Minimally Invasive Transverse Distal Metatarsal Osteotomy (MITO) for Hallux Valgus Correction: Early Outcomes of Mild to Moderate vs Severe Deformities.

BACKGROUND: We compared the radiological and clinical outcomes of mild to moderate and severe hallux valgus (HV) treated with minimally invasive distal metatarsal transverse osteotomy (MITO) performed by a single surgeon. METHODS: Eighty-four patients who underwent MITO between May 2018 and March 2020 were recruited and followed for at least 24 months. The severe group was defined as having a preoperative hallux valgus angle (HVA) >40 degrees or preoperative first-to-second intermetatarsal angle (1-2 IMA) >16 degrees; the mild to moderate group was defined as having an HVA <40 degrees and a 1-2 IMA <16 degrees. Pre- and postoperative measurements of the HVA, 1-2 IMA, distal metatarsal articular angle, and tibial sesamoid position were obtained. The visual analog scale for pain, the Foot and Ankle Outcome Score, and the Medical Outcomes Study Short Form Health Survey-36 physical component summary were used to assess clinical outcomes. RESULTS: A total of 116 feet were included in this study and median follow-up period of 29.0 months (range, 24-52 months). Both groups showed significant improvements in all radiologic parameters postoperatively, with the degrees of correction greater in the severe group than in the mild to moderate group. All clinical scores improved significantly from the preoperative to the last follow-up visit. Final clinical outcomes and degrees of improvement were comparable in both groups. CONCLUSION: This study showed that short-term radiographic results for patients with either mild to moderate or severe HV treated with MITO were favorable. Overall clinical outcomes were comparable to those of conventional treatments. In this series, we found MITO with screw fixation to be a satisfactory surgical option for patients with mild to severe HV deformities. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparing the effects of dexmedetomidine and dexamethasone as perineural adjuvants on peripheral nerve block: A PRISMA-compliant systematic review and meta-analysis.

BACKGROUND: Dexmedetomidine (Dexm), a selective alpha-2 adrenoceptor agonist, and dexamethasone (Dexa), a very potent and highly selective glucocorticoid, have both been proven effectively to prolong the duration of local anesthetics (LA) in regional anesthesia. However, data comparing the efficacy of Dexm and Dexa as perineural adjuvants are inconsistent. Therefore, this systematic review and meta-analysis of randomized and quasi-randomized controlled trials (RCTs) was conducted to compare the effects of Dexm and Dexa when used as LA adjuvants on peripheral nerve block (PNB). METHODS: We systematically searched PubMed, Cochrane Library, EMBASE, Web of Science, and ScienceDirect databases up to October, 2020. The primary outcome was the duration of analgesia. Secondary outcomes included incidence of rescue analgesia, cumulative opioid consumption, time required for onset of sensory and motor blockades, duration of sensory and motor blockades, incidence of postoperative nausea and vomiting (PONV), and side effect-associated outcomes (e.g., bradycardia, sedation, hypotension, rates of infection, and neurological complications). The study was registered on PROSPERO, number CRD42020188796. RESULTS: After screening of full-text relevant articles, 13 RCTs that met the inclusion criteria were retrieved for this systematic review. It was revealed that perineural Dexm provided equivalent analgesic duration to perineural Dexa. Besides, the intake of Dexm increased the incidence of rescue analgesia in limbs surgery, as well as the cumulative opioid consumption, and decreased the time required for onset of sensory and motor blockades for long-acting LA (all P < .05). Other analysis revealed insignificant difference between the 2 groups in terms of the incidence of PONV (P > .05). Additionally, 2 studies demonstrated that Dexm possesses more sedative properties than Dexa (P < .05). CONCLUSIONS: This meta-analysis indicated that the analgesic duration of Dexm and Dexa as LA adjuvants in PNB is the same. Meanwhile, the effects of perineural Dexm and Dexa on some secondary outcomes, including the incidence of rescue analgesia, cumulative opioid consumption, and time required for onset of sensory and motor blockades, are associated with the surgical site and type of LA.

Combined open calcaneocuboid, naviculocuneiform and subtalar dislocation: A case report and literature review.

Open dislocations of the midfoot and subtalar joints are extremely rare injuries. Understanding the anatomy of these joints and the various injury patterns is imperative to obtain stable concentric reduction and provide good functional outcome. We present a report of a 26- year old male who was involved in a road traffic accident and sustained open dislocations of the calcaneocuboid, naviculocuneiform and subtalar joints. He initially underwent external fixation in view of the severe soft tissue injury. After improvement of the soft tissue condition, he underwent K-wiring of the calcaneocuboid joint, buttress plating of the talonaviculocuneiform joint, peroneal tendon reconstruction using hamstring allograft and defect coverage with a free anterolateral thigh flap. With appropriate rehabilitation protocols, patient recovered well and was allowed to weight bear as tolerated by 10 weeks. His wounds healed completely by 4 months. We report this case considering the rarity of the combined calcaneocuboid, naviculocuneiform and subtalar dislocations which were successfully managed.

Mycobacterium fortuitum and Mycobacterium abscessus infections in the foot and ankle in two immunocompetent patients.

