Iatrogenic Damage to Neurovascular and Soft Tissue Structures During Lateral Release of Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Techniques.

Lateral release is often an integral step in surgical correction of hallux valgus and can be performed using open or minimally invasive techniques. We investigated whether these techniques cause iatrogenic damage to arteries, nerves, tendons, or joint capsules. In this cadaver study, lateral release was performed on 9 pairs of specimens by a specialized foot surgeon. The specimens were randomly assigned to each group. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Iatrogenic damage to arteries, nerves, tendons, or joint capsules was rare, regardless of the surgical technique used. However, with the minimally invasive technique, the tendon of the extensor hallucis longus muscle and the sensitive terminal branches of the fibular nerve were at risk due to their anatomical proximity to the access portal. The deep transverse metatarsal ligament was potentially at risk if the adductor hallucis muscle was completely detached from the lateral sesamoid. When the deep transverse metatarsal ligament was transected there was risk of damaging the underlying plantar neurovascular structures. Both surgical techniques are safe in terms of the risk of injury to neighboring neurovascular and soft tissue structures.

Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach.

PURPOSE: To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus. METHODS: Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors. RESULTS: Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision. CONCLUSION: A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.

Comparison of Ligament-Repair Techniques for the Syndesmosis: A Simulated Cadaveric Weight-Bearing Computed Tomography Analysis.

Although the literature describes a variety of reconstructive techniques for the syndesmosis, only few studies offer comparative data. Therefore, the authors compared 2 different ligament repair techniques for the syndesmosis. Sixteen paired fresh-frozen human cadaveric lower limbs were embedded in polymethyl methacrylate mid-calf and placed in a custom-made weightbearing simulation frame. Computed tomography scans of each limb were obtained in a simulated foot-flat loading (75N) and single-leg stance (700N) in 5 different foot positions (previously reported data). One of each pair was then reconstructed via 1 of 2 methods: a free medial Achilles tendon autograft or a long peroneal tendon ligament repair. The specimens were rescanned, compared with their respective intact states and directly with each other. Measurements of fibular diastasis, rotation, anteroposterior translation, mediolateral translation, and fibular shortening were performed on the axial cuts of the computed tomography scans, 1 cm proximal to the roof of the plafond. There was no significant difference in fibular positioning with direct comparison of the reconstructions. Comparisons with their respective intact states, however, showed differences in their abilities to control reduction, most notably in the externally rotated and dorsiflexed positions of the foot. Neither reconstruction was clearly superior in restoring physiologic conditions. Only with a comparison of each technique to its respective intact state were differences between the techniques revealed, a benefit of this particular testing method.

Computed Tomography Analysis for Quantification of Displacement of the Distal Fibula in Different Foot Positions With Weightbearing and Sequentially Increased Instability: An Anatomic Cadaveric Study on Syndesmosis.

Syndesmotic injuries are quite common, but accurate diagnosis and treatment can be difficult, in part because of individual anatomic variation and complex movements of the fibula in the incisura. The current cadaveric study was designed to investigate changes in the position of the fibula in the incisura during simulated weightbearing in different foot positions and with sequential sectioning of syndesmotic and deltoid ligaments. Sixteen paired, fresh-frozen cadaveric limbs were embedded in polymethylmethacrylate mid-calf and placed in a weightbearing simulation frame. Computed tomography scans were obtained while the legs were in a simulated foot-flat position (75 N) and single-leg stance (700 N) in 5 foot positions: neutral, 15° external rotation, 15° internal rotation, 20° dorsiflexion, and 20° plantar flexion. The anterior-inferior tibiofibular ligament, posterior tibiofibular ligament complex, deltoid, and interosseous membranes were sectioned sequentially and rescanned. Measurements of fibular diastasis, rotation, anterior-posterior and medial-lateral translation, and fibular shortening were performed. The most destructive state resulted in the largest displacement at the syndesmosis. The degree of subluxation in all ligament states was dependent on the foot position. External rotation created statistically significant displacement at all levels of injury. There were no significant differences between sides of the same donor. Our data demonstrate the importance of foot position in reduction at the syndesmosis under weightbearing. The current ex vivo model could be used to evaluate other aspects of this injury or the value of reconstructive techniques in the future.

Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation.

OBJECTIVES: To reduce mechanical complications after osteosynthesis of femoral neck fractures, improved fixation techniques have been developed including blade or screw-anchor devices. This biomechanical study compares different fixation systems used for treatment of unstable femoral neck fractures with evaluation of failure mode, load to failure, stiffness, femoral head rotation, femoral neck shortening and femoral head migration. METHODS: Standardized Pauwels type 3 fractures (AO/OTA 31-B2) with comminution were created in 18 biomechanical sawbones using a custom-made sawguide. Fractures were stabilized using either SHS-Screw, SHS-Blade or Rotationally Stable Screw-Anchor (RoSA). Femurs were positioned in 25 degrees adduction and ten degrees posterior flexion and were cyclically loaded with an axial sinusoidal loading pattern of 0.5 Hz, starting with 300 N, with an increase by 300 N every 2000 cycles until bone-implant failure occurred. RESULTS: Mean failure load for the Screw-Anchor fixation (RoSA) was 5100 N (IQR 750 N), 3900 N (IQR 75 N) for SHS-Blade and 3000 N (IQR 675 N; p = 0.002) for SHS-Screw. For SHS-Screw and SHS-Blade we observed fracture displacement with consecutive fracture collapse as the main reason for failure, whereas RoSA mainly showed a cut-out under high loadings. Mean stiffness at 1800 N was 826 (IQR 431) N/mm for SHS-Screw, 1328 (IQR 441) N/mm for SHS-Blade and 1953 (IQR 617) N/mm for RoSA (p = 0.003). With a load of 1800 N (SHS-Screw 12° vs. SHS-Blade 7° vs. RoSA 2°; p = 0.003) and with 2700 N (24° vs. 15° vs. 3°; p = 0.002) the RoSA implants demonstrated a higher rotational stability and had the lowest femoral neck shortening (p = 0.002), compared with the SHS groups. At the 2700 N load point, RoSA systems showed a lower axial (p = 0.019) and cranial (p = 0.031) femoral head migration compared to the SHS-Screw. CONCLUSIONS: In our study, the new Screw-Anchor fixation (RoSA) was superior to the comparable SHS implants regarding rotational stability and femoral neck shortening. Failure load, stiffness, femoral head migration, and resistance to fracture displacement were in RoSA implants higher than in SHS-Screws, but without significance in comparison to SHS-Blades.

Soft tissue micro-circulation in the healthy hindfoot: a cross-sectional study with focus on lateral surgical approaches to the calcaneus.

PURPOSE: Open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis represents the current gold standard in calcaneal fracture treatment, but it is associated with a wound complication rate of up to 30%. Literature suggests that micro-circulation is one of the key factors for sufficient wound healing. The aim of this study was to evaluate soft tissue micro-circulation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in non-trauma situations, with special attention to surgical approaches. METHODS: Micro-circulation of the lateral hindfoot of 125 participants was non-invasively measured at 2 and 8 mm depths, utilizing a Micro-Lightguide O2C® spectrophotometer. Blood flow (BF [AU]) and oxygen saturation (SO2 [%]) of ten measurement points (MPs) were documented. Demographic factors (age, gender, body mass index [BMI], systolic/diastolic blood pressure, smoking, and pack-years) and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach, and a self-modified extended lateral approach) were analyzed. RESULTS: The SO2 assessments at 2- and 8-mm depths revealed higher values in males (p = 0.043; p = 0.025). There was a correlation between higher age and lower 2 mm BF (p = 0.044). Smoking history and number of pack-years did not predict micro-circulation. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach (p < 0.001). The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters (SO2 (2 mm), p < 0.001; SO2 (8 mm), p = 0.001; BF (2 mm), p < 0.001; BF (8 mm), p < 0.001), compared to the surrounding area. CONCLUSIONS: In non-trauma situations, young males were associated with better micro-circulatory supply of the lateral hindfoot. There was a trend for higher blood flow in regions of the Palmer and Ollier approach. The distal calcaneal tuberosity was clearly superior in all micro-circulatory parameters when compared to the surrounding area.

Effects of low-intensity pulsed ultrasound on soft tissue micro-circulation in the foot.

