The effect of bony morphology on anterior cruciate ligament injury and surgery.

The exploration of underlying biological risk factors for anterior cruciate ligament (ACL) injury has generated a substantial body of literature describing the role of bony morphology of the knee. Morphological risk factors, such as poor tibiofemoral joint congruity, a narrow femoral intercondylar notch, and an increased posterior tibial slope (PTS), have been implicated in contributing to knee instability and biomechanical abnormalities. Additionally, investigations into sex-specific differences in bony morphology have unveiled distinct risk profiles for males and females. In light of these findings, surgical considerations for individuals with high-risk bony morphology have been developed. Procedures like anterior closing wedge high tibial osteotomy, aiming to address increased PTS, and lateral extra-articular tenodesis for patients with specific risk factors, have been established. The aim of this review is to provide an overview of the current evidence describing the relationship between bony morphology and ACL injury. Moreover, this review aims to discuss the surgical management and outcomes concerning patients exhibiting high-risk anatomic features.

A new guide for enhancing dental implant placement: an in vitro assessment of accuracy.

This study aimed to design a new surgical guide for controlling the mesiodistal distance between implant osteotomies and adjacent teeth as well as the osteotomy depth in partially edentulous patients. The guide kit was designed with design software and milled with a CNC (computer numerical control) router. The guide consisted of 2 components-stoppers and crown guides-for determining the drilling depth and mesiodistal position, respectively. The stoppers were designed in 7.5-, 9.5-, and 11.5-mm lengths, and the crown guides were fabricated with outer diameters of 5.0, 6.0, 7.0, and 8.0 mm. The accuracy of the guide was assessed by preparing a total of 20 implant osteotomies in 4 partially edentulous models and comparing the dimensions of the actual osteotomies to the values that were predicted to occur with the use of the surgical guides. Osteotomies were prepared using the 7.5-mm stopper with either the 7.0- or 8.0-mm crown guide. Cone beam computed tomography (CBCT) was used to obtain images for analysis of osteotomy-tooth mesiodistal distances, which were predicted to be 3.0 or 5.5 mm, depending on position; interosteotomy mesiodistal distances, which were predicted to be 3.0 mm; and osteotomy depth, which was predicted to be 11.5 mm. A 1-sample t test was used to determine if there were significant differences between the predicted values and the measurements of the guided osteotomies on the CBCT images of the mandibular models, and an independent t test was conducted to compare the results of 3.0- and 5.5-mm osteotomy-tooth distances (α = 0.05). Differences between the predicted and actual values of the interosteotomy mesiodistal distance (P = 0.516) and osteotomy depth (P = 0.847) were not statistically significant. The actual osteotomy-tooth mesiodistal distances were significantly different from the predicted values of 3.0 (P = 0.000) and 5.5 mm (P = 0.001), with higher mean differences of 0.46 and 0.60 mm, respectively. The designed guide had a high accuracy in achieving optimal linear interosteotomy mesiodistal distances and osteotomy depths, and the obtained mean values were clinically acceptable.

Rehabilitation-Specific Predictors of Pain Intensity and Physical Activity Levels in Individuals With Acetabular Dysplasia 6 Months After Periacetabular Osteotomy.

INTRODUCTION: Individuals with acetabular dysplasia often report hip joint instability, pain, and poor hip-related function. Periacetabular osteotomy (PAO) is a surgical procedure that aims to reposition the acetabulum to improve joint congruency and improve pain and function. We aimed to examine the influence of presurgery clinical measures on functional recovery following PAO and the associations among clinical outcomes after PAO. METHODS: We screened 49 potential participants, 28 were enrolled, and 23 completed both study visits (pre-PAO and 6 months post-PAO). We evaluated dynamometer-measured hip and thigh strength, loading patterns during a squat and countermovement jump (CMJ), pain intensity, and device-measured physical activity (PA) levels (light, moderate-to-vigorous PA [MVPA], and daily steps). We used linear regression models to examine the influence of muscle strength (peak torque; limb symmetry index [LSI]) and loading patterns before PAO on pain intensity and PA levels in individuals 6 months following PAO. Additionally, we used Pearson correlation coefficient to examine cross-sectional associations among all variables 6 months following PAO. RESULTS: Lower extremity muscle strength and loading patterns during the squat and CMJ before PAO did not predict pain intensity or device-measured PA levels in individuals 6 months following PAO (p > 0.05). Six months following PAO, higher knee extensor LSI was associated with higher time spent in MVPA (r = 0.56; p = 0.016), higher hip abductor LSI was associated with both lower pain (r = 0.50; p = 0.036) and higher involved limb loading during the squat task (r = 0.59; p = 0.010). Lastly, higher hip flexor LSI was associated with higher CMJ takeoff involved limb loading (r = 0.52; p = 0.021) and higher involved hip extensor strength was associated with higher CMJ landing involved limb loading (r = 0.56; p = 0.012). CONCLUSION: Six months after PAO, higher hip and thigh muscle strength and strength symmetry were associated with lower pain, higher PA levels, and greater normalized limb loading during dynamic movement tasks.

