Suture Button Technique for Tibialis Anterior Tendon Transfer for the Treatment of Residual Clubfoot.

BACKGROUND: The Ponseti method has revolutionized the treatment of idiopathic clubfoot, but recurrence remains problematic. Dynamic supination is a common cause of recurrence, and the standard treatment is tibialis anterior tendon transfer using an external button. Although safe and effective, the placement of the button on the sole creates a pressure point, which can lead to skin ulceration. In our institution, a suture button has been used for the tibialis anterior tendon transfer and we report our results here. METHODS: Two senior authors' case logs were retrospectively reviewed to identify 23 patients (34 feet) for tibialis anterior tendon transfer using a suture button. Complications and additional operative procedures were assessed by reviewing operative notes, follow-up visit clinic notes, and radiographs. The mean age of the patients was 6 years 2 months (SD 40 months) and the average follow-up duration was 67.1 weeks (SD 72 weeks). RESULTS: There were 5 complications (14.7%). Recurrence occurred bilaterally in 1 patient (5.9%) but did not require reoperation. Other complications included a cast-related pressure sore (2.9%) and an infection (2.9%) requiring irrigation with debridement along with hardware removal. CONCLUSIONS: Tibialis anterior tendon transfer using a suture button was a safe procedure with theoretical advantage of providing stronger fixation and reducing the risk of skin pressure necrosis compared to the standard external button technique. We believe a suture button could allow earlier rehabilitation and may afford stronger ankle eversion. Prospective studies are required to compare the differences in functional outcomes between the procedures. LEVEL OF EVIDENCE: Level IV, case series, therapeutic study.

Safety Profile and Short-term Outcomes of BST-CarGel as an Adjunct to Microfracture for the Treatment of Chondral Lesions of the Hip.

BACKGROUND: Acetabular cartilage lesions are a common abnormality found in patients undergoing hip arthroscopic surgery and may cause pain and functional limitations. Several strategies have been developed to treat chondral defects, with no overwhelming success. Recently, BST-CarGel has gained interest as a scaffolding material that can be injected into the microfracture site to stabilize the clot and facilitate cartilage repair. PURPOSE: To perform a retrospective analysis of prospectively collected data to evaluate the safety profile and short-term clinical and radiographic outcomes of patients treated arthroscopically with BST-CarGel for acetabular chondral defects in conjunction with microfracture. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective chart review was performed on all patients who underwent hip arthroscopic surgery by the senior surgeon to identify those who had BST-CarGel applied to their hip from November 2014 to July 2016, and basic demographic information for those patients was obtained. Operative reports and patient charts were reviewed to assess intraoperative and postoperative complications as well as to obtain the details of surgery, including lesion size and treatment method of the labrum (repair vs reconstruction). All patients filled out self-reported questionnaires, including the international Hip Outcome Tool (iHOT), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sports Profile (HOS-SP) at the time of consultation and at 1 year postoperatively, and results were used to assess the clinical outcomes of surgery. RESULTS: Thirty-seven patients (37 hips) with a mean age of 36.19 years at the time of the index procedure were evaluated. There were 30 male patients, and 20 procedures were performed on the right hip. The minimum follow-up was 1 year, with a mean follow-up of 12.72 months. There were no major adverse events of deep vein thrombosis, blood vessel or nerve damage, hemarthrosis, arthralgia, or device-related adverse events. Two patients (5.4%) were readmitted because of pain, probably resulting from an inflammatory reaction to BST-CarGel. At 1 year postoperatively, there were statistically significant improvements in the iHOT (40.4 to 59.1; P < .001), HOS-ADL (60.6 to 71.4; P = .02), and HOS-SP (36.9 to 51.6; P = .01) scores. When the patients were subdivided based on the chondral defect size, the iHOT score improved for all chondral defect sizes, and the HOS-SP score improved in patients with medium (2-4 cm2) and very large (>6 cm2) chondral defects. In addition, the iHOT score improved whether the patients had their labrum repaired or reconstructed (P < .001 and P = .02, respectively). CONCLUSION: The arthroscopic treatment of chondral acetabular defects with BST-CarGel demonstrates a satisfactory safety profile, with statistically significant improvement in patient-reported clinical outcome scores, even for those with very large chondral defect sizes.

Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty.

BACKGROUND: Total joint replacement (TJR) is increasingly performed in older patients with more comorbidities, who are considered at higher risk for postoperative complications. We aimed to identify and calculate the odds ratio of the risk factors for infection, revision and death 3 months and 1 year after TJR as well as for postoperative blood transfusion and longer hospital stay. METHODS: We analyzed all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases in Nova Scotia between Apr. 1, 2000, and Mar. 31, 2014, as identified from the Discharge Abstract Database. We used the Charlson Comorbidity Index as a surrogate measure of comorbidities. We used hospital and physician billings data and Nova Scotia Vital Statistics data to identify the postoperative events in this cohort. RESULTS: A total of 10 123 primary THA and 17 243 primary TKA procedures were performed during the study period. The mean patient age was 66.1 (standard deviation 11.7) years and 67.1 (standard deviation 9.3) years, respectively. With THA, the risk of infection was higher in patients with heart failure and those with diabetes. For TKA, liver disease and blood transfusion were associated with a higher risk of infection. Revision rates were higher among patients with hypertension and those with paraparesis/hemiparesis for THA, and among patients with metastatic disease for TKA. Significant risk factors for death included metastatic disease, older age, heart failure, myocardial infarction, dementia, rheumatologic disease, renal disease, blood transfusion and cancer. Multiple medical comorbidities and older age were associated with higher rates of blood transfusion and longer hospital stay. CONCLUSION: We have identified the risk factors associated with higher rates of postoperative complications and longer hospital stay after TJR. The results enable individualized risk stratification during the preoperative consultation.

CONTEXTE: Les arthroplasties totales (AT) sont de plus en plus pratiquées chez les patients âgés présentant de plus nombreuses comorbidités et considérés de ce fait exposés à un risque accru de complications postopératoires. Nous avons voulu déterminer et calculer le rapport des cotes pour les facteurs de risque d'infection, de révision chirurgicale et de décès 3 mois et 1 an après l'AT, de même que de transfusions sanguines postopératoires et de prolongation du séjour hospitalier. MÉTHODES: Nous avons analysé toutes les interventions primaires pour prothèse totale de la hanche (PTH) et prothèse totale du genou (PTG) en Nouvelle-Écosse entre le 1er avril 2000 et le 31 mars 2014, répertoriées dans la base de données sur les congés des patients. Nous avons utilisé le score de comorbidité de Charlson comme marqueur de substitution des comorbidités. Nous avons utilisé les données de facturation des hôpitaux et des médecins et les données de l'état civil de la Nouvelle-Écosse pour recenser les événements postopératoires dans cette cohorte. RÉSULTATS: En tout, 10 123 PTH primaires et 17 243 PTG primaires ont été effectuées pendant la période de l'étude. L'âge moyen des patients était de 66,1 ans (écart-type 11,7) et de 67,1 ans (écart-type 9,3), respectivement. Avec la PTH, le risque d'infection a été plus élevé chez les patients atteints d'insuffisances cardiaques et les patients diabétiques, tandis qu'avec la PTG, il a été plus élevé chez les patients atteints de maladie hépatique et traités par transfusions sanguines. Les taux de révision chirurgicale ont été plus élevés chez les patients hypertendus et ceux qui souffraient de paraparésie ou d'hémiparésie dans les cas de PTH, et chez les patients atteints de maladies métastatiques dans les cas de PTG. Les facteurs de risque de décès significatifs incluaient maladie métastatique, âge avancé, insuffisance cardiaque, infarctus du myocarde, démence, maladie rhumatismale, maladie rénale, transfusions sanguines et cancer. La présence de comorbidités multiples et l'âge avancé ont été associés à des taux plus élevés de transfusions sanguines et à des séjours hospitaliers plus longs. CONCLUSION: Nous avons déterminé les facteurs de risque associés aux taux plus élevés de complications postopératoires et aux séjours hospitaliers prolongés après une AT. Les résultats permettent d'établir une stratification individualisée des risques dès la consultation préopératoire.

