Should We Use Intermetatarsal Angle as Primary Determinant to Define the Limits of Distal Chevron Osteotomy?

Classic treatment algorithms limit the use of distal chevron osteotomy (DCO) to cases with an intermetatarsal angle (IMA) <14°. As the IMA increases, it is accepted that the contact between the metatarsal head and shaft will be insufficient. We have investigated the reliability of IMA to predict contact area percentage after DCO. Preoperative radiographs of patients with hallux valgus were subdivided as mild, moderate, and severe using traditional algorithms. After excluding the mild cases, we randomly selected 100 patients (50 moderate and 50 severe) and calculated the estimated bony contact (EBC) with our method and investigated the percentage of patients who could have >50% contact area if we perform a DCO. Thirty of 50 (60%) and 17 of 50 (34%) patients had >50% EBC in moderate and severe groups, respectively. We performed DCO for 24 patients (14 moderate and 10 severe cases). The 100-point American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarso-phalangeal-interphalangeal scale was used to assess the clinical outcome. For the moderate group, we calculated mean IMA 16° (standard deviation [SD] ± 1.4°) and mean EBC 66.9% (SD ± 10.8%). For the severe group, we calculated mean IMA 20.9° (SD ± 0.7°) and mean EBC 63.1% (SD ± 10.4%). Paired t tests showed significant improvement comparing preoperative and postoperative AOFAS scores, IMA, hallux valgus angle, and sesamoid position for all operated patients (p < .001). We did not see any recurrence of hallux valgus or hallux varus and had only 1 minor complication that we managed conservatively. IMA may not always be a reliable parameter to predict the stability of DCO. Because the stability depends on the contact surfaces of osteotomy fragments, metatarsal head diameter and remaining bone contact should be the primary concerns. Two patients with the same IMA can have a different contact surface varying on a broad spectrum.

Anatomic locking plate and coracoclavicular stabilization with suture endo-button technique is superior in the treatment of Neer Type II distal clavicle fractures.

INTRODUCTION: The purpose of this retrospective study was to compare the clinical results of three different fixation techniques for the treatment of Neer Type IIb fractures. We hypothesized that anatomic locking plate and coracoclavicular stabilization with suture endo-button technique provides more stable and biomechanically superior fixation among others with low complication rates. METHODS: Thirty six patients with Neer Type IIb fractures treated were evaluated. Patients were divided into three groups according to surgical choice that was performed: tension band and coracoclavicular suture stabilization with k-wires was defined as Group 1, anatomic locking plate and coracoclavicular stabilization with screw was defined as Group 2, and anatomic locking plate and coracoclavicular stabilization with suture endo-button (LPES) was defined as group 3. Mean age was 36.1 years, and mean follow-up period was 32.4 months. Radiological follow-ups and constant were recorded and compared at 3, 6, 12 and 24 months. RESULTS: At 3rd and 12th month follow-up in the LPES group, mean constant scores were statistically higher than other two groups (p < 0.01). The difference between other two groups was insignificant (p > 0.05). At 6th month follow-up, mean constant scores in LPES group were higher than other groups; there was less statistical significance than other time zones (p < 0.05). CONCLUSION: Anatomic locking plate combined with suture endo-button for CC ligament reinforcement is a reliable method to achieve osteosynthesis and stabilization for Neer Type IIb distal clavicle fractures without compromising physiology of shoulder.

Effect of Arthroscopic Acromioplasty on the Isometric Abduction Strength.

