Non-weightbearing compared with weightbearing x-rays in hallux valgus decision-making.

OBJECTIVE: To report the effect of weightbearing x-ray imaging on clinical decisions in hallux valgus. Weightbearing (WB) x-ray is standard imaging for symptomatic hallux valgus (HV). In our clinical practice, often patients are presenting with non-weightbearing (NWB) x-rays. Repeated imaging requires additional radiation, justified only if expected to benefit patient's treatment. In this study, the influence of WB status on radiological HV parameters and on clinical decisions was analyzed. METHODS: In the dataset of WB and NWB x-rays, the hallux valgus (HVA) and intermetatarsal angle (IMA) were measured and differences analyzed. Clinical decisions for 10 x-ray pairs were studied among 40 respondents. RESULTS: The WB and NWB HVA difference ranged - 16 to 16° (p < 0.001) and IMA - 3.4 to 5.8° (p < 0.001). In only 45% of cases, the decisions based on NWB and WB imaging were consistent (kappa (95% CI) = 30.0 (23.7-36.3)). CONCLUSIONS: Clinical decisions based on WB and NWB radiographs vary significantly. NWB films overestimate early and underestimate advanced HV deformity. Repeating radiographs is justified in patients presenting with NWB radiographs of symptomatic HV.

Arthroscopic Latarjet Stabilization: Analysis of the Learning Curve in the First 90 Primary Cases: Early Clinical Results and Computed Tomography Evaluation.

PURPOSE: To assess the learning curve of arthroscopic Latarjet, evaluating time of surgery, clinical outcomes, complications, revisions, and recurrence. METHODS: Arthroscopic Latarjet procedures performed from 2011 to 2016 were reviewed. Satisfaction rate, subjective shoulder value, Walch-Duplay, Rowe scores, range of motion, and stability were evaluated on clinical examination. Graft position and fusion were analyzed using computed tomography. All patients were divided into 3 chronological groups. RESULTS: Ninety patients (3 groups of 30) were available for clinical evaluation (96,8%). The mean follow-up was 23.7 months. Surgical time was significantly (P = .0028) longer in group I (mean 128 minutes, standard deviation [SD] 33.6) when compared with groups II (mean 102 minutes, SD 16.2) and III (mean 108 minutes, SD 21.8). A regression analysis and cumulative sum learning curve analysis showed the surgeon oscillated around mean operative time (112.7 minutes; SD 27.2) after 30 procedures. The number of intraoperative complications was significantly greater (P = .024) in Group I (5 cases; 17%) compared with zero in group II, and 3 (10%) in group III. All 3 cases (3.3%) of recurrence were reported in group I (P = .033). Significantly, 2 of 3 patients with recurrence had intraoperative graft complications (P = .0107). Overall patient satisfaction was evaluated as 92%, SSV 90%, Walch-Duplay and Rowe scores, respectively, 79 and 81 points. Nine revisions (10%) were reported. No significant differences were found between the results and revisions of the 3 chronological groups. CONCLUSIONS: This study confirms that the arthroscopic Latarjet procedure provides good clinical and radiologic results at short-term follow-up. The surgical time, frequency of complications, and number of hardware problems significantly decreased after the first 30 cases. As such, surgeons should be aware of the elevated potential for complications and recurrence early in the learning curve-serious intraoperative complications are important risk factors for recurrence. LEVEL OF EVIDENCE: III. Therapeutic study: case-control study.

Intraoperative graft-related complications are a risk factor for recurrence in arthroscopic Latarjet stabilisation.

PURPOSE: The goal of this study was to evaluate clinical and radiological outcomes after arthroscopic Latarjet stabilisation in anterior shoulder instability. METHODS: Ninety-three patients after primary arthroscopic Latarjet stabilisation were reviewed. Satisfaction, subjective shoulder value (SSV), Walch-Duplay and Rowe scores, and range of motion and stability were evaluated on clinical examination. Computed tomography (CT) was used to analyse graft position and fusion. RESULTS: Ninety patients (96.8%) were available for clinical and 85 for CT evaluation. The mean follow-up was 23.7 months (13-50, SD 7.1) and age at surgery was 26.2 years (16-44, SD 5.6). Intraoperative complications were reported in eight patients (8.9%) and recurrence in three (3.3%). Significantly, two out of three patients with recurrence had intraoperative graft complications (p = 0.0107). Forty-one patients (45.6%) reported the feeling of "subjective return to sport anxiety". External rotation with arm at the side was 59° (10-90°, SD 20) with 15° (0-70°, SD 17) of loss of rotation. These two factors correlated with results the most. Patient satisfaction was evaluated as 92% (40-100, SD 14) and SSV 90% (30-100, SD12). Revision rate after primary surgery was 10%. CT showed graft healing in 81 (95.3%) patients. A graft position between 2 and 5 o'clock was found in 70 (83.4%) patients and flush to the anterior glenoid rim in 34 (40.5%). Osteolysis of the superior part of the graft was found in 55 (64.7%) patients. CT evaluation showed no correlation with clinical results. CONCLUSION: Arthroscopic Latarjet stabilisation demonstrates satisfactory results in short-term follow-up; however, intraoperative graft-related complications are a risk factor for recurrence. "Subjective return to sport anxiety" and loss of external rotation with the arm at the side are factors worsening the results. Graft position imperfections and osteolysis of the superior part of the graft reported in CT evaluation do not influence the clinical results.

