Head Reduction Osteotomy With Additional Containment Surgery Improves Sphericity and Containment and Reduces Pain in Legg-Calvé-Perthes Disease.

BACKGROUND Severe femoral head deformities in the frontal plane such as hips with Legg-Calvé-Perthes disease (LCPD) are not contained by the acetabulum and result in hinged abduction and impingement. These rare deformities cannot be addressed by resection, which would endanger head vascularity. Femoral head reduction osteotomy allows for reshaping of the femoral head with the goal of improving head sphericity, containment, and hip function. QUESTIONS/PURPOSES Among hips with severe asphericity of the femoral head, does femoral head reduction osteotomy result in (1) improved head sphericity and containment; (2) pain relief and improved hip function; and (3) subsequent reoperations or complications? METHODS Over a 10-year period, we performed femoral head reduction osteotomies in 11 patients (11 hips) with severe head asphericities resulting from LCPD (10 hips) or disturbance of epiphyseal perfusion after conservative treatment of developmental dysplasia (one hip). Five of 11 hips had concomitant acetabular containment surgery including two triple osteotomies, two periacetabular osteotomies (PAOs), and one Colonna procedure. Patients were reviewed at a mean of 5 years (range, 1-10 years), and none was lost to followup. Mean patient age at the time of head reduction osteotomy was 13 years (range, 7-23 years). We obtained the sphericity index (defined as the ratio of the minor to the major axis of the ellipse drawn to best fit the femoral head articular surface on conventional anteroposterior pelvic radiographs) to assess head sphericity. Containment was assessed evaluating the proportion of patients with an intact Shenton's line, the extrusion index, and the lateral center-edge (LCE) angle. Merle d'Aubigné-Postel score and range of motion (flexion, internal/external rotation in 90° of flexion) were assessed to measure pain and function. Complications and reoperations were identified by chart review. RESULTS At latest followup, femoral head sphericity (72%; range, 64%-81% preoperatively versus 85%; range, 73%-96% postoperatively; p = 0.004), extrusion index (47%; range, 25%-60% versus 20%; range, 3%-58%; p = 0.006), and LCE angle (1°; range, -10° to 16° versus 26°; range, 4°-40°; p = 0.0064) were improved compared with preoperatively. With the limited number of hips available, the proportion of an intact Shenton's line (64% versus 100%; p = 0.087) and the overall Merle d'Aubigné-Postel score (14.5; range, 12-16 versus 15.7; range, 12-18; p = 0.072) remained unchanged at latest followup. The Merle d'Aubigné-Postel pain subscore improved (3.5; range, 1-5 versus 5.0; range, 3-6; p = 0.026). Range of motion was not observed to have improved with the numbers available (p ranging from 0.513 to 0.778). In addition to hardware removal in two hips, subsequent surgery was performed in five of 11 hips to improve containment after a mean interval of 2.3 years (range, 0.2-7.5 years). Of those, two hips had triple osteotomy, one hip a combined triple and valgus intertrochanteric osteotomy, one hip an intertrochanteric varus osteotomy, and one hip a PAO with a separate valgus intertrochanteric osteotomy. No avascular necrosis of the femoral head occurred. CONCLUSIONS Femoral head reduction osteotomy can improve femoral head sphericity. Improved head containment in these hips with an often dysplastic acetabulum requires additional acetabular containment surgery, ideally performed concomitantly. This can result in reduced pain and avascular necrosis seems to be rare. With the number of patients available, function did not improve. Therefore, future studies should use more precise instruments to evaluate clinical outcome and include longer followup to confirm joint preservation. LEVEL OF EVIDENCE Level IV, therapeutic study.

Dynamic intraligamentary stabilization and primary repair: A new concept for the treatment of knee dislocation.

BACKGROUND Traumatic knee dislocation represents a rare but devastating injury. Several controversies persist regarding type of treatment, surgical timing, graft selection, repair versus reconstruction of the medial and lateral structures, surgical techniques and postoperative rehabilitation. A new technique for primary ACL stabilization, dynamic intaligamentary stabilization (DIS) was developed at the authors' institution. The purpose of this study was to analyze the clinical and radiological outcomes of surgically treated traumatic knee dislocations by means of the DIS technique for the ACL, primary suturing for PCL, MCL and LCL. METHODS Between 2009 and 2012, 35 patients treated surgically for traumatic knee dislocation with primary anterior cruciate ligament (ACL) reconstruction with DIS, suturing of the posterior cruciate ligament (PCL) and primary complete repair of collaterals, were evaluated clinically (IKDC score, SF12 health survey, Lysholm score, Tegner score) and radiologically with a mean follow up of 2.2 years (range 1.00-3.50 years) years. Instrumented anterior-posterior translation was measured (KT-2000). RESULTS Anterior/posterior translation (KT-2000) for the healthy and injured limb was 4.8mm (range 3-8mm) and 7.3mm (range 5-10) (89N) respectively. Valgus and varus stress testing in 30° flexion was normal in 26 (75%) and 29 (83%) patients, respectively. The IKDC score was B in 29 (83%) and C in 6 (17%) patients, while the mean Tegner score was 6 (range 4-8). The mean Lysholm score was 90.83 (range 81-95) and mean SF-12 physical and mental scores were 54.1 (range 45-60) and 51.0 (range 39-62) respectively. In 2 patients, a secondary operation was performed. CONCLUSIONS Early, one stage reconstruction with DIS can achieve good functional results and patient satisfaction with overall restoration of sports and working capacity without graft requirements.

