Comparison of two versus three-screw fixation for biplanar chevron medial malleolar osteotomy.

PURPOSE: This study was designed to compare the clinical outcomes and complications of using two versus three screws to fix the biplanar chevron medial malleolar osteotomy (MMO). PATIENTS AND METHODS: A retrospective review was conducted on 43 patients (46 ankles) who underwent biplanar chevron MMO to treat talus osteochondral lesions. Of these, MMO was fixed with two parallel screws placed perpendicular to the osteotomy plane in 16 ankles, while in the remaining 30 ankles, MMO was secured with two parallel screws plus an additional third screw inserted parallel to the tibial plafond. Patients were divided into two groups based on the fixation method and clinical outcomes, union and malunion rates, and complications were compared. RESULTS: Demographic and clinical characteristics such as age (p: 0.411), gender distribution (p: 0.119), affected side (p: 0.126), lesion grades (p: 0.056), and lesion sizes (p: 0.310), immobilization (p: 0.119) and weight-bearing periods (p: 0.252) were statistically similar across both groups. Initial malreduction were observed in five cases within the three-screw group and one case in the two-screw group (p: 0.307). However, neither group exhibited any progressive step-off or gap in the follow-up radiographs, and osteotomy union was achieved in all patients. Delayed union was observed in one patient from the three-screw group. Significant improvements in American Orthopedic Foot and Ankle Society scores were observed in both groups, with no functional discrepancies evident at the final follow-up (p: 0.488). CONCLUSIONS: The study found no significant differences in union rates, complications, or clinical outcomes between two and three-screw fixation methods for medial malleolar osteotomies (MMO). Both methods allowed for effective MMO fixation without loss or displacement post-surgery, suggesting their safety and efficacy. LEVEL OF EVIDENCE: Level III, retrospective comparison.

Prediction Of Palmaris Longus Tendon Length And Thickness Through Simple Anthropometric Measurements.

OBJECTIVE: This study aimed to test whether palmaris longus tendon (PLT) length and thickness can be predicted from simple anthropometric measurements. MATERIALS AND METHODS: 120 healthy volunteers with bilateral PL muscles were enrolled in this prospective study. PLT length and thickness were measured by ultrasonographic examination. Anthropometric measurements included body height, weight, forearm length, and wrist circumference. Correlation, linear regression, and Bland-Altman plot were used for analysis. RESULTS: The mean PLT length and thickness were 10.8±1.4 cm and 4.0±0.9 mm, respectively. Body height and PLT length had a moderate positive correlation (r:0.407, p:0.001), and forearm length and PLT thickness had a weak positive correlation (r:0.229, p:0.001). The regression analysis showed that body height was the best predictor for PLT length, and forearm length was the best predictor for PLT thickness. The regression equations were as follows: PLT length=0.276+(0.062×height) (r2=0.165, p<0.001) and PLT thickness=1.373+(0.108×forearm length) (r2=0.052, p<0.001). The predicted PLT lengths and thicknesses were calculated using these regression formulas and compared with the actual thicknesses and lengths using the Bland-Altman plot. The upper and lower limits of agreement (95% CI) ranged from -2.54 cm to 2.51 cm for actual PLT length and predicted PLT length and from -1.76 mm to 1.74 mm for actual PLT thickness and predicted PLT thickness in the Bland-Altman plot with a weak agreement and proportional bias. CONCLUSIONS: These findings indicate that height and forearm length have limited accuracy in predicting PLT length and thickness. The preoperative ultrasonographic examination can provide valuable assistance, particularly in cases that require grafts with precise length and thickness requirements.

Comparison of five different fluoroscopic methods for identifying the MPFL femoral footprint.

PURPOSE: The success of medial patellofemoral ligament (MPFL) reconstruction is closely linked to the precise positioning of the femoral tunnel. Intraoperative fluoroscopy is commonly utilized to identify the MPFL footprint. This study aimed to ascertain the most accurate fluoroscopic method among the five previously described methods used to determine the MPFL femoral footprint. MATERIALS AND METHODS: Using 44 well-preserved dry femur bones, the MPFL femoral insertion site was demarcated using anatomical bony landmarks, namely the center of the saddle sulcus between the medial epicondyle, adductor tubercle and gastrocnemius tubercle. Fluoroscopic true lateral knee images were acquired and measurements taken, referencing established methods by Schottle et al., Redfern et al., Wijdicks et al., Barnett et al., and Kaipel et al. The distance between anatomic and fluoroscopic MPFL footprints was then measured on digital fluoroscopic images. The accuracy of the locations was compared using a margin of error of 5 and 7 mm. RESULTS: The Schottle method consistently emerged superior, showcasing the smallest mean distance (3.2 ± 1.2 mm) between the anatomic and radiographic MPFL footprints and a high in-point detection rate of 90.9% under 5 mm criteria. While the Redfern method displayed perfect accuracy (100%) within the 7 mm criteria, the Schottle method also performed 97.7% accuracy. CONCLUSIONS: For intraoperative identification of the MPFL footprint using fluoroscopy, the Schottle method is the most consistent and accurate among the assessed methods. Thus, its accuracy in detecting the MPFL footprint makes it recommended for MPFLR to ensure optimal outcomes. LEVEL OF EVIDENCE: Level IV, cadaveric study.

