Percutaneous removal of hardware after orthopedic surgery: Is it safe? and What are patients saying?

OBJECTIVES: To analyze our patient's complication profile and rate after removal of hardware (ROH) surgery, and survey our patients to ask their overall status and improvement in symptomatology post-operatively. DESIGN: Retrospective chart review and survey. SETTING: Academic, tertiary referral center. PATIENTS/PARTICIPANTS: 173 patients with 314 pieces of hardware. Seventy-six patients (43.9%) responded to our survey. INTERVENTION: ROH surgery. MAIN OUTCOME MEASUREMENTS: Patient demographics and complications were recorded. All patients were sent a brief 3-question survey which asked: (1) Why did you get your hardware removed? (2) How did your overall status change after ROH? (3) How did the ROH affect your stiffness, pain, swelling, and mobility? RESULTS: There were 10 complications (5.5%): 5 infections, 2 with unresolved pain, 1 hematoma, 1 chronic regional pain syndrome exacerbation, and 1 recurrent deformity. All infections were treated with oral antibiotics and improved. All other complications resolved with treatment except for the patient who developed recurrent deformity. Patients underwent ROH surgery because their doctor suggested it (76.3%) and to improve mobility (39.5%). 86.9% reported their overall status improved after ROH. They improved regarding stiffness (73.7%), pain (73.6%), swelling (61.8%), and mobility (76.3%). Similar results were seen among different implants removed. CONCLUSIONS: The majority of patients who underwent percutaneous ROH were satisfied. They reported improvement in stiffness, pain, swelling and mobility (greatest improvement). The complication rate was low (5.5%). ROH can be a meaningful operation to patients allowing them to improve their quality of life with a low complication rate. LEVEL OF EVIDENCE: Level IV.

Limb salvage reconstruction of the lower limb with complex ankle arthrodesis and magnetic internal lengthening nail.

PURPOSE: With advances in orthopedic implants, the use of intramedullary lengthening devices has gained increasing popularity as an alternative technique compared to lengthening with external fixators, with alleged comparable or better outcomes. The aim of this study is to report our single-center technique and outcomes of combined ankle arthrodesis and proximal tibial lengthening using external fixator with a motorized intramedullary nail, respectively. METHOD: Fourteen patients with post-traumatic advanced ankle arthritis underwent staged ankle arthrodesis with external fixator and proximal tibial lengthening using the PRECICE® ILN. Amount of shortening, length achieved, bone healing index, infection rate, ankle fusion rate, and ASAMI score were evaluated. RESULTS: The average age was 44 years old (range, 30-62). The mean follow up is 70 months (range, 43-121.4). The average amount of limb shortening for patients after ankle fusion was 36.7 mm (18-50) while lengthening was 35.9 mm (range, 18-50). Patients had the nail implanted for an average of 479 days (range, 248-730). Ankle fusions were healed in an average of 178.3 days. There were no surgical infections. All osteotomy-lengthening sites healed after an average 202 days (106-365). The mean bone healing index (BHI) was 56.0 days/cm (21.2-123.6) among the whole cohort. There were no cases of nonunion. ASAMI bone scores were excellent or good among all patients. CONCLUSION: Ankle arthrodesis with external fixation along with proximal tibial lengthening using motorized IMN yielded high rates of fusion and successful lengthening. This technique could be offered as a reasonable alternative to using external fixation for both purposes. LEVEL OF EVIDENCE: Level IV, Retrospective cohort study.

Avoiding Compartment Syndrome, Vascular Injury, and Neurologic Deficit in Tibial Osteotomy: An Observational Study of 108 Limbs.