Osteotomy of the distal femur. Surgical technique using the LCP Pediatric Condylar Plate 90°.

OBJECTIVE Correction of all kind of deformities at the distal part of the femur (supracondylar). INDICATIONS Flexion, extension osteotomies, and varus or valgus, and external or internal rotation osteotomies, and shortening osteotomies of the distal femur or combined surgical procedures (e.g., extension and de-rotation osteotomy). CONTRAINDICATIONS Osteotomy through unknown bony process. SURGICAL TECHNIQUE LCP system provides angular stable fixation. POSTOPERATIVE MANAGEMENT Without concomitant surgical procedures of soft tissue (e.g., patellar tendon shortening), early functional rehabilitation is possible with immediate weight bearing (35 kg for small fragment plates and 70 kg for large fragment plates). RESULTS The surgical procedure is safe and is associated with few complications. Overall complication rate in this series of patients was 3%.

Periacetabular osteotomy restores the typically excessive range of motion in dysplastic hips with a spherical head

BACKGROUND Residual acetabular dysplasia is seen in combination with femoral pathomorphologies including an aspherical femoral head and valgus neck-shaft angle with high antetorsion. It is unclear how these femoral pathomorphologies affect range of motion (ROM) and impingement zones after periacetabular osteotomy. QUESTIONS/PURPOSES (1) Does periacetabular osteotomy (PAO) restore the typically excessive ROM in dysplastic hips compared with normal hips; (2) how do impingement locations differ in dysplastic hips before and after PAO compared with normal hips; (3) does a concomitant cam-type morphology adversely affect internal rotation; and (4) does a concomitant varus-derotation intertrochanteric osteotomy (IO) affect external rotation? METHODS Between January 1999 and March 2002, we performed 200 PAOs for dysplasia; of those, 27 hips (14%) met prespecified study inclusion criteria, including availability of a pre- and postoperative CT scan that included the hip and the distal femur. In general, we obtained those scans to evaluate the pre- and postoperative acetabular and femoral morphology, the degree of acetabular reorientation, and healing of the osteotomies. Three-dimensional surface models based on CT scans of 27 hips before and after PAO and 19 normal hips were created. Normal hips were obtained from a population of CT-based computer-assisted THAs using the contralateral hip after exclusion of symptomatic hips or hips with abnormal radiographic anatomy. Using validated and computerized methods, we then determined ROM (flexion/extension, internal- [IR]/external rotation [ER], adduction/abduction) and two motion patterns including the anterior (IR in flexion) and posterior (ER in extension) impingement tests. The computed impingement locations were assigned to anatomical locations of the pelvis and the femur. ROM was calculated separately for hips with (n = 13) and without (n = 14) a cam-type morphology and PAOs with (n = 9) and without (n = 18) a concomitant IO. A post hoc power analysis based on the primary research question with an alpha of 0.05 and a beta error of 0.20 revealed a minimal detectable difference of 4.6° of flexion. RESULTS After PAO, flexion, IR, and adduction/abduction did not differ from the nondysplastic control hips with the numbers available (p ranging from 0.061 to 0.867). Extension was decreased (19° ± 15°; range, -18° to 30° versus 28° ± 3°; range, 19°-30°; p = 0.017) and ER in 0° flexion was increased (25° ± 18°; range, -10° to 41° versus 38° ± 7°; range, 17°-41°; p = 0.002). Dysplastic hips had a higher prevalence of extraarticular impingement at the anteroinferior iliac spine compared with normal hips (48% [13 of 27 hips] versus 5% [one of 19 hips], p = 0.002). A PAO increased the prevalence of impingement for the femoral head from 30% (eight of 27 hips) preoperatively to 59% (16 of 27 hips) postoperatively (p = 0.027). IR in flexion was decreased in hips with a cam-type deformity compared with those with a spherical femoral head (p values from 0.002 to 0.047 for 95°-120° of flexion). A concomitant IO led to a normalization of ER in extension (eg, 37° ± 7° [range, 21°-41°] of ER in 0° of flexion in hips with concomitant IO compared with 38° ± 7° [range, 17°-41°] in nondysplastic control hips; p = 0.777). CONCLUSIONS Using computer simulation of hip ROM, we could show that the PAO has the potential to restore the typically excessive ROM in dysplastic hips. However, a PAO can increase the prevalence of secondary intraarticular impingement of the aspherical femoral head and extraarticular impingement of the anteroinferior iliac spines in flexion and internal rotation. A cam-type morphology can result in anterior impingement with restriction of IR. Additionally, a valgus hip with high antetorsion can result in posterior impingement with decreased ER in extension, which can be normalized with a varus derotation IO of the femur. However, indication of an additional IO needs to be weighed against its inherent morbidity and possible complications. The results are based on a limited number of hips with a pre- and postoperative CT scan after PAO. Future prospective studies are needed to verify the current results based on computer simulation and to test their clinical importance.