Impact of surgery simulation using a 3-dimensional printed model on outcomes of hallux valgus surgery with distal chevron osteotomy: A randomized controlled trial.

OBJECTIVE:  This study aimed to compare the outcomes of traditional surgery (TS) with those of a 3-dimensional model-assisted surgery (3DS) in hallux valgus (HV) surgery with distal chevron osteotomy. METHODS: This randomized controlled trial study included 30 patients randomly grouped as TS and 3DS. In the 3DS group, the surgery was simulated on the 3D model before surgery, and that simulation was used as a guide during surgery. Various parameters, such as angles of the HV, intermetatarsal (IM), and distal metatarsal articular, were measured pre-surgery and during the final follow-up. The extent of lateralization of the first metatarsal (FM) head and plantar displacement of the FM head were assessed. Metrics like the duration of the osteotomy+lateralization+K wire fixation, tourniquet time, and fluoroscopy usage were recorded. All assessments were conducted independently and blindly. Patients remained unaware of their group allocation and the randomization procedure. RESULTS: Both groups showed no statistical differences in gender, operated side, age, or follow-up duration. For instance, in the 3DS group (n=15, age: 44.6 ± 9.6 years, male/female: 14/1, side right/left: 11/4, follow-up duration: 29.4 ± 8.7 months) and TS group (n=15, age: 44.8 ± 9.6 years, male/female: 13/2, side right/left: 10/5, follow-up duration: 28.8 ± 8.4 months). The 3DS group, however, showed better metrics with osteotomy+lateralization+K wire fixation, tourniquet duration, and number of fluoroscopies at 12.4 ± 1.2 minutes, 41.5 ± 3.8 minutes, 2.5 ± 0.6 times. In contrast, the TS group recorded 17.1 ± 1.5 minutes, 50.8 ± 3.4 minutes, and 3.3 ± 0.8 times, respectively (P <.001 for all). The 3DS group also achieved a more significant restoration of the IM angle (P < .001). Postsurgery, the 3DS group demonstrated superior outcomes in FM head lateralization, FM shortening, and plantar displacement (P <.001, P <.001 and P = .006, respectively, for all metrics). Only 1 patient in the 3DS group experienced a pin-tract infection, which was treated with wound care and oral antibiotics. CONCLUSION: Simulating surgery on a 3D model and using it as a guide significantly enhances surgical outcomes. Benefits include reduced operation time, tourniquet duration, decreased fluoroscopy usage, and improved first-ray alignment. The 3DS method also ensures better lateralization of the first metatarsal head and correction of the IM. Although 3D model-assisted HV chevron osteotomy surgery provides ideal deformity correction, it does not significantly affect postoperative functional outcomes. LEVEL OF EVIDENCE: Level I, Therapeutic Study. Cite this article as:Süer O, Özer MA, Govsa F, Öztürk AM, Aktuglu SK. Impact of surgery simulation using a 3-dimensional printed model on outcomes of hallux valgus surgery with distal chevron osteotomy: A randomized controlled trial. Acta Orthop Traumatol Turc., 2024;58(2):95-101.

Effects of high tibial osteotomy on the coronal, sagittal, and axial alignments of the ankle joint.

BACKGROUND: No comprehensive study has been conducted on the effects of high tibial osteotomy (HTO) on the coronal, sagittal, and axial alignments of the ankle joint. Therefore, this study aimed to investigate the multiplane changes in the ankle joint following HTO using the EOS biplanar X-ray imaging system. METHODS: The medical records of 43 patients who underwent HTO for the treatment of medial knee osteoarthritis were retrospectively reviewed. Preoperative and postoperative EOS images and lower-extremity scanograms were evaluated; the correlations between the outcomes were evaluated. RESULTS: After HTO, the ankle joint axis point on the weight-bearing line showed significant lateralization (p < .001). The knee lateral ankle surface angle increased significantly in the sagittal alignment (p < .001). The distal tibia showed a significant internal rotation in the axial plane (p = .022). Tibial rotation showed no significant relationship with the other parameters. CONCLUSIONS: HTO induced lateralization of the ankle joint axis (coronal), increased the posterior tibial slope (sagittal), and caused the internal rotation of the distal tibia (axial). Axial changes in the distal tibia showed no significant relationship with other coronal and sagittal parameters of the ankle joint. We suggest that surgeons should consider, during HTO, that the ankle joint axis shifts laterally and distal tibia has tendency to rotate internally after HTO.

Clinical and radiological outcomes of ankle joint preserving surgical reconstruction for talar neck non-unions-A series of 8 cases.

