly associated with progressive degeneration (P < 0.01). The Lysholm and Kujala scores were significantly lower in the progression group (87.9 and 85.3, respectively) than in the nonprogression group (91.6 and 93.6, respectively) (P < 0.05). The odds ratio of the flexion contracture resulting in progression of patellofemoral cartilage degeneration was 4.63 (95% confidence interval, 1.77–12.1). No association was detected between progressive degeneration and age, sex, body mass index, Kellgren-Lawrence grade, or radiographic parameters.ConclusionsFlexion contracture may be associated with progression of cartilage degeneration at the patellofemoral joint and may negatively affect the clinical outcomes after open wedge, high tibial osteotomy.

The Safety of Wide-Awake, Local Anesthesia, No Tourniquet Hand Surgery: Two Cases of Digital Ischemia

PURPOSE: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery has gained popularity in recent years. Lidocaine with low-dose epinephrine is used to minimize blood loss and improve patient comfort. WALANT surgery reduces the need for preoperative testing, avoids sedation requirements, allows for patient cooperation during surgery, and decreases cost and procedure time.1 Multiple studies show that local anesthesia with epinephrine is safe to use in the fingers;1,2 however, a few cases of ischemia have been reported.3,4 MATERIALS AND METHODS: We present 2 cases of digital ischemia after WALANT surgery that were successfully reversed with phentolamine. RESULTS: Case 1—A 31-year-old female with rheumatoid arthritis underwent nail plate removal for chronic paronychia performed under a digital block (5 ml of 1% lidocaine with 1:100,000 epinephrine). The patient presented to the emergency room 12 hours later with persistent ischemia and anesthesia. Topical nitroglycerin cream and a warm compress were applied with minimal improvement. Five milligrams of phentolamine in 1 ml of sterile saline was injected at the base of the proximal phalanx with complete resolution of ischemia within 2 hours. At 1-week follow-up, the patient’s finger was perfused. Case 2—A 76-year-old female with multiple medical comorbidities, including cardiac stents (on apixaban) and COPD (on 3 L of home oxygen), underwent trigger finger release under local anesthesia (6 ml of 1% lidocaine with 1:100,000 epinephrine mixed 1:1 with 0.25% plain bupivacaine). She returned to clinic 4 hours later with persistent ischemia. Topical nitroglycerin cream and a warm compress were applied without improvement. 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the A1 pulley. After 90 minutes, there was some improvement but the finger remained ischemic distal to the proximal interphalangeal joint. Another 1.5 mg of phentolamine in 1 ml of sterile saline was injected at the level of the proximal interphalangeal joint with significant improvement. At 10-day follow-up, the patient’s finger was perfused. CONCLUSION: Prolonged digital ischemia after WALANT surgery is rare, but surgeons should counsel patients on warning signs and be prepared for phentolamine rescue when needed. The incidence of epinephrine-induced digital ischemia may increase as WALANT surgery gains popularity. It is mandatory for surgeons performing WALANT procedures to have access to phentolamine. REFERENCES: 1. Al Youha S, Lalonde DH. Update/review: changing of use of local anesthesia in the hand. Plast Reconstr Surg Glob Open. 2014;2:e150. 2. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119:260–266. 3. Zhu AF, Hood BR, Morris MS, et al. Delayed-onset digital ischemia after local anesthetic with epinephrine injection requiring phentolamine reversal. J Hand Surg Am. 2017;42:479 e471–479 e474. 4. Zhang JX, Gray J, Lalonde DH, et al. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017;42:e119–e123.

