Alternative Treatment of Gonarthrosis: Proximal Fibular Osteotomy.

INTRODUCTION: Gonarthrosis is arthrosis of the knee joint, a chronic non-inflammatory disease manifested by progressive destruction of the intra-articular cartilage, accompanied by abnormal formation of the bones form the joint, changes in the synovial membrane and synovial fluid. Gonarthrosis is the most common type of arthrosis. Gonarthrosis can be treated conservatively and operatively. Among well-established surgical options for the treatment of medial gonarthrosis are high tibial osteotomy (HTO), unicompart-mental knee arthroplasty (UKA), and total knee arthroplasty (TKA). Proximal fibular osteotomy (PFO) or superior partial fibulectomy is a relatively recent procedure proposed to reduce knee pain in patients with medial compartment. AIM: Our study aims to demonstrate an alternative treatment for gonarthrosis with proximal fibular osteotomy and reduced knee pain in patients with medial compartment osteoarthritis of the knee. MATERIALS AND METHODS: At the Department of Orthopedics and Traumatology at J.Z.U "Borka Taleski" Prilep in the period from 2018 to 2021, 14 cases were treated, of which 11 were female and 3 were male. All patients were aged between 62 and 82 years with a mean age of 71.3 years. Patients had a severe degree of gonarthrosis (III/IV) according to Kellgren-Lawrence classification. Arthroscopy was performed in 2 patients. The fibula osteotomy was 7 cm away from the fibular head, with 1 cm resected bone fragment from the fibula. RESULTS: The average duration of the surgery was 30 minutes. Patients were followed up on the 7th day, first month, 3 months and 6 months after surgery. The final evaluation of function was done after 6 months by examining the active and passive movements of the knee joint. In all 14 patients we have excellent results with pain reduction, improvement of movement and quality of life. CONCLUSION: Proximal fibular osteotomy is an option for medial compartment osteoarthritis of the knee. Current literature is limited to small case series which report good outcomes in pain reduction, including the correction of varus deformity in medial gonarthrosis. Further studies are needed to determine the place of the PFO in the medial gonarthrosis management algorithm before it can be recommended for routine clinical use.

The effect of the ankle syndesmosis reduction quality on the short-term functional outcome following ankle fractures.

INTRODUCTION: A few radiographic techniques have been proposed to evaluate ankle syndesmosis reduction. The purpose of this study was to analyze post-operatively with CT-scanning the quality of ankle syndesmotic reduction. Moreover, to assess the impact of quality of syndesmotic reduction to functional outcome. MATERIALS AND METHODS: A prospective cohort study focused on patients older than 17 years with lateral and medial malleolar fracture with verified syndesmotic disruption. EXCLUSION CRITERIA: open fracture, concomitant injury, surgery delayed for more than 24 hours, additional posterior malleolar fracture, ASA score of ≥ 3, complication requiring revision surgery, articular step or gap of ≥ 2mm on the postoperative CT scans. RESULTS: Out of 41 patients, 34 participants completed the follow-up. There was a male predominance (20 patients - 58.82%) and the mean age was 48.46±16.1 years (range (20-72 years). 22 patients (64.71%) have sustained type B fracture, while in 12 patients (35.29%) the fracture was of a type C. The reduction was classified as anatomical in 26 patients (76.50%), while in 8 patients (23.50%) the reduction of the syndesmosis was non-anatomical. In those 26 patients in whom the reduction was anatomical, 17 (65.39%) were males and there were 18 (66.67%) type B fractures. In the patients with non-anatomical reduction, 3 patients (37.5%) were of a male gender and there was the equal number of type B and C fractures. The statistical analysis showed significantly favorable scores for both AOFAS score and VAS scale for the patients with anatomical reduction. CONCLUSION: Functional analysis showed a strong association with the CT observed reduction quality and both the AOFAS score and VAS scale. Further studies are desirable to provide further evidence in relation to the findings of this study.

Results of Arthroscopic Treatment of Chronic Patellar Tendinopathy.

BACKGROUND: The surgical treatment of chronic patellar tendinopathy could be open or arthroscopic. A general agreement on the best surgical treatment option is still lacking. PURPOSE: The aim of our study was to evaluate the clinical results after a minimally invasive arthroscopic treatment of chronic patellar tendinopathy including a resection of the lower patellar pole. METHODS: The study included 14 patients with a mean age of 26 years and chronic patellar tendinopathy refractory to non-operative treatment of more than 6 months. All patients underwent arthroscopic debridement of the adipose tissue of the Hoffa's body posterior to the patellar tendon, debridement of abnormal patellar tendon and resection of the lower patellar pole. Preoperative and postoperative evaluation was undertaken using clinical examination, magnetic resonance imaging (MRI) and the Lysholm and Victorian Institute of Sport Assessment-Patella (VISA-P) scores. Return to sports and postoperative complications were also assessed. The mean follow-up was 12.2 ± 0.9 months. RESULTS: All 14 patients continued with sport activities, but only 12 of them (85.7%) achieved their presymptom sporting level. The median time to return to preinjury level of activity was 3.9 ± 0.8 months. Patients showed a major improvement in the mean Lysholm score from 51.1 ± 3.8 to 93.4 ± 4.2 (p=0.001) and in the mean VISA-P score from 42.1 ± 3.5 to 86.7 ± 8.4 (p=0.001) There were no postoperative complications. CONCLUSION: We found that this arthroscopic technique gives reduced morbidity and satisfactory outcome resulting in significantly faster recovery and return to sports in patients with chronic patellar tendinopathy.

