Croatian rotatory oblique three-dimensional osteotomy (CROTO) - a modified Wilson's osteotomy for adult hallux valgus intended to prevent dorsal displacement of the distal fragment and to reduce shortening of the first metatarsal bone.

Aim To evaluate biomechanical and clinical outcomes of a newly developed modification of the Wilson's osteotomy for hallux valgus: a three-dimensional subcaptial correction of the metatarsal head position with a simultaneous lateral and plantar shift with derotation intended to reduce displacement of the distal fragment and shortening of the first metatarsal bone. Methods Thirty four feet (28 female patients) underwent the new procedure and were evaluated before and 12 to 84 months (median=25.5) after the surgery. Results Plantar shift of the distal fragment was achieved in all feet. Shortening of the first metatarsal was moderate: ≤6 mm in 32/34 feet, 7 and 10 mm in the remaining two. Median difference in metatarsal index post- vs. pretreatment was -4.0. The hallux valgus angle, intermetatarsal and distal metatarsal articular angles were reduced in all feet. The American Orthopaedic Foot and Ankle Society score improved in all feet (median increase= 51.5). Conclusion The method allows for a lateral and plantar shift with derotation of the distal fragment and a mild/moderate shortening of the first metatarsal bone.

Association between computed tomography findings and clinical symptoms in chronic rhinosinusitis with and without nasal polyps.

Objective of this study was to test whether there is a difference between chronic rhinosinusitis patients with (CRSwNP) and without (CRSsNP) nasal polyps in the association of extent of disease on CT scans with symptom severity and health-related quality-of-life (HRQL) impairment. Data sets from 271 chronic rhinosinusitis (CRS) patients who completed the Sino-Nasal Outcome Test 22 (SNOT-22) and visual analog scale (VAS) scores were subjected to principal component analysis (PCA) to identify a symptom components related to CRS. After controlling for demographics, medical therapy, and comorbidities, the association between symptom components/items excluded from PCA and Lund-Mackay score (LMS) was evaluated. No association was found between the total SNOT-22 score and LMS in CRS patients. There was an independent association between a higher "nasal" symptom component derived from SNOT-22 PCA and LMS in patients with CRSwNP (p < 0.001), but not in CRSsNP patients, with a statistically significant difference between two patient subsets (p = 0.003). In patients with CRSsNP, higher (worse) SNOT-22 "facial pain" was associated with lower LMS (p = 0.022), although the estimated change in LMS was modest. Considering VAS PCA components, higher "nasal" symptoms were associated with higher LMS in CRSwNP patients (p < 0.001) but not in CRSsNP, with a statistically significant difference between CRS groups (p = 0.024). A higher "pain" PCA component was associated with lower LMS in CRSsNP patients (p = 0.019). This study found significant differences in the relationship between symptom burden and CT scores between CRS phenotypes and no association between HRQL impairment and CT scores.

Differences in the Sino-Nasal Outcome Test 22 and visual analog scale symptom scores in chronic rhinosinusitis with and without nasal polyps.

BACKGROUND: Chronic rhinosinusitis (CRS) with and without polyps has a high impact on health-related quality of life (HRQL), but the difference in HRQL and symptom presentation between two clinical phenotypes of CRS has not been specifically evaluated before now. OBJECTIVE: To evaluate patterns of symptoms and HRQL disease-specific domains affected in patients with CRS by comparing differences between two clinical phenotypes, adjusted for demographics, major risk factors, comorbidities, current medical treatment, and previous surgery. METHODS: A group of 251 patients with CRS completed the visual analog scale (VAS) symptom severity score and the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire. Data sets were analyzed by using principal component analysis (PCA) to identify a set of symptom components, together with the items excluded from PCA, which were then analyzed for differences between patients with CRS with nasal polyps (CRSwNP) and patients with CRS without nasal polyps (CRSsNP). RESULTS: PCA of SNOT-22 items identified six components, three referred to CRS-specific symptoms termed "nasal"; "extranasal, rhinologic"; and "olfactory/cough"; and three referred to HRQL impairment termed "sleep disturbance," "functional disturbance," and "emotional disturbance." Nasal obstruction, ear pain, ear fullness, and fatigue were excluded from PCA and treated as separate outcomes. Patients with CRSwNP had significantly worse nasal symptoms, olfactory/cough symptoms, and nasal obstruction. Patients with CRSsNP scored significantly worse with regard to fatigue and to sleep and functional disturbances. The PCA results for VAS scores identified three symptom components: pain, nasal symptoms, and pharyngeal symptoms. Patients with CRSwNP had significantly worse VAS nasal symptoms but less pronounced VAS pain symptoms than patients with CRSsNP. The total SNOT-22 score between the groups was not significantly different. CONCLUSION: With controlling of covariates that may influence the severity of the disease, this study showed significant differences in symptom patterns and different aspects of HRQL impairment between patients with CRSwNP and patients with CRSsNP, however, with no difference in the total HRQL score.

