Conventional vs. endoscopic-assisted curettage of benign bone tumours. An experimental study.

BACKGROUND: This experimental study aimed at directly comparing conventional and endoscopic-assisted curettage towards (1) amount of residual tumour tissue (RTT) and (2) differences between techniques regarding surgical time and surgeons' experience level. METHODS: Three orthopaedic surgeons (trainee, consultant, senior consultant) performed both conventional (4x each) and endoscopic-assisted curettages (4x each) on specifically prepared cortical-soft cancellous femur and tibia sawbone models. "Tumours" consisted of radio-opaque polyurethane-based foam injected into prepared holes. Pre- and postinterventional CT-scans were carried out and RTT assessed on CT-scans. For statistical analyses, percentage of RTT in relation to total lesion's volume was used. T-tests, Wilcoxon rank-sum tests, and Kruskal-Wallis tests were applied to assess differences between surgeons and surgical techniques regarding RTT and timing. RESULTS: Median overall RTT was 1% (IQR 1 - 4%). Endoscopic-assisted curettage was associated with lower amount of RTT (median, 1%, IQR 0 - 5%) compared to conventional curettage (median, 4%, IQR 0 - 15%, p = 0.024). Mean surgical time was prolonged with endoscopic-assisted (9.2 ± 2.9 min) versus conventional curettage (5.9 ± 2.0 min; p = 0.004). No significant difference in RTT amount (p = 0.571) or curetting time (p = 0.251) depending on surgeons' experience level was found. CONCLUSIONS: Endoscopic-assisted curettage appears superior to conventional curettage regarding complete tissue removal, yet at expenses of prolonged curetting time. In clinical practice, this procedure may be reserved for cases at high risk of recurrence (e.g. anatomy, histology).

Is single-stage bilateral medial opening wedge high tibial osteotomy advisable?

PURPOSE: To validate the safety and clinical results of single-stage bilateral versus unilateral medial opening wedge high tibial osteotomy (HTO). METHODS: A propensity-matched cohort study was performed from March 2020 to March 2021 in our medical center. Data were prospectively collected. Including 34 patients who underwent single-stage bilateral medial opening HTO(SSBHTO), and 68 cases in the unilateral group. Propensity-matched ration was 2:1 based on age, sex, and body mass index using R software. Comparisons of the length of hospital stay, operative time, blood loss, postoperative adverse events, 90-day readmission rate, conversion to TKA rate, self-reported VAS and WOMAC scores were made to investigate the safety and clinical results of bilateral HTO. RESULTS: The mean length of hospital stay was 7.36 ± 2.23 days for SSBHTO and 7 days (IQR, 3 days; range, 4 to 23 days) for the unilateral group (P = 0.219). The mean operative time was 144 ± 47 min for bilateral HTO and 105(37.5) mins for a unilateral OWHTO (P < 0.001). The mean blood loss was 150(100) ml for SSBHTO and 100(50) ml for unilateral OWHTO (P < 0.001). There were no significant difference of the adverse events and 90-day readmission rate between two groups. No failed HTO or conversion to knee arthroplasty were observed at the end of follow-up. VAS, pain, stiffness, and functional scores of the WOMAC scale were essentially comparable of two groups one year after surgery (P > 0.05). CONCLUSIONS: A single-stage bilateral medial opening wedge high tibial osteotomy is advisable for patients with knee osteoarthritis. Patients benefit from avoiding secondary anesthesia, postoperative complications, and substantial cost savings. LEVEL OF EVIDENCE: Therapeutic Level III.

Double-Bundle Medial Collateral Ligament Reconstruction Improves Anteromedial Rotatory Instability.