INTRODUCTION: Tibial deformities are common, but substantial concern may be associated with corrective osteotomy regarding major complications reported in classic literature. Such studies chiefly focused on high tibial osteotomy, with relatively little investigation of other areas and types of deformity. The primary aim of this study was to identify the rate of compartment syndrome, vascular injury, nerve injury, and other major complications after elective tibial osteotomy. METHODS: One hundred eight tibia osteotomies performed during 2019 to 2021 were evaluated, representing all tibia osteotomies except situations of existing infection. A retrospective chart review was performed to identify patient demographics, surgical indications, anatomic location of osteotomy, fixation used, and complications prompting additional surgery. RESULTS: The most common osteotomy locations were high tibial osteotomy (35/108 = 32%, 32/35 = 91% medial opening, and 3/35 = 9% medial closing), proximal metaphysis (30/108 = 28%), and diaphysis (32/108 = 30%). The most common fixation was plate and screw (38/108 = 35%) or dynamic frame (36/108 = 33%). Tranexamic acid was administered to 107/108 = 99% of patients and aspirin chemoprophylaxis was used for 83/108 = 86%. A total of 33/34= 97% of anterior compartment prophylactic fasciotomies were performed for diaphyseal or proximal metaphysis osteotomies. No events of compartment syndrome, vascular injury, nerve injury, or pulmonary embolism occurred. One patient required débridement to address infection. Additional surgery for delayed/nonunion occurred for nine segments (8%). Additional surgery for other reasons were performed for 10 segments (9%), none resulting in reduced limb function. CONCLUSION: Tibial osteotomy can be safely performed for a variety of indications in a diverse range of patients, without a notable risk of the most feared complications of compartment syndrome, vascular injury, and neurologic deficit. Prophylactic fasciotomy and reducing postoperative bleeding using tranexamic acid, along with location-specific safe surgical techniques, may help prevent major complications and thereby facilitate optimized deformity care.

Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms.

Aims: The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening. Materials and methods: Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction. Results: From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients' pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion. Conclusion: Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur. Clinical significance: Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal.The BHI in femurs was not affected by radiographic changes. How to cite this article: Reif TJ, Geffner A, Hoellwarth JS, et al. Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms. Strategies Trauma Limb Reconstr 2023;18(2):94-99.

Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation.

BACKGROUND: When lengthening the tibia segment using motorized internal lengthening nails (MILN), undesired distal migration of the proximal fibula segment is prevented by tibiofibular stabilization, traditionally using a screw. A tightened cortical suspensory fixation rope (tether) is an alternative option, but its appropriateness has never been studied. The primary outcome was comparing the amount of proximal fibular migration between patients who were stabilized with either a tether or a screw. The secondary outcome was to evaluate the effect of fibular migration on the clinical outcome between both groups. METHODS: A retrospective study was conducted on patients who underwent tibial lengthening with MILN between April 2016 and June 2022. Two cohorts were compared: 18 limbs with tether fixation versus 29 limbs with screw fixation. Data on the patient's age, sex, etiologies, and clinical outcomes were collected. Radiographic measurements included the lengthening distance and the amount of proximal fibular migration. RESULTS: In total, 47 limbs from 41 patients, with average age 35.01 ± 13.72 years old. There were 28 males (68.29%) and 13 females (31.71%). The tether group demonstrated a statistically significant greater distance of migration than the screw group (p < 0.001), with an average migration distance of 8.39 ± 5.09 mm and 2.59 ± 3.06 mm, respectively. No correlation was found between the amount of tibial lengthening and the distance of proximal fibular migration in both the tether group (p = 0.96) and the screw group (p = 0.32). There was no significant difference in the change of knee extension between both groups (p = 0.3), and no patients reported knee pain or tightness. CONCLUSION: A screw provides better resistance to proximal tibiofibular joint migration during MILN lengthening, but the difference appears clinically inconsequential. Either option appears suitable.

Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis.

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and 16 were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value ≤ .001; I2 = 87.01%) after 46.68 ± 7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I2=81.59%) with less than 5 years follow-up and 28% (95% CI: 16%-41%; p value≤0.001 I2=69.03%) for patients with more than 5 years follow-up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM < 20°, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

Management of Segmental Tibial Bone Defects With the Magnetic Motorized Intramedullary Transport Nail: A Case Series.