Ultrasound screening for decentered hips in children with severe cerebral palsy: a preliminary evaluation.

BACKGROUND: Ultrasound (US) is routinely used for hip screening in children with developmental hip disorders, whereas standard hip surveillance in children with cerebral palsy is based on repeated X-ray assessments. OBJECTIVE: To evaluate US as a diagnostic tool in screening for decentered hips in children with cerebral palsy. MATERIALS AND METHODS: We conducted a prospective, diagnostic single-center assessor-blind study that included consecutive children (age 2-8 years) with cerebral palsy and severe motor disability who underwent US and X-ray hip assessment. US lateral longitudinal scans were used to determine lateral head distance. X-ray assessment was used to determine migration percentage. Diagnostic properties of lateral head distance in detecting hips with a migration percentage ≥0.33 (which requires preventive treatment) were evaluated overall (n = 100) and for hips assessed at the age 24-60 months (n = 38) or >60 to ≤96 months (n = 62). Fifty hips underwent US assessment by two investigators to evaluate inter-rater reliability and agreement. RESULTS: Prevalence of migration percentage ≥0.33 was 22.0% overall and 26.2% and 19.4% in the younger and older age-based subsets, respectively. Lateral head distance well discriminated hips with a migration percentage ≥0.33 (areas under the receiver operating characteristics [ROC] curves 94%, 99% and 92%, respectively). At the optimum cut-off values of lateral head distance (5.0, 5.0 and 4.8 mm, respectively), sensitivity was 95.5%, 100% and 100% overall and in the two age-based subsets, respectively, whereas specificity was 85.9%, 96.4% and 72.0%, respectively. Consequently, positive predictive value was relatively low, but negative predictive value was 98.5% (95% CI 92.1-100) overall and 100% (97.5% one-sided CI 87.2-100) and 100% (97.5 one-sided CI 90.2-100) in the two age-based subsets, respectively. Inter-rater reliability was high (intraclass correlation coefficient = 0.98, 95% CI 0.97-0.99) and 95% limits of agreement were reasonably narrow (-1.203 mm to 0.995 mm). CONCLUSION: In children with cerebral palsy, US can be reliably used in screening for decentered hips and can greatly reduce the need for repeated radiographic assessments, thus reducing radiation burden in these children.

Long-term follow-up of congenital distal tibiofibular diastasis: a report of two female patients.

Congenital diastasis of the inferior tibiofibular joint is an extremely rare variant of dysplastic tibial anomaly, which is usually associated with significant shortening of the lower leg and ipsilateral foot deformity due to talus incarceration in the distal tibiofibular mortise. The purpose of this study was to present the long-term results of reconstructive treatment and the functional outcome after a follow-up of 11-16 years. The principles of extremity preservation and reconstruction with the Ilizarov frame have shown a stable ankle joint, a plantigrade foot, and fully independent outdoor ambulation in both patients at the final follow-up. We concluded that amputation should not be performed under this condition.

[Surgical treatment of hallux valgus deformity at the Department of Orthopaedic Surgery, Zagreb School of Medicine, in the period 1981-2000]. / Lijecenje haluksa valgusa u Klinici za ortopediju u razdoblju od 1981. do 2000. godine.