BACKGROUND: New techniques have been proposed to better address anteromedial rotatory instability in a medial collateral ligament (MCL)-injured knee that require an extra graft and more surgical implants, which might not be feasible in every clinical setting. PURPOSE: To investigate if improved resistance to anteromedial rotatory instability can be achieved by using a single-graft, double-bundle (DB) MCL reconstruction with a proximal fixation more anteriorly on the tibia, in comparison with the gold standard single-bundle (SB) MCL reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen human cadaveric knees were tested using a 6 degrees of freedom robotic simulator in intact knee, superficial MCL/deep MCL-deficient, and reconstruction states. Three different reconstructions were tested: DB MCL no proximal tibial fixation and DB and SB MCL reconstruction with proximal tibial fixation. Knee kinematics were recorded at 0°, 30°, 60°, and 90° of knee flexion for the following measurements: 8 N·m of valgus rotation (VR), 5 N·m of external tibial rotation, 5 N·m of internal tibial rotation, combined 89 N of anterior tibial translation and 5 N·m of external rotation for anteromedial rotation (AMR) and anteromedial translation (AMT). The differences between each state for every measurement were analyzed with VR and AMR/AMT as primary outcomes. RESULTS: Cutting the superficial MCL/deep MCL increased VR and AMR/AMT in all knee positions except at 90° for VR (P < .05). All reconstructions restored VR to the intact state except at 90° of knee flexion (P < .05). The DB MCL no proximal tibial fixation reconstruction could not restore intact AMR/AMT kinematics in any knee position (P < .05). Adding an anterior-based proximal tibial fixation restored intact AMR/AMT kinematics at ≥30° of knee flexion except at 90° for AMT (P < .05). The SB MCL reconstruction could not restore intact AMR/AMT kinematics at 0° and 90° of knee flexion (P < .05). CONCLUSION: In this in vitro cadaveric study, a DB MCL reconstruction with anteriorly placed proximal tibial fixation was able to control AMR and AMT better than the gold standard SB MCL reconstruction. CLINICAL RELEVANCE: In patients with anteromedial rotatory instability and valgus instability, a DB MCL reconstruction may be superior to the SB MCL reconstruction, without causing extra surgical morbidity or additional costs.

Supratubercle Anterior Closing Wedge Osteotomy: No Changes in Patellar Height and Significant Decreases in Anterior Tibial Translation at 6 Months Postoperatively.

BACKGROUND: Because of the increased prevalence of revision anterior cruciate ligament (ACL) reconstruction, there has been a desire to understand the role of posterior tibial slope on increased anterior tibial translation and increased ACL graft forces. One potential concern in supratubercle anterior closing wedge proximal tibial osteotomy (ACW-PTO) for decreasing the posterior tibial slope is the risk of altering the patellar height. PURPOSE: To radiographically assess changes in (1) patellar height, (2) anterior tibial translation, and (3) posterior tibial slope after supratubercle ACW-PTO. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent supratubercle ACW-PTO by a single surgeon between July 2019 and June 2023 were included. Standardized lateral knee weightbearing radiographs to assess patellar height (via the Caton-Deschamps index), anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle, and posterior tibial slope were obtained at 4 time points (preoperatively and 1 day, 3 months, and 6 months postoperatively). Paired t test was used to compare differences between preoperative, 1-day, and 3- and 6-month values for patellar height as measured using the Caton-Deschamps index and for posterior tibial slope. Paired t test was also used to compare differences in the preoperative and 6-month postoperative values for anterior tibial translation. RESULTS: In 20 patients after ACW-PTO, the Caton-Deschamps index demonstrated a significant increase in patellar height on postoperative day 1 (P < .001) but no significant differences at 3 (P = .057) and 6 (P = .176) months postoperatively. Anterior tibial translation on standing lateral knee radiographs was significantly decreased by a mean of 8.9 mm from preoperatively to 6 months postoperatively (P < .001). Posterior tibial slope was significantly decreased by a mean of 11.2° from preoperatively to 6 months postoperatively (P < .001). CONCLUSION: Supratubercle ACW-PTO performed for ACL reconstruction failure in the setting of an increased posterior tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, after ACW-PTO, there was a significant decrease in anterior tibial translation and posterior tibial slope.

[Influence and risk factors of lateral hinge fracture on early effectiveness of supramalleolar osteotomy].