Refracture after plate removal following ulnar shortening osteotomy for ulnar impaction syndrome – a retrospective case–control study

Refracture after plate removal following ulnar shortening osteotomy (USO) is a rare, but very distressing for both the patient and surgeon. This case–control study was performed to identify predictive factors for refracture incidence. A total of 245 patients, who had undergone USO between 2008 and 2018 were included in the study. We evaluated the basic demographic characteristics/clinical factors preoperatively. Radiological variables, such as dorsal subluxation of the ulna and pre/postoperative ulnar variance, and variables associated with operative conditions, such as triangular fibrocartilage complex degeneration classification, the use of a parallel double-blade saw, the type of plate, number of screws, and plate position, were investigated. Finally, the accuracy of osteotomy and any traces of incomplete healing after plate removal were evaluated. The no-refracture group consisted of 234 patients, whereas the refracture group consisted of eleven patients. The results of univariate analyses revealed that age, bone mineral density, accuracy of osteotomy, and presence of osteotomy traces were significantly associated with refracture. However, during multivariate analysis, low BMD was the only factor significantly associated with refracture. Nevertheless, the accuracy of osteotomy and absence of osteotomy traces were strongly associated with each other in the no-refracture group (p < 0.001, Cram’s V coefficient = 0.36). Low BMD was sole independent predicting factor of refracture after plate removal in USO. Additionally, precise parallel osteotomy is critical for safety after plate removal following USO. Subsequent healing with no radiological traces of osteotomy after plate removal would be associated with absence of refracture. Level of Evidence Level III, case–control study.

Surgical treatment outcome of wrist flexion contracture in children with cerebral palsy through temporary extra-articular arthrodesis

Background. The surgical approaches adopted for the treatment of wrist flexion contracture can be categorized into soft tissue intervention (such as lengthening or transplantation of tendons) and bone operations that stabilize the wrist joint. We developed a technique for temporary arthrodesis of the wrist joint to combine the main advantages of both the approaches, that is, the stability of arthrodesis by the installed metal construction and the possibility of active movements in the wrist joint after removal of the structure.&#x0D; Aim. To compare the effectiveness of a new method of surgical treatment of wrist flexion contracture in children with cerebral palsy, such as temporary extra-articular arthrodesis and transplantation of the hand flexors to the extensors, according to Green.&#x0D; Materials and methods. We conducted a comparative analysis of the treatment outcomes between the following 2 groups of patients: group 1 (n = 13) patients underwent a tendon transplantation of m. flexor carpi ulnaris on m. extensor carpi radialis brevis/longus (Green operation), while group 2 (n = 13) patients underwent temporary arthrodesis of the wrist joint with a bone plate for a period of 1 year. The patients in group 2, after the removal of metal structures, underwent a 14-day course of rehabilitation before evaluation of their treatment outcomes. A comparative analysis of the treatment results between the groups 1 and 2 was performed 1 year after arthrodesis and plate removal and at 1 year after muscle transplantation. The range of active and passive movements in the wrist joint was analyzed throughout. In addition, the functionality of the upper limb was assessed with reference to the international classification system of MACS 2002 and the Block and Box test.&#x0D; Results. In the group 1 patients, an increase in the passive range of motion (+9.7) was noted. In both the groups, a significant increase was recorded in the amplitude of active movements (31.9 in group 1 and 45.7 in group 2). The upper limb functionality index MACS, on evaluating the condition of the arm as a whole, appeared to be almost identical in both the groups. In the group 1 patients, the average dynamics of the Block and Box test as a result of treatment was 8 additional cubes, while it was only 1.6 in the group 2 patients.&#x0D; Conclusion. The Green operation was less effective in comparison with the operation of temporary arthrodesis as a method of correcting the flexion contracture of the wrist joint. However, the functional performance of the Green operation was higher. The choice of the optimal surgical treatment technique can be determined as follows. In children with a high functional perspective, the Green operation is preferred. However, in children with doubtful functional prospects where the correction of severe contracture is the main aim, temporary arthrodesis may be preferable.

Can medial stability be preserved after open wedge high tibial osteotomy?