BACKGROUND: Talar neck non-unions result in significant hindfoot deformity and morbidity and are infrequently reported in the literature. The optimal surgical management for this condition is evolving, with various authors reporting the results of open reduction and internal fixation (ORIF) with bone grafting (BG), ankle fusion and modified Blair fusion. We performed this study to report the clinical and radiological outcomes of a cohort of talar neck non-unions managed by ankle joint preserving reconstruction. METHODS: This was an ambispective study which included 8 patients (7 male and 1 female) with talar neck non-unions. All patients underwent ORIF+BG through dual approaches. Additional medial malleolar osteotomy was done in 2 cases, and calcaneofibular split approach to the subtalar joint in 3. Adjunct subtalar fusion was done in 5 cases. Clinical and radiological evaluation was performed pre- and post-operatively. Functional outcomes were assessed by the Manchester Oxford Foot Questionnaire (MOxFQ). RESULTS: The mean age of patients 32.3 ± 13.1 years. The mean surgical delay was 4.1 ± 1.7 months. As per Zwipp and Rammelt classification of post-traumatic talar deformities, 5 cases were classified as Type 3, 2 were Type 4, and 1 was Type 1. Union was achieved in 7 cases at a mean of 3.4 ± 1.3 months. One case had progressive collapse, which was managed by pantalar arthrodesis. All 3 cases where subtalar fusion was not performed primarily demonstrated subtalar arthrosis, but none required a secondary subtalar fusion. The MOxFQ score from 61.1 ± 10.1 to 41 ± 14.1 postoperatively (P = 0.005). The mean follow-up was 14.6 ± 6.8 months. CONCLUSION: ORIF+BG of the talar neck, with or without subtalar fusion has the potential to achieve solid union, correct the hindfoot deformity and improve functional outcomes. However, larger studies with longer follow-up are needed to evaluate the long-term efficacy of this procedure.

Less risk of patellofemoral degeneration without significant clinical and survivorship difference for distal tibial tuberosity high tibial osteotomy compared to biplanar high tibial osteotomy over a mid-term follow-up.

PURPOSE: This study aims to compare the mid-term radiographic, clinical results and survivorship between distal tibial tuberosity high tibial osteotomy (DTT-HTO) and conventional biplanar medial open-wedge high tibial osteotomy (cOW-HTO). METHODS: The weight-bearing line ratio (WBL%) and medial proximal tibial angle (MPTA) were evaluated using a standing anteroposterior view of lower extremity. The posterior tibial slope (PTS), Caton-Deschamps index (CDI), tilting angle (TT) and lateral shift ratio (LSR) were evaluated using the lateral views and Merchant views. The Knee Society (KS) knee and function score, Lysholm score, and Anterior Knee Pain Scale (Kujala score) were were used to evaluate the functional outcomes. All parameters were evaluated preoperatively and at the final follow-up. The postoperative complications and survivorship for both groups were also evaluated during the follow-up period. RESULTS: The WBL% and MPTA exhibited no significant differences between the two groups preoperatively and at the final follow-up. The postoperative CDI and TT in the cOW group decreased significantly compared with the DTT group (p = .037 and .041, respectively). The PF grade showed a significant increase after DTT-HTO and cOW-HTO (p = .036 and <0.001, respectively). Furthermore, the postoperative PF grade of cOW group was significantly higher than that of DTT group (p = .039). The KS knee and function score, Lysholm score, and Kujala score for both groups improved similarly at the final follow-up. The survivorship free of revision was 92.7 % in the DTT group and 94.2% in the OW group. CONCLUSIONS: Despite observing a lower risk of PF joint progression in DTT-HTO compared to cOW-HTO, the clinical outcomes and survivorship after DTT-HTO and cOWHTO were comparable over a mid-term follow-up.

Intelligent electromagnetic navigation system for robot-assisted intraoral osteotomy in mandibular tumor resection: a model experiment.

Background: Mandibular tumor surgery necessitates precise osteotomies based on tumor boundaries; however, conventional osteotomies often lack accuracy in predicting osteotomy positions and planes, potentially leading to excessive resection of normal bone tissues or residual tumors, thus compromising postoperative quality of life and clinical outcomes. Robotic-assisted surgery (RAS) augmented with artificial intelligence (AI) offers precise localization capabilities, aiding surgeons in achieving accurate osteotomy positioning. This study aimed to evaluate the feasibility and accuracy of a robotic magnetic navigation system for positioning and osteotomy in an intraoral surgical trial of a mandibular tumor model. Methods: Patient computed tomography (CT) imaging data of mandibular chin and body tumors were utilized to create 3D printed models, serving as study subjects for mandibular tumor resection. Ten pairs of models were printed for the experimental and control groups. The experimental group (EG) underwent osteotomy using a robot-assisted surgical navigation system, performing osteotomy under robotic navigation following alignment based on preoperative design. The control group (CG) underwent traditional surgery, estimating osteotomy position empirically according to preoperative design. Postoperative CT scans were conducted on both models, and actual postoperative results were compared to preoperative design. Osteotomy accuracy was evaluated by positional and angular errors between preoperatively designed and actual osteotomy planes. Results: For ten randomly selected spots on the left and right sides, respectively, the EG group had mean distance errors of 0.338 mm and 0.941 mm. These values were obtained from the EG group. In the EG group, on the left side, the mean angular errors were 14.741 degrees, while on the right side, they were 13.021 degrees. For the 10 randomly selected spots on the left and right sides, respectively, the CG had mean distance errors of 1.776 mm and 2.320 mm. This is in contrast to the results obtained by the EG. It was determined that the left side had a mean angle error of 16.841 degrees, while the right side had an error of 18.416 degrees in the CG group. The above results indicated significantly lower point errors of bilateral osteotomy planes in the experimental group compared to the control group. Conclusion: This study demonstrates the feasibility of electromagnetic navigation robot-assisted intraoral osteotomy for mandibular tumors and suggests that this approach can enhance the precision of clinical surgery.