Objective: To evaluate the influence of lateral hinge fracture (LHF) on the early effectiveness of supramalleolar osteotomy (SMO) and to explore the related risk factors for LHF. Methods: A total of 39 patients (39 feet) with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively. There were 10 males and 29 females, aged from 41 to 71 years (mean, 57.7 years). According to Takakura stage, there were 6 feet in stage Ⅱ, 19 feet in stage Ⅲa, and 14 feet in stage Ⅲb. The LHF was recognized by the immediate postoperative X-ray film. The osteotomy healing time and the changes of pain visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and tibiotalar angle (TT) before and after operation were compared between patients with and without LHF. The age, gender, affected side, body mass index, Takakura stage, preoperative VAS score, preoperative AOFAS score, preoperative TAS, preoperative TLS, preoperative TT, SMO correction angle, osteotomy distraction, distance from medial osteotomy to ankle joint line (MD), and distance from lateral osteotomy to ankle joint line (LD) were compared between with and without LHF patients, and further logistic regression analysis was used to screen the risk factors of LHF during SMO. Results: All patients were followed up 12-54 months (mean, 27.1 months). During operation, 13 feet developed LHF (group A) and 26 feet did not develop LHF (group B). X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation; the osteotomy of other patients healed, and there was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, there were significant differences in VAS score, AOFAS score, TAS, TLS, and TT of the two groups when compared with preoperative ones ( P<0.05), but there was no significant difference in the changes of above indicators before and after operation between the two groups ( P>0.05). The differences in SMO correction angle, osteotomy distraction, and LD between with and without LHF patients were significant ( P<0.05), and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO ( P<0.05). Conclusion: Too high or too low lateral hinge position during SMO may lead to LHF, but as long as appropriate treatment and rehabilitation measurements are taken, the early effectiveness is similar to that of patients without LHF.

Comparison of tibial fracture plate length, placement, and fibular integrity effects on plate integrity through finite element analysis.

Minimally invasive plate osteosynthesis is the most commonly used minimally invasive surgery technique for tibial fractures, possibly involving single or dual plate methods. Herein, we performed a finite element analysis to investigate plate strength according to the plate type, length, and presence of a fibula by constructing a three-dimensional tibia model. A thickness of 20 mm was cut 50 mm distal from the lateral plateau, and the ligaments were created. Plates were modeled with lengths of 150, 200, and 250 mm and mounted to the tibia. Screws were arranged to avoid overlapping in the dual plating. The von-Mises stress applied to the plates was measured by applying a load of 1 body weight. Dual plates showed the least stress with low displacement, followed by medial and lateral plates. As the plate length increased, the average stress gradually decreased, increasing plate safety. The difference in the influence of the fibula depending on the presence of proximal fibula osteotomy showed that the average stress increased by 35% following proximal fibula osteotomy in the D1(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Non Proximal fibula osteotomy) and D1P(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Proximal fibula osteotomy) models, confirming the necessity of the fibula model. There is no consensus guideline for treatment of this kind of fracture case. A single fracture plate can decrease the risk of skin damage, ligament damage, and wound infection, but because of its design, it cannot provide sufficient stability and satisfactory reduction of the condylar fragment, especially in cases of comminution or coronal fracture. So, these results will help clinicians make an informed choice on which plate to use in patients with tibial fractures.

Displaced Proximal Tibia Fracture After Proximal Tibial Autograft Harvest: A Case Report.

Background: A 60-year-old female underwent proximal tibial autograft harvest for a Cotton osteotomy. Her postoperative course was complicated by psychogenic non-epileptic seizure (PNES) episodes leading to unintentional weightbearing. Knee radiographs at 6 weeks post-procedure demonstrated a displaced proximal tibia fracture through the autograft harvest site. Further clinical review revealed metabolic derangements consistent with secondary hyperparathyroidism. Initial nonoperative treatment led to atrophic varus nonunion requiring definitive treatment with total knee arthroplasty with revision components. Conclusion: This case describes a rare complication of proximal tibial autograft harvest and highlights the importance of preoperative metabolic workup and bone health optimization.Level of Evidence: IV.

Outcomes of Simultaneous Lengthening and ACL Reconstruction in Fibular Hemimelia: A Retrospective Case Series.