Two Stage Minimally Invasive Method with Locking Plate Application on Distal Tibia Fractures - Our Experience.

INTRODUCTION: In the past distal tibia fractures, including intraarticular fractures, frequently led to poor functional outcomes. The Ruedi-Allgower four steps open method, and later the Patterson and Sirkin recommendations for delayed operative treatment has made a drastic advancement in the treatment of these fractures. The two-stage minimally-invasive protocol using locking plate fixation proved a historical turning point, improving functional results to the highest levels compared to all other methods. AIM: To present the superior results of the two-stage minimally-invasive method using locking plate fixation, making this a historic step forward in treating distal tibia fractures. MATERIAL AND METHODS: A prospective longitudinal study, collecting data from Traumatology-Clinic in the 2014-2016 periods, available for nine-month follow-up. Twenty-three patients were finally included in the study. RESULTS: In analysing the data collected, we focused our attention on the final functional outcomes as indicated by dorsiflexion nine months after injury and also according to the AOFAS Ankle-Hindfoot Scale. Results were excellent with no or minimal consequences. Where complications were present, these were benign and did not require further surgery. CONCLUSION: We believe this modern method for the treatment of distal tibia fractures should be applied routinely and considered as the gold standard in this domain.

Fate of the syndesmotic screw--Search for a prudent solution.

INTRODUCTION: Ankle fractures are common injuries. Since the recognition of the importance of syndesmotic injury in ankle fractures, much of the scientific work has been focused on concomitant syndesmotic injury. Despite the invention of novel devices for restoration and maintenance of the congruent syndesmosis following syndesmotic injury, the metallic syndesmotic screw is still considered to be the "gold standard". The aim of this study was to compare the clinical results in patients who retained the syndesmosis screw with those in whom the screw was removed following open reduction and internal fixation of the malleolar fracture associated with syndesmosis disruption. MATERIALS AND METHODS: This was a retrospective study of 82 patients. Minimum follow-up was 12 months. Clinical evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analogue Scale (VAS) for patient general satisfaction. The condition of the screw (removed, intact or broken), presence of radiolucency around the syndesmotic screw and the tibiofibular clear space were recorded using final follow-up radiographs. RESULTS: Three cortices were engaged in 66 patients (80%) and quadricortical fixation was performed in the remaining 16 patients (20%). The number of engaged cortices did not correlate with the clinical outcome and screw fracture. A single syndesmotic screw was used in 71 patients (86%. The mean AOFAS score in the group with intact screw (I) was 83; the scores in the group with broken screw (B) and removed screw (R) were 92.5 and 85.5, respectively. There was a statistically significant difference between the three groups: this was due to the difference between groups I and B; the difference between groups I and R and groups B and R were not statistically significant. There were no statistically significant differences in VAS results. CONCLUSION: There were no statistically significant differences in clinical outcome between the group with the screw retained and the group in which the screw was removed; however, the group with broken screws had the best clinical outcome based on AOFAS score. Widening of the syndesmosis after screw removal was not evident. We do not recommend routine syndesmosis screw removal.

The effects of time-to-surgery on mortality in elderly patients following hip fractures.

INTRODUCTION: Mortality occurring as a consequence of hip fracture in older patients is very high. Mortality is highest in the first few months after the injury, and this rate is kept at a high level within the first six months postoperatively. Current guidelines indicate that surgery should be performed within 48 hours of injury because early surgery is associated with lower rates of perioperative complications and mortality. AIM: To analyse the effects of time-to-surgery on mortality in elderly patients with hip fracture. MATERIAL AND METHODS: The research was conducted at the University Traumatology Clinic in Skopje, where 120 patients with hip fracture of age 65 and above were treated. The age span was 55-95 years, with a mean age of 73.9±9.8 years. The time frame for the research and the follow-up of the patients was 6 months. Inclusion criteria included patients aged above 65 and isolated proximal femur fractures. Survival time for patients after six months was determined with the Kaplan-Meier product-limit method. Statistical significance was evaluated at level of p<0.05. RESULTS: The mean time from patient admission to surgical intervention was 3.07±1.5 days (range 0-6 days). Hospitalization time averaged 11±4.7 days. We separated our patient population into two groups, one consisting of patients operated in the first two days, the other after two days. The patient death rate in the first group of 25 patients operated in the first 48 hours was a total of 4 patients (16%) after 6 months. The second group, 95 patients operated after 48 hours, showed a significant rise in mortality--32 patients (33.7%). The mean survival time of patients operated within 48 hours is 168.8 days, while the mean survival time of patients operated after 48 hours from their hospital admission was 143.6 days. CONCLUSION: Delay in surgery is associated with significant increase in mortality. Patients should have their operation as soon as possible after admission to hospital, preferably in the first 48 hours.