Anatomy of the tibial incisura as a risk factor for syndesmotic injury.

BACKGROUND: The study aims at comparing the bony anatomy of the syndesmosis in patients who sustained a high fibular fracture with syndesmosis disruption and that of the non-injured population. We hypothesised that there are certain anatomical features making the syndesmosis susceptible to injury. METHODS: The CT examinations of 75 patients who sustained a high fibular fracture with syndesmosis disruption and control group of 75 patients with unrelated foot problems were compared. The depth, fibular engagement and rotational orientation of the tibial incisura were analyzed. RESULTS: With the median values of the control group as cutoff there were 71% shallow, 71% disengaged and 77% retroverted syndesmoses in the injury group. The differences between the groups were statistically significant for every measure (P<.002 to P>.0001). CONCLUSIONS: Patients with a shallow, disengaged and retroverted bony configuration of the syndesmosis are overrepresented among patients with syndesmosis disruption.

EFAS Score - Multilingual development and validation of a patient-reported outcome measure (PROM) by the score committee of the European Foot and Ankle Society (EFAS).

BACKGROUND: A scientifically sound validated foot and ankle specific score validated ab initio for different languages is missing. The aim of a project of the European Foot and Ankle Society (EFAS) was to develop, validate, and publish a new score(the EFAS-Score) for different European languages. METHODS: The EFAS Score was developed and validated in three stages: (1) item (question) identification, (2) item reduction and scale exploration, (3) confirmatory analyses and responsiveness. The following score specifications were chosen: scale/subscale (Likert 0-4), questionnaire based, outcome measure, patient related outcome measurement. For stage 3, data were collected pre-operatively and at a minimum follow-up of 3 months and mean follow-up of 6 months. Item reduction, scale exploration, confirmatory analyses and responsiveness were executed using analyses from classical test theory and item response theory. RESULTS: Stage 1 resulted in 31 general and 7 sports related questions. In stage 2, a 6-item general EFAS Score was constructed using English, German, French and Swedish language data. In stage 3, internal consistency of the scale was confirmed in seven languages: the original four languages, plus Dutch, Italian and Polish (Cronbach's Alpha >0.86 in all language versions). Responsiveness was good, with moderate to large effect sizes in all languages, and significant positive association between the EFAS Score and patient-reported improvement. No sound EFAS Sports Score could be constructed. CONCLUSIONS: The multi-language EFAS Score was successfully validated in the orthopaedic ankle and foot surgery patient population, including a wide variety of foot and ankle pathologies. All score versions are freely available at www.efas.co.

Vitamin D concentration in patients with normal and impaired bone union.

BACKGROUND: The aim of the study was to compare vitamin D concentration in patients treated due to delayed bone union and non-union (pseudoarthrosis) and patients with normal fracture healing. MATERIAL/METHODS: A retrospective case-control study was conducted. We enrolled 35 patients with inexplicable (standard and correct surgery, closed fracture, no comorbid metabolic diseases) fracture healing impairment, and 35 patients assigned by age and measurement season. Vitamin D (as 25OHD) concentration was measured in all patients. RESULTS: Vitamin D deficiency was reported in 86% of examined patients. No difference was shown between groups in deficiency prevalence. CONCLUSIONS: Previous studies indicated decreased vitamin D concentration in patients with impaired fracture healing. However, these studies did not include control groups. No difference was demonstrated between patients with normal fracture healing and those with impaired bone union in terms of vitamin D deficiency prevalence.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

Periprosthetic fractures after shoulder arthroplasty: a systematic review.

