Middle-sized posterior malleolus fractures: Fixed versus non-fixed - A prospective randomized study.

PURPOSE: This study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome. METHODS: A prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10-25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years. RESULTS: Demographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001). CONCLUSION: Although there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor. LEVEL OF EVIDENCE: Level I; prospective randomized controlled study.

Functional Outcomes of Autologous Matrix-Related Chondrogenesis to Treat Large Osteochondral Lesions of the Talus.

BACKGROUND: Osteochondral lesions of the talus (OLT) treatment is widely debated when the lesion size exceeds 150 mm2. The aim of this study was to assess functional outcome and satisfaction rates of the autologous matrix-related chondrogenesis (AMIC) technique and compare the outcomes for OLTs larger than 150 mm2 that were classified as primary, primary with local tumor-related OLT, or revision cases. METHODS: A total of 77 patients who were operated by AMIC were included. The average age of the population was 39.6 years. The mean body mass index (BMI) was 27.2. Smoker rate was 28.5% of the population. Forty-two patients were primary cases, 14 patients had primary with local tumor-related OLT, and 18 patients were revision cases. Overall and subgroup functional outcomes were evaluated by visual analog scale (VAS) and Foot and Ankle Disability Index (FADI) scores. Satisfaction rates were queried, and failures were recorded. RESULTS: After a median follow-up of 32 months, the score improvement for primary, primary with local tumor-related, and revision group were for VAS, 5.4 ± 0.4, 5.6 ± 0.7, and 3.6 ± 0.8, and for FADI, 46.5 ± 3.8, 45.3 ±6.5, and 26.6 ± 6.7, respectively (P < .001). Intergroup comparison showed greater improvement for the primary OLT group when compared to the revision group (P < .001). The failure rates for the primary, primary with local tumor-related, and revision group were 4.8%, 11.8%, and 38.9%, respectively. CONCLUSION: AMIC procedure provides good functional outcome and satisfactory rates in patients with primary and primary with local tumor-related OLT larger than 150 mm2, but in revision cases, the AMIC success rate was not encouraging as all had advanced OLT operative interventions. LEVEL OF EVIDENCE: Level III, therapeutic retrospective study.

The Charcot Reconstruction Preoperative Prognostic Score's Evaluation with Complication Rate and Functional Outcome.

BACKGROUND: Charcot's neuroarthropathy (CN) treatment is still controversial, and the results are controversial. Owing to patient comorbidities, surgical intervention carries a high risk of complications. Thus, foreseeing the possible results of planned treatment is crucial. We retrospectively evaluated the Charcot Reconstruction Preoperative Prognostic Score (CRPPS) in patients with surgically treated CN. METHODS: Twenty-two feet of 20 patients were included in the study. Two groups were formed according to their CRPPS. Twelve patients with values less than 4 were defined as group A, and eight patients with values of 4 or greater were defined as group B. Mean follow-up was 61 months (range, 5-131 months). Groups were compared according to American Orthopaedic Foot and Ankle Society (AOFAS) scores, Foot and Ankle Disability Index (FADI) scores, and complication rates. RESULTS: Group A and B mean AOFAS scores were 76.83 (range, 71-85) and 70.5 (range, 20-85), respectively. All of the patients were improved according to AOFAS and FADI scores, but no correlation was found with the CRPPS. None of the group A patients required additional intervention, but five patients in group B underwent revision surgery. No amputations were performed. CONCLUSIONS: The CRPPS is focused on feasibility. The data needed to fill the scoring system is easily obtainable from medical records even retrospectively, and the score is helpful to predict a patient's outcome after CN-related surgery. Herein, CRPPS values of 4 or greater were related to high complication rates and lower functional outcomes.

Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study.