[Analysis of the therapeutic effect of trochanteric flip osteotomy combined with Kocher-Langenbeck approach for high acetabular posterior wall fracture].

OBJECTIVE: Evaluation of the clinical efficacy of f trochanteric flip osteotomy combined with Kocher-Langenbeck approach for high acetabular posterior wall fracture. METHODS: Between January 2020 and December 2022, 20 patients with high acetabular posterior wall fractures were retrospectively analyzed, including 12 males and 8 females, aged 18 to 75 years old. They were divided into two groups according to the different surgical methods. Ten patients were treated with greater trochanteric osteotomy combined with Kocher-Langenbeck approach as the observation group, including 5 males and 5 females, aged from 18 to 75 years old. Ten patients were treated with Kocher-Langenbeck approach alone as the control group, including 7 males and 3 females, aged from 18 to 71 years old. Matta reduction criteria were used to evaluate the reduction quality of the two groups, and Harris score was used to compare the hip function of the two groups at the latest follow-up. The operation time, blood loss and postoperative complications of the two groups were analyzed. RESULTS: All patients were followed up for 10 to 24 months. According to the Matta fracture reduction quality evaluation criteria, the observation group achieved anatomical reduction in 6 cases, satisfactory reduction in 3 cases, and unsatisfactory reduction in 1 case, while the control group only achieved anatomical reduction in 3 cases, satisfactory reduction in 3 cases, and unsatisfactory reduction in 4 cases. At the final follow-up, the Harris hip score ranged from 71.4 to 96.6 in the observation group and 65.3 to 94.5 in the control group. According to the results of Harris score. The hip joint function of the observation group was excellent in 6 cases, good in 3 cases, and fair in 1 case. The hip joint function of the control group was excellent in 2 cases, good in 3 cases, fair in 3 cases, and poor in 2 cases. In the observation group, the intraoperative blood loss ranged from 300 to 700 ml, and the operation duration ranged from 120 to 180 min;in the control group, the intraoperative blood loss ranged from 300 to 650 ml, and the operation duration ranged from 100 to 180 min. Complications in the observation group included 1 case of traumatic arthritis and 1 case of heterotopic ossification, while complications in the control group included 3 cases of traumatic arthritis, 3 cases of heterotopic ossification and 1 case of hip abduction weakness. CONCLUSION: Trochanteric flip osteotomy combined with the Kocher-Langenbeck approach significantly improved anatomical fracture reduction rates, enhanced excellent and good hip joint function outcomes, and reduced surgical complication incidence compared to the Kocher-Langenbeck approach alone. Clinical application of this combined approach is promising, although larger studies are needed for further validation.

[Ilizarov technique combined with center of rotation dome-shaped osteotomy for the treatment of juvenile distal femoral valgus deformity].

OBJECTIVE: To investigate the effect of Ilizarov technique combined with rotational center dome-shaped osteotomy in the treatment of juvenile distal femoral valgus deformity. METHODS: A retrospective study was conducted to analyze the clinical data of 11 patients with valgus deformity of the distal femur who had been admitted and followed up completely from January 2016 to October 2020. There were 7 males and 4 females. The 6 patients were on the right side and 5 patients were on the left side. The age ranged from 10 to 14 years old. The center of roration of angulation(CORA) was identified at the distal femur deformity, and dome-shaped osteotomy was performed with the CORA as the midpoint. The annular external fixator was installed according to the needle threading principle of Ilizarov external fixation, and the distal femur was cut off. The valgus deformity under visual inspection of the distal femur was corrected immediately, and the external fixator was fixed and maintained. The residual deformity and shortening were corrected according to the force line and length of the lower limbs suggested by the weight-bearing full-length anteroposterior and lateral X-rays of both lower limbs. RESULTS: All 11 patients were followed up for 13 to 25 months. The time of wearing external fixator was 12 to 17 weeks. In the last follow-up, both lower limbs were measured by the weight-bearing full-length anteroposterior and lateral X-rays, and the length of both lower limbs of 11 patients were equal, and the deformities were corrected. The score of hospital for special surgery (HSS) was used to evaluate the knee function, all of which were excellent. CONCLUSION: The Ilizarov technique was applied in the treatment of distal femoral valgus deformity in adolescents using a rotating central dome-shaped osteotomy. Visual femoral valgus deformity was corrected immediately during the operation. After the operation, residual deformities and shortening were dynamically adjusted and corrected according to the force line and shortening degree of lower extremities indicated by the weight-bearing anteroposterior and lateral radiographs of both lower limbs, with minimal damage and fast recovery.

