Percutaneous distal osteotomy of lesser metatarsals (DMMO) for treatment of metatarsalgia with metatarsophalangeal instability.

BACKGROUND: Clinical and radiological results of percutaneous distal metatarsal minimally invasive osteotomy (DMMO) of the lesser rays for surgical treatment of primary metatarsalgia due to plantar overpressure with metatarsophalangeal instability are described. The aim of this prospective study was to assess the efficacy, feasibility and safety of this minimally invasive surgical (MIS) technique, verifying the possibility to lower the complication rate related to surgical exposures, to reduce operating times with comparable functional and cosmetic results to those reported with traditional open procedures. METHODS: Hundred and six consecutive percutaneous distal osteotomies without fixation (DMMO) of the second, third or fourth metatarsal bones were performed in 57 patients (70ft) with a mean age at the surgery of 60.2 years (30-81) for treatment of metatarsalgia with metatarsophalangeal instability. Patients were clinically assessed with the AOFAS and Coughlin's Scores, the latter classifying the results in relation to the patient's subjective satisfaction. RESULTS: The mean follow-up was of 45.0±13.3months (24-68). All patients reported the disappearance or reduction of the pain that they had experienced prior to the operation around the metatarsal heads. The mean overall AOFAS score improved from 42.7±13.4 points (9-77) to 92.8±8.6 points (44-100) at the time of final follow-up. Patient subjective satisfaction according to Coughlin's classification was excellent in 62ft (88.6%), good in 7ft (10.0%), fair in 0ft and poor in one foot (1.4%). CONCLUSIONS: We consider the percutaneous distal lesser metatarsal osteotomy without fixation (DMMO) a reliable surgical option in metatarsalgia due to metatarsophalangeal instability in early stages as in grade I and II according to Coughlin classification.

Navicular tenosuspension with anterior tibialis tendon (Young procedure) associated to calcaneo-stop for the treatment of paediatric flexible flatfoot: clinical and ultrasound study.

BACKGROUND AND AIM OF THE WORK: Flexible flatfoot is one of the most common deformities in pediatric orthopaedics. Arthroeresis procedures are designed to correct this deformity. Among them, calcaneo-stop is a procedure with both biomechanical and proprioceptive properties. There could be other surgical procedure combined, such as a percutaneous Achilles tendon lengthening and the Gould tibialis posterior retension or Young tibialis anterior navicular tenosuspension. This study analyzed the clinical and sonographic results of 36 patients following flexible flatfoot surgical treatment with a calcaneo-stop arthroeresis combined with Achilles lengthening and a Young procedure. METHODS: From March 2001 to August 2014, 36 patients (54 feet) were treated with calcaneo-stop arthroeresis, percutaneous Achilles tendon lengthening and Young's tenosuspension. The clinical assessment and a sonography of the anterior tibialis tendon (ATT) were performed in all patients. RESULTS: The average follow-up was 7.4 years (range 8 months-14 years) with a satisfactory outcome in 51 feet (94.5%). No major and minor complications were observed. In four cases the calcaneo-stop was removed for pain and low tolerance of the patient. The AOFAS score and the talocalcaneal angle did not have statistically significant in case of ATT was or not still inserted in the navicular at the follow-up. CONCLUSIONS: The calcaneo-stop procedure is a simple, reliable and minimally invasive procedure for the treatment of pediatric flexible flatfoot. Although the indications for the Young tenosuspension as an isolated procedure is very narrow, it can still be an effective procedure when combined to calcaneo-stop. The key to appropriate utilization is a thorough understanding of the biomechanics of the foot function and a specific appreciation of the function of the ATT.

Acetabular reconstruction with the Burch-Schneider antiprotrusio cage and bulk allografts: minimum 10-year follow-up results.

Reconstruction of severe pelvic bone loss is a challenging problem in hip revision surgery. Between January 1992 and December 2000, 97 hips with periprosthetic osteolysis underwent acetabular revision using bulk allografts and the Burch-Schneider antiprotrusio cage (APC). Twenty-nine patients (32 implants) died for unrelated causes without additional surgery. Sixty-five hips were available for clinical and radiographic assessment at an average follow-up of 14.6 years (range, 10.0 to 18.9 years). There were 16 male and 49 female patients, aged from 29 to 83 (median, 60 years), with Paprosky IIIA (27 cases) and IIIB (38 cases) acetabular bone defects. Nine cages required rerevision because of infection (3), aseptic loosening (5), and flange breakage (1). The average Harris hip score improved from 33.1 points preoperatively to 75.6 points at follow-up (P < 0.001). Radiographically, graft incorporation and cage stability were detected in 48 and 52 hips, respectively. The cumulative survival rates at 18.9 years with removal for any reason or X-ray migration of the cage and aseptic or radiographic loosening as the end points were 80.0% and 84.6%, respectively. The use of the Burch-Schneider APC and massive allografts is an effective technique for the reconstructive treatment of extensive acetabular bone loss with long-lasting survival.

Long-term results of femoral revision with the Wagner Self-Locking stem.