OBJECTIVE: The aim of this study was to determine the effects of age and body mass index (BMI) on the functional outcomes, satisfaction rates, and recovery time after open debridement and reattachment surgery in non-athletic patients with insertional Achilles tendinopathy (IAT). METHODS: In this retrospective study, 33 non-athletic patients (34 ankles) in whom open debridement and reattachment surgery was performed for IAT from 2006 to 2016 were included. Change in pain intensity was assessed using a Visual Analogue Scale (VAS) preoperatively and at the final follow-up. Functional assessment was done by preoperative and postoperative American Orthopaedics Foot and Ankle Score (AOFAS) and final follow-up Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A). Patient satisfaction was evaluated by Roles - Maudsley score (RMS). The recovery time was defined as the time interval from the first appearance to postoperative relief of symptoms and recording. In addition, the recurrent Haglund's deformity was determined by postoperative control radiographs. RESULTS: The mean age at the time of the operation was 51.19 years. The mean follow-up was 61.75±8.49 months. According to BMI, 5 patients were determined as morbid obese, 19 as obese, 3 as overweight, and 6 as normal. The mean VAS score significantly decreased from 8.5 preoperatively to 1.3 postoperatively (p<0.001). The mean AOFAS score significantly improved from 55.8 preoperatively to 92 postoperatively (p<0.001). Postoperative VISA-A score was 86% (range=32%-100%). According to RMS, 22 patients reported the result as excellent, 8 as good, 2 as fair, and 1 as poor. The mean recovery time was 11.8 (range=2-60) months, but one patient did not reach a symptom free status and thus was not included in the recovery time analysis. Postoperative control radiographs revealed signs of recurrence deformity in four patients. Recovery time showed a negative correlation with the age of the patients (r=-0.65). Postoperative scores and BMI showed no significant correlations with the recovery time on the basis of Spearman's rho test (p=0.196). CONCLUSION: The results of this study have shown that open debridement and reattachment surgery may be an effective surgical method in relieving pain and improving functional status with high satisfaction rate and acceptable recovery time in the management of non-athletic patients with IAT. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Spinopelvic alignment does not change after bilateral total hip arthroplasty in patients with bilateral Crowe type-IV developmental dysplasia of the hip.

OBJECTIVE: This prospective study aimed to evaluate the changes in the sagittal alignment after total hip arthroplasty (THA) in patients with hip osteoarthritis (OA) secondary to Crowe type-IV developmental dysplasia of the hip (DDH) and whether THA would contribute to the relief of low-back pain (LBP). METHODS: A total of 27 patients (2 men and 25 women) with bilateral hip OA secondary to Crowe type-IV DDH were enrolled in this study. Their mean age at the time of surgery was 40,36±12,35. All patients underwent simultaneous, bilateral THA between January 2015 and December 2016. Clinical assessment included Oswestry disability index (ODI) score and Harris hip score (HHS), and pelvic incidence (PI), sacral slope (SS), lumbar lordosis (LL), and pelvic tilt (PT) were measured from radiographs. RESULTS: Preoperatively, all the patients had hip and low-back pain. Preoperative and final follow-up ODI scores were 48.3 and 3.9 (p=0.000), respectively. HHS changed from 43.54 to 92.68 (p=0.000). PT and PI significantly changed from -20.4°±20.4° to 3.2°±16.7° (p=0.001) and from 26.6°±35.1° to 47.4°±17.9° (p=0.001), respectively. There were no significant differences regarding the SS and LL measurements. Age or limb-length discrepancy was not significantly associated with the spinopelvic alignment measurements. CONCLUSION: Restoring the function of the hip with THA is shown to improve hip-associated LBP, but the accompanying hyperlordosis does not change. THA in patients with bilateral Crowe type-IV hips relieves hip pain as well as associated LBP. Hyperlordosis of the lumbar vertebra does not change after surgery, but PI and PT changes are observed; this improvement might have a role in the relief of LBP. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

One step treatment of talus osteochondral lesions with microfracture and cell free hyaluronic acid based scaffold combination.

OBJECTIVE: The aim of this study was to assess the effectiveness of microfracture and cell free hyaluronic acid (HA) based scaffold combination in the treatment of talus osteochondral defects (OCD). METHODS: This study retrospectively evaluated the clinical results of the 20 patients (14 males and 6 females, mean age at the time of surgery: 32.9 years (range: 16-52 years)) who were treated with MFx and cell-free HA-based scaffold combination for talus OCD smaller than 1.5 cm2 and deeper than 7 mm. Results were evaluated with AOFAS and VAS scores. Also, patients' satisfaction was questioned. RESULTS: Patients were evaluated after an average follow-up of 20.3 months. Intraoperative measurements showed that mean depth of the lesions were 10.4 ± 1.9 mm after debridement. The mean preoperative AOFAS score was 57.45 ± 9.37, which increased to 92.45 ± 8.4 postoperatively (p < 0.05). VAS score was improved from 7.05 ± 2.45 to 1.65 ± 2.20 postoperatively (p < 0.05). CONCLUSION: MFx and cell-free HA-based scaffold combination appear to be a safe and efficient technique that provide good clinical outcomes for lesions deeper than 7 mm. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Surgical Treatment of Neglected Bilateral Hemophilic Equinus Contracture With External Fixation: A Case Report.