Triple osteotomy of first ray for severe hallux valgus surgery: Long-term follow-up.

This study aimed to present a retrospective case series of the long-term results of severe hallux valgus treated with triple osteotomy of the first ray. Patients with severe hallux valgus treated with a basal medial opening wedge, distal chevron, and Akin osteotomy from 2008 to 2012 were identified from the electronic medical records. Radiological outcomes such as pre- and postoperative hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle) were collected. Patients were contacted to complete foot and ankle outcome score (FAOS). Nineteen patients underwent 20 triple osteotomies of the first ray. Clinical data and FAOS were collected at a median follow-up of 10.2 years. There was a significant improvement in hallux valgus angle, intermetatarsal angle, and distal metatarsal articular angle from pre- to postoperatively, both at initial and final radiographic follow-up (P < .0001). Patient satisfaction was high, with median FAOS of 94.5 (symptoms), 97 (function/activities of daily living), 100 (function/sport and recreation), 85 (foot and ankle-related quality of life), and 100 (pain). Triple first-ray osteotomy is a successful mode of treatment for severe hallux valgus, with high levels of patient satisfaction and excellent improvement in radiological parameters measured over long-term follow-up.

Results of medial patellofemoral ligament reconstruction with and without tibial tubercle osteotomy in patellar instability: a systematic review and single-arm meta-analysis.

PURPOSE: To confirm which method provides lower rate of recurrent instability and superior clinical outcomes. METHOD: We searched PubMed, Embase and Web of Science for the trials involving one intervention or both for patellar instability: medial patellofemoral ligament reconstruction (MPFLR) with and without tibial tubercle osteotomy (TTO). The postoperative Kujala score, Lysholm score, Tegner scores and the rate of recurrent instability (dislocation or subluxation) were analyzed as the primary clinical outcome parameters in a random or fixed effects meta-analysis. RESULTS: In total, 43 articles met inclusion criteria after full-text review. A total of 2046 patients were analyzed. The overall mean age was 20.3 years (range, 9.5-60.0 years), with a mean follow-up time of 3.2 years (range, 1-8 years). The mean Kujala scores in MPFLR and MPFLR + TTO were 89.04 and 84.44, respectively. There was significant difference in Kujala scores between MPFLR and MPFLR + TTO (MD = 4.60, 95%CI: 1.07-8.13; P = 0.01). The mean Lysholm scores in MPFLR and MPFLR + TTO were 90.59 and 88.14, respectively. There was no significant difference in Lysholm scores between MPFLR and MPFLR + TTO (MD = 2.45, 95%CI: -3.20-8.10; P = 0.40). The mean Tegner scores in MPFLR and MPFLR + TTO were 5.30 and 4.88, respectively. There was no significant difference in Tegner scores between MPFLR and MPFLR + TTO (MD = 0.42, 95%CI: -0.39-1.23; P = 0.31). At final follow-up, the rates of recurrent instability in MPFLR and MPFLR + TTO were 3% and 4%, respectively. There was no significant difference in the rates between MPFLR and MPFLR + TTO (OR = 0.99, 95%CI: 0.96-1.02; P = 0.4848). CONCLUSION: MPFLR and MPFLR + TTO are effective and reliable treatments in the setting of patellofemoral instability. MPFLR seems to show a better performance in functional outcomes than MPFLR + TTO. Moreover, their rates of recurrent instability are very low, and no significant difference exists.

[Effectiveness of minimally invasive treatment of hallux valgus with small incision external articular osteotomy].

Objective: To compare the effectiveness of small incision external articular minimally invasive osteotomy and traditional Chevron osteotomy in the treatment of hallux valgus. Methods: A retrospective analysis was conducted on the clinical data of 58 patients (58 feet) with hallux valgus who were admitted between April 2019 and June 2022 and met the selection criteria. Among them, 28 cases were treated with small incision external articular minimally invasive osteotomy (minimally invasive group), and 30 cases were treated with traditional Chevron osteotomy (traditional group). There was no significant difference in baseline data such as age, gender, disease duration, Mann classification, and preoperative inter metatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), forefoot width, tibial sesamoid position (TSP) score, American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score, visual analogue scale (VAS) score, psychological score (SF-12 MCS score) and physiological score (SF-12 PCS score) of short-form 12 health survey scale, and range of motion (ROM) of metatarsophalangeal joint between the two groups ( P>0.05). The incision length, operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, weight-bearing walking time, fracture healing time, and incidence of complications were recorded and compared between the two groups; as well as the changes of imaging indexes at last follow-up, and the clinical function score and ROM of metatarsophalangeal joint before operation, at 6 weeks after operation, and at last follow-up. Results: All patients were followed up 11-31 months, with an average of 22 months. The incision length and intraoperative blood loss in the minimally invasive group were significantly less than those in the traditional group ( P<0.05), and the intraoperative fluoroscopy frequency and operation time in the minimally invasive group were significantly more than those in the traditional group ( P<0.05); but no significant difference was found in weight-bearing walking time and fracture healing time between the two groups ( P>0.05). There was 1 case of skin injury in the minimally invasive group and 3 cases of poor incision healing in the traditional group; all patients had good healing at the osteotomy site, and no complication such as infection, nerve injury, or metatarsal head necrosis occurred. At last follow-up, the imaging indexes of the two groups significantly improved when compared with those before operation ( P<0.05). The changes of DMAA and TSP score in the minimally invasive group were significantly better than those in the traditional group ( P<0.05), and there was no significant difference in the changes of IMA, HVA, and forefoot width between the two groups ( P>0.05). The clinical scores and ROM of metatarsophalangeal joint significantly improved in the two groups at 6 weeks after operation and at last follow-up when compared with preoperative ones ( P<0.05), and the indicators in the minimally invasive group were significantly better than those in the traditional group ( P<0.05). Conclusion: Compared with traditional Chevron osteotomy, small incision external articular minimally invasive osteotomy can effectively improve HVA, IMA, and forefoot width, correct foot deformities, and has less trauma. It can better correct the first metatarsal pronation deformity and restore the anatomical position of the sesamoid bone, resulting in better effectiveness.