SUMMARY: Critical-sized bone defects in the tibia can arise as sequelae of trauma, infection, tumor, or the treatment of congenital limb deficiencies. Treatment of these defects often requires bone transport, which has traditionally been accomplished using circular external fixators. The development of a bone transport nail facilitated tibia reconstruction through distraction osteogenesis using an all-internal device, thus avoiding the complications associated with chronic external fixation. Given the rarity of these cases, few studies have been published on the reconstruction outcomes using this implant. We sought to investigate the bone healing indices (including regenerate consolidation and time to docking site union) associated with the use of a magnetically controlled all-internal bone transport nail for the reconstruction of 4 patients treated for posttraumatic tibial bone loss. Perioperative and device-related complications are also reported.

Radiographic findings involved in knee osteoarthritis progression are associated with pain symptom frequency and baseline disease severity: a population-level analysis using deep learning.

PURPOSE: To (1) develop a deep-learning (DL) algorithm capable of producing limb-length and knee-alignment measurements, and (2) determine the association between limb-length discrepancy (LLD), coronal-plane alignment, osteoarthritis (OA) severity, and patient-reported knee pain. METHODS: A multicenter, prospective patient cohort from the Osteoarthritis Initiative between 2004 and 2015 with full-limb standing radiographs at 12 month follow-up was included. A convolutional neural network was developed to automate measurements of the hip-knee-ankle (HKA) angle, femur, and tibia lengths, and LLD. At 12 month follow-up, patients reported their frequency of knee pain since enrollment and current level of knee pain. RESULTS: A total of 1011 patients (2022 knees, 52.3% female) with an average age of 61.2 ± 9.0 years were included. The algorithm performed 12,312 measurements in 5.4 h. ICC values of HKA and LLD ranged between 0.87 and 1.00 when compared against trained radiologist measurements. Knees producing pain most days of the month were significantly more varus (mean HKA:- 3.9° ± 2.8°) or valgus (mean HKA:2.8° ± 2.3°) compared to knees that did not produce any pain (p < 0.05). In varus knees, those producing pain on most days were part of the shorter limb compared to nonpainful knees (p < 0.05). Baseline Kellgren-Lawrence grade was significantly associated with HKA magnitude, LLD, and pain frequency at 12 month follow-up (p < 0.05 all). CONCLUSION: A higher frequency of knee pain was associated with more severe coronal plane deformity, with valgus deviation being one degree less than varus on average, suggesting that the knee tolerates less valgus deformation before symptoms become more consistent. Knee pain frequency was also associated with greater LLD and baseline KL grade, suggesting an association between radiographically apparent joint degeneration and pain frequency. LEVEL OF EVIDENCE: IV case series.

Calcium sulfate in the management of osteomyelitis: A systematic review and meta-analysis of comparative studies.

BACKGROUND: Calcium sulfate (CS) is used extensively as an antibiotic carrier in the treatment of chronic osteomyelitis, largely due to its biodegradable nature. The aim of this systematic review and meta-analysis is to analyze the comprehensive performance of CS in the literature when compared to other biomaterials or treatments for osteomyelitis. We assess the ability of CS to eradicate infection and achieve other key clinical outcomes. METHODS: All studies comparing the use of CS to any other surgical technique for the surgical management of osteomyelitis were eligible for analysis. The indication for surgery in each case was chronic osteomyelitis. The minimum dataset required included details regarding infection eradication rates, union rates (in cases of nonunion), all-cause revision surgery and wound leakage. The primary outcome variables of concern were infection eradication and all-cause revision surgery. Secondary outcome variables included union and wound leakage. A random effects meta-analysis was performed. RESULTS: Five studies were deemed eligible for inclusion. The CS group had a significantly higher rate of infection eradication (P = .013) and a significantly lower rate of revision for all causes (P < .001) when compared to the comparative group. In total, the CS group had 30 cases of wound leakage compared to 8 in the comparative group (P = .064). CONCLUSION: CS demonstrates superior rates of infection eradication and all-cause revision when compared with alternative treatment methods for chronic osteomyelitis. While the current study reports on differing but nonsignificant rates of wound leakage between CS and other treatments, future studies are required to accurately investigate this clinically important complication.