The aim of this study is to evaluate operative treatment of hallux valgus deformity at the Department of Orthopedic surgery, Zagreb School of Medicine, and present our protocol for the management of hallux valgus deformity. In the time period from 1981 to 2000 operative procedures for hallux valgus deformity were performed on 1211 feet in 820 patients (788 females and 32 males). Criteria for operative treatment were: increased hallux valgus angle (HVA), increased first intermetatarsal angle (IMTA), first metatarsophalangeal joint arthritis, pain and cosmetic reasons. Radiographic observations as well as clinical and subjective evaluation were made preoperatively and after the surgery. Observations were classified using Helal's modification of Boney and McNab classification. Resection of the proximal end of the proximal phalanx was performed in 250 patients (402 feet) with 55% of excellent results (221 patients over 60 years of age). Distal first metatarsal Austin osteotomy was performed in 312 patients (429 feet) with 49% of excellent results (210 feet, mean patient age 50 years, mean HVA 27 degrees, mean IMTA 15 degrees). Distal first metatarsal Mitchell osteotomy was performed in 230 patients (380 feet) with 40% of excellent results (152 feet, mean patient age 24 years, mean HVA 26 degrees, mean IMTA 15 degrees). Our experience in the operative treatment of hallux valgus deformity suggests that in order to achieve excellent results after surgery, strict criteria for each operative method must be applied.

Regional anesthesia for upper extremity surgery--our experience.

Brachial plexus block using axillary approach is a simple and safe method of regional anesthesia often used for elbow, forearm and hand surgery. Different techniques can be used to achieve brachial plexus block. On using perivascular approach to brachial plexus, we neither searched for paresthesia nor used nerve stimulator to identify the correct needle position within the neurovascular sheet. Axillary artery was palpated and a mixture of local anesthetic agents was injected into the neurovascular sheet above and below axillary artery at the site of strongest artery pulsation. The local anesthetic solution comprised equal volumes of lidocaine 2% and bupivacaine 0.5% without adrenaline, in a total volume of 30-40 mL, depending on body mass. This technique is used in more than 150 patients per year at our department. In the present study, 158 patients undergoing upper extremity surgery under brachial plexus block were retrospectively assessed. Successful anesthesia was achieved in 135 (85.0%) patients using brachial plexus block alone, 19 (12.5%) patients required additional medication, two patients required supplementation with intravenous regional anesthesia, and another two patients required general anesthesia. The incidence of successful blocks, latency time of onset, local and systemic complications or allergic skin reactions were investigated. There were no significant complications attributed to the anesthetic technique.

Mitchell and Wilson metatarsal osteotomies for the treatment of hallux valgus: comparison of outcomes two decades after the surgery.

BACKGROUND: At short-term followup, the Mitchell osteotomy appears to provide more symptomatic improvement than the Wilson osteotomy. We compared the outcomes of the two procedures two decades after the surgeries. METHODS: In a two-center retrospective study, 30 patients (35 feet) who had Mitchell osteotomies and 28 patients (35 feet) who had Wilson osteotomies were evaluated 20 to 22 years after surgery for correction of the hallux valgus angle (HVA) and intermetatarsal (IMA) angle, changes in the shortening of the first metatarsal and improvement in the overall status (a composite radiographic and clinical outcome according to Bonney and McNab). RESULTS: With adjustment for the preoperative values and surgical center (analysis of covariance), the HVA (degrees) had a higher correction in the Mitchell group (p = 0.075), while IMA was comparably corrected by the two methods. Shortening of the first metatarsal was greater in the Wilson group (Mitchell-Wilson = -1.93, 95% CI -2.69 to -1.17, p < 0.001). Before the surgery, overall status was graded "poor" or "good" in all feet (28/7 Mitchell, 29/6 Wilson). After the surgery, the status was graded "excellent" or "good" (29/6) in the Mitchell group, and "excellent," "good" or "poor" (25/7/3) in the Wilson group. The status was improved by at least one grade-level in all 35 feet in the Mitchell group and in 31 of 35 feet in the Wilson group. With stratification for the preoperative status, the proportion of "improvements" was higher in the Mitchell group (Mitchell-Wilson = 11.1%, 95% CI 0.7 to 21.5%, p = 0.036). In an alternative analysis (logistic regression), with adjustment for the preoperative status, center, and IMA values, the Mitchell method also appeared superior in this outcome (likelihood ratio test p = 0.021). CONCLUSIONS: As assessed 20 to 22 years after the surgery, the Mitchell osteotomy resulted in less shortening of the first metatarsal in a somewhat greater proportion of feet with an improved overall status than the Wilson method.