Introduction Acromioplasty is a widely performed procedure for various rotator cuff pathologies with good outcomes and high patient satisfaction. However, few studies have focused on its potential complications. Previous cadaveric studies have demonstrated that a considerable portion of the deltoid muscle is detached from its acromial origin following arthroscopic acromioplasty, but the clinical relevance of this muscle detachment has not been investigated. The goal of our research was to examine the influence of arthroscopic acromioplasty on abduction strength and to assess whether acromial anatomy plays a role in any potential effect. Methods From a preliminary sample of 87 individuals who were diagnosed with isolated impingement syndrome and underwent arthroscopic acromioplasty, 74 patients who met the inclusion criteria were ultimately included in the study. The patients were divided into two groups according to their acromion morphology: Bigliani type 2 (33 patients) and type 3 (41 patients). The isometric abduction strength of the two groups was measured by a handheld dynamometer (Isobex®; Cursor AG, Berne, Switzerland) at different abduction angles preoperatively and at the first, third, and sixth months following surgery and was statistically compared. Results Both groups showed reduced abduction strength postoperatively; however, the strength of abduction in the Bigliani type 3 group returned to near preoperative values in the third month. Although increased mean abduction strength was recorded at 30° abduction in the sixth month, this difference was not statistically significant (p=0.78). In the Bigliani type 2 group, compared with those in the sixth-month group, the preoperative abduction strength decreased from 8.32 kg to 6.0 kg (p = 0.047), 6.57 kg to 5.15 (p = 0.025), and 6.1 kg to 4.56 kg (p = 0.006) at 30, 60, and 90° abduction, respectively.  Conclusions Arthroscopic acromioplasty decreased isometric abduction strength in patients with a Bigliani type 2 acromion. Patients should be counseled about this loss, which might be especially important for professional athletes and heavy manual workers.

Posterolateral wall integrity in reverse oblique intertrochanteric fracture fixation: A new perspective in evaluation.

BACKGROUND: Treatment of reverse oblique fractures has the highest complication rate among proximal femur fractures. Although intramedullary nailing is the preferred treatment option, a high failure rate has been reported. Previous studies have identified several contributing factors to these failures, yet the significance of posterolateral wall integrity in ensuring postoperative stability has not been emphasized. This study aims to investigate the impact of posterolateral wall integrity on the failure rates of reverse oblique intertrochanteric fractures treated with intramedullary nails (IMN) and assess the vulnerability of certain IMN designs to these failures. METHODS: Between 2010 and 2016, 53 patients with reverse oblique fractures were analyzed to identify factors associated with IMN failure. Variables such as posterolateral wall integrity, quality of reduction, posteromedial support, and IMN design were considered as potential risk factors. Logistic regression analysis was conducted to evaluate these risk factors, with statistical significance defined as p<0.05. RESULTS: Eleven cases of implant failure were identified. Univariate statistical analysis indicated that loss of posterolateral support (p=0.002), IMN with single-screw proximal fixation (p=0.048), poor reduction quality (p=0.004), and loss of posteromedial support (p=0.040) were associated with implant failure. Multivariate analysis confirmed loss of posterolateral support (p=0.009), poor reduction quality (p=0.039), and loss of posteromedial support (p=0.020) as independent risk factors for failure. However, IMN with single proximal fixation (p=0.859) did not significantly impact fixation failure. CONCLUSION: Reverse oblique intertrochanteric fractures with compromised posterolateral support exhibit a high rate of mechanical failure when treated with IMN. Additionally, poor reduction quality and loss of posteromedial support increase the risk for failure of these fractures. An IMN design featuring dual separate proximal screw fixations could provide better stability compared to a design with a single proximal screw, thereby reducing the risk of mechanical failure.

Adaptation of the International Fitness Scale and Self-Perceived Health-Related Physical Fitness Questionnaire into Turkish.