Cutibacterium acnes Infection as a Cause of Nonunion After Ulnar-Shortening Osteotomy.

Ulnar-shortening osteotomy is a reliable solution to treat ulnar impaction syndrome, but it has a significant rate of nonunion as a known complication. Generally nonunion after the procedure is attributed to noninfectious causes. When infections happen, they follow the microbiological trends of nonunions elsewhere in the body. We present a case of ulnar-shortening osteotomy using an oblique-cut osteotomy system that resulted in septic nonunion. At the time of revision surgery, Cutibacterium acnes and Staphylococcus hominis were isolated from the osteotomy site. The patient was successfully treated using intravenous antibiotics and the two-stage Masquelet technique and eventually went on to bony union. As C acnes is rarely encountered in this context, this report highlights the need to consider all possible pathogens in the workup of a potentially septic nonunion. Surgeons should consider bacteria such as C acnes that require prolonged incubation for isolation from cultures, which may not be part of many institutions' usual protocol. [Orthopedics. 2024;47(4):e211-e213.].

Post-traumatic Coracoclavicular Ligament Ossification: A Case Report and Surgical Technique.

CASE: A patient presented with complete coracoclavicular ligament ossification after an unnoticed acromioclavicular joint Rockwood Type IV dislocation. He had full passive range of motion in the glenohumeral joint but was disabled by a loss of both active (80°) and passive (90°) abduction due to insufficient passive scapulo-thoracic motion. He was treated with an arthroscopic osteotomy of the coracoclavicular ligament ossification. CONCLUSION: One year after the surgery, active abduction was improved by 45° (80°-125°) with no recurrence of the ossification on the radiographs. Arthroscopic osteotomy of complete coracoclavicular ligament ossification seems effective in restoring abduction in these patients. LEVEL OF EVIDENCE: IV.

Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (> 10 cm) caused by osteomyelitis and aseptic non-union.

BACKGROUND: Clinical repair of critical-sized bone defects (CBDs) in the tibial diaphysis presents numerous challenges, including inadequate soft tissue coverage, limited blood supply, high load-bearing demands, and potential deformities. This study aimed to investigate the clinical feasibility and efficacy of employing 3D-printed prostheses for repairing CBDs exceeding 10 cm in the tibial diaphysis. METHODS: This retrospective study included 14 patients (11 males and 3 females) with an average age of 46.0 years. The etiologies of CBDs comprised chronic osteomyelitis (10 cases) and aseptic non-union (4 cases), with an average defect length of 16.9 cm. All patients underwent a two-stage surgical approach: (1) debridement, osteotomy, and cement spacer implantation; and (2) insertion of 3D-printed prostheses. The interval between the two stages ranged from 8 to 12 weeks, during which the 3D-printed prostheses and induced membranes were meticulously prepared. Subsequent to surgery, patients engaged in weight-bearing and functional exercises under specialized supervision. Follow-up assessments, including gross observation, imaging examinations, and administration of the Lower Extremity Functional Scale (LEFS), were conducted at 3, 6, and 12 months postoperatively, followed by annual evaluations thereafter. RESULTS: The mean postoperative follow-up duration was 28.4 months, with an average waiting period between prosthesis implantation and weight-bearing of 10.4 days. At the latest follow-up, all patients demonstrated autonomous ambulation without assistance, and their LEFS scores exhibited a significant improvement compared to preoperative values (30.7 vs. 53.1, P < 0.001). Imaging assessments revealed progressive bone regeneration at the defect site, with new bone formation extending along the prosthesis. Complications included interlocking screw breakage in two patients, interlocking screw loosening in one patient, and nail breakage in another. CONCLUSIONS: Utilization of 3D-printed prostheses facilitates prompt restoration of CBDs in the tibial diaphysis, enabling early initiation of weight-bearing activities and recovery of ambulatory function. This efficacious surgical approach holds promise for practical application.