PURPOSE: Low-intensity pulsed ultrasound (LIPUS) has been shown to accelerate bone healing and is considered to increase blood flow. The aim of this study was to assess changes in micro-circulation of the foots' soft tissue in response to LIPUS intervention. We hypothesised improved micro-circulation in response to LIPUS. METHODS: Micro-circulation was assessed in 2 mm and 8 mm-deep skin of 50 healthy volunteers using non-invasive laser-doppler spectrophotometry (O2C-device). Measurements were performed before LIPUS-intervention (pre), directly after intervention (post) and 20, 40 and 60 minutes after LIPUS. RESULTS: All parameter of micro-circulation increased directly after LIPUS intervention at 8 mm depth. Participants with a low pre-intervention flow showed the largest changes (p < 0.001) with an increased post-flow of 38%. SO2 levels increased significantly after intervention (p = 0.045) and decreased after 60 minutes in comparison to pre-intervention status. rHb levels after 60 min were significantly higher in comparison to pre-intervention levels. CONCLUSION: In healthy volunteers, low-intensity pulsed ultrasound led to significant short-term changes in microcirculation of the foot. Younger subjects with a low pre-flow level and smokers showed a higher potential to increase blood flow after LIPUS.

[Fractures of the ankle joint in elderly patients]. / Frakturen des oberen Sprunggelenks beim älteren Patienten.

The number of ankle fractures in elderly patients is increasing. The aim of treatment of ankle fractures in the elderly is to guarantee a possible unlimited autonomy and quality of life for patients. This is achieved by minimization of the complications and impairments after ankle joint fractures. Decisive for the further course is the initial treatment. The results are essentially determined by the soft tissue management, reduction and stable osteosynthesis; however, an orthogeriatric co-management with the implementation of treatment paths and standard operating procedures is recommended. The advantages of an interdisciplinary cooperation of trauma surgeons and geriatricians are obvious in this situation.

Influence of tibialis posterior muscle activation on foot anatomy under axial loading: A biomechanical CT human cadaveric study.

BACKGROUND: Collapse of the medial longitudinal arch and subluxation of the subtalar joint are common occurrences in adult flatfoot deformity. Controversy exists about the role of the tibialis posterior (TP) tendon as first and/or essential lesion. Subtle changes in the foot configuration can occur under weight bearing. PURPOSE: This human cadaveric study is designed to investigate the effect that isolated actuation of the TP tendon has on the medial longitudinal arch and the hindfoot configuration under simulated weight bearing. METHODS: A radiolucent frame was developed to apply axial loading on cadaveric lower legs during computer tomography (CT) examinations. Eight pairs of fresh-frozen specimens were imaged in neutral position under foot-flat loading (75N) and under single-leg stance weight bearing (700N) without and with addition of 150N pulling force on the TP tendon. Measurements of subtalar joint subluxation, forefoot arch angle and talo-first metatarsal angle were conducted on each set of CT scans. RESULTS: Subtalar subluxation, talo-first metatarsal angle and talo-navicular coverage angle significantly increased under single-leg stance weight bearing, whereas forefoot arch angle significantly decreased. Actuation of the TP tendon under weight bearing did not restore the forefoot arch angle or correct subtalar subluxation and talo-metatarsal angle. CONCLUSION: Significant effect that weight bearing has on the medial longitudinal arch and the subtalar joint configuration is demonstrated in an ex-vivo model. In absence of other medial column derangement, actuation of the TP tendon alone does not seem to reconstitute the integrity of the medial longitudinal arch or correct the hindfoot subluxation under weight bearing. CLINICAL RELEVANCE: The findings of this study together with the developed model for ex-vivo investigation provide a further insight in foot anatomy.

Displaced intra-articular calcaneal fractures: is there a consensus on treatment in Germany?