This study aims to investigate the Turkish validity and reliability of the International Fitness Scale (IFIS) and the Self-Perceived Health-Related Physical Fitness Questionnaire for Children (SPHQ-C) aged 10-17. The measurement tools were translated into Turkish by two independent researchers and back-translated. Then, the content validity was established with a group of 13 individuals (Sample 1) who presented to the sports medicine clinic. The pilot application phase was initiated. A sample of 372 individuals (Sample 2) studying in the provincial center was selected for piloting the measurement tools with the ALPHA-FIT Test Battery. The test-retest application of the measurement tools with a 15-day interval was carried out with 207 individuals (Sample 3) not included in Sample 2. The authors calculated that the content validity ratio values for the items in the IFIS ranged from 0.85 to 1.00, with a content validity index of 0.94 for the scale. In the SPHQ-C, these values were found to be between 0.92 and 1.00, with a content validity index of 0.99. According to the Z-score difference analysis for both measurement tools, the construct validity of all items was achieved (p < 0.05). In the Bland-Altman plot test conducted for the IFIS-TR, the mean difference was calculated as 0.11, the standard deviation of the differences was 1.57, and the p-value was determined as 0.31. For the SPHQ-C-TR, the mean difference was -0.15, the standard deviation of the differences was 1.95, and the p-value was determined as 0.26. The Kappa coefficients for the items of the IFIS-TR ranged from 0.45 to 0.52, while for the SPHQ-C-TR, the Kappa coefficients ranged from 0.47 to 0.75. Confirmatory factor analysis conducted on Sample 2 confirmed model fit indices with covariance among some items of the measurement tools (IFIS-TR: e1-e3; SPHQ-C-TR: e1-e2, e1-e3, e2-e3, e3-e4, e6-e7, e8-e9). The IFIS and SPHQ-C measurement tools have been adapted into Turkish, and their validity and reliability have been established.

Bicortical versus unicortical pedicle screws in direct vertebral rotation: an in vitro experimental study.

STUDY DESIGN: In vitro experimental study. OBJECTIVE: This study aimed to evaluate the biomechanical properties of bicortically placed and laterally oriented screws, which may represent an alternative approach for challenging sites during direct vertebral rotation (DVR). SUMMARY OF BACKGROUND DATA: DVR corrects the transverse plane deformity and the thoracic hump in idiopathic scoliosis. However, instrumentation of the convex side of the scoliosis apex may pose a challenge, not allowing the placement of suitable sized screws in adequate direction. METHODS: Forty-eight calf vertebrae were used and each vertebral body was instrumented with 1 pedicle screw as follows: unicortical group (n=16), a short screw was unicortically placed and directed laterally; bicortical group (n=16), a short screw was bicortically placed again in lateral direction; control group (n=16), a screw with ideal length and direction was placed. Vertebral bodies were rigidly anchored in a custom device. Each screw was rotated using a constant length lever arm while collecting "force to failure" data. RESULTS: Significantly better results were obtained with bicortical screwing when compared with unicortical screwing (335.4±45.6 vs. 239.5±58.50 N, P<0.001). However, mean "force to failure" was significantly higher in the controls than in the bicortical group (415.8±49.2 vs. 335.4±45.6 N, P<0.001). CONCLUSIONS: Bicortical screw placement may provide a biomechanically superior construct than unicortical screw placement for resisting DVR maneuver during scoliosis correction. This technique may represent an effective and safe approach, particularly for the convex side of the scoliosis apex, with increased resistance to derotational forces and decreased risk of bone failure. Further clinical studies are warranted for firmer conclusions.

Effects of the grade, stability, chronological classification and being either unilateral or bilateral of the slip on the treatment by in situ single screw fixation of patients with slipped capital femoral epiphysis.

PURPOSE: The effects of the grade, stability, chronological classification and being either unilateral or bilateral of the slip on the outcomes of the treatment by in situ single screw fixation of the Slipped capital femoral epiphysis were investigated. METHODS: 34 hips of 24 patients (7 girls, 17 boys; mean age 12.04 years; range 9-14; 14 slips acute, 7 slips acute on chronic, 13 slips chronic; 22 slips stable, 12 slips unstable; 20 slips Grade 1, 13 slips Grade 2, 1 slips Grade 3) between 2003 and 2009 were involved in the study. During the controls; range of motion, walking abnormalities, Trendelenburg test, use of assistive devices during mobilization, existence of pain and complications were evaluated. The evaluation of clinical results was made according to the average Harris Hip Score. RESULTS: 10 of 24 patients showed evidence of a slip of the contralateral hip on average 10.6 (6-16) months after the initial operation. At mean 41.52 ± 8.08 months controls, the Harris Hip Score was found 77.41 ± 14.66, hip-joint motions, flexion 120° (70°-140°), abduction 40° (20°-60°), internal rotation 25° (10°-40°). Evaluation at the last follow-up showed significant differences between single hip slip than both hip slip, stable slip than unstable slip and Grade 1 slip than Grade 2 slip. In the last control of one patient with a Grade 3 slip, avascular necrosis has been observed. Considering the effect on the clinical results of the chronological classification of the no slip, significant differences have been seen between the clinical outcomes of the acute, chronic or acute on chronic slips. DISCUSSION: The outcomes of the treatment by in situ single screw fixation are negatively affected by increase in the grade of slip, instability of the slip and existence of slip at both hips.