STRYDE versus PRECICE magnetic internal lengthening nail for femur lengthening.

INTRODUCTION: Magnetic internal lengthening nails (MILNs) have been used for femoral lengthening to avoid complications associated with external fixation. The titanium version of the MILN (PRECICE®) has been in use since 2011 but had limitations (50-75 lb) in post-operative weight bearing. A new stainless-steel version of the MILN (STRYDE®) allows 150-250 lb of post-operative weight bearing. The aim is to compare the outcomes of using these two different MILNs for both unilateral and bilateral femoral lengthening. METHODS: A single-center, retrospective cohort study was conducted in which patients' records were reviewed from the period from January 2017 to March 2020. A total of 66 femoral lengthening procedures were included in the study and were divided into two groups: STRYDE® group (30 femora) and PRECICE® group (36 femora). Outcomes assessed were the 6-months post-operative Limb Deformity-Scoliosis Research Society (LD-SRS) Score, adjacent joint range of motion (ROM), average distraction rate, bone healing index (BHI), and complications. RESULTS: No statistically significant difference was found between the two groups in regard to the (LD-SRS) score, hip ROM, or knee ROM. Statistically significant differences were found between the two groups in regard to BHI (average of 0.84 months/cm and 0.67 months/cm for STRYDE® and PRECICE®, respectively) and distraction rate (average of 0.6 mm/day and 0.9 mm/day for STRYDE® and PRECICE®, respectively). No mechanical nail complications were reported in the STRYDE® group compared to three events of nail failure in the PRECICE® group. One femur in the PRECICE® group needed BMAC injection for delayed healing compared to four femurs in the STRYDE® group. CONCLUSION: The STRYDE® MILN yields comparable functional results to those of PRECICE® MILN and shows fewer mechanical nail complications. However, STRYDE® MILN requires a slower distraction rate and yields slower healing (larger BHI). LEVEL OF EVIDENCE: Level III, Therapeutic study.

Core psychosocial issues for children and adolescents in the context of limb lengthening and reconstruction surgery treatment.

PURPOSE: Addressing the psychosocial needs of adolescents can improve surgical outcomes. The aim of this retrospective comparative study was to understand the core psychosocial factors that shaped the experiences of adolescents who underwent multiple limb lengthening/reconstruction surgeries (LLRS). METHODS: A novel 62-question survey was developed and administered to 31 patients from the study institution. Data was obtained using a self-report inventory assessing medical care, communication/connection to doctor, peer relations, physical space, self-esteem, counselling/clergy, physical/emotional support, school issues and concerns about future. This survey and demographic questions were administered to young adults (now aged 18 to 30 years) who underwent LLRS treatment between the ages of 11 to 20 years. RESULTS: Psychosocial needs were determined to be within the categories of body image/self-esteem, subjective perception of treatment, patient-physician relationship, role of parents, peer interactions, academic performance and hospital experience. Patients valued parental involvement while also wanting their surgeon to speak directly to them. They preferred to be in private rooms on the paediatric floor and to not socialize while in the hospital. They were indifferent to keeping up with friends, speaking to a counsellor and having their surgeon inquire about their emotions. They expressed concern about pain, carrying out activities and the financial impact of surgery. CONCLUSIONS: Adolescent LLRS patients value focused psychosocial support from their surgeon and caregivers. This perceived level of support influences their ability to cope with their condition. These findings helped us understand the psychological issues and preferences of adolescents who underwent LLRS and can assist orthopaedic surgeons in providing holistic care. LEVEL OF EVIDENCE: IV.