INTRODUCTION: Open reduction in displaced intra-articular calcaneal fractures entails a high rate of wound healing deficits and infections as well as an uncertain outcome, which leads to remaining ambiguity in treatment preferences. METHODS: Between January and July 2011, we emailed 575 German chairpersons of trauma and/or orthopaedic departments, asking them to complete a 31-question web-based survey regarding three broad domains: fracture classification, surgical treatment algorithms and risk factors for wound healing deficits. RESULTS: The response rate was 47 %. With an incidence of 77 %, open reduction via an extended lateral approach and plate fixation was the main treatment option for displaced intra-articular fractures of the joint-depression-type (Sanders II or III). Percutaneous techniques were only preferred in individual cases, with mainly precarious wound situations (59 %) as well as in patients with a reduced general health condition (ASA 3 and 4; 41 %). The re-operation rate due to infections and wound healing deficits after an extended lateral approach was reported with a percentage of 0-5 % by 88 % of the respondents. Participants stated that especially a poor microcirculation of the foot, disregard of soft tissue conserving techniques, overall condition of the patient, smoking, long time-to-surgery and operation time are the main reasons for wound healing deficits. CONCLUSION: Given the extended lateral approach as the preferred treatment option, we found minimally invasive techniques and primary arthrodesis of the lower ankle joint play a minor role in treating intra-articular calcaneal fractures in Germany. Ninety percent of our respondents stated less than 5 % of patients required re-operations due to infections and wound healing deficits. Level of Evidence Level V, expert opinion.

Is percutaneous suturing superior to open fibrin gluing in acute Achilles tendon rupture?

PURPOSE: Open fibrin gluing is reported to enable anatomical reconstruction with less soft tissue compromise than suture repair. Our main objective was to compare the complication rate, function, pain and disability of the two operative approaches of percutaneous suture using the Paessler technique and open fibrin gluing. METHODS: Sixty-four patients (two centres, retrospective cohort study, 2000-2009) who had undergone acute Achilles tendon repair with either percutaneous suture (n = 27; 44 years) or open fibrin glue (n = 37; 45 years) took part in a follow-up examination after a median of 63 months (range, six to 180). Ankle range of motion, calf and ankle circumferences and return to work and sports activities were evaluated. Isokinetic und sonographic evaluation results were retrieved. RESULTS: Complications were noted in 22 patients (34 %). Delayed wound healing without evidence of surgical site infection was found in three patients in the fibrin group and two patients in the suture group. Postoperative scar tenderness described as pain at the rim of the shoe was significantly more frequent in the suture group (p = 0.03). Re-rupture requiring re-operation occurred in one patient. Transient paresthesia of the heel occurred in 12 patients. No sural nerve lesions were reported. There was no significant difference between groups regarding lower leg circumference, disability, or function. Ultrasound and isokinetic measurements did not reveal a significant difference between the two methods. CONCLUSIONS: The present study suggests that open fibrin gluing is a reasonable alternative to percutaneous repair of acute ruptures of the Achilles tendon and both techniques can yield reliably good results.

First Tarsometatarsal Arthrodesis: An Anatomic Evaluation of Dorsomedial Versus Plantar Plating.

Fusion of the first tarsometatarsal joint is a widely used procedure for the correction of hallux valgus deformity. Although dorsomedial H-shaped plating systems are being increasingly used, fusion can also be achieved by plantar plating. The goal of the present study was to compare these 2 operative techniques based on the anatomic considerations and show the potential pitfalls of both procedures. Six pairs of deep-frozen human lower legs were used in the present cadaveric study. In a randomized manner, either dorsomedial arthrodesis or plantar plating through a medial incision was performed. With regard to arterial injury, the plantar technique resulted in fewer lesions (plantar, 4 injuries [66.7%] to the terminal branches of the first digital branch of the medial plantar artery; dorsomedial, 3 injuries [50%] to the main trunks of the plantar metatarsal arteries and the first dorsal metatarsal artery). With respect to injury to the veins, the plantar procedure affected significantly fewer high-caliber subcutaneous trunk veins. The nerves coursing through the operative field, such as the saphenous and superficial fibular nerves, were compromised more often by the dorsal approach. Neither the plantar plating nor the dorsomedial plating technique was associated with injury to the insertion of the tibialis anterior muscle. Both studied techniques are safe, well-established procedures. Arthrodesis with plantar plating, however, offers additional advantages and is a reliable tool in the foot and ankle surgeon's repertoire.

Lateral soft-tissue release through a medial incision: Anatomic comparison of two techniques.

