Effect of the Reversed L-Shaped Osteotomy on the Round Sign: Not All Hallux Valgus Deformities May Need Proximal Derotation to Correct the Radiographic Appearance of Metatarsal Pronation

Background Metatarsal pronation has been claimed to be a risk factor for hallux valgus recurrence. A rounded shape of the lateral aspect of the first metatarsal head has been identified as a sign of persistent metatarsal pronation after hallux valgus correction. This study investigated the derotational effect of a reversed L-shaped (ReveL) osteotomy combined with a lateral release to correct metatarsal pronation. The primary hypothesis was that most cases showing a positive round sign are corrected by rebalancing the metatarsal-sesamoid complex. We further assumed that the inability to correct the round sign might be a risk factor for hallux valgus recurrence. Methods We retrospectively evaluated 266 cases treated with a ReveL osteotomy for hallux valgus deformity. The radiologic measurements were performed on weightbearing foot radiographs preoperatively, at an early follow-up (median, 6.2 weeks), and the most recent follow-up (median, 13 months). Univariate and multivariate logistic regression analyses identified risk factors for hallux valgus recurrence (hallux valgus angle [HVA] ≥ 20 degrees). Results A preoperative positive radiographic round sign was present in 40.2% of the cases, of which 58.9% turned negative after the ReveL osteotomy (P 30 degrees (odds ratio [OR] = 5.3, P 15 degrees (OR = 74.9; P < .001), and postoperative positive round sign (OR = 5.3, P = .008). Cases with a positive round sign at the most recent follow-up had a significantly higher recurrence rate than those with a negative round sign (22.7% vs 5.9%, P < .001). Conclusion The ReveL osteotomy corrected a positive round sign in 58.9%, suggesting that not all hallux valgus deformities may need proximal derotation to negate the radiographic appearance of the round sign. A positive round sign was found to be an independent risk factor for hallux valgus recurrence. Further 3-dimensional analyses are necessary to better understand the effects and limitations of distal translational osteotomies to correct metatarsal pronation. Level of Evidence Level IV, case series

Computer-assisted corrective osteotomy of malunited pediatric radial neck fractures - Three-dimensional postoperative accuracy and clinical outcome

Neglected or incorrect treatment of pediatric radial neck fractures may lead to symptomatic malunions. Computer-assisted corrective osteotomies with patient-specific guides have been proposed as a promising technique for the reconstruction of malunited long bone deformities. The aim of this study was to evaluate the accuracy and clinical outcome of this technique in children with malunited fractures of the radial neck. Four children (two male, two female; mean age 12 (10-16) years) underwent computer-assisted closing wedge osteotomy of the radial neck. The contralateral uninjured side was used as a reconstruction template. CT scans were performed eight weeks postoperatively to confirm bony consolidation and to quantify residual 3D rotational and translational displacement error. Clinical outcome (pain, range of motion) and overall satisfaction were documented. Preoperative subluxation of the radial head could be corrected in two of three patients. One patient had to be revised due to secondary traumatic loss of reduction. At the last follow-up (mean 16 (range, 12-24) months), all patients were pain free for activities of daily living (preoperative pain: visual analogue scale 6). Pain during sport activities could be substantially reduced (visual analogue scale 8→2). Although the procedure failed to improve range of motion, none of the patients had limitations regarding work, daily or sports activities. Yet, restricted range of motion was considered as a cosmetic problem in one patient. Full consolidation of the osteotomy site, with no signs of avascular necrosis of the radial head, was achieved in all patients. The deformity could be substantially reduced, from a 3D angle of 13-40° to 3-7° (58-89% deformity correction). Computer-assisted corrective osteotomy is a novel technique for the treatment of radial neck malunions that led to adequate pain reduction and 3D accuracy of deformity correction in our small case series. Despite the lack of improved range of motion, all patients were satisfied and would undergo the same procedure again. LEVEL OF EVIDENCE Level IV, Case Series, Treatment Study

Feasibility of iliosacral screw placement in patients with upper sacral dysplasia

BACKGROUND Exact knowledge of the sacral anatomy is crucial for the percutaneous insertion of iliosacral screws. However, dysplastic anatomical patterns are common. In addition to a preoperative computed tomography (CT) analysis, conventional radiographic measures may help to identify upper sacral dysplasia and to avoid damage to surrounding structures. Aiming to further increase safety in percutaneous iliosacral screw placement in the presence of sacral dysmorphism, this study examined the prevalence of previously established radiographic signs and, in addition, defined the "critical SI angle" as a new radiographic criterion. METHODS Pelvic CT scans of 98 consecutive trauma patients were analysed. Next to assessment of established signs indicating upper sacral dysplasia, the critical sacroiliac (SI) angle was defined in standardized pelvic outlet views. RESULTS The critical SI angle significantly correlates with the presence of mammillary bodies and an intraarticular vacuum phenomenon. With a cut-off value of - 14.2°, the critical SI angle detects the feasibility of a safe iliosacral screw insertion in pelvic outlet views with a sensitivity of 85.9% and a specificity of 85.7%. CONCLUSIONS The critical SI angle can support the decision-making when planning iliosacral screw fixation. The clinical value of the established signs of upper sacral dysplasia remains uncertain

Midterm Clinical and Radiological Outcome After Autologous Matrix-induced Chondrogenesis (AMIC) for Osteochondral Lesions of the Talus

Category: Ankle Introduction/Purpose: Autologous matrix-induced chondrogenesis (AMIC) has recently become an interesting treatment option for osteochondral lesions of the talus since it combines safety and efficacy with overcoming several drawbacks of other surgical techniques. With AMIC, donor side morbidity of osteochondral autografts is eliminated, two-step procedures like matrix-induced autologous chondrocyte implantation are minimized to a more cost-effective single step and restrictions due to limited availability of osteochondral allografts are resolved. The purpose of this study was to evaluate the therapeutic efficacy of AMIC by analyzing AMIC-repaired osteochondral talar lesions in consecutively