Minimally Invasive vs Open Approach for First Metatarsophalangeal Joint Arthrodesis: Short Report of Early Results.

BACKGROUND: We aim to compare early surgical results between groups who underwent minimally invasive surgery (MIS) vs open first metatarsophalangeal (MTP) arthrodesis to treat end-stage hallux rigidus. METHODS: We conducted a retrospective cohort review of 65 patients who underwent a first MTP fusion procedure at an academic medical center between 2015 and 2023. Success of fusion was determined radiographically. Postoperative complications were identified through medical record review. RESULTS: Sixty-seven first MTP fusion surgeries (41 open and 26 MIS) were performed on 65 patients with a primary diagnosis of hallux rigidus. Open surgery and MIS groups had similarly high fusion rates: 95% (39/41) and 96% (25/26), respectively (P = .84). We identified no difference in overall complication rates: 20% for open surgery and 23% for MIS (P = .73). CONCLUSION: This retrospective analysis of 67 first MTP arthrodesis procedures showed no significant differences in fusion success or complications in the short term when comparing MIS to open surgery. Further studies are needed to elucidate potential differences between MIS vs open surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Influence of Talar Displacement on Articular Contact Mechanics: A 3D Finite Element Analysis Study Using Weightbearing Computed Tomography.

BACKGROUND: Talar displacement is considered the main predictive factor for poor outcomes and the development of post-traumatic osteoarthritis after ankle fractures. Isolated lateral talar translation, as previously studied by Ramsey and Hamilton using carbon powder imprinting, does not fully replicate the multidirectional joint subluxations seen in ankle fractures. The purpose of this study was to analyze the influence of multiple uniplanar talar displacements on tibiotalar contact mechanics utilizing weightbearing computed tomography (WBCT) and finite element analysis (FEA). METHODS: Nineteen subjects (mean age = 37.6 years) with no history of ankle surgery or injury having undergone WBCT arthrogram (n = 1) and WBCT without arthrogram (n = 18) were included. Segmentation of the WBCT images into 3D simulated models of bone and cartilage was performed. Three-dimensional (3D) multiple uniplanar talar displacements were simulated to investigate the respective influence of various uniaxial displacements (including lateral translation, anteroposterior translation, varus-valgus angulation, and external rotation) on the tibiotalar contact mechanics using FEA. Tibiotalar peak contact stress and contact area were modeled for each displacement and its gradations. RESULTS: Our modeling demonstrated that peak contact stress of the talus and tibia increased, whereas contact area decreased, with incremental displacement in all tested directions. Contact stress maps of the talus and tibia were computed for each displacement demonstrating unique patterns of pressure derangement. One millimeter of lateral translation resulted in 14% increase of peak talar contact pressure and a 3% decrease in contact area. CONCLUSION: Our model predicted that with lateral talar translation, there is less noticeable change in tibiotalar contact area compared with prior studies whereas external rotation greater than 12 degrees had the largest effect on peak contact stress predictions. LEVEL OF EVIDENCE: Level V, computational simulation study.

The epidemiology and management of iliopsoas hematoma with femoral nerve palsy: A descriptive systematic review of 174 cases.

INTRODUCTION: Iliopsoas hematoma with femoral nerve palsy is a rare phenomenon with no consensus treatment algorithm. The objective of this study was to perform a systematic review of all reported cases of femoral nerve palsy secondary to iliopsoas hematoma to better elucidate it's optimal treatment. MATERIALS AND METHODS: Queries of the PubMed, Embase, and Cochrane databases were performed for reports available in English of femoral nerve palsy secondary to iliopsoas, psoas, or iliacus hematoma. 1491 articles were identified. After removal of duplicated publications and review of abstract titles via a majority reviewer consensus, 217 articles remained for consideration. Dedicated review of the remaining articles (including their reference sections) yielded 122 articles representing 174 distinct cases. Clinical data including patient age, sex, medical history, use of pharmacologic anticoagulation, sensory and motor examination at presentation and follow-up, hematoma etiology and location, time to intervention, and type of intervention were collected. Descriptive statistics were generated for each variable. RESULTS: Femoral nerve palsy secondary to iliopsoas hematoma occurred at a mean age of 44.5 years old. A majority of patients (60%) were male, and a majority of hematomas (54%) occurred due to pharmacologic anticoagulation. Most hematomas (57%) were treated conservatively, and almost half (49%) - regardless of treatment modality - resulted in persistent motor deficits at final follow-up. A minority of patients treated surgically (34%) had residual motor deficit at final follow-up, while 66% of those treated medically had resultant motor deficits, although no direct statistical comparison was able to be performed. DISCUSSION AND CONCLUSIONS: The disparate available data on iliopsoas hematoma with femoral nerve palsy precludes the completion of a true metanalysis, and therefore any conclusions on an optimal treatment algorithm. Based on review of the literature, small to moderate hematomas are often treated conservatively, while larger hematomas with progressive neurological symptoms are usually managed with a percutaneous decompression or surgery. LEVEL OF EVIDENCE: IV.

Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery.

OBJECTIVES: The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions. DESIGN: Retrospective cohort study. SETTING: Two Level-1 trauma centers. PATIENTS/PARTICIPANTS: Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating. INTERVENTION: Dual plating through either a single anterior incision, or dual medial/lateral incisions. MAIN OUTCOME MEASUREMENTS: Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05). RESULTS AND CONCLUSIONS: In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach. LEVEL OF EVIDENCE: III.

Spontaneous iliacus haematoma with femoral nerve palsy: an appeal to involve surgical teams early.

We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.