Femoral revision total hip arthroplasty may be a complex procedure due to extensive periprosthetic bone loss. Fluted, tapered stems provide secure axial and rotational stability in the distal femur. We retrospectively evaluated the long-term outcome of the cementless Wagner Self-Locking prosthesis (Sulzer Orthopedics Ltd, Winterthur, Switzerland). From 1992 to 1998, 68 consecutive femoral revisions were performed in 66 patients using the Wagner tapered stem. Twenty-five patients deceased for unrelated causes without additional surgery. The studied group consisted of 41 hips in 41 patients, 12 males and 29 females, aged from 29 to 80 years (mean 61 years). Thirty-five hips (85.4%) included severe deficiency of bone stock. A transfemoral approach was carried out in 32 cases (78%). Bone grafting was never supplemented. Average follow-up was 13.9 years (range 10.4 to 15.8 years). Clinical evaluation was performed using Harris Hip Score (HHS). Osseointegration of the stem and progression of periprosthetic bone remodelling were assessed radiographically. Five stems required rerevision because of deep infection (2), progressive subsidence (2) complicated by hip instability and head-neck disassembly, and old dislocation following acetabular component failure (1). Four hips (9.7%) dislocated, and 8 stems (19.5%) subsided significantly. Average HHS improved from 33 points preoperatively to 75 points at the latest follow-up examination (p < 0.001). Thirty-three of the 36 unrevised stems (91.7%) had radiographic evidence of bone ingrowth. A constant or decreased resorption of the femoral bone was detected in 34/36 patients (94.4%). The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the end points were 92.0% and 96.6%, respectively. The current study documents the efficacy of distal fixation to the diaphysis in revision of bone-deficient femoral components, supporting the use of tapered, fluted stems. Higher-risk complications (dislocation, subsidence) should be minimized by the development of modular stems.

Deep external pudendal artery injury after percutaneous adductor tenotomy during THA in ankylosing spondylitis.

Arterial injuries following total hip arthroplasty (THA) are uncommon and are usually related to revision THA. Deep external pudendal artery injury and delayed bleeding due to percutaneous adductor tenotomy during THA has not been reported.A 62-year-old man with bilateral hip osteoarthritis and ankylosing spondylitis was treated with right cementless THA. Persistent severely limited hip abduction after prosthetic implantation required a percutaneous adductor tenotomy, which was performed bilaterally. No clinical signs of bleeding existed postoperatively. On postoperative day 3, the patient had a hypotensive attack, his right anteromedial thigh at the tenotomy site was distended, and the hemoglobin was 5.9 g/dL. Computed tomography angiography of the iliac and femoral vessels showed a right hematoma medial to the common femoral artery, with active contrast extravasation. Volumetric data reconstruction revealed active bleeding from the right external pudendal artery into an inguinal collection. Angiography was performed by the standard Seldinger technique via the contralateral femoral artery. A guiding catheter was placed as near to the lesion as possible. A microcatheter system and microguidewire were used for superselective catheterization, and 2 embolization coils were used to control the bleeding. The patient remained hemodynamically stable and was discharged 12 days later. Two-year follow-up was uneventful.The deep external pudendal artery may be injured during percutaneous adductor tenotomy, especially in patients with fragile arterial walls, and life-threatening complications may occur. Angiography and embolization are the best treatment options.

A minimum of 10-year follow-up of the Burch-Schneider cage and bulk allografts for the revision of pelvic discontinuity.

Eighteen consecutive hips with pelvic discontinuity and associated periprosthetic bone deficiency were treated with bulk allografts and Burch-Schneider antiprotrusio cage. Clinical and radiographic follow-up was performed at an average of 13.5 (range, 10.5-16.6) years. Three cages required re-revision because of infection (1) and aseptic loosening (2). Average Harris hip score improved from 31.9 to 77.0 points (P < .001). A severe resorption of the bone graft occurred in 2 hips. The stability of the cage was detected in 13 cases. The cumulative survival rate at 16.6 years with acetabular revision for any reason, radiographic loosening, or unhealing of the discontinuity as the end point was 72.2%. The use of Burch-Schneider cage and bulk allografts is an effective technique for the treatment of pelvic discontinuity.

Percutaneous Distal Osteotomy of the Fifth Metatarsal for Correction of Bunionette.

INTRODUCTION: Percutaneous distal metaphyseal osteotomy, a subcapital linear osteotomy of the fifth metatarsal performed through a minimally invasive percutaneous approach and stabilized with a single Kirschner wire, without soft-tissue procedures, enables the surgeon to achieve consistently good correction of a fifth metatarsal bunionette deformity. STEP 1 WIRE INSERTION: It is mandatory to place the wire in a parosteal position to allow medial displacement of the metatarsal head at the osteotomy site. STEP 2 SKIN INCISION: Make a short skin incision directly to the bone on the lateral side of the distal metaphysis of the fifth metatarsal. STEP 3 PERIOSTEAL DETACHMENT: Detach the periosteum surrounding the bone at the site of the planned osteotomy with a small scissors inserted percutaneously, dorsally initially and then plantarly. STEP 4 OSTEOTOMY: Perform the osteotomy with a micromotorized Lindemann bone cutter, avoiding damage to the surrounding structures by drilling the lateral cortex first and then the medial cortex, keeping the bone cutter in the same lateral entry hole and its tip inside the medullary canal. STEP 5 CORRECTION: The correction is usually satisfactory when contact between the lateral aspect of the metatarsal head and the medial cortex of the metatarsal neck is achieved in the frontal plane. STEP 6 STABILIZATION: Stabilize the osteotomy site with the 2-mm Kirschner wire, driven distal to proximal into the medullary canal of the fifth metatarsal as far as its base. STEP 7 POSTOPERATIVE CARE: Apply adhesive tape with a plantar, kidney-shaped pad. RESULTS: In our study of this technique24, the American Orthopaedic Foot & Ankle Society (AOFAS) score improved from a mean and standard deviation of 51.9 ± 10.2 points preoperatively to 98.4 ± 2.6 points at the time of final follow-up. In 73% of the feet, there was complete resolution of pain at the fifth metatarsophalangeal joint without any functional limitation (AOFAS score of 100). In 20% of the cases, the AOFAS score was 95 points with some decrease in function and a need to use comfortable shoes. In the remaining 7% of the patients, the AOFAS score was 93 points with mild asymptomatic malalignment. No nonunions or recurrences were observed. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.