Results of talectomy for inveterate or recurrent clubfoot.

INTRODUCTION: The aim of the present study was to define indications for talectomy in congenital paralytic, dystrophic or idiopathic, inveterate or recurrent, clubfoot. HYPOTHESIS: Talectomy is a valid option for paralytic, dystrophic or idiopathic, inveterate or recurrent, clubfoot. PATIENTS AND METHODS: A single-center retrospective series comprised 52 clubfeet in 31 patients. Etiology was paralytic in 34 feet (65%) (17 arthrogryposes, 10 myelomeningoceles, 4 encephalopathies, 3 peripheral neuropathies), dystrophic in 6 (12%) and idiopathic in 12 (23%). In 27 feet, there was history of surgery (52%). Mean age at talectomy was 4.7 years. In 45 feet (87%), there were associated procedures (soft-tissue release, tendon surgery, calcaneal or lateral arch osteotomy, tibiocalcaneal fusion) and talectomy was isolated in 7 feet (13%). Mean follow-up was 9 years. Final assessment was based on the modified Ghanem and Seringe classification (G&S) and the Ankle-Hindfoot Scale (AHS). RESULTS: All feet required at least one complementary procedure, either in the same step or as revision. Revision surgery was performed in 17 cases (33%), including all 7 feet with isolated talectomy (7 calcaneal tendon lengthenings, 10 mid- or hind-foot osteotomies, 6 tibiocalcaneal fusions, one calcaneocuboid fusion, and 2 progressive corrections by external fixator). Finally, 33 feet (63%) had good G&S results, 44 (85%) were pain-free, and 40 (77%) were plantigrade. DISCUSSION: Talectomy for paralytic or dystrophic inveterate or recurrent clubfoot provided satisfactory medium-term results. Associated to other procedures, it achieves a pain-free plantigrade foot in most cases. Tibiocalcaneal fusion has an analgesic effect. Talectomy may, however, not be indicated in idiopathic clubfoot, given the patients' high functional demand and the existence of alternative treatments. LEVEL OF EVIDENCE: IV, retrospective series.

Spontaneous healing of lateral femoral cutaneous nerve injury and improved quality of life after total hip arthroplasty via a direct anterior approach.

PURPOSE: How the symptomatology of lateral femoral cutaneous nerve (LFCN) injury changes after total hip arthroplasty (THA) via direct anterior approach (DAA) is not known. Our hypothesis was that the symptoms of LFCN injury after THA via DAA in longer follow-up periods would resolve spontaneously, leading to an improved quality of life (QOL). The aims of this study were to investigate how the symptom LFCN injury changed after DAA-THA, and how those changes affected QOL. METHODS: We investigated the incidence of LFCN injury after DAA-THA using self-reported questionnaires at two time points (initial survey: August 2014, present survey: August 2015). QOL was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire, and the Forgotten Joint Score-12 (FJS-12). Types (dysesthesia or hypesthesia) and changes of the symptom were surveyed. RESULTS: About 122 hips at average12.8 months postoperatively (initial survey), and of those, 89 hips at average 26.2 months postoperatively (present survey) were analyzed. The incidence of LFCN injury decreased significantly, from 31.9% to 11.2% ( p < 0.001). Spontaneous improvement of symptoms was seen in 96%. The difference of FJS-12 between patients with and without LFCN injury at the initial survey disappeared at the present survey. The dysesthesia group showed significant correlations between rate of improvement in LFCN injury and increase of QOL. CONCLUSION: Most symptoms of LFCN injury resolved spontaneously with longer follow-up periods. In particular, improvement of dysesthesia as a symptom of LFCN injury was associated with better QOL.

Kinematic Effects of Cervical Laminoplasty for Cervical Spondylotic Myelopathy on the Occipitoatlantoaxial Junction.