Hemophilia is a disorder of blood coagulation with X-linked recessive inheritance. It is characterized by uncontrollable hemorrhage, and 80% of these occur intraarticularly. With recurrent hemarthrosis, recurrent synovitis occurs, which eventually leads to the formation of articular contractures. The key to the prevention of hemophilic joint complications is successful prevention of bleeding and management of the initial hemarthrosis. However, after the development of a rigid contracture, surgical correction remains the only method to correct the deformity. Achilles tendon lengthening, synovectomy, anterior osteophyte resection, corrective osteotomies, external fixators, or arthrodesis should be considered as surgical options. In the present report, we describe our experience using hybrid-type external fixators to manage bilateral neglected rigid equinus contractures in a hemophilic patient, with 78 months of follow-up data.

What Determines the Success of Closed-Wedge High Tibial Osteotomy: Severity of Malalignment, Obesity, Follow-up Period, or Age?

OBJECTIVES: High tibial osteotomy (HTO) is a well-established procedure for the treatment of medial knee osteoarthritis originating from malalignment of the lower extremity. The current study was designed to evaluate the clinical and radiographic results of closed-wedge HTO for the treatment of medial knee osteoarthritis and to reveal factors affecting the outcome. METHODS: A retrospective study was conducted with 138 patients who were operated on for medial knee osteoarthritis between 2000 and 2007 using closed-wedge HTO. Preoperative and follow-up physical examination findings, body mass index (BMI) values, and Hospital for Special Surgery (HSS) and Lysholm knee scores were reviewed. Radiographic evaluation included measurement of the mechanical axis preoperatively and the most recent follow-up orthoroentgenograms. The follow-up knee scores were evaluated according to preoperative mechanical axis, obesity, age, follow-up period, and gender of the patient. The mechanical axis measurement was assessed based on obesity, age, and follow-up period. RESULTS: The mean preoperative and latest follow-up mechanical axis was 4.92o±4.24o varus and 3.43o±3.74o valgus, respectively (p=0.0001). Improvement in the Lysholm (p=0.0001) and HSS (p=0.0001) knee scores was significant. The preoperative mechanical axis, obesity, follow-up period, and gender had no negative effect on the follow-up knee scores, whereas a preoperative age over 50 years had a negative effect on the follow-up knee score. Obesity and the length of the postoperative follow-up period did not have a negative effect on the postoperative mechanical axis, whereas a preoperative age over 50 had a negative effect on the postoperative mechanical axis. CONCLUSION: The results of this study suggest that medial knee osteoarthritis may be treated successfully with closed-wedge HTO. The analysis indicated that factors such as obesity, the degree of preoperative deformity, and gender do not adversely affect the success of treatment. However, a preoperative age over 50 adversely affected the outcome.

Surgical Treatment Options for the Diabetic Charcot Hindfoot and Ankle Deformity.

Charcot neuroarthropathy is associated with progressive, noninfectious, osteolysis-induced bone and joint destruction. When the ankle and/or hindfoot is affected by the destruction process, management is further complicated with collapse and destruction of the talar body, which increases instability around the ankle. In this patient population, arthrodesis is the most commonly used surgical procedure. Internal fixation, external fixation, or a combination of both can be used for the treatment. Decision making between them should be individualized according to the patient characteristics.

Surgical treatment results for flexible flatfoot in adolescents.

OBJECTIVE: Idiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults. METHODS: A total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances. RESULTS: All procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet. Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again. CONCLUSION: Soft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults. LEVEL OF CLINICAL EVIDENCE: Level IV, Therapeutic study.