PurposeThis study evaluated the medial joint stability after high tibial osteotomy (HTO) releasing the superficial medial collateral ligament (sMCL) without cutting and repairing.MethodsTwenty-one patients who performed HTO were enrolled. After an L-shaped incision was made in the pes anserinus, the sMCL was released from the distal portion during surgery. After plate fixation, the sMCL was reattached and the pes anserinus was repaired underneath the plate. Plate removal was performed after 31.1 ± 14.2 months. Before HTO, a valgus force of 40 N was exerted at extension for reference values. Before and after plate removal, a valgus force of 40 N was exerted at extension and at a flexion position of 20°. Medial stability was evaluated by measuring the joint line convergence angle (JLCA).ResultsThe JLCAs in the extension state before HTO and plate removal were 1.64° ± 1.15° and 1.83° ± 1.36°, respectively; there was no significant difference (p = 0.198). There was also no significant difference in JLCA before HTO and after plate removal (p = 0.835). There was also no significant difference in JLCA before and after plate removal both at a knee extension and flexion position of 20° (p = 0.348 and p = 0.456, respectively).ConclusionsReleasing the sMCL without cutting and repairing the pes anserinus underneath the plate during medial open wedge HTO could facilitate the maintenance of medial joint stability.

Intra-articular distal radius fractures treated with variable angle locking compression plates: An outcome analysis

Background: Methods for surgical fixation of intra-articular distal end radius fractures has been on an evolving course. One among the novel developments is the use of variable angle locking plate. Its multidirectional locking option facilitates fixation of even the most complex of the fractures, especially in osteoporotic bone. Aim: To study the functional and radiological outcome of operative management of intra-articular fractures of distal end of radius with variable angle locking compression plates. Material & Methods: 56 adult patients (36 males and 20 females) who had intra-articular distal radius fractures satisfying the study criteria & treated at Sunshine hospitals, Secunderabad, Telangana, India between October 2015 and September 2017 using variable angle locking compression plates were taken up for the study. The cases were followed up at 6 weeks, 3 months, 6months and 12 months postoperatively. During each visit, functional outcome was assessed using Demerit score system of Gartland and Werley. Radial height, radial angulation and palmar angulation were measured from the xray to assess the radiological outcomes. Results: There were 2 type B1, 8 type B2, 16 type B3, 13 type C1, 12 type C2 and 5 type C3 as per the AO classification. Functional assessment showed 29(51.78%) excellent results, 21(37.5%) good results, 6(10.71%) fair results and no poor results There was no significant difference in the radiological parameters between different follow-ups as signified by p value >0.05 implying that there was no loss of fixation. One patient had flexor pollicis longus tendon rupture at 13 months postop & was managed by Plate removal + transfer of Flexor Digitorum Superficialis tendon. Two patients developed superficial wound infection which susbsided with oral antibiotics. One patient developed Reflex Sympathetic Dystrophy which was managed medically. One patient had Screw malpositioning but remained asymptomatic through out the follow up period. Conclusion: Variable angle locking plate offers predictable and good outcome in intra-articular fractures of the distal end of the radius.

True Antiglide Fixation of Weber B Ankle Fractures has Lower Rates of Removal of Hardware

Category:Trauma; AnkleIntroduction/Purpose:Plating of unstable OTA/AO 44-B1 lateral malleolus fractures has been associated with pain, peroneal irritation, and subsequent hardware removal. There has been speculation that this is due to the prominent plate and distal screw placement. Previous studies have looked at posterior vs lateral plate position but have had fairly low numbers in each group. The purpose of this study was to retrospectively compare the rates of hardware removal in unstable OTA/AO-type 44-B1 lateral malleolus fractures fixed with a posterior, true anti-glide plate with no screws in the distal segment versus those that were fixed with a similarly placed posterior, neutralization construct that included screws in the distal fragment thus evaluating the role of the distal screw in rates of hardware removal.Methods:Skeletally mature patients that were treated for an isolated OTA/AO 44-B1 fracture over a ten-year period (2007- 2017) were reviewed. Fractures treated with a single posterior plate were included and those fixed with a direct lateral plate were excluded. We evaluated post-op radiographs to determine application of a true anti-glide plate or a neutralization plate with screws in the distal fragment. Radiographic follow-up was used to determine bony union, malunion and need for hardware removal. Hardware removal was determined as entire plate removal; isolated syndesmotic screw removal was not included. Patients were excluded if they had less than six months of follow up. Relative risk was determined for the rate of hardware removal based on fixation technique.Results:There were 548 OTA/AO 44-B1 fractures treated over the course of ten years (2007-2017). After screening, 88 patients were included in the study. The majority of excluded patients lacked adequate follow-up. Average age of the cohort was 46 years old (range 17-84), with 47 females and 41 males included. Average length of follow up was forty months (range 6.1- 140.3). There were 28 patients in the true anti-glide plate group and sixty in the neutralization plate group. Five (18%) in the anti- glide plate group and 19 (32%) in the neutralization plate underwent a second procedure of hardware removal. Relative risk of hardware removal was 0.56 (95% CI 0.23-1.36, p=0.2). There was a 100% union rate with 0% malunion in both groups.Conclusion:Anti-glide plating has a near 50% relative risk reduction in the rate of hardware removal when compared to posterior based neutralization plating. Fractures fixed with or without distal screws had equivalent excellent results related to bony union and alignment. A true anti-glide plating construct should be considered as a safe and effective way of managing OTA/AO 44-B1 lateral malleolus fractures with a lower relative risk of a second operation for hardware removal.