Comparison of four different screw configurations for the fixation of Fulkerson osteotomy: a finite element analysis.

BACKGROUND: Conventionally, two 4.5 mm cortical screws inserted toward the posterior tibial cortex are usually advocated for the fixation of Fulkerson osteotomy. This finite element analysis aimed to compare the biomechanical behavior of four different screw configurations to fix the Fulkerson osteotomy. MATERIALS AND METHODS: Fulkerson osteotomy was modeled using computerized tomography (CT) data of a patient with patellofemoral instability and fixed with four different screw configurations using two 4.5 mm cortical screws in the axial plane. The configurations were as follows: (1) two screws perpendicular to the osteotomy plane, (2) two screws perpendicular to the posterior cortex of the tibia, (3) the upper screw perpendicular to the osteotomy plane, but the lower screw is perpendicular to the posterior cortex of the tibia, and (4) the reverse position of the screw configuration in the third scenario. Gap formation, sliding, displacement, frictional stress, and deformation of the components were calculated and reported. RESULTS: The osteotomy fragment moved superiorly after loading the models with 1654 N patellar tendon traction force. Since the proximal cut is sloped (bevel-cut osteotomy), the osteotomy fragment slid and rested on the upper tibial surface. Afterward, the upper surface of the osteotomy fragment acted as a fulcrum, and the distal part of the fragment began to separate from the tibia while the screws resisted the displacement. The resultant total displacement was 0.319 mm, 0.307 mm, 0.333 mm, and 0.245 mm from the first scenario to the fourth scenario, respectively. The minimum displacement was detected in the fourth scenario (upper screw perpendicular to the osteotomy plane and lower screw perpendicular to the posterior tibial cortex). Maximum frictional stress and maximum pressure between components on both surfaces were highest in the first scenario (both screws perpendicular to the osteotomy plane). CONCLUSIONS: A divergent screw configuration in which the upper screw is inserted perpendicular to the osteotomy plane and the lower screw is inserted perpendicular to the posterior tibial cortex might be a better option for the fixation of Fulkerson osteotomy. Level of evidence Level V, mechanism-based reasoning.

Comparison of longitudinal and inverted L-type capsulorrhaphy in hallux valgus correction surgery.

The purpose of this study is to investigate clinical and radiographic differences between longitudinal capsulorrhaphy and inverted L-type capsulorrhaphy in patients diagnosed with hallux valgus (HV) to whom distal chevron osteotomy and HV distal soft-tissue procedure combination surgery was implemented.A total of 36 patients and 48 feet on whom distal chevron osteotomy and HV distal soft-tissue procedure combination surgery was implemented upon diagnosis of HV were included in the study. The patients were separated into 2 groups according to capsulorrhaphy technique, as group 1 (24 feet) wherein longitudinal capsulorrhaphy was implemented and group 2 (24 feet) wherein inverted-L type capsulorrhaphy was implemented. Both groups were compared preoperatively and postoperatively in terms of American Orthopedic Foot and Ankle Society HV score, visual analogue scale (VAS) pain score, HV angle (HVA), intermetatarsal angle and complications.Comparing the radiological data of both groups, the decrease in terms of HVA was significant in Group 2; however, no significant difference was detected in terms of other data. Postoperative hallux varus was observed 1 one patient in Group 2; however, this case was not statistically significant.In the distal chevron osteotomy and distal soft-tissue procedure combination, applied as a HV correction surgery technique, comparing inverted L-type capsulorrhaphy with longitudinal capsulorrhaphy techniques, it was observed that inverted L-type capsulorrhaphy was more effective in correcting the HVA. However, it should be kept in mind that L-type capsulorrhaphy is also the technique wherein hallux varus complication occurred. As a result, the conclusion was reached that both techniques are applicable and effective in HV correction surgery and the choice should be made by considering the command of the surgeon on the technique.

Lateral foot pain due to os vesalianum pedis in a young football player; a case report and review of the current literature.