Limb Length Discrepancy and Angular Deformity due to Benign Bone Tumors and Tumor-like Lesions.

Benign bone tumors and tumor-like lesions are frequently diagnosed in children and adolescents. The immature skeleton is at risk for growth disturbances and deformity because of the effects of the lesions on normal bone architecture and the physis. The development, manifestation, and severity of the limb length inequality and deformity differs between the various bone pathologies. Distraction osteogenesis, osteotomy, and guided growth are key tools in the treatment of limb inequality and deformity using a combination of external and internal fixation devices.

Comparison and Validation of Preoperative Planning Techniques for Distal Femoral Osteotomies and Proximal Tibial Osteotomies.

Preoperative planning is important for accurate intraoperative execution in many surgical fields. Planning for distal femoral osteotomies (DFOs) and proximal tibial osteotomies (PTOs) consists of choosing the level of the osteotomy, measuring the angle of the osteotomy based on hip-knee-ankle alignment, and choosing a proper osteotomy wedge size. Medical imaging IT solutions company Sectra has implemented a new osteotomy tool in their radiographic system that is simpler than the accepted standard of modified center of rotation of angulation (mCORA) technique, yet unvalidated. In this study, we aim to compare the Sectra osteotomy tool versus the mCORA technique to measure the osteotomy angles as well as wedge sizes in both DFOs and PTOs to validate this new tool.We enrolled n = 30 consecutive patients with DFOs and n = 30 PTOs from the last year. The Pearson correlation coefficient (PCC) along with descriptive statistics was used to evaluate for similarity between the two techniques. We also compared interobserver and intraobserver reliability using intraclass correlation coefficients (ICC).The PCC for osteotomy angles in DFOs and PTOs were both 0.998 (p < 0.001 for both). For wedge sizes, the PCC in DFOs was 0.993 and 0.980 in PTOs (p < 0.001 for both). ICCs were high for both interobserver measurements in osteotomy angles and wedge sizes (range: 0.989-0.999) as well as intraobserver measurements (0.994-0.999).The Sectra osteotomy tool is a validated tool for preoperative measurements of DFOs and PTOs. It is reliable and simpler than the current practice of the mCORA technique. We suggest future studies to analyze this Sectra osteotomy tool in other settings as to incorporate it into widespread clinical use.

Hip-Sparing Equalization Procedures for Leg-Length Discrepancy After Total Hip Arthroplasty: A Retrospective Case Series.

BACKGROUND: Leg-length discrepancy (LLD) after primary THA is not uncommon. Little is known, however, about the role of hip-sparing procedures for equalization of LLD after THA. QUESTIONS/PURPOSES: The aim of this study is to report our experiences with these techniques in patients presenting at one institution over a 10-year period. METHODS: We retrospectively reviewed records at one institution to find patients who had sought surgical treatment for LLD after THA between January 2007 and August 2017. Patients who had LLD related to conditions other than the THA, such as bone loss or traumatic defects, were excluded. We recorded the time after THA, laterality, and LLD. Assessment of LLD was performed using clinical and radiographic examinations. Patient demographics and true LLD were recorded, as were prior conservative treatment, equalization procedure performed, final leg length after equalization surgery, time to healing, and complications. RESULTS: After exclusion of patients with LLD related to other causes, eight patients in whom conservative treatment had failed and who had undergone hip-sparing leg-length equalization surgery were included in the study. The average age was 44.6 years (range, 18 to 66 years). Seven of the patients were female. The pre-operative mean LLD was 3.1 cm (range 1.5 to 7 cm). In those who were long after THA, ipsilateral (THA-side) shortening of femur with a retrograde intramedullary nail (IMN; n = 1) or with a plate (n = 1) was performed. In those who were short after THA, ipsilateral femur lengthening with retrograde Precice nails (n = 2), ipsilateral tibial lengthening with Precice nails (n = 2), or contralateral femur shortening with a retrograde IMN (n = 2) was performed. The average time to full consolidation or union was 6.6 months (range, 2 to 19 months). Two patients had delayed union. All patients but one were satisfied with final results. CONCLUSION: We believe that hip-sparing equalization procedures can be part of the treatment algorithm of LLD after THA. These advancements in the field are promising and might expand the indications of lengthening and equalization procedures to include LLD after THA.