Union Rates and Deformity Correction Using the Hintermann Osteotomy in Type IIb Flatfoot Deformity

Category:Ankle; HindfootIntroduction/Purpose:Multiple Lateral column lengthening procedures have been described for the correction of the abduction component of stage II flatfoot deformity. The Hintermann osteotomy, although technically difficult, offers powerful lengthening of the lateral column with low risk of violating the articular cartilage of the subtalar joint as compared to the more widely performed Evans osteotomy. This study reports on the radiographic and clinical outcomes of the Hintermann osteotomy performed by a single surgeon.Methods:Patients who underwent reconstruction for stage II flatfoot deformity with a Hintermann lateral column lengthening were restrospectively identified. The talus-1st metatarsal angle, percent talus uncoverage, calcaneal pitch, lateral column length, CC joint subluxation, and distance from CC joint to the osteotomy were measured on pre and postop radiographs. Radiographic union was also assessed. The Kellgren-Lawrence scale was used to assess degenerative changes at the ST, CC, and TN joints.Charts were reviewed for comorbidities, clinical evidence of union, time to protected weightbearing, time to unrestricted weightbearing, signs of peroneal irritation, clinical signs of osteoarthritis progression, and complications. A paired students t test was used to identify differences in radiographic parameters.Results:Twenty-six patients (30 feet) met inclusion criteria. All osteotomies achieved union with only 1 (1/30) instance of delayed union. Average duration before clinical and radiographic union was 12.6 weeks (9-37). The AP Talus-1st metatarsal angle decreased on average of 12.3 degrees (STD 9.1) (p<0.0001). Percent talus uncoverage decreased on average 17.7 percent (STD 11.5%) (p<0.0001). Subluxation at the CC joint was found to increase on average 1.63mm (STD 1.99) (p<0.01). Only 3 patients (10%) had radiographic progression of osteoarthritis at either the CC or ST joint. No patients showed clinical signs of osteoarthritis and none went on to fusion. One patient had lateral hardware pain necessitating plate removal.Conclusion:The Hintermann osteotomy is a powerful tool for lateral column lengthening. In this series there was significant correction of the preoperative abduction deformity with no nonunions. Degenerative changes in the surrounding hindfoot joints were rare. One benefit of the Hintermann osteotomy is its ability to preserve the articular cartilage of the anterior and middle facets.

Selective Glenohumeral external rotation deficit \u2013 sequelae of post-ORIF deltoid adhesions after treatment of the proximal humerus fracture