BACKGROUND: The distal soft tissue procedure is an integral part of hallux valgus surgery, providing soft tissue balance and alignment restoration of the first metatarsophalangeal joint. Various approaches have been established to this end. For techniques that do not include a separate dorsal incision, lateral release may be achieved via a transarticular approach or via a medial incision and a dorsal flap over the first metatarsal. Compared to the double-incision technique, these techniques are not only cosmetically superior and thus meet the demands of most surgeons and patients. MATERIAL AND METHODS: Using six pairs of frozen cadaveric feet, lateral release was performed using one of the above techniques in a randomized manner with pair comparison. The specimens were then dissected and the completeness of the release as well as any damage to anatomic structures was documented. RESULTS: The transarticular technique enabled complete release of the metatarsal-sesamoid suspensory ligament (MSL) and the transverse and oblique head of the adductor hallucis muscle in five of six specimens. The comparative technique enabled the same in only two of six cases for the adductor hallucis muscle and in four cases for the MSL. The transarticular approach achieved complete release of the lateral joint capsule in three of six specimens, whereas the dorsal approach achieved no release in any specimen. Neither of the methods caused any macroscopic injury to the surfaces of the first metatarsophalangeal joint. The examined arteries, veins, and nerves remained intact in all specimens treated with the transarticular approach, but dorsal release resulted in one documented injury to the first dorsal metatarsal artery and its concomitant veins. CONCLUSIONS: Compared to release by dissection superficially to the extensor tendons, transarticular release provides a more complete lateral release and less injuries to neurovascular bundles. Further anatomic and clinical studies are needed, however, before conclusive recommendations can be made.

A biomechanical comparison of fixed angle locking compression plate osteosynthesis and cement augmented screw osteosynthesis in the management of intra articular calcaneal fractures.

PURPOSE: The purpose of this study was to investigate whether cement-augmented screw osteosynthesis results in stability comparable to conventional fixed-angle locking plate osteosynthesis using cadaveric bones to model a Sanders type 2B fracture. METHODS: Seven pairs of fresh frozen human calcanei and the corresponding tali were used. The specimens were assigned pairwise to two study groups in a randomised manner. In order to determine the initial quasi-static stiffness of the bone-implant construct, testing commenced with quasi-static compression ramp loading; subsequently, sinusoidal cyclic compression loading at 2 Hz was performed until construct failure occurred. Initial dynamic stiffness (cycle 1), range of motion (ROM), cycles to failure and load to failure were determined from the machine data during the cyclic test. In addition, at 250-cycle intervals, Böhler's angle and the critical angle of Gissane were determined on mediolateral X-rays shot with a triggered C-arm; 5° angle flattening was arbitrarily defined as a failure criterion. RESULTS: Bone mineral density was normally distributed without significant differences between the groups. The augmented screw osteosynthesis resulted in higher stiffness values compared to the fixed-angle locking plate osteosynthesis. The fracture fragment motion in the locking plate group was significantly higher compared to the group with augmented screw osteosynthesis. CONCLUSIONS: The results of this study indicate that in our selected test set-up augmented screw osteosynthesis was significantly superior to the conventional fixed-angle locking plate osteosynthesis with respect to primary stability and ROM during cyclic testing.

Biomechanical comparison of a lateral polyaxial locking plate with a posterolateral polyaxial locking plate applied to the distal fibula.