Background: Fibular hemimelia is the most common congenital long bone deficiency. It is often associated with femoral and tibial deficiencies which result in a clinically evident leg length discrepancy. The primary soft tissue concern is ACL/PCL deficiency. If treatment includes bony lengthening, joint stability is imperative to avoid complications. In this study, we detail a novel technique for long bone lengthening and ACL reconstruction in a single, cohesive surgery. This consolidates the need for multiple procedures and offers improved limb length symmetry and knee stability for this patient population. Clinical outcomes of pediatric patients with hemimelia who underwent either femoral or tibial lengthening with PRECICE® nail and concomitant ACL reconstruction are presented. Methods: After IRB approval, we identified five patients with complex fibular hemimelia who underwent ACL reconstruction and concomitant lengthening with at least two years of follow-up. Two patients (40%) presented with congenital short femur, and three (60%) with congenital short tibia. In each case, ACL reconstruction and either femoral or tibial guided growth via PRECICE® nail were performed. Operative techniques involving both soft tissue and bony methodology are described in detail. Results: All patients had objective improvement in knee stability as assessed both intra and post operatively, as well as successful intermedullary lengthening without complications related to joint stability. Three patients had minor complications unrelated to joint stability that did not interfere with overall result. Conclusion: Fibular hemimelia associated with hypoplasia of bony and soft tissue structures can be successfully addressed with concomitant ligamentous reconstruction at the time of implantation of lengthening devices. This addresses knee instability and reduces both number of operative procedures and potential complications related to joint instability while pursuing bony lengthening. Level of Evidence: V.

Evaluation of the long-term effect of selective tibial neurotomy for the treatment of spastic foot using a personal goal-centered approach.

OBJECTIVE: The objective of this study was to evaluate the long-term effectiveness of selective tibial neurotomy (STN) for the treatment of the spastic foot using a goal-centered approach. METHODS: Between 2011 and 2018, adult patients with a spastic foot (regardless of etiology) who received STN followed by a rehabilitation program were included. The primary outcome was the achievement of individual goals defined preoperatively (T0) and compared at 1-year (T1) and 5-year (T5) follow-up by using the Goal Attainment Scaling methodology (T-score). The secondary outcomes were the presence of spastic deformities (equinus, varus, and claw toes), modified Ashworth scale (MAS) score for the targeted muscles, and modified Rankin Scale (mRS) score at T0, T1, and T5. RESULTS: Eighty-eight patients were included. At T5, 88.7% of patients had achieved their goals at least "as expected." The mean T-score was significantly higher at T1 (62.5 ± 9.5) and T5 (60.6 ± 11.3) than at T0 (37.9 ± 2.8) (p < 0.0001), and the difference between T1 and T5 was not significant (p = 0.2). Compared to T0, deformities (equinus, varus, and claw toes; all p < 0.0001), MAS score (p < 0.0001), and mRS score (p < 0.0001) were significantly improved at T1 and T5. Compared to T1, MAS score increased slightly only at T5 (p = 0.05) but remained largely below the preoperative value. There was no difference between T1 and T5 regarding other clinical parameters (e.g., deformities, walking abilities, mRS score). CONCLUSIONS: This study found that STN associated with a postoperative rehabilitation program can enable patients to successfully achieve personal goals that are sustained within a 5-year follow-up period.

The Intermalleolar Method for Intraoperative Rotational Assessment of the Tibia-A Prospective Clinical Validation Study.

OBJECTIVES: To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT). DESIGN: Prospective cohort study. SETTING: Academic Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023. OUTCOME MEASURES AND COMPARISONS: Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation. RESULTS: Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively. CONCLUSIONS: The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reconstruction of congenital pseudarthrosis of the radius with a vascularized tibial periosteal transplant: A case report.

Congenital pseudarthrosis of the forearm poses a considerable challenge because of its rarity. The objective of this report is to introduce a novel surgical technique for its treatment. Here, we document a case of congenital pseudarthrosis of the radius in a 3-year-old boy diagnosed with type-1 neurofibromatosis. The surgical treatment involved the excision of approximately 9 cm of native radial periosteum and a bifocal radius osteotomy, which was supplemented with a vascularized tibial periosteal transplant to facilitate bone healing. Anastomosis between the anterior tibial vessels and radial vessels was performed. No immediate or late postoperative complications were observed. After 3 weeks, a robust callus formation was observed, and during a follow-up examination 3 years and 4 months later, a wide range of active forearm rotation was noted. This report suggests that vascularized periosteal flaps show promise as a viable treatment option for congenital pseudarthrosis of the forearm. They offer an alternative to vascularized fibular grafts or single-bone forearm constructs.

Loop technique for anterior cruciate ligament reconstruction combined with anterolateral structure reinforcement: technical description and clinical results.