BackgroundThe deltopectoral approach is commonly used for plate stabilization of proximal humerus fracture. Although adhesions between the deltoid, plate, and humerus are common sequelae of plate ORIF, little is known about their effect on the range of movement and a function of the shoulder. To confirm their impact, the preoperative and intraoperative evaluation of the range of motion (ROM) was measured during the sequential arthroscopic release of adhesions, with special regard to external rotation. Postoperative ROM and subjective shoulder function were also evaluated.MethodsEighteen patients treated with ORIF of the proximal humerus were scheduled to the unified arthroscopic procedures comprising sequential limited subacromial bursectomy, removal of the adhesions between the deltoid, plate, and humerus, as well as the plate removal. The ROM of the operated and opposite shoulders were assessed before surgery, intraoperatively and after a minimum two-year follow-up, with special regard to external rotation in adduction (AddER) and abduction (AbdER). Besides, the Constant-Murley score and Subjective Shoulder Value (SSV) were evaluated before a plate removal and after a minimum two-year follow-up after the surgery.ResultsDeltoid adhesion release correlated with considerable and statistically significant improvement of AddER (p < 0.0002) but not with the intraoperative range of AbdER. Significant improvement of AddER, but also of AbdER and other range of motion was noted at the follow-up. The improvement of the affected shoulder function following arthroscopic plate removal was considerable and statistically significant according to the modified Constant-Murley score (p < 0,01) and SSV (p < 0.0000) after a minimum of two-year follow-up.ConclusionsOur findings are the first to highlight the influence of deltoid muscle, plate, and humerus adhesions on limiting external rotation in adduction after ORIF treatment of proximal humerus fractures. These observations allow the identification of a new shoulder evaluation symptom: Selective Glenohumeral External Rotation Deficit (SGERD) as well as functional deltohumeral space.

Surgical Management of Bilateral Mandibular Angle Fractures With a Third Molar in Line of Fracture: A European Multicenter Survey

The aim of this survey was to investigate the surgical management of bilateral mandibular angle fracture (BMAF) in Europe. Data were collected from 2008 to 2018 on patients ≥ 16years of age who underwent open reduction internal fixation (ORIF) for BMAF with a third molar in the fracture line. The study was conducted at 6 European trauma centers. The following data were recorded: sex, age, cause of the fracture, type of fracture (nondisplaced, displaced, comminuted), type of approach (intraoral, transbuccal, or extraoral), thickness of the plate (≤1.4mm or ≥1.5mm), number of plates, cause of plate removal, and third molar extraction status. 25 patients with BMAF (24 males, 1 female, 17 to 83years old [mean: 28.2years]) were collected. The main cause of BMAF was assault, and the main surgical approach was intraoral. The most common types of BMAF were displaced+undisplaced (11 patients), displaced+displaced (7 patients), undisplaced+undisplaced (6 patients), and comminuted+comminuted (1 patient). Osteosynthesis was performed with 2 ≤1.4mm plates on 1 angular fracture and 1 ≤1.4mm plate on the other fracture in 11 patients, 1 ≤1.4mm plate on both angular fractures in 6 patients, 1 ≥1.5mm plate on both fractures in 5 patients, and 2 ≤1.4mm plates on both fractures in the remaining 3 patients. Out of 25 patients with BMAF, 7 third molars were extracted during ORIF. Among these patients, angular fracture fixation was performed in 3 cases with 1 ≥1.5mm plate and in 4 patients with 2 ≤1.4mm plates. This retrospective multicenter survey indicates a trend of treating with open reduction and rigid internal fixation at least 1 angular fracture of BMAF and those cases requiring extraction of the third molar in the line of fracture.

Three-dimensional realignment and slope reducing osteotomy with anatomic ACL reconstruction in patients with revision anterior cruciate ligament deficiency