Os vesalianum pedis is a rare accessory ossicle located at the 5th metatarsal base. This anatomic variation is typically asymptomatic and usually detected incidentally on routine foot radiographs. However, it may be a source of lateral foot pain and rarely become symptomatic following traumatic ankle injuries such as an inversion ankle sprain. To date, seven symptomatic os vesalianum pedis cases that required surgical treatment have been reported in the current literature. Herein, a 17-year-old professional football player with a symptomatic os vesalianum pedis was presented. The ossicle was surgically removed upon failure of conservative treatment. At the sixth month, the patient returned to sport without any restriction or pain. Clinical presentation, diagnosis, and treatment options of symptomatic os vesalianum pedis were discussed with an extensive literature review.

Drilling through anteromedial portal with a femoral aiming device ensures a sufficient length and a proper graft position, and prevents posterior wall breakage during anterior cruciate ligament reconstruction.

OBJECTIVE: The aim of this study was to evaluate the characteristics of the femoral tunnel (FT) which was drilled through the AM portal by using a femoral aimer device and AP stability of the knee. METHODS: Thirty-eight patients, with the mean age 29.6 (range: 20-43) years, were evaluated after ACL reconstruction. The mean follow-up time was 31.9 (range: 16-57) months. The FT was drilled using a femoral aimer with different offset according to the graft size measured, through the AM portal. The semitendinous and gracilis tendon autograft was used for reconstruction. The angles of FT and the exit point on the lateral condyle were measured on AP views of the knee. AP stability of the knee was measured with the KT-2000. RESULTS: The mean angle of FT was 46.5° (± 8.4°), on the AP view. The mean distance between the exit point of FT and the most distal end of the femoral condyles was 46.7 (± 4.9) mm. The mean FT length was 36.1 (± 3.1) mm. The mean difference of anterior translation compared to the intact knee was 1.9 (± 1.6) mm. Except the three patients, with "one positive" pivot shift test, in the remaining 35 knees stability was equal to the healthy knee. CONCLUSIONS: Femoral drilling by using a femoral aimer device through AM portal provided long enough FT for safe graft fixation and appropriate coronal plan obliquity. The exit point was far proximal from the insertion site of the popliteus tendon and lateral collateral ligament. Furthermore, the AM portal technique significantly improved AP stability of the knee.

Effects of montelukast sodium on tendon healing: An experimental study.

INTRODUCTION: Montelukast sodium (MS) a selective leukotriene antagonist of the cysteinyl leukotriene receptor, has been used in the treatment of asthma and allergic rhinitis. In this study, we evaluated the effect of MS on the early inflammatory phase (histological) of nonsynovial tendon healing. MATERIALS AND METHODS: Rats were divided randomly into two groups (n = 6 each). MS (Singulair) was administered to one group at 10 mg/kg/day [250 g/day intraperitoneally (i.p.)]. The control group was administered 250 g/day of 0.9% saline i.p. This nonsynovial tendon was longitudinally divided at the midportion, cut transversely and then sutured. In both groups, the rats were sacrificed by decapitation 10 days later. RESULTS: Decreased inflammatory cell infiltration and more properly oriented collagen fibres were observed in the MS group's histopathological specimens as compared to the control group's (P < 0.05). Additionally, vascularity was decreased in the MS group. CONCLUSION: MS decreased tendon healing, apparently by inhibiting the early inflammatory phase of nonsynovial tendon healing.

Management of Vancouver type B2 and B3 femoral periprosthetic fractures using an uncemented extensively porous-coated long femoral stem prosthesis.

OBJECTIVE: The purpose of this study was to evaluate the clinical results of femoral revision using an uncemented extensively porous-coated long femoral stems with or without onlay strut allografts in the treatment of Vancouver type B2 and B3 periprosthetic femoral fractures. MATERIALS AND METHODS: We retrospectively reviewed 17 cases of periprosthetic femoral fracture (eight B2 and nine B3) treated with the uncemented extensively porous-coated long femoral stem. Clinical outcomes were assessed with Harris Hip Score and Barthel ADL index. Radiological evaluations were conducted using Beals and Towers' criteria. Any complication during the follow-up period was recorded. RESULTS: The average follow-up period was 41.7 ± 31.08 (range, 15-132) months. The average Harris Hip Score was 68.2 ± 18.4 (range, 32-100), and the average Barthel ADL index was 80.1 ± 19.75 (range, 30-100) points at the final follow-up. All fractures were united, and a good graft consolidation was achieved in 5 of 9 cases. There was femoral stem subsidence in 4 cases less than 10 mm without an evidence of loosening both radiologically and clinically. The radiological results using Beals and Towers' criteria were excellent in eight hips, good in five and poor in four. CONCLUSIONS: An uncemented extensively porous-coated long femoral stem together with or without onlay strut allografts provides a good fracture stability that promotes fracture healing and offers a successful solution for the management of Vancouver type B2 and B3 femoral periprosthetic fractures.