First Metatarsophalangeal Joint Degeneration: Arthroscopic Treatment

Arthroscopic treatment of hallux rigidus is appropriate after failed nonoperative treatment. Debridement with cheilectomy, and fusion are the main indications for arthroscopic treatment of hallux rigidus. If the cartilage damage is extensive and the patient has consented, then a fusion is performed at the same sitting.

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Kinematic and electromyographic analysis of the overhead squat in individuals showing excessive medial knee displacement

Dynamic knee valgus is a multi-planar motion that has been associated with anterior cruciate ligament injuries and patellofemoral pain syndrome. Clinical assessment of dynamic knee valgus can be made by looking for the visual appearance of excessive medial knee displacement (MKD) in the double-leg squat (DLS). The purpose of this dissertation was to identify the movement patterns and neuromuscular strategies associated with MKD during the DLS. Twenty-four control subjects and eight individuals showing MKD during the DLS participated in the study. Significant differences were verified between subjects that demonstrated MKD and a control (CON) group for the eletromyographic amplitude of adductor magnus, biceps femoris, vastus lateralis and vastus medialis muscles (p < 0.05), during the descending phase of the DLS. During the ascending phase were found group differences for adductor magnus and rectus femoris muscles (p < 0.05). Results from kinematic analysis revealed higher minimum and maximum values of ankle abduction and knee internal rotation angles (p < 0.05) for the MKD group. Also, individuals showing excessive MKD had higher hip adduction/abduction excursion. Our results suggested that higher tibial internal rotation and knee internal rotation angles in the initial position of the DLS are associated with MKD. The neuromuscular strategies that contributed to MKD were higher adductor magnus activation, whereas biceps femoris, vastus lateralis and vastus medialis activated more to stabilize the knee in response to the internal rotation moment.

Descripción de resultados de la reconstrucción de placa plantar en inestabilidad de la segunda articulación metatarsofalángica

Objetivo: Describir los desenlaces funcionales, complicaciones postoperatorias, dolor y satisfacción de un grupo de pacientes con diagnóstico de inestabilidad de segunda articulación metatarsofalángica y lesión de la placa plantar, que fueron intervenidos quirúrgicamente para su reconstrucción en el Hospital Universitario de cuarto nivel Fundación Santa Fé de Bogotá, en el periodo comprendido entre Enero de 2010 hasta Diciembre de 2015. Métodos: Estudio descriptivo de corte transversal que evalúa desenlaces funcionales, dolor y satisfacción para un grupo consecutivo de pacientes con diagnóstico de inestabilidad de la segunda articulación metatarsofalángica que fueron intervenidos quirúrgicamente mediante reconstrucción de la placa plantar entre Enero de 2010 a Diciembre de 2015 en el Hospital Universitario Fundación Santa fe de Bogotá. Resultados: El procedimiento se realizó a 39 pacientes (40 MTF), encontrando mejoría en dolor, función y satisfacción. El dolor postoperatorio paso de severo a leve en el 80% de los pacientes, 67.5% de los pacientes presentaron prueba de aprehensión positiva, 85% alineamiento adecuado, el reporte de escala de AOFAS postoperatoria fue de 87, y los resultados fueron satisfactorios en un 94.5%. La principal complicación con la cirugía fue la extensión residual del dedo operado (22.5%). Conclusiones: La reconstrucción de la placa plantar en casos de inestabilidad metatarsofalángica ha demostrado tener resultados satisfactorios, en el presente estudio encontramos mejoría respecto a dolor, función y satisfacción posterior a la realización del procedimiento. Sin embargo puede presentar complicaciones como extensión residual del dedo o elevación, rigidez y recidiva.