Purpose: The goal of this study was to review available literature on periprosthetic shoulder fractures to evaluate epidemiology, risk factors and support clinical decision-making regarding diagnostics, preoperative planning, and treatment options. Methods: Two authors cross-checked the PubMed and Web of Science medical databases. The inclusion criteria were as follows: original human studies published in English, with the timeframe not limited, and the following keywords were used: 'periprosthetic shoulder fracture,' 'total shoulder arthroplasty periprosthetic fractures,' 'total shoulder arthroplasty fracture,' and 'total shoulder replacement periprosthetic fracture.' Seventy articles were included in the review. All articles were retrieved using the aforementioned criteria. Results: The fracture rate associated with total shoulder arthroplasty varied between 0 and 47.6%. Risk factors for periprosthetic fractures were female gender, body mass index < 25 kg/m2, smoking, rheumatoid arthritis, and Parkinson's disease. The most commonly used classification is the Wright and Coefield classification. Periprosthetic fractures can be treated both, conservatively and operatively. Conclusion: Periprosthetic fracture frequency after shoulder arthroplasty ranges from 0 to 47.6%. The most common location of the fracture is the humerus and most commonly occurs intraoperatively. The most important factor influencing treatment is stem stability. Fractures with stem instability require revision arthroplasty with stem replacement. Fractures with a stable stem depending on the location, displacement and bone stock quality can be treated both conservatively and operatively. For internal fixation plates with cables and screws are most commonly used.

Chronic Syndesmotic Injuries: Arthrodesis versus Reconstruction.

"Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise."

Operative Setup to Improve Sagittal Syndesmotic Reduction: Technical Tip.

We analyzed the operative measures that may be used to reduce the likelihood of sagittal syndesmotic malreduction. Hence, we propose a simple technical tip to avoid sagittal plane malreduction of the fibula within the syndesmosis in ankle fractures. Supporting the leg under the heel should be avoided when performing syndesmotic reduction for unstable malleolar fractures, and support under the calf should be used instead. Our observations have been confirmed in 6 cadaver specimens. We observed that there was a significant anterior subluxation of the fibula when the leg was supported under the heel. No significant difference between the intact and unstable state was present when the leg was supported under the calf. In conclusion, during syndesmotic reduction and fixation in supine position, supporting the foot under the heel should be avoided.

Correlation of Incisura Anatomy With Syndesmotic Malreduction.

BACKGROUND: The anatomy of the syndesmosis is variable, yet little is known on the correlation between differences in anatomy and syndesmosis reduction results. The aim of this study was to analyze the correlation between syndesmotic anatomy and the modes of syndesmotic malreduction. METHODS: Bilateral postreduction ankle computed tomography (CT) scans of 72 patients treated for fractures with syndesmotic disruption were analyzed. Incisura depth, fibular engagement into the incisura, and incisura rotation were correlated with degree of syndesmotic malreduction in coronal and sagittal planes as well as rotational malreduction. RESULTS: Clinically relevant malreduction in the coronal plane, sagittal plane, and rotation affected 8.3%, 27.8%, and 19.4% of syndesmoses, respectively. The syndesmoses with a deep incisura and the fibula not engaged into the tibial incisura were at risk of overcompression, anteverted incisuras at risk of anterior fibular translation, and retroverted incisuras at risk of posterior fibular translation. CONCLUSIONS: Certain morphologic configurations of the tibial incisura increased the risk of specific syndesmotic malreduction patterns. LEVEL OF EVIDENCE: Level III, comparative study.

X-ray features to predict ankle fracture mechanism.

INTRODUCTION: The genetic Lauge-Hansen classification has been traditionally used for reconstruction of the mechanism of ankle injury. The ability of the Lauge-Hansen classification to predict actual mechanism of the injury has been questioned in recent studies, leaving a void in medicolegal reasoning. The aim of this study is to identify morphologic features of malleolar fractures on plain X-rays that may be used to reveal the fracture mechanism. MATERIAL AND METHODS: Radiographs of 78 patients with acute malleolar fractures were analyzed and compared with fracture mechanisms reported by these patients. RESULTS: A modified Pankovich classification of medial malleolus fractures and the presence of a posterior malleolus fracture were able to significantly predict the mechanism of fracture reported by the patient (p<0.05). Lateral fracture morphology was not useful for predicting the fracture mechanism except for infrasyndesmotic fractures pointing to a supination mechanism. CONCLUSION: A supination mechanism of the fracture can be predicted by observing pure ligamentous or chip-avulsion deltoid injury. The presence of an anterior colliculus fracture of the medial malleolus is correlated with a pronation mechanism. A fracture of the posterior malleolus correlates with pronation while an intact posterior malleolus correlateds with supination as a fracture mechanism. Absolute determination of fracture mechanism from the X-ray morphology of the fracture is impossible in the majority of cases.

Ankle fracture - Correlation of Lauge-Hansen classification and patient reported fracture mechanism.