Comparison of proximal junctional kyphosis rate according to fusion level.

INTRODUCTION: There are two main accepted reasons of Proximal junctional kyphosis (PJK) after Scheuermann's kyphosis treatment; overcorrection of initial curve and fusion that is too short proximally. The purpose of this study was to evaluate the incidence of PJK in patients who have been previously treated for Schuermann's kyphosis with a curve exceeding 70° and corrected under 40° according to proximal fusion level T2 or T3. METHODS: We retrospectively evaluated 30 patients treated for Schuermann's kyphosis with single stage posterior only procedure. We included patients that we achieved at least 50% correction of the initial curve. The surgeries were performed at the same institution by a single senior spinal surgeon. Patients were divided into two groups according to proximal fusion level T2 (16 patients) or T3 (14 patients) and evaluated for PJK, follow-ups ended three years after surgery. RESULTS: Mean age was 22.7 in T2 and 21.6 years in T3 group. Mean preoperative Cobb angle was 78° in T2 and 78.7° in T3 group. The mean postoperative Cobb angle was 33.2° in T2 and 35° in T3 group. None of the patients showed neurologic complications. Four patients had PJK in T3 group and one needed revision. CONCLUSIONS: Selecting T2 as the proximal fusion level in Schuermann's kyphosis may decrease the incidence of PKJ. Studies with a larger number of patients needed to verify our results.

Do Magnetically Controlled Growing Rods Stimulate Longitudinal Vertebral Growth in Early-Onset Scoliosis Patients?

OBJECTIVE: Distraction-based systems are the most common systems used in the treatment of early-onset scoliosis. In addition to its corrective and deformity progression preventive properties, its vertebral growth stimulation effect has been proved. Recently popularized magnetically controlled growing rods (MCGRs) showed superior results in terms of outcomes and decreased complication rate. Its vertebral growth stimulation effect has not been studied. The aim of the study is to evaluate the vertebral growth stimulation effect in patients treated with MCGR. METHODS: Patients with progressive scoliosis treated by dual MCGR, who had no obvious lumbar vertebral deformity and had a regular 3-month interval spinal lengthening for at least 30 months, were subdivided into 2 groups according to the inclusion of L3 vertebra within instrumentation segments. The L3 vertebral vertical and horizontal lengths were measured postoperatively and at the last follow-up, and their differences were analyzed statistically in both groups. RESULTS: Twenty-four patients were included; 18 of them had an L3 vertebra outside instrumentation segments, while the other 6 had spanned by MCGR. Uninstrumented L3 were followed up for an average of 36 months. The height difference between initial postoperative examination and the last follow-up was 3.55 mm ± 0.63 mm, and the width difference was 3.85 mm ± 0.75 mm. Conversely, patients with instrumented L3 were followed up for a mean of 38.9 months. Their initial postoperative examination and last follow-up differences in height and width were 6.91 mm ± 1.11 mm and 3.66 mm ± 0.92 mm, respectively. CONCLUSIONS: Frequent distractions stimulate longitudinal vertebral growth in vertebrae spanned by MCGR.

Mid-length Pedicle Screws in Posterior Instrumentation of Scoliosis.