Biomechanical and Functional Improvements Gained by Proximal Tibia Osteotomy Correction of Genu Varum in Patients with Knee Pain.

BACKGROUND: Mechanical axis malalignment contributes to abnormal forces across the knee joint. Genu varum, or increased medial mechanical axis deviation (MAD), increases force transmission and contact pressures to the medial compartment. With increasing MAD and femoral-tibial mechanical axis angle (MAA), contact forces within the medial or lateral compartment of the knee significantly increase with increasing deformity. This may lead to knee pain, further deformity, and medial compartment degenerative joint disease, which can interfere with participation in sports and diminish quality of life. PURPOSES/QUESTIONS: We sought to evaluate patients with knee pain with bilateral genu varum and determine the effect of bilateral proximal tibial osteotomies on knee biomechanics, deformity correction, and functional outcomes. METHODS: This was a single-center, prospective study of eight limbs in four patients. Consecutive patients presenting with knee pain and bilateral genu varum originating from the proximal tibia were included. All patients underwent staged bilateral proximal tibial osteotomies with gradual deformity correction with an external fixator. Subjects underwent a three-dimensional (3D) instrumented motion analysis during level walking. A 3D lower extremity model was built and bilateral knee frontal plane kinematics and kinetics during the stance phase of gait were determined. Radiographic analysis was performed including assessment of MAD, MAA, and medial proximal tibial angle (MPTA). Functional outcomes were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), the 36-item Short-Form Survey (SF-36), the Lower Limb Questionnaire (LLQ), and a visual analog scale (VAS) for pain. RESULTS: The average time in the external fixator for a single limb was 97 days. The average follow-up period was 310 days. All biomechanical outcomes significantly improved, including knee adduction angle (7.8° to 1.8°), knee adduction moments (first peak, - 0.450 to - 0.281 nm/kg, and second peak, - 0.381 to - 0.244 nm/kg), and knee adduction moment impulse (- 0.233 to - 0.150 nm s/kg). There was a significant improvement in MAA, MAD, and MPTA. All patients showed qualitative improvement in mean scores on VAS (11.8 to 0.0), LLQ (77 to 93), KOOS (64 to 84), and SF-36 (71 to 88). CONCLUSION: These findings suggest that bilateral proximal tibial osteotomy may be effective in improving knee biomechanics during gait and correcting mechanical alignment in patients with bilateral genu varum. Patients also demonstrated improvement in functional outcome scores. This technique should thus be considered in patients with varus knee osteoarthritis in the setting of genu varum to alleviate symptoms and potentially decrease further clinical deterioration.

Tranexamic Acid Reduces Postoperative Blood Loss in Distal Femoral Osteotomy.