Infiltration of local anesthetic in the Interspace between the popliteal artery and capsule of the posterior knee "IPACK block" versus adductor canal block "ACB" for pain relief after open wedge high tibial osteotomy: a randomized clinical trial.

BACKGROUND: A high tibial osteotomy is usually associated with severe postoperative pain. Both adductor canal block (ACB) and interspace between the popliteal artery and capsule of the posterior knee (IPACK) have been described as effective block techniques for providing analgesia after knee surgeries, with few comparisons in wedge osteotomy cases. We aim to compare the postoperative analgesic profile of the previously mentioned two block techniques in patients undergoing tibial osteotomies. METHODS: Sixty patients were enrolled in this randomized prospective trial (30 received IPACK and 30 received ACB). Both blocks were installed before the spinal anesthesia after infiltration of 2 mL lidocaine 2%. Twenty mL of bupivacaine 0.25% mixed with dexamethasone as anesthetic adjuvant were used for both blocks. The postoperative analgesic profiles were compared between the two groups. RESULTS: Postoperative pain scores were lower in the IPACK group, and that decrease was evident throughout the first 10 hours postoperatively. Additionally, the duration of analgesia was much prolonged with the same block (487.50±82.39 vs. 301.93±92.06 minutes with ACB). There was a significant decline in postoperative analgesic consumption (1.27±0.45 vs. 1.8±0.61 gm, P=0.000), and a significant increase in the ambulation distance (19.10±0.60 vs. 17.73±0.45 m, P=0.000) with a significant decline in the duration of hospitalization (43.27±7.61 vs. 54±8.35 hours) in the IPACK group compared to the ACB group. CONCLUSIONS: IPACK is a superior block technique compared to ACB in patients undergoing high tibial osteotomy regarding postoperative analgesia, ambulation distance, and patient satisfaction with little rate of adverse events in both groups.

Biomechanical comparison of reverse offset-L osteotomy and chevron osteotomy in cadaveric hallux valgus surgery.

OBJECTIVE: Chevron osteotomy offers near-excellent clinical results and adequate stability at lower shift percentages, among the techniques used to correct hallux valgus deformity. This cadaveric study aimed to compare the Chevron osteotomy with the reverse offset-L osteotomy, which may provide a greater surface area and a more stable geometry to withstand higher cantilever forces at higher shift percentages. METHODS: Metatarsal bones obtained from 20 human cadavers with similar bone quality were divided into two groups: Chevron osteotomy was applied to the 1st group and reverse offset-L osteotomy was applied to the 2nd group. The load-to-failure, displacement in the y-axis, and total displacement values of both groups were compared statistically. Furthermore, bone densities were compared between the groups with computed tomography imaging. RESULTS: When outliers in both groups were excluded, a statistically significant difference was found in favor of reverse offset-L (143 ± 42 vs. 204 ± 51.2 N, p = 0.02) in terms of failure load. The groups were similar in terms of displacement on the y-axis and total displacement values. Bone densities were similar. CONCLUSION: The reverse offset-L osteotomy has been shown to withstand greater loads before failure compared to the standard Chevron osteotomy. This significant difference in load-to-failure may enable reverse offset-L to provide reliable stability in osteotomies performed in advanced HV cases requiring higher shifts.

Factors associated with joint survival after transposition osteotomy of the acetabulum in patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia.

Aims: The aim of this study was to determine the clinical outcomes and factors contributing to failure of transposition osteotomy of the acetabulum (TOA), a type of spherical periacetabular osteotomy, for advanced osteoarthritis secondary to hip dysplasia. Methods: We reviewed patients with Tönnis grade 2 osteoarthritis secondary to hip dysplasia who underwent TOA between November 1998 and December 2019. Patient demographic details, osteotomy-related complications, and the modified Harris Hip Score (mHHS) were obtained via medical notes review. Radiological indicators of hip dysplasia were assessed using preoperative and postoperative radiographs. The cumulative probability of TOA failure (progression to Tönnis grade 3 or conversion to total hip arthroplasty) was estimated using the Kaplan-Meier product-limited method. A multivariate Cox proportional hazards model was used to identify predictors of failure. Results: This study included 127 patients (137 hips). Median follow-up period was ten years (IQR 6 to 15). The median mHHS improved from 59 (IQR 52 to 70) preoperatively to 90 (IQR 73 to 96) at the latest follow-up (p < 0.001). The survival rate was 90% (95% CI 82 to 95) at ten years, decreasing to 21% (95% CI 7 to 48) at 20 years. Fair joint congruity on preoperative hip abduction radiographs and a decreased postoperative anterior wall index (AWI) were identified as independent risk factors for failure. The survival rate for the 42 hips with good preoperative joint congruity and a postoperative AWI ≥ 0.30 was 100% at ten years, and remained at 83% (95% CI 38 to 98) at 20 years. Conclusion: Although the overall clinical outcomes of TOA in patients with advanced osteoarthritis are suboptimal, favourable results can be achieved in selected cases with good preoperative joint congruity and adequate postoperative anterior acetabular coverage.