Introduction:Current incidence of recurrent anterior cruciate ligament (ACL) instability is 5%, but revision surgery is challenging and requires a thorough analysis of potential risk factor. Moreover, recurrent and chronic ACL instability can result in medial tibio-femoral osteoarthritis (OA). Beside various soft tissue patterns, bony morphologies like a steep posterior tibial slope are associated with an increased anterior tibial translation (ATT) and rotatory instability in the ACL deficient knee. To address the instability and the osteoarthritis a combined procedure is necessary in these patients, however, little is known about the efficacy of such combined procedures. Therefore, the objective of this study was to evaluate the patient reported outcomes and knee stability following combined high tibial osteotomy (HTO) with ACL reconstruction in middle-aged patients with recurrent or chronic cruciate ligament deficiency and mild to moderate medial compartment osteoarthritis (OA). Hypotheses: Methods:Surgical reports and prospectively collected patient reported outcome scores (IKDC, Lysholm, WOMAC, VAS for pain, and Tegner activity score) as well as clinical examination were evaluated retrospectively with a mean follow up of 45.2 ± 14.7 months. Inclusion criteria were 1) high tibial osteotomy with concomitant anatomic ACL reconstruction. Data at final followup were compared to baseline values using the Wilcoxon signed rank test (p < 0.05).Results:44 patients met the inclusion criteria. 16/44 suffered a graft failure after primary ACL reconstruction, and 8/44 had chronic ACL instability, but had a previous subtotal medial meniscus resection. Mean patient age at surgery was 38.2 ± 10.5 years (range: 18 – 63) with a mean varus alignment of 4.5° ± 1.5°. All patient reported significantly improved outcome scores at final follow-up (VAS 4.3 to 1.5, Lysholm 52.4 to 73.5, IKDC 56.5 to 70.9). However, the change in Tegner score at final follow-up (3.4 to 4.5) was not significant. At final followup 25/44 patients had a removal of the fixation plate.Conclusion:The results of this study indicate, that high tibial osteotomy combined with anatomic single bundle ACL reconstruction is a good treatment option in active middle aged patients suffering from recurrent or chronic ACL deficiency with mild to moderate medial compartment OA. At a median follow-up of 24 months patient reported outcome scores were improved. Especially in patients with multiple ACL reconstruction failures realignment osteotomies should be considered.

Incidence for volar locking plate removal following distal radius fracture surgery

IntroductionDistal radius fracture is the most common fracture in adults. The most common treatment for distal radius fracture is non-operative cast immobilization, although there are injuries that require surgical treatment. During the past decade, studies have reported a large increase in the surgical treatment of distal radius fractures with open reduction and internal fixation using volar locking plates. The aim of this study was to investigate the incidence and trends for plate removal after plate fixation of distal radius fractures.Materials and methodsThe study covered all patients 18 years of age and older who had a surgically treated distal radius fracture with open reduction and internal fixation in Finland between 1998 and 2016. Patient data were obtained from the Finnish National Hospital Discharge Register. The association between increased number of platings and plate removals was examined by calculating the removal rates. The study population comprises all patients on a national level, and therefore we did not use statistical testing to analyze the data.ResultsA total of 18,298 patients had surgically treated distal radius fracture with volar plate in Finland during the 19-year study period from January 1, 1998 to December 31, 2016. The number of plate removal operations over the same time period was 2560. The removal rates decreased from over 20% in 1998 to less than 12% in 2016. The mean time period between plating and plate removal operations was 367 days. Most of the plate removals (n = 2235; 87.3%) were conducted during the first 2 years after plating.ConclusionPlate removals have not increased as rapidly as plating operations. The removal rate has declined markedly during the last decade. Nowadays, approximately 11% of distal radius plates are removed.

Tardy posterior interosseous nerve palsy associated with operated proximal shaft of radius fracture: a rare case report

&lt;p&gt;Tardy Posterior interosseous nerve palsy (PIN) is rare diagnosis. It is a mostly motor nerve. It is prone to injury around radio-humeral joint due to its proximity to joint and neck of radius. Early diagnosis is must to improve recovery. In our case, 39-year-old male presented with tardy PIN palsy secondary to united proximal shaft radius fracture with implant in situ. Electrodiagnostic studies revealed motor radial neuropathy left upper limb. Magnetic resonance imaging (MRI) brachial plexus and screening of cervical spine was normal. After preoperative investigation, patient underwent PIN neurolysis with plate removal. Postoperatively patient started showing improvement after 2 months. Patient recovered to achieve good grip at end of 8 months. Early diagnosis followed by nerve exploration is necessary for good recovery and improvement.&lt;/p&gt;

Retraction Notice: Volar locking plate removal following distal radius fractures: indications and outcomes for 71 fractures.

Retraction Notice: Volar locking plate removal following distal radius fractures: indications and outcomes for 71 fractures.