PURPOSE: We describe a surgical technique for ACL reconstruction combined with anterolateral structure reinforcement and report early clinical follow-up results. METHODS: The semitendinosus and gracilis tendons are braided into 5 strands and the ACL femoral tunnel and tibial tunnel are created. The graft is passed through the tunnel with the use of a traction suture and the tibial end is fixed with absorbable interference screws at 30° of knee flexion. The ACL graft traction suture is used as an anterolateral reconstruction structure to pass through the proximal exit of the ACL femoral tunnel and then through the depth of the iliotibial bundle to the anterior to Gerdy's tubercle, a bony tunnel is created from the anterior to Gerdy's tubercle to the goose foot, and the traction suture is passed through this bony tunnel to form a Loop structure at 20° of knee flexion. Between March 2021 and May 2022 IKDC score, Lysholm score, and Tegner score were performed preoperatively and 6-12 months postoperatively in 24 consecutive patients who met the indications for this procedure and underwent surgery. The patient's maximum flexion angle, the circumference of the thigh, and the stress X-ray between the operated and healthy knee were measured. RESULTS: Patients showed significant improvement in IKDC score, Lysholm score and Tegner score at a mean follow-up of 7 months postoperatively compared to preoperatively. No significant increase in anterior tibial displacement was found between the patient's operated side and the healthy side. CONCLUSION: The Loop technique ACLR combined with ALSA can be used in patients with an ACL tear combined with a high degree of positive pivot shift. The patient's subjective perception was significantly improved from the preoperative period and knee stability was restored. LEVEL OF EVIDENCE: IV, therapeutic study.

Effects of the Application Local Zoledronic Acid On Different Dental Implants in Rats On Osseointegration.

Objective: Recently, a lot of research has been done around the world to popularize the osseointegration of dental implants. In this study, it was investigated the effect of local zoledronic acid application on implants with machined (MAC), resorbable blast materials (RBM), sandblasted and acid-etched (SLA) surface implants integrated in rat tibias. Methodology: A total of 60 female Wistar rats weighing between 270 and 300 g were used in the study. The rats were passing divided into six classes: controls; MAC (n = 10), RBM (n = 10), SLA (n = 10), and local zoledronic acid (LZA) applied groups; LZA-MAC (n = 10), LZA-RBM (n=10) and LZA-SLA (n = 10) and implants were surgically placement into rat tibias in general anesthesia. After a four-week experimental period, the biomechanical bone implant connection level was determined with reverse torque analysis. Results: Osseointegration levels were detected highly in SLA and RBM surface compared with the machined surfaced implants in both control and treatment groups (p < 0.05). Additionally, local application of zoledronic acid in both three groups; implants increased the biomechanic osseointegration level compared with the controls (p < 0.05). Conclusion: In this research, we observe that the local application of the zoledronic acid could increase the osseointegration, and RBM and SLA surface could be better than machined surfaced implants in terms of bone implant connection. In addition, local application of zoledronic acid may be a safer method than systemic application.

An in-vitro three-dimensional surgical simulation technique to predict tibial tunnel length in transtibial posterior cruciate ligament reconstruction.

BACKGROUND: During the transtibial posterior cruciate ligament (PCL) reconstruction, drilling depth excessively longer than the tibial tunnel length (TTL) is an important reason to cause popliteal neurovascular bundle injury when preparing the tibial tunnel. This study aims to develop an in-vitro three-dimensional surgical simulation technique to determine the TTL in anteromedial (AM) and anterolateral (AL) approaches. METHODS: A total of 63 knees' 3-dimensional (3D) computed tomography models were included in this study. The SuperImage system was used to reconstruct the 3D knee model and locate the tibial PCL site. The established 3D knee model and the coordinates of the tibial PCL site were imported into Rhinoceros 3D modeling software to simulate AM and AL tibial tunnel approaches with different tibial tunnel angles (TTA). The TTL and the tibial tunnel height (TTH) were measured in this study. RESULTS: In AM and AL tibial tunnel approaches, the TTL showed a strong correlation with the TTA (for AM: r = 0.758, p < 0.001; for AL: r = 0.727, p < 0.001). The best fit equation to calculate the TTL based on the TTA was Y = 1.04X + 14.96 for males in AM approach, Y = 0.93X + 17.76 for males in AL approach, Y = 0.92X + 14.4 for females in AM approach, and Y = 0.94X + 10.5 for females in AL approach. CONCLUSION: Marking the TTL on the guide pin or reamer could help to avoid the drill bit over-penetrated into the popliteal space to damage the neurovascular structure.