Study Design: Prospective analysis of collected data. Purpose: We determine the need for the use of mid-length pedicle screws (screws with 2.5-mm long increments) during posterior spinal instrumentation. Overview of Literature: Many biomechanical studies have been performed showing that increasing the pedicle screw insertion depth provides an improved resistance to pullout, cyclic loading, and derotational forces, but no intermediate length screws were used. Methods: We prospectively evaluated 120 patients who received posterior segmental instrumentation for structural scoliosis. Preoperatively, 91.44-cm long cassette anteroposterior (AP), lateral, and AP bending radiographs and multiplanar computed tomography were performed in all patients routinely. We measured chord length to determine the maximum probable screw length of all vertebrae. All pedicle screws were attempted to be placed as long as possible. The main intention was at least to engage the subcortical bone of the anterior vertebral cortex. Especially in the apical region, the screws were attempted to be inserted bicortically. The length, level, region, and side of each screw were recorded. Screws with 5-mm increments were called standard length screws (SLS), and middle-sized screws with 2.5-mm increments were called mid-length screws (MLS). Results: Of 2,846 pedicle screws inserted, 1,575 (55.4%) were SLS and 1,271 (44.6%) were MLS, demonstrating a need for MLS in scoliosis surgery (p <0.05). The need for MLS increased significantly in the thoracic region, apical vertebrae, and convex side (p <0.05). Conclusions: If anterior cortex engagement or longer placement of pedicle screws is intended during scoliosis surgery, for safer placement, screws with 2.5-mm increments should be available in posterior instrumentation systems.

A review of literature: Mosaicoplasty as an alternative treatment for resection of patellar osteoid osteoma and cartilage reconstruction.

Osteoid osteoma is an uncommon benign tumor and causes severe pain, being worse at night, that responds dramatically to nonsteroidal anti-inflammatory medications. An osteoid osteoma of the patella is very rare and if it arise close to chondral surface differential diagnosis may be challenging. In three patients the osteoid osteoma was completely excised by nidus removal by mosaicoplasty set with open surgical technique. The patients were followed up in average for 31 (16-48 months) months with annual clinical and radiographic evaluations. There were no relapse of the pain and no residual recurrent tumor. The aim of the treatment for osteoid osteoma is to remove entire nidus by open surgical excision or by percutaneous procedures such as percutaneous radiofrequency and laser ablation. Mosaicoplasty is a good alternative for treatment of osteoid osteoma of the patella in the subchondral bone.

Comparison of the Pullout Strength of Different Pedicle Screw Designs and Augmentation Techniques in an Osteoporotic Bone Model.

STUDY DESIGN: Mechanical study. PURPOSE: To compare the pullout strength of different screw designs and augmentation techniques in an osteoporotic bone model. OVERVIEW OF LITERATURE: Adequate bone screw pullout strength is a common problem among osteoporotic patients. Various screw designs and augmentation techniques have been developed to improve the biomechanical characteristics of the bone-screw interface. METHODS: Polyurethane blocks were used to mimic human osteoporotic cancellous bone, and six different screw designs were tested. Five standard and expandable screws without augmentation, eight expandable screws with polymethylmethacrylate (PMMA) or calcium phosphate augmentation, and distal cannulated screws with PMMA and calcium phosphate augmentation were tested. Mechanical tests were performed on 10 unused new screws of each group. Screws with or without augmentation were inserted in a block that was held in a fixture frame, and a longitudinal extraction force was applied to the screw head at a loading rate of 5 mm/min. Maximum load was recorded in a load displacement curve. RESULTS: The peak pullout force of all tested screws with or without augmentation was significantly greater than that of the standard pedicle screw. The greatest pullout force was observed with 40-mm expandable pedicle screws with four fins and PMMA augmentation. Augmented distal cannulated screws did not have a greater peak pullout force than nonaugmented expandable screws. PMMA augmentation provided a greater peak pullout force than calcium phosphate augmentation. CONCLUSIONS: Expandable pedicle screws had greater peak pullout forces than standard pedicle screws and had the advantage of augmentation with either PMMA or calcium phosphate cement. Although calcium phosphate cement is biodegradable, osteoconductive, and nonexothermic, PMMA provided a significantly greater peak pullout force. PMMA-augmented expandable 40-mm four-fin pedicle screws had the greatest peak pullout force.