BACKGROUND: Polyaxial locking plates are becoming popular for the fixation of distal fibula fractures. This study establishes how construct stiffness and plate loosening, measured as range of motion, differs between lateral and posterolateral plate location. METHODS: Seven matched pairs of cadaver fibulae were osteotomized in standardized fashion to produce a Weber type B distal fibula fracture. The fragments were fixated with an interfragmentary lag screw and polyaxial locking plates, with one fibula in each pair receiving a posterolateral anti-glide-plate, and the other a lateral neutralization-plate. In a biomechanical test, the bending and torsional stiffnesses of the constructs and the ranges of motion (ROM) were measured and subjected to a paired comparison. RESULTS: The laterally plated group had a higher median (interquartile range) bending stiffness (29.2 (19.7) N/mm) and a smaller range of motion (2.06 (1.99) mm) than the posterolaterally plated group (14.6 (20.6) N/mm, and 4.11 (3.28) mm, respectively); however, the results were not statistically significant (pbending=0.314; pROM=0.325). Similarly, the torsional stiffness did not differ significantly between the two groups (laterally plated: 426 (259) Nmm/°; posterolaterally plated: 248 (399) Nmm/°; ptorsion=0.900). The range of motion measurements between the two groups under torsional loading were also statistically insignificant (laterally plated: 8.88 (6.30) mm; posterolaterally plated: 15.34 (12.64) mm; pROM=0.900). CONCLUSION: In biomechanical cadaver-model tests of Weber type B fracture fixation with polyaxial locking plates, laterally plated constructs and posterolaterally plated constructs performed without significantly difference. Therefore, other considerations, such as access morbidity, associated injuries, patient anatomy, or surgeon's preference, may guide the choice of plating pattern. Further clinical studies will be needed for the establishment of definitive recommendations. CLINICAL RELEVANCE: Information on the behavior of polyaxial locking plates is relevant to surgeons performing internal fixation of distal fibula fractures.

[Treatment of symptomatic end-stage osteoarthritis of the ankle with anterolateral approach and an anatomical plate]. / Sprunggelenkarthrodese über einen anterolateralen Zugang mit einer anatomischen Platte.

OBJECTIVE: The aim of this paper is to describe the anterolateral approach using an anatomical plate for ankle arthrodesis and to present the first mid-term results with this technique in a high-risk population. INDICATIONS: The indication for arthrodesis of the ankle joint with this described technique is moderate to severe osteoarthritis of the ankle. CONTRAINDICATIONS: In addition to the general contraindications typical of any operation, there is a specific contraindication in cases of active infection of the soft tissues and accompanying osteomyelitis at the ankle. SURGICAL TECHNIQUE: The incision is made along the course of the peroneus tertius muscle. After that, the mobilization of the peroneus superficialis nerve is carried out, followed by the mobilization of the long extensor tendons, especially the extensor digitorum muscle in a medial direction opening the capsule and removal of the residual cartilage on the distal tibia and talus. Subsequently, the subchondral sclerosis is opened, and the implantation of a suitable osteosynthesis material, e.g., an anatomical angle-stable plate, is carried out. Finally, wound closure is performed involving the muscle belly of the extensor digitorum muscle covering the plate. POSTOPERATIVE MANAGEMENT: Immobilization of the ankle for 5-7 days in a dorsal knee-high splint. Retention in a walker after decongestion for another 5 weeks. Increased loading can be done after X­ray/computed tomography (CT) control from the 6th week. RESULTS: In all, 11 patients were observed retrospectively for an average of 14 months. There were no complications. The European Foot and Ankle Society (EFAS) score improved significantly from 3.3 to 17.8 points. All patients were subjectively satisfied with the result and would have the operation again.

Lapidus Arthrodesis for Correction of Hallux Valgus Deformity: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of this study was to evaluate and compare different fixation methods to achieve Tarsometatarsal joint I (TMT-1) arthrodesis in patients with hallux valgus regarding radiographic correction, complication profile, and clinical outcomes. METHODS: A systematic review and meta-analysis included primary literature results of evidence level 1 to 3 studies in German and English. Inclusion and exclusion criteria were established and applied, along with parameters suitable for comparison of data. RESULTS: 16 studies with a total of 1176 participants met the inclusion criteria for this analysis. Twelve evaluation criteria were compared among 3 fixation techniques; comprised of a screw-only, dorsomedial plating- and plantar plating cohort. There was no statistical difference in deformity correction (both intermetatarsal- and hallux valgus angle), or AOFAS score between the cohorts. The complication rate was 13% in the plantar-, 19.5% in the dorsomedial-, and 24.5% in the screw cohort. Nonunion was seen in 0.7% of participants in the plantar, 1.4% in the dorsomedial, and 5.3% in the screw group. The time until complete weightbearing correlated positively with the development of nonunion, with a coefficient of 0.376 (P = .009). Hardware removal was performed in 11.8% of patients in the dorsomedial cohort, 7.7% in the screw cohort, and 3.6% in the plantar cohort. CONCLUSION: Based on the results of meta-analysis of heterogeneous studies, plantar plating facilitated early weightbearing and patient mobilization compared to the other fixation methods, while carrying the lowest nonunion, hardware removal, and general complication risk. However, owing to the relatively small number of patients in the plantar plating group, more work is necessary to elucidate the benefits of plantar plating for a first tarsometatarsal joint arthrodesis. Development of complications appears to be largely dependent on the fixation model, rather than patient mobilization alone.Level of Evidence: 3.