Tibial Axis-to-Talus Distance: A Clinically Reliable Measurement for Sagittal Translation of the Talus in Total Ankle Arthroplasty.

Background: Sagittal talar translation is an important factor influencing the sagittal alignment of total ankle arthroplasty (TAA). Thus, accurate measurement of sagittal talar translation is crucial. This study proposes a simple method (tibiotalar distance [TTD]) that can quantify talar translation without being affected by the ankle and subtalar joint condition or the talar component position in patients with TAA. Methods: We enrolled 280 eligible patients (296 ankles) who underwent primary TAA between 2005 and 2019 and retrospectively reviewed them for sagittal talar translation. The TTD was measured for each patient on weight-bearing lateral ankle radiographs by 3 raters. In addition, we analyzed interrater and intrarater reliability for the TTD method. Results: We found that the TTD method could quantify the talar translation and was not affected by the preoperative condition of the ankle joint surface, subtalar joint pathologies, or the postoperative talar component position. The TTD method showed an excellent intraclass correlation coefficient (> 0.9) in all interrater and intrarater reliability analyses. In the analysis of 157 healthy, unoperated contralateral ankles, we identified that TTD showed a Gaussian distribution (p = 0.284) and a mean of 38.91 mm (normal range, 29.63-48.20 mm). Conclusions: The TTD method is a simple and reliable method that could be applied to patients with TAA to assess the sagittal talar translation regardless of the pre-and postoperative joint condition and implantation status.

Improvement of absorbability, osteoconductivity, and strength of a ß-tricalcium phosphate spacer for opening wedge high tibial osteotomy: clinical evaluations with 106 patients.

BACKGROUND: An ideal synthetic spacer for medial opening wedge high tibial osteotomy (MOWHTO) has not yet been developed. The authors have developed a new ß-tricalcium phosphate (ß-TCP) spacer with 60% porosity (N-CP60) by modifying the micro- and macro-pore structures of a conventional ß-TCP spacer (CP60) that is widely used in clinical practice. The purpose of this study was to compare the absorbability, osteoconductivity, and in vivo strength of the N-CP60 spacer with those of the CP60 spacer, when used in MOWHTO. METHODS: First, the porosity, diameter distribution of macro- and micropores, and compressive strength of each ß-TCP block were examined using methodology of biomaterial science. Secondly, a clinical study was performed using a total of 106 patients (106 knees) with MOWHTO, who were followed up for 18 months after surgery. In these knees, the N-CP60 and CP-60 spacers were implanted into 49 tibias and 57 tibias, respectively. The absorbability and osteoconductivity were radiologically evaluated by measuring the area of the implanted spacer remaining unabsorbed and assessing with the Hemert's score, respectively. The incidence of cracking in the implanted spacers was determined using computed radiography. Statistical comparisons were made with non-parametric tests. The significance level was set at p = 0.05. RESULTS: The N-CP60 and CP60 blocks had almost the same porosity (mean, 61.0% and 58.7%, respectively). The diameter of macropores was significantly larger (p < 0.0001) in the N-CP60 block than in the CP60 block, while the diameter of micropores was significantly smaller (p = 0.019) in the N-CP60 block. The ultimate strength of the N-CP60 block (median, 36.8 MPa) was significantly greater (p < 0.01) than that of the CP60 block (31.6 MPa). As for the clinical evaluations, the absorption rate of the N-CP60 spacer at 18 months after implantation (mean, 48.0%) was significantly greater (p < 0.001) than that of the CP60 spacer (29.0%). The osteoconductivity of the N-CP60 spacer was slightly but significantly higher (p = 0.0408) than that of the CP60 spacer only in zone 1. The incidence of in vivo cracking of the posteriorly located N-CP60 spacer at one month (mean, 75.5%) was significantly lower (p = 0.0035) than that of the CP60 spacer (91.2%). CONCLUSIONS: The absorbability, osteoconductivity, and compressive strength of the new N-CP60 spacer were significantly improved by modifying the macro- and micro-pore structures, compared with the conventional CP60 spacer. The N-CP60 spacer is more clinically useful than the CP60 spacer. TRIAL REGISTRATION NUMBER: H29-0002.

