Reoperation risk of periprosthetic fracture after primary total hip arthroplasty using a collared cementless or a taper-slip cemented stem.

Aims: The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. Methods: We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. Results: A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Conclusion: Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease.

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Towards understanding Müller-Weiss disease from an analysis of 95 cases.

BACKGROUND: The single existing classification of Müller-Weiss Disease (MWD), based solely upon Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. METHODS: Navicular compression, medial extrusion, metatarsal lengths, Kite's, lateral and dorsoplantar talo-first metatarsal angles were measured in 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. RESULTS: Group 1 "early-onset" MWD feet (n = 11) had greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had lateral navicular fracture. Only 1 had moderate degeneration at the talonavicular joint (TNJ) with none requiring surgery yet. Group 2 "Müller-Weissoid" feet (n = 23) had radiologically normal navicular in their fifties and developed MWD on average 5 years later. They had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 "late-onset" MWD presented in the sixth decade. Only TNJ was involved in Group 3 A (n = 16). Group 3B (n = 20) affected TNJ more than NCJ and had the greatest number of Maceira stage V disease. Group 3 C "reverse Müller-Weiss disease", which affected NCJ more than TNJ (n = 25), had greatest midfoot abduction and overlength of the second metatarsal. No fracture occurred in group 3 A compared to 65% and 32% in groups 3B and 3 C, respectively. CONCLUSIONS: With need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatments. We theorize pathogenetic pathways in the various groups.

Misdiagnosis of Extraskeletal Osteochondroma in the Foot: A Report of 3 Cases.

CASES: Two women presented with newly growing callosities beneath the first and second metatarsal heads, initially believed to reflect gastrocnemius tightness and plantar plate pathology. In another man, swelling at the posterolateral aspect of the heel was mistaken for a Haglund deformity. Subsequent imaging of each patient led to delayed diagnosis of extraskeletal osteochondroma (ESO). Surgical excision resolved symptoms in all 3 with no recurrence over 12 months later. CONCLUSIONS: Whenever bony prominences newly develop in soft tissues of the foot, ESO should be suspected and appropriate imaging obtained. We describe physical features to help differentiate ESO from other common causes of foot overload.

Concomitant Dislocation of the Hallucal Interphalangeal Joint and Extra-Articular Dislocation of Its Sesamoid: A Case Report.

CASE: A 22-year-old man sustained closed dislocation of the hallucal interphalangeal joint (HIPJ). Painful limitation of movements persisted 2 months after closed reduction. Magnetic resonance imaging revealed dislocation of the hallucal interphalangeal joint sesamoid (HIPJS) from its intra-articular attachment on the superior surface of the plantar plate to an extra-articular subcutaneous location, plantar and lateral to the flexor hallucis longus tendon. The HIPJS was enucleated through a plantar approach, and the foot remains pain-free 18 months later. CONCLUSIONS: This case represents an unusual combination of HIPJ dislocation and extra-articular dislocation of its sesamoid. Raised awareness of the HIPJS, its normal anatomical location, and configuration will avoid delayed diagnosis.

The lateral malleolar bony fleck classified by size and pathoanatomy: The IOFAS classification.

BACKGROUND: This study analyzes position of the peroneal tendons and status of the superior peroneal retinaculum (SPR) whenever a lateral malleolar bony flake fracture occurs. METHODS: Twenty-four patients had a lateral malleolar bony fleck on anteroposterior ankle radiographs, either in isolation or associated with other hindfoot injuries. We studied size of the bony flecks, presence or absence of peroneal tendon dislocation and pathoanatomy on CT scans. RESULTS: In 11 patients, a small bony fleck lies within the superior peroneal retinaculum and contiguous periosteum, which are stripped off the lateral fibula (Class II lesions). Tendons dislocate into the subperiosteal pouch thus formed, resembling Class I lesions without associated bony avulsion. Treatment for Class II is same as for Class I injuries. In 8 patients with a big bony fleck, tendons dislocate into the fracture site and SPR is intact (Class III lesions). In Class IV lesions, observed in 5 patients with 2-part calcaneal fracture/dislocation, SPR remains intact and peroneal tendons are not dislocated. The invariably large fleck results from the displacing lateral calcaneal fragment abutting against the fibula, whereas the dislocating tendons cause the bony avulsions in Classes II and III. CONCLUSIONS: Due to pathoanatomical differences, surgical approach and natural history of neglected lesions differ depending on size of the bony fleck. The SPR must not be incised in case of big Class III flecks.

Irreducible tongue-type calcaneal fracture due to interposition of flexor hallucis longus.

We present a rare case of interposition of the flexor hallucis longus (FHL) tendon blocking percutaneous closed reduction of a displaced tongue-type calcaneal fracture, and necessitating open repositioning of the tendon and internal fixation through a single extensile lateral approach. Although not recognized until during surgery, with a high index of suspicion, preoperative diagnosis of this injury combination should be possible on high resolution CT, thus enabling better planning of the procedure. The presence of a small sustentacular fragment, especially if markedly displaced or rotated, should further alert the physician as to increased likelihood of such tendon entrapment within the fracture. In the literature, fracture fixation and extrication of the FHL tendon have been performed via either or both lateral and medial approaches. A medial approach may prove necessary when there is severe displacement or rotation of the sustentacular fragment. Arthroscopically assisted surgery may aid in disengaging the tendon from within the fracture site.

Reconstruction of healed elongated anterior tibial and extensor hallucis longus tendons in a young active farmer.

A case of open traumatic lacerations of the anterior tibial tendon (ATT) and extensor hallucis longus (EHL) tendon that both healed in continuity but significantly elongated position following primary repair, resulting in foot drop and sagging of the great toe affecting gait and function, is presented. An adequate immobilization and protection in the early post-operative period is very important and a secure technique for reconstructing a healed elongated anterior tibial tendon is described.

Vertical axis dislocation with coronal fracture of the patella: A previously unreported injury pattern.

The patella usually dislocates laterally. Less commonly, intra-articular dislocation occurs about either the vertical or horizontal axis. Patellar fractures are generally transverse with varying degrees of comminution, and less frequently vertical in the sagittal plane. We present a 9-year follow-up of a previously undescribed coronal patellar fracture associated with vertical axis dislocation of the patella. The mechanism of this severe injury is described.