Percutaneous navigated screw fixation of glenoid fractures.

BACKGROUND: Open or percutaneous arthroscopic-based procedures are reported to fix unstable or displaced intra-articular glenoid fractures. Approach related morbidity has to be considered for open procedures, and arthroscopic-based procedures are demanding. Therefore an alternative percutaneous navigated approach is described. TECHNICAL PROCEDURE: In an experimental setting an operative workflow was simulated to evaluate the best position of the patient on the operation table, the operating room set up and the fixation technique for the dynamic reference base of the navigation system. Based on two clinical cases, screw fixation of glenoid fractures via a posterior percutaneous approach is described, using a 2D-fluoroscopic based navigation system. Compared to the common approaches, the advantages and disadvantages of this procedure are discussed. CONCLUSION: The described technique of percutaneous navigated screw fixation of glenoid fractures is an alternative minimal invasive procedure. A reduction of approach related morbidity and more rapid return to function could be expected. The intraoperative results and postoperative functional outcome of both cases are promising.

Modified Lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: a preliminary report.

BACKGROUND: TMT-1 arthrodesis is an established method in hallux valgus surgery, but it is technically demanding and typically calls for a period of postoperative immobilization. METHODS: In this cohort study, initial experience with a plantar plate is described. 58 patients (59 arthrodesis) were included. RESULTS: The mean duration of protected full weight bearing was 7 weeks. 94.12% patients were satisfied with the results, bony union was achieved in 98.31%. The Foot Function Index improved by 33 to a mean of 8 (p<.001). The postoperative Mayo Clinic Forefoot Score was excellent in 47.04 and good in 47.04%. The mean hallux valgus angle improved by 24.4-13.2° (p<.001). The mean first intermetatarsal angle improved by 11.2-5.2° (p<.001). CONCLUSION: Initial experience with this form of fixation appears to provide suitable stability, allow early-protected weight bearing, with an acceptable level of complications.

Indications and possible limitations using medio-plantar plate systems in tarsometatarsal 1 fusions - A cadaveric study.

BACKGROUND: The tarsometatarsal 1 arthrodesis is an adequate treatment for moderate to severe hallux valgus deformity and instability of the first ray. Plantar plating arthrodesis has been shown to provide better mechanical stability and fewer postoperative complications than screw fixation or medial plating. The medio-plantar plate is a new plate design for Lapidus arthrodesis. It could combine the biomechanical advantages of the plantar plate and the anatomical overview of a medial plate. However, the implanted material can cause irritation of the tibialis anterior, which in some cases may require removal of the material. The purpose of this study was to examine the possibility of tendon irritation following medio-plantar first tarsometatarsal joint arthrodesis using cadaveric specimens. METHODS: The study involved the simulated surgical procedure of medio-plantar plate arthrodesis on 30 lower extremities. After the plates were fixed, a thorough examination of the feet was conducted to assess any tendon irritation and to determine a recommendation for placement of the medio-plantar plate based on the Olewnik classification. RESULTS: Irritation of the tibialis anterior tendon components with the medio-plantar plate depends mainly on the anatomic norm variant, classified according to Olewnik et al. A medio-plantar plate is particularly recommended in TA tendon Olewnik type 3 and type 5. The positioning of a medio-plantar plate in Olewnik type 1 and type 2 tendons depends on the anatomic fit of the medio-plantar plate and the bony configuration of the TMT 1 joint. A large portion of the TA tendon must be detached, so a different plate design may be preferred in these patients. CONCLUSIONS: TMT 1 arthrodesis with medio-plantar plating of the first tarsometatarsal joint should be performed considering the anatomic TA tendon variations. LEVEL OF EVIDENCE: Level V, Expert Opinion includes Case Reports and Technique Tips.