STUDY DESIGN: A retrospective evaluation of sagittal angular motion from cervical spinal flexion to extension. OBJECTIVE: To evaluate the kinematic effects of cervical laminoplasty for cervical spondylotic myelopathy (CSM) on the occipitoatlantoaxial junction. SUMMARY OF BACKGROUND DATA: The kinematic effects of cervical laminoplasty for CSM on the occipitoatlantoaxial junction remain controversial. METHODS: A total of 65 CSM patients who were treated with cervical laminoplasty ranging from the C3 to C7 vertebrae were included in the study. After surgery, all patients wore a Philadelphia collar for the first week and began cervical range of motion exercises as soon as possible. Functional plain radiographs were obtained preoperatively and at 1 and 3 years postoperatively. Sagittal angular motion from cervical spinal flexion to extension was measured using the Cobb technique at 7 cervical segments (Oc-C1, C1-C2, C2-C3, C3-C4, C4-C5, C5-C6, and C6-C7). We defined the contribution of each segment's mobility to the total angular mobility of the cervical spine as percent segmental mobility. RESULTS: Total cervical angular mobility significantly decreased after cervical laminoplasty. There were no significant differences in Oc-C2 angular mobility; however, C2-C7 angular mobility had significantly decreased by 3 years postoperatively. No significant differences in percent segmental mobility were observed at 1 year postoperatively except at the C3-C4 segment. By 3 years postoperatively, percent mobility at the Oc-C1 and C1-C2 segments had significantly increased, whereas that at the C3-C4 and C5-C6 segments had significantly decreased. CONCLUSIONS: Our results suggest that, although the contribution of occipitoatlantoaxial junctional mobility to total cervical mobility increases, dynamic mechanical stress to the occipitoatlantoaxial junction does not increase following laminoplasty, and no adjacent segmental disorder at the occipitoatlantoaxial junction was observed within 3 years postoperatively. We hypothesized that early removal of the cervical collar and early cervical range of motion exercises may contribute to these kinematic changes.

Benefit and risk in short term after total hip arthroplasty by direct anterior approach combined with dual mobility cup.

PURPOSE: No previous reports have described the benefits and risks associated with the dual mobility cup (DMC) in primary THA via direct anterior approach (DAA). The aim of this study was to compare the safety and rate of early postoperative complication of the DAA with the DMC for THA with those of the DAA with a single standard cup, and to investigate the influence of the learning curve of the use of DMC on intra- and perioperative outcomes. METHODS: We retrospectively investigated 60 hips treated in the single-DAA group and 60 hips treated in the dual-DAA group. A primary/secondary outcome variable was the presence of any intra- or perioperative complication within the first 6 months/the operative time and hip function at 6 months postoperatively. We also analyzed influence of the learning curve of the use of DMC on intra- and perioperative outcomes. RESULTS: No intraoperative complications were observed in either group. One anterior dislocation and one periprosthetic hip fracture were occurred in the single-DAA group. The surgical times in the single-DAA and dual-DAA groups were 112.0 ± 20.9 and 121.0 ± 26.9 min (p < 0.001). There was no significant difference in the 6-month postoperative hip function scores between the two groups. There was no influence of the learning curve of the use of DMC on intra- and perioperative outcomes. CONCLUSION: We have demonstrated the short-term safety and lack of inferiority of using the DMC in the DAA compared with the standard single mobility cup.

Suprascapular Nerve Block Versus Interscalene Block as Analgesia After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Noninferiority Trial.

PURPOSE: To compare the efficacy of suprascapular nerve block (SSB) and interscalene block (ISB) as postoperative analgesia within the first 24 hours after arthroscopic supraspinatus and/or infraspinatus tendon repair. METHODS: A single-blind, randomized controlled study was performed between 2013 and 2014. The inclusion criteria were arthroscopic supraspinatus and/or infraspinatus tendon repair confirmed intraoperatively, with or without associated procedures, and informed consent. The exclusion criteria were a previously operated shoulder, repair of the subscapularis tendon, and an allergy to local anesthetics. ISB was performed under ultrasound guidance by an anesthesiologist, whereas SSB was performed based on specific anatomic landmarks by a surgeon. The primary evaluation criterion was mean shoulder pain score during the first postoperative 24 hours assessed on a visual analog scale by the patient. The secondary criteria were complications of locoregional anesthesia, the use of analgesics in the recovery room (the first 2 hours) until postoperative day 7, and pain (visual analog scale) during the first week. Forty-four patients were needed for this noninferiority study. An institutional review board approved the study. RESULTS: Seventy-four patients were randomized, and 59 met the intraoperative inclusion criteria. Six patients were excluded (1 for pneumothorax after ISB, 1 for unsuccessful SSB, and 4 for incomplete questionnaires). None of the patients were lost to follow-up. There was no significant difference between the SSB and ISB groups in mean pain score for the first 24 hours (P = .92) or the first 7 days (P = .05). However, there was significantly less pain in the ISB group in the recovery room (P = .01). Consumption of analgesics was comparable between the groups, but the SSB group took significantly more morphine in the recovery room. CONCLUSIONS: In this prospective, randomized controlled study, SSB was as effective as ISB for mean pain control within the first 24 hours but ISB was more effective in relieving pain in the recovery room after arthroscopic supraspinatus and/or infraspinatus tendon repair. LEVEL OF EVIDENCE: Level I, therapeutic, randomized controlled study.