Short Segment Spinal Instrumentation in Early-onset Scoliosis Patients Treated With Magnetically Controlled Growing Rods: Surgical Technique and Mid - Short-term Outcomes.

STUDY DESIGN: A prospective, a single-institution, nonrandomized study. OBJECTIVE: The aim of this study was to evaluate the safety and effectivity of short-segment instrumentation in early-onset scoliosis (EOS) patients treated by magnetic-controlled growing rods (MCGRs). SUMMARY OF BACKGROUND DATA: Despite the common use of conventional growing rods and the recent popularity of MCGR in the treatment of progressive EOS, distal instrumented vertebra and number of the spanned levels are not standardized. METHODS: Patients with progressive EOS, characterized by the major thoracic curve and nonstructural compensatory curve, were a candidate to be treated by dual MCGR short segment spinal instrumentation spanning the major thoracic curve; such patients are followed up for a minimum period of 30 months. Radiological data were collected and analyzed in terms of Cobb angle of both primary and secondary curve, kyphosis angle, T1-T12, and T1-S1 distances, and T1-T12/T1-S1 ratio in preoperative, postoperative, and last follow-up. RESULTS: Sixteen patients with different diagnoses of EOS, mean age at the operation was 7 years and 10 months (5 years and 6 months-9 years and 10 months), and mean period of follow-up was 37 (30-54) months. The Cobb angle of both major and compensatory curve are corrected by the mean value of 62° (44-85), 35° (22-45) preoperatively to 29° (12-49), 14° (9-24) postoperatively, and maintained at 28° (10-47), 10° (2-20) in the last follow-up, respectively. The T1-T12/T1-S1 ratio was 0.58 preoperatively, 0.6 postoperatively, and 0.62 at the last follow-up. The average yearly T1-T12 and T1-S1 length increase were calculated as 7 and 9 mm/year, respectively. CONCLUSION: Selective fusion principals are applicable to EOS, in that short segment instrumentation with MGCR in thoracic curve EOS patients is an effective technique in correction of both structural and compensatory curve, and in maintaining the correction during subsequent nonsurgical spinal distraction. LEVEL OF EVIDENCE: 4.

Total hip arthroplasty without femoral osteotomy in patients who had high and low dislocation due to developmental dysplasia of the hip.

BACKGROUND: Various surgical techniques and outcome results have been reported after primary total hip arthroplasty for the treatment of patients dysplastic hips. Low failure and complication rates have been reported when the acetabular component has been placed in the true acetabulum. The current study reports the results of primary total hip arthroplasty in patients with high and low dislocation for whom the acetabular component was placed in the true acetabulum without femoral or trochanteric osteotomy. METHODS: 26 primary total hip replacements were performed on 22 patients. The mean duration of follow-up was 8.9 years.There were 4 men and 18 women. 17 hips were classified as type B (low dislocation) and 9 as type C (high dislocation), according to the classification system of Hartofilakidis et al. Acetabular components were placed in the true acetabulum without osteotomy for all patients. RESULTS: At the time of final follow-up (mean 8.9 years) the average Harris Hip Score was 85 points. Femoral head autograft was used in 9 hips to supplement acetabular coverage. In 8 patient linear calcar fracture. 7 fixed with Dall-Mile cable and 1 fixed with a side plate. On radiologic evaluation, 2 incidents of asymptomatic osteolysis, 1 of acetabular loosening, 1 graft resorption, and 1 impingement (correlated with physical examination) were identified. 2 patients had neuropraxia and were treated medically. There were no early or late infections. Only 1 patient with acetabular loosening required revision surgery. CONCLUSIONS: Although it is surgically difficult to place the acetabular component in the true acetabulum without femoral or trochanteric osteotomy, at the final follow-up we report favourable results. Long-term follow-up is needed to verify our results.