Blood loss remains a significant source of morbidity and mortality in orthopaedic surgery, with transfusions associated with an increased risk of infection, length of stay, delayed rehabilitation, and significantly increased hospitalization costs. The purpose of this study was to assess whether the use of tranexamic acid (TXA) is effective in reducing postoperative blood loss in patients undergoing distal femoral osteotomy (DFO). A retrospective review was performed of all patients undergoing DFO by a single surgeon from 2010 to 2017, with a change in protocol occurring in 2014, after which all patients received TXA. Patients in the TXA group (n = 24) received 1-g TXA immediately prior to incision followed by a second dose of 1-g TXA 4 hours after the administration of the first dose. Patients in the control group (n = 28) did not receive TXA. Drainage was recorded through a subfascial drain that remained for 24 hours postoperatively. Postoperative hemoglobin, hematocrit, and transfusions, as well as demographic factors, including age, gender, body mass index (BMI), medical comorbidities, and ASA (American Society of Anesthesiologists) class, were recorded. Multivariate regression analysis adjusting for potential confounding variables was performed. With the exception of gender, the two groups did not differ significantly in baseline characteristics, including age, BMI, and ASA class. There was a significant difference in postoperative blood loss, with those receiving TXA having a mean drain output of 184.2 versus 242.1 mL for the control group (p = 0.02), which persisted after regression analysis (p < 0.005). Blood loss differed between patients who received one (250 mL) dose and those who received two (162.2 mL) doses of TXA, although this difference was insignificant (p = 0.489). There were no differences in postoperative hemoglobin and hematocrit levels. One patient (control group) required blood transfusion postoperatively. There were no complications related to TXA. In conclusion, TXA results in less postoperative blood loss in DFO, with the most pronounced effect in those who receive two doses. Future research should involve a larger, prospective study to assess for differences in postoperative hemoglobin/hematocrit levels and transfusion rates.

Carbon-Fiber-Reinforced Polymer Intramedullary Nails Perform Poorly in Long-Bone Surgery.

BACKGROUND: Carbon-fiber-reinforced (CFR) polymer has produced great excitement in the orthopedic community as a material that will reduce bone healing times and provide improved image quality. Osteotomy stabilized with an intramedullary (IM) nail has become a common technique to address post-traumatic malalignment of the lower extremity. PURPOSES/QUESTIONS: The following questions were asked: (1) Did CFR polymer nails provide a rapid healing time after long bone osteotomy, shortening, or fracture? (2) Did the CFR polymer nails produce unexpected complications? METHODS: A retrospective review was conducted in patients who received CFR polymer IM nails for various indications, from April 2016 to January 2017 in a deformity and trauma practice, ï»¿using patient charts and radiographs. The primary outcomes were time to union and incidence of complications including nonunion, hardware failure, neurovascular injury, venous thromboembolism, and infection. RESULTS: Twelve patients who received CFR polymer IM nails in 16 limbs for various indications were included in our analysis. Patients were followed for an average of 16.9 months. Eleven limbs underwent realignment and were corrected an average of 23° through a diaphyseal osteotomy. Three limbs underwent limb-shortening surgery, an average of 25 mm, through an open, excisional osteotomy of the femoral diaphysis. Two diaphyseal, closed tibia fractures underwent routine IM nailing. The average time to union was 107.6 days, which included all limbs that united (11/16, 69%). Nonunion occurred in 5/16 (31%) of limbs. Complications recorded included nonunion and hardware failure, most of which resulted in unplanned surgery. CONCLUSIONS: The use of the CFR polymer IM nail was associated with loss of fixation and nonunion after surgeries that have traditionally healed uneventfully. The increased elasticity of the CFR polymer allows for more motion at the osteotomy/fracture interface than the stiffer titanium counterparts, exposing long-bone osteotomies to delayed union and nonunion, a finding seen with CFR polymer plates. The overwhelmingly poor early results of this device applied to a long-bone deformity practice have led these authors to abandon the use of this implant.

The PRECICE magnetic IM compression nail for long bone nonunions: a preliminary report.