Safety in early experience with a direct anterior approach using fluoroscopic guidance with manual leg control for primary total hip arthroplasty: a consecutive one hundred and twenty case series.

BACKGROUND AND PURPOSE: An encouraging result with direct anterior approach (DAA) is attractive for both patients and surgeons. However, the risks associated with beginning to use DAA require further analysis of the learning curve and better countermeasures to ensure safety. We ask whether the complication rate in the DAA by the inexperienced surgeon could be decreased with specific countermeasures. Our hypothesis was that the complication rate would be low even in early phase of the learning curve using the DAA with these particular countermeasures. PATIENTS AND METHODS: We investigated a consecutive series of 120 primary THA using the DAA with four specific countermeasures; 1) defined exclusion criteria for DAA; 2) no positioning table; 3) use of fluoroscopy as much as required; and 4) having an experienced assistant for DAA (one who has performed the procedure in more than 100 cases). The operative time, the time of fluoroscopic use during the operation, intra and post-operative complications, re-operation for any reason, and cup and stem alignment were investigated. RESULTS: Although the operation times were similar, the duration of fluoroscopy decreased with surgeons' experience. There were no intra-operative complications and no re-operations for any reason. One anterior dislocation was observed in one patient. The mean cup inclination and anteversion angle was 39.7° ± 7.6° and 30.3° ± 7.6°; 43.3 % of stems were positioned in flexion, 55.8 % in the neutral position on the lateral view. CONCLUSION: We demonstrated a lower complication rate during our early experience with the DAA using four countermeasures. Using these countermeasures for the first 40 cases may be useful for surgeons who are considering DAA.

Morbidity of graft harvesting versus bone marrow aspiration in cell regenerative therapy.

PURPOSE: Using bone marrow mesenchymal stem cells (MSCs) with aspiration from the iliac crest is commonly used in reconstructive orthopaedic surgery. Because bone marrow aspiration is a percutaneous technique, the morbidity as compared with the classical bone graft should be decreased. METHOD: Therefore in a retrospective review of 523 consecutive cases of bone marrow aspiration performed at the Henri Mondor Hospital from 1990 to 2006 for the treatment of fractures, minor and major complications were identified and compared to the number of complications observed during the same period with 435 classical iliac crest bone graft procedures performed for the same indications of treatment of fractures. Minor complications included superficial infections, superficial seromas, and minor haematomas. Major complications included herniation of abdominal contents through massive bone graft donor sites, vascular injuries, deep infections at the donor site, neurologic injuries, deep haematoma formation requiring surgical intervention or transfusion, and iliac wing fractures. RESULT: Bone marrow aspiration decreased significantly the number of complications as compared with harvesting classical iliac crest bone graft that was associated with significant morbidity. Adverse events were significantly lower (p < 0.01) in the 523 procedures with bone marrow aspiration as compared with the 435 bone iliac crest piece harvesting. This was true for anaemia (16 cases versus 87 cases), for early pain (six versus 152), persistent pain (two versus 21), neuralgia (three versus 11), minor complications (ten versus 56), and major complications (three cases versus 22 cases). CONCLUSION: In our series the number of complications with bone marrow aspiration was ten times less than the complications observed with the classical technique of bone piece harvesting from the iliac crest, and the complications were clearly less severe.