Guided Growth to Treat Anterolateral Tibial Bowing Associated with Congenital Pseudarthrosis of the Tibia.

BACKGROUND: Anterolateral tibial bowing associated with congenital tibial pseudarthrosis occurs often in patients with neurofibromatosis type 1 and results from the inability of the fractured bone to unite, leading to persistent nonunion, abnormal bone growth, and further bowing of the tibia. Current surgical and nonsurgical approaches demonstrate persistent nonunion or refracture, often resulting in amputation. METHODS: This report describes the management of 3 patients with anterolateral tibial bowing and NF1 who underwent distal tibia-guided growth. RESULTS: The patients had an average age of 1.6 years at initial operation, with a total of 3 to 4 surgeries over an average of 2.1 years. The latest follow-up on all patients is included, at a mean of 5.1 years after the initial operation. All 3 patients experienced substantial functional improvement and improved alignment of the mechanical axis of the tibia. One patient has experienced refracture. CONCLUSIONS: Our study indicates that guided growth can serve as an additional surgical option to improve ALTB and potentially reduce the risk of fracture and pseudarthrosis by restoring normal mechanical alignment. LEVEL OF EVIDENCE: Level-IV, Case Series.

Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot's joint.

INTRODUCTION: Charcot arthropathy is a progressive disorder of the ankle and foot joints that can lead to foot deformity and instability. Surgical intervention is often necessary for deformity and ulcer management during the chronic phase. The device used for arthrodesis remains a challenge. METHODS: This clinical trial study included diabetic patients aged 40 years or older with Charcot foot. Lateral approach with lateral malleolar osteotomy was used to access the ankle joints and remove the cartilage. A small incision was made on the plantar aspect of the foot to pass an appropriately sized intramedullary nail. Demographic information, medical history, surgical details and Clinical data were collected at 2-week and 1-year follow-ups using the Ankle-Hindfoot Scale (AOFAS) score and the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) health utility score. RESULTS: Twenty-six patients with a mean age of 63 ± 0.23 years were included in the study. The findings showed significant improvements in AOFAS questionnaire items related to pain score, length of the walk, walking surfaces, walking disorders, sagittal alignment, back leg alignment, sustainability, alignment and the total score (P value < 0.001). The EQ-5D-5L questionnaire also showed a significant improvement in the total score (P value = 0.002). CONCLUSION: This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies.

How effective is proximal fibular osteotomy in redistributing joint pressures? Insights from an HTO comparative in-silico study.

BACKGROUND: Knee osteoarthritis (KOA) represents a widespread degenerative condition among adults that significantly affects quality of life. This study aims to elucidate the biomechanical implications of proximal fibular osteotomy (PFO), a proposed cost-effective and straightforward intervention for KOA, comparing its effects against traditional high tibial osteotomy (HTO) through in-silico analysis. METHODS: Using medical imaging and finite element analysis (FEA), this research quantitatively evaluates the biomechanical outcomes of a simulated PFO procedure in patients with severe medial compartment genu-varum, who have undergone surgical correction with HTO. The study focused on evaluating changes in knee joint contact pressures, stress distribution, and anatomical positioning of the center of pressure (CoP). Three models are generated for each of the five patients investigated in this study, a preoperative original condition model, an in-silico PFO based on the same original condition data, and a reversed-engineered HTO in-silico model. RESULTS: The novel contribution of this investigation is the quantitative analysis of the impact of PFO on the biomechanics of the knee joint. The results provide mechanical evidence that PFO can effectively redistribute and homogenize joint stresses, while also repositioning the CoP towards the center of the knee, similar to what is observed post HTO. The findings propose PFO as a potentially viable and simpler alternative to conventional surgical methods for managing severe KOA, specifically in patients with medial compartment genu-varum. CONCLUSION: This research also marks the first application of FEA that may support one of the underlying biomechanical theories of PFO, providing a foundation for future clinical and in-silico studies.