INTRODUCTION: The magnetic intramedullary (IM) compression nail is capable of providing sustained compression for the treatment of nonunions of long bones. This ability was previously only possible with the use of external fixation. We asked the following questions: How effective is the IM compression nail at achieving union? How do we know when adequate compression has been attained? Which types of nonunions are good candidates for this treatment? MATERIALS AND METHODS: Fourteen patients with nonunions of the tibia (5) or femur (9) were treated with the PRECICE IM compression nail. The average age was 49 years number of previous surgeries was 1.9, 7 were atrophic and 7 normotrophic, 3 were metaphyseal and 11 diaphyseal. All PRECICE IM nails were pre-distracted prior to implantation. Compression was applied post-operatively until the locking bolts were seen on X-ray to be bending or the nail was no longer shortening despite applying the external magnet. RESULTS: Union was achieved in 13/14 cases. The time to union was 24.5 weeks (range 11-60). The two proximal tibia metaphyseal nonunions, both deformed into varus (4°) and flexion (10°) after compression was applied with one failing to unite. The distal tibia metaphyseal and diaphyseal nonunions did not deform upon compression. Three patients had positive cultures and were treated with IV antibiotics for 6 weeks followed by 3 months of oral suppression without subsequent infection. No mechanical nail failures were seen. CONCLUSIONS: The IM compression nail was successful at applying compression, preventing deformity, and obtaining union in all diaphyseal and in distal tibia metaphyseal nonunions. Signs of active compression are bending of the locking bolts and failure of the nail to shorten. Proximal tibia metaphyseal nonunion may not be suited for this treatment.

Standardization of torsional CT measurements of the lower limbs with threshold values for corrective osteotomy.

INTRODUCTION: Re-establishing anatomic rotational alignment of shaft fractures of the lower extremities remains challenging. Clinical evaluation in combination with radiological measurements is important in pre- and post-surgical assessment. Based on computed tomography (CT), a range of reference values for femoral torsion (FT) and tibial torsion (TT) have historically been reported, which require standardization to optimize the significant intra- and inter-observer variability. The aims of this study were (re-)evaluation of the reference FT and TT angles, determination of the normal intra-individual side-to-side torsional differences to aid the surgical decision-making process for reoperation, and development of a novel 3D measurement method for FT. MATERIALS AND METHODS: In this retrospective study, we included 55 patients, without any known torsional deformities of the lower extremities. Two radiologists, independently, measured the rotational profile of the femora using the Hernandez and Weiner CT methods for FT, and the tibiae using the bimalleolar method for TT. The intra-individual side-to-side difference in paired femora and paired tibiae was determined. A 3D technique for FT assessment using InSpace® was designed. RESULTS: FT and TT demographic values were lower than previously reported, with mean FT values of 5.1°-8.8° and mean TT values of 25.5°-27.7°. Maximal side-to-side differences were 12°-13° for FT and 12° for TT. The Weiner method for FT was less variable than the Hernandez method. The new 3D method was equivocal to the conventional CT measurements. CONCLUSION: The results from this study showed that the maximal side-to-side tolerance in asymptomatic normal adult lower extremities is 12°-13° for FT and 12° for TT, which could be a useful threshold for surgeons as indication for revision surgery (e.g., derotational osteotomy). We developed a new 3D CT method for FT measurement which is similar to 2D and could be used in the future for virtual 3D planning.

Management of Extra-articular Deformity in the Setting of Total Knee Arthroplasty.

Extra-articular deformities of the femur and tibia in conjunction with advanced knee osteoarthritis pose unique challenges for the arthroplasty surgeon. Careful preoperative planning is needed to evaluate both the intra- and extra-articular deformities and to determine the best route to total knee arthroplasty. An intra-articular compensatory correction can typically be performed if the extra-articular deformity is distant from the joint or if preoperative templating shows that bony cuts do not interfere with ligamentous attachments. Staged osteotomy followed by arthroplasty is beneficial in severe cases in which bony cuts are excessive or would interfere with soft-tissue structures and in cases with leg-length discrepancy. Osteotomies can be performed percutaneously and fixed with intramedullary nails, external fixators, or plate and screw constructs. Ligamentous laxity after correction and risk of peroneal nerve injury are increased in extra-articular deformity cases and must be considered during the knee arthroplasty procedure with increased implant constraint and patient counseling, respectively. Computer-assisted navigation has an emerging role in total knee arthroplasty in patients with extra-articular deformity.