Scarf versus chevron osteotomy in hallux valgus: a randomized controlled trial in 96 patients.

BACKGROUND: The degree of correction of hallux valgus deformity using a distal chevron osteotomy is reported as limited. The scarf osteotomy is reported to correct large intermetatarsal angles (IMA). The purpose of this study was to evaluate if one technique gave greater correction of the IMA and hallux valgus angle (HVA) than the other. METHODS: After informed consent, 96 feet in 83 patients were randomized into two treatment groups (49 scarf and 47 chevron osteotomies). The results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Valgus Scale and radiographic HVA and IMA measurements. RESULTS: At 27 (range 23-31) months followup both groups improved. The AOFAS score in the chevron group improved from 48 to 89 points and in the scarf group from 47 to 91 points. In the chevron group the HVA corrected from 30 to 17 degrees, and in the scarf group the HVA corrected from 29 to 18 degrees. In both groups, the IMA was corrected from 13 to 10 degrees. The differences were not statistically significant. Three patients in the chevron group developed a partial metatarsal head necrosis. In the scarf group, four patients developed grade 1 complex regional pain syndrome compared to one patient in the chevron group. CONCLUSIONS: No differences of statistical significance could be measured between the two groups with respect to the AOFAS score, HVA, and IMA. Although both groups showed good to excellent results, we favor the chevron osteotomy because the procedure is technically less demanding.

Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results.

The percutaneous compression plate (PCCP) is a new implant for the minimally invasive treatment of pertrochanteric hip fractures that might reduce blood loss, wound problems and prevent devascularization of bone fragments. A quicker operation with minimal blood loss is better in the older patients. We performed a prospective, randomized clinical trial to compare the PCCP with the well-known dynamic hip screw (DHS). A total of 71 patients with an Evans type 1A-D pertrochanteric hip fractures were included. We measured the operation duration, blood loss, wound healing, complications, fracture healing and functional outcome. In total, 33 PCCP and 38 DHS were implanted. The mean operation times were 69.2 and 46.6 min for DHS and PCCP, respectively (P = 0.000). Blood transfusions were given in 24 DHS patients compared with six PCCP patients (P = 0.000). There were 27 haematomas in the DHS group and eight in the PCCP group (P = 0.000). There were no differences in fracture healing and the functional outcome between the two implants (P = 0.767, ns). Although this is a preliminary study with a relatively small number of patients and short follow-up, the PCCP seems similar to the DHS in relation to bone healing and stability, but with significant advantages for blood loss, soft tissue healing and operation time.

Fatal pulmonary fat embolism after dorsal spinal fusion.

Fatal pulmonary fat embolism is a rare complication in elective orthopaedic surgery. It has been described previously as occuring during intramedullary manipulations and in trauma patients. We present the case of a 56-year-old slender housewife with severe radicular complaints because of lumbar spinal stenosis. She underwent a dorsal bilateral decompression of L4/L5 and L5/S1 in combination with an instrumented dorsolateral spinal fusion. Transpedicular fixation of L4/L5/S1 was accomplished by titanium Rodegerdts implants. Both iliac crests were used for harvesting autologous bone grafts. The intra-operative course was uneventful; however, 6 h after surgery, despite resuscitation, she expired. Autopsy revealed macroscopic gross fatty infiltration of lung parenchyma with oedema. We believe there is no relation between this complication and the transpedicular instrumentation. The position of the patient and the extent of the harvesting technique could be critical in preventing this serious complication.

Is long-term follow-up justified after excision of a thin melanoma (less than or equal to 1.5 mm)? A retrospective analysis of 206 patients.

From 1964 to 1988, 231 patients underwent local excision as the single treatment of melanoma with a thickness of less than or equal to 1.5 mm. We investigated the prognostic value of several factors on cancer-specific survival and cancer-specific disease-free survival, from time of excision on, by performing life-table analysis on 206 evaluable patients. Recurrence developed in 11 patients; local recurrence occurred in four patients, hematogenic spread in three patients and lymph node metastases in another four patients. Six patients died as a result of the disease. Tumors with a thickness of less than or equal to 1.5 mm have an excellent prognosis regardless of the localization of the melanoma. At 15 years cancer-specific survival was 92.3% and cancer-specific disease-free survival was 86.9%. Recurrence was successfully treated with hope for cure in 4 patients. This figures does not justify aggressive follow-up for all patients.