Surgical interventions for treating hallux valgus and bunions.

BACKGROUND: Hallux valgus (lateral angulation of the great toe towards the lesser toes, commonly known as bunions) presents in 23% to 35% of the population. This condition leads to poor balance and increases the risk of falling, adding to the difficulty in fitting into shoes and pain. Conservative (non-surgical) interventions treating pain rather than curing deformity are usually first-line treatments. When surgery is indicated, the overall best surgical procedure is an ever-evolving topic of discussion. OBJECTIVES: To assess the benefits and harms of different types of surgery compared with placebo or sham surgery, no treatment, non-surgical treatments and other surgical interventions for adults with hallux valgus. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and trial registries to 20 April 2023. We did not apply any language or publication restrictions. SELECTION CRITERIA: We included randomised controlled trials evaluating surgical interventions for treating hallux valgus compared to placebo surgery or sham surgery, no treatment, non-surgical treatment or other surgical interventions. The major outcomes were pain, function, quality of life, participant global assessment of treatment success, reoperation (treatment failure), adverse events and serious adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and the certainty of evidence using GRADE. MAIN RESULTS: We included 25 studies involving 1597 participants with hallux valgus. All studies included adults and most were women. One study compared surgery (V-shaped osteotomy) with no treatment and with non-surgical treatment. Fifteen studies compared different surgical techniques, including a V-shaped osteotomy (Chevron osteotomy), to other types of osteotomy. Nine studies compared different simple osteotomy techniques to each other or to a mid-shaft Z-shaped osteotomy (Scarf osteotomy). Most trials were susceptible to bias: in particular, selection (80%), performance (88%), detection (96%) and selective reporting (64%) biases. Surgery versus no treatment Surgery may result in a clinically important reduction in pain. At 12 months, mean pain was 39 points (0 to 100 visual analogue scale, 100 = worst pain) in the no treatment group and 21 points in the surgery group (mean difference (MD) -18.00, 95% confidence interval (CI) -26.14 to -9.86; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in function. At 12 months, mean function was 66 points (0 to 100 American Orthopedics Foot and Ankle Scale (AOFAS), 100 = best function) in the no treatment group and 75 points in the surgery group (MD 9.00, 95% CI 5.16 to 12.84; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in little to no difference in quality of life. At 12 months, mean quality of life (0 to 100 on 15-dimension scale, 100 = higher quality of life) was 93 points in both groups (MD 0, 95% CI -2.12 to 2.12; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may result in a slight increase in participant global assessment of treatment success. At 12 months, mean participant global assessment of treatment success was 61 points (0 to 100 visual analogue scale, 100 = completely satisfied) in the no treatment group and 80 points in the surgery group (MD 19.00, 95% CI 8.11 to 29.89; 1 study, 140 participants; low-certainty evidence). Evidence was downgraded for bias due to lack of blinding and imprecision. Surgery may have little effect on reoperation (relative effect was not estimable), adverse events (risk ratio (RR) 8.75, 95% CI 0.48 to 159.53; 1 study, 140 participants; very low-certainty evidence), and serious adverse events (relative effect was not estimable), but we are uncertain. Surgery versus non-surgical treatment Surgery may result in a clinically important reduction in pain; a slight increase in function and participant global assessment of treatment success; and little to no difference in quality of life (1 study, 140 participants; low-certainty evidence). We are uncertain about the effect on reoperation, adverse events and serious adverse events (1 study, 140 participants; very low-certainty evidence). Complex versus simple osteotomies Complex osteotomies probably result in little to no difference in pain compared with simple osteotomies (7 studies, 414 participants; moderate-certainty evidence). Complex osteotomies may increase reoperation (7 studies, 461 participants; low-certainty evidence), and may result in little to no difference in participant global assessment of treatment success (8 studies, 462 participants; low-certainty evidence) and serious adverse events (12 studies; data not pooled; low-certainty evidence). We are uncertain about the effect of complex osteotomies on function and adverse events (very low-certainty evidence). No study reported quality of life. AUTHORS' CONCLUSIONS: There were no trials comparing surgery to placebo or sham. Surgery may result in a clinically important reduction in pain when compared to no treatment or non-surgical treatment. Surgery may also result in a slight increase in function and participant global assessment of treatment success compared to no treatment or non-surgical treatment. There may be little to no difference in quality of life between surgery and no treatment or non-surgical treatment. We are uncertain about the effect of surgery on reoperation (treatment failure), adverse events or serious adverse events, when compared to no treatment or non-surgical treatment. Complex and simple osteotomies demonstrated similar results for pain. Complex osteotomies may increase reoperation (treatment failure) and may result in little to no difference in participant global assessment of treatment success and serious adverse events compared to simple osteotomies. We are uncertain about the effect of complex osteotomies on function, quality of life and adverse events.