Does restoration of focal lumbar lordosis for single level degenerative spondylolisthesis result in better patient-reported clinical outcomes? A systematic literature review.

It is controversial whether the surgical restoration of sagittal balance and spinopelvic angulation in a single level lumbar degenerative spondylolisthesis results in clinical improvements. The purpose of this study to systematically review the available literature to determine whether the surgical correction of malalignment in lumbar degenerative spondylolisthesis correlates with improvements in patient-reported clinical outcomes. Literature searches were performed via Ovid Medline, Embase, CENTRAL and Web of Science using search terms "lumbar," "degenerative/spondylolisthesis" and "surgery/surgical/surgeries/fusion". This resulted in 844 articles and after reviewing the abstracts and full-texts, 13 articles were included for summary and final analysis. There were two Level II articles, four Level III articles and five Level IV articles. Most commonly used patient-reported outcome measures (PROMs) were Oswestery disability index (ODI) and visual analogue scale (VAS). Four articles were included for the final statistical analysis. There was no statistically significant difference between the patient groups who achieved successful surgical correction of malalignment and those who did not for either ODI (mean difference -0.94, CI -8.89-7.00) or VAS (mean difference 1.57, CI -3.16-6.30). Two studies assessed the efficacy of manual reduction of lumbar degenerative spondylolisthesis and their clinical outcomes after the operation, and there was no statistically significant improvement. Overall, the restoration of focal lumbar lordosis and restoration of sagittal balance for single-level lumbar degenerative spondylolisthesis does not seem to yield clinical improvements but well-powered studies on this specific topic is lacking in the current literature. Future well-powered studies are needed for a more definitive conclusion.

Radiographic Diagnosis of Pincer-Type Femoroacetabular Impingement: A Systematic Review.

BACKGROUND: Femoroacetabular impingement (FAI) is a well-recognized condition that causes hip pain and can lead to early osteoarthritis if not managed properly. With the increasing awareness and efficacy of operative treatments for pincer-type FAI, there is a need for consensus on the standardized radiographic diagnosis. PURPOSE: To perform a systematic review of the evidence regarding imaging modalities and radiographic signs for diagnosing pincer-type FAI. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature review was performed in 2016 using the Cochrane, PubMed, and Embase search engines. All articles focusing on a radiographic diagnosis of pincer-type FAI were reviewed. Each of the included 44 articles was assigned the appropriate level of evidence, and the particular radiographic marker and/or type of imaging were also summarized. RESULTS: There were 44 studies included in the final review. Most of the articles were level 4 evidence (26 articles), and there were 12 level 3 and 6 level 2 articles. The crossover sign was the most commonly used radiographic sign (27/44) followed by the lateral center-edge angle (22/44). Anteroposterior (AP) pelvis plain radiographs were the most commonly used imaging modality (33 studies). Poor-quality evidence exists in support of most currently used radiographic markers, including the crossover sign, lateral center-edge angle, posterior wall sign, ischial spine sign, coxa profunda, acetabular protrusion, and acetabular index. There is poor-quality conflicting evidence regarding the use of the herniation pit to diagnose pincer-type FAI. Some novel measurements, such as ß-angle, acetabular roof ratio, and acetabular retroversion index, have been proposed, but they also lack support from the literature. CONCLUSION: No strong evidence exists to support a single best set of current radiographic markers for the diagnosis of pincer-type FAI, largely due to the lack of better quality trials (levels 1 and 2) that compare conventional radiographic findings with the gold standard, which is the intraoperative findings. More sophisticated imaging modalities such as computed tomography and magnetic resonance arthrography are often needed to diagnose pincer-type FAI, and these investigations are relatively accurate in assessing labral pathology or cartilage damage.