INTRODUCTION: The genetic Lauge-Hansen classification is used for reconstruction of the mechanism of ankle injury. In this study, we addressed the question of agreement between the mechanism of the fracture as postulated by the Lauge-Hansen classification and mechanism reported by the patient in rotational ankle fractures. MATERIAL AND METHODS: Radiographs of 78 patients with acute malleolar fractures were analyzed and compared with fracture mechanisms reported by these patients. RESULTS: The patient reported mechanisms were in concordance with the mechanism deducted from the X-rays in 49% of cases. Only 17% of patients who recalled a pronation trauma actually had radiographs classified as pronation fractures while 76% of patients who recalled a supination trauma were also radiographically classified as having sustained supination type fractures. CONCLUSION: The Lauge-Hansen classification should be used with caution for determining the actual mechanism of injury as it was able to predict the patient reported fracture mechanism in less than 50% of cases. A substantial percentage of fractures appearing radiographically as supination type injuries may have been actually produced by a pronation fracture mechanism.

Aseptic Destruction of the Elbow Joint after Radial Head Replacement. Case Study.

Radial head replacement should be a routine treatment in cases of non-reconstructable radial head fractures. With the growing number of radial head arthroplasties, we are going to see more complications related to this procedure. We describe a case of aseptic destruction of the elbow joint, probably related to the release of polyethylene particles from the prosthetic head. Removal of the implant and extensive synovectomy was performed, leading to an excellent clinical outcome with reduction of pain and increase in the range of motion. The clinical improvement was not accompanied by radiographic change.

Translation, Cultural Adaptation and Validation of Polish Version of Foot and Ankle Outcomes Questionnaire.

BACKGROUND: The Polish orthopaedic literature lacks a tool to measure patient reported treatment outcomes in the foot and ankle. MATERIAL AND METHODS: The translation and cultural adaptation of the Foot and Ankle Outcomes Questionnaire was performed in accordance with relevant guidelines. The Polish version of the questionnaire was tested to check its test retest reliability, internal consistency and construct validity. RESULT: The Polish version of the questionnaire was prepared. Testing of the questionnaire revealed acceptable test retest reliability, internal consistency and construct validity. CONCLUSION: The translation, cultural adaptation and testing of the Polish version of patient related outcome measuring tool for the foot and ankle is described.

Hallux checkrein deformity resulting from the scarring of long flexor muscle belly - case report.

A case of posttraumatic checkrein deformity of the hallux is presented. This deformity is most often caused by scarring of the muscle belly or tethering of the tendon. A 22-year old woman developed a hallux checkrein deformity after a bimaleolar fracture. Intraoperatively, a linear scar tethering the muscle belly to the posterior tibia was observed. Resection of the scar allowed for full flexor hallucis longus mobility. Full hallux range of motion as well as foot function was restored. The cause of the checkrein deformity in our patient was a scar tethering the flexor hallucis belly to the posterior tibia.

Is the postero-medial portal safe in posterior ankle arthroscopy?

BACKGROUND: Posterior ankle arthroscopy is considered to pose a risk of neurological and vascular complications. Some authors consider the postero-medial portal to be risky and recommend using only the postero-lateral portal. The aim of this study was to analyze the margin of error offered by posterior ankle arthroscopy portals. MATERIAL AND METHODS: Twenty MRI studies of the ankle joint were analyzed. The paths of the postero-medial and postero-lateral portals were drawn. Next, the path of the probe was diverged to aim at the neurovascular bundle and the angle of deviation was measured. We analyzed the distance between the probe located directly laterally to the flexor hallucis longus tendon and the neurovascular bundle. RESULTS: The mean angle of deviation leading to collision with neurovascular bundle structures was 53.3° (range 37-70°) and 30.75° (range 22-41°) for the postero-medial and postero-lateral portals, respectively, p<0.05. The mean minimal distance between and the probe and the bundle was 12 mm (range 5-15 mm) and 13 mm (range 8-18 mm) for the postero-medial and postero-lateral portals, respectively, p>0.05. CONCLUSIONS: 1. The postero-medial arthroscopic portal is at least as safe as the postero-lateral one in posterior ankle arthroscopy. 2. Keeping instruments strictly laterally to the flexor hallucis longus tendon leaves at least 5 mm distance from the neurovascular bundle.

Femoral insufficiency fractures with bisphosphonate therapy. Cases study.

The aim of this paper is to analyze on clinical cases specific features of femoral insufficiency fractures during bisphosphonates therapy. We are presenting two insufficiency femoral fractures (2 patients) in patients receiving bisphosphonate therapy. These two cases represent new type of femoral fractures. These are low energy or spontaneous fractures of diaphysis and subtrochanteric region. Prodromal pain is often observed. On x-rays thick lateral cortex, its ellipsoid thickening and transverse or oblique fracture line is observed. Many authors link such fractures to long-term bisphosphonate therapy. Patients on long term bisphosphonate therapy present with new and specific fracture pattern of femoral bone. Fractures of this pattern are extremely rare. The risk benefit ratio of bisphosphonates therapy is not changed.