Nontuberculous mycobacteria (NTM) infections of the musculoskeletal system are commonly missed due to its rarity and the absence of systemic symptoms. A high clinical index of suspicion is required to recognize such infections as they may occur in immunocompetent hosts. We present two cases of foot and ankle NTM infections involving Mycobacterium fortuitum and Mycobacterium abscessus in two such patients. The first case involves an 83-year old lady who presented with a two-month history of multiple foot abscesses initially treated at a rural hospital. She underwent drainage and debridement of her foot, with eventual cultures growing Pseudomonas aeruginosa and Mycobacterium abscessus. She was initially treated with clarithromycin and doxycycline. At one year follow-up review, her wound healed completely. The second case involves a 55-year old man who presented with infection following midfoot fusion and anterolateral thigh flap for an open complex fracture dislocation of his right foot. Cultures eventually grew Mycobacterium fortuitum and he was treated with cefoxitin, clarithromycin and doxycycline. 10 months after his initial injury, the infection has cleared and his flap was clean. Through these 2 cases, we hope to highlight the unusual presentations of such infections and illustrate that with a high initial index of suspicion and appropriate treatment, these infections can be treated successfully.

Incidence and anatomical distribution of hand tumours: a Singapore study.

INTRODUCTION: Hand tumours are frequently encountered in clinical practice. A list of differential diagnoses of the most common hand tumours based on anatomical location would be helpful for clinicians. We aimed to determine the anatomical distribution of hand tumours seen at a hand surgery practice in Singapore. METHODS: The medical records of 50 men and 65 women (mean age 41.7 [range 17-74] years) who underwent excision of hand tumours between 1 June 2010 and 31 December 2012 were reviewed. The histological diagnoses and anatomical locations of the tumours were analysed. The locations were divided into three main groups: (a) distal to the metacarpophalangeal joints (MCPJs); (b) between the MCPJs and carpometacarpal joints (CMCJs); and (c) between the CMCJs and the radiocarpal joint (RCJ). RESULTS: Overall, the most common tumours excised from the hand were ganglions (n = 66/116, 56.9%) and giant cell tumours of the tendon sheath (GCTTSs; n = 11/116, 9.5%). However, distal to the MCPJs, GCTTSs (n = 11/39, 28.2%) were more common than ganglions (n = 7/39, 17.9%). Most of the ganglions (n = 59/66, 89.4%) arose from between the CMCJs and RCJ. CONCLUSION: Most hand tumours were benign. Ganglions were the most common tumours between the CMCJs and RCJ, while GCTTSs were the most common tumours distal to the MCPJs.

Cadaveric Anatomical Study of Sural Nerve: Where is The Safe Area for Endoscopic Gastrocnemius Recession?

PURPOSE: To ascertain in cadavers where the sural nerve crosses the gastro-soleus complex and where the gastrocnemius tendon merges with the Achilles tendon in relation to the calcaneal tuberosities. METHODS: Twelve cadaveric lower limbs (6 right and 6 left) were dissected. The distances between the calcaneal tuberosities and the lateral border of the Achilles tendon where the sural nerve crosses from medial to lateral, as well as to the gastrocnemius tendon insertion into the Achilles tendon, were measured. RESULTS: The mean and median longitudinal distances from the calcaneal tuberosity to where the sural nerve crosses the lateral border of the Achilles tendon are 9.9cm and 10cm respectively (range 7cm to 14cm). The mean and median longitudinal distances from the calcaneal tuberosity to where the gastrocnemius tendon inserts into the Achilles tendon are 19.9cm and 18.5cm (range 17cm to 25cm) respectively. CONCLUSION: It is generally safe to place the posterolateral incision more than 14cm above the calcaneal tuberosity to avoid the sural nerve if surgeons plan to use a posterolateral incision for endoscopic recession. The distance between the calcaneal tuberosity to the gastrocnemius tendon insertion into the Achilles tendon is too highly variable to be used as a landmark for locating the gastrocnemius insertion.

Radiographic study of the proximal femur morphology of elderly patients with femoral neck fractures: is there a difference among ethnic groups?

INTRODUCTION: This study aimed to determine ethnic differences in the proximal femur morphology of elderly patients with femoral neck fractures in Singapore. METHODS: We reviewed the medical records of 101 men and 288 women aged 60-109 (mean 76.4) years who underwent hip hemiarthroplasty for femoral neck fractures between 1 June 2010 and 31 December 2015. Patients' age, gender and race were recorded. Plain anteroposterior radiography was used to measure the following: calcar width to canal width ratio of the ipsilateral femur; neck-shaft angle; hip offset; neck length; and neck width of the contralateral proximal femur. RESULTS: Chinese women had slightly larger femoral heads (mean 43.88 mm) as compared to Malay (mean 42.92 mm, p = 0.044) and Indian (mean 42.34 mm, p = 0.025) women. Chinese women also had a significantly lower mean calcar-to-canal width ratio (0.606) as compared to Malay (0.664, p = 0.002) and Indian (0.693, p = 0.004) women. The mean neck-shaft angle of Chinese women was significantly greater than that of Indian women (137.48° vs. 127.00°, p = 0.001). CONCLUSION: We found statistically significant differences in the femoral head sizes and calcar-to-canal width ratios among women of different ethnic groups. There were also differences in neck-shaft angles between Chinese and Indian women, and between Malay and Indian women.

Alendronate-associated ulnar and tibial fractures: a case report.

Bisphosphonates are widely used to prevent osteoporotic fractures. Long-term use has resulted in unexpected subtrochanteric fractures in some elderly patients. We report a patient on long-term alendronate therapy who sustained fractures of the ulna and tibia sequentially over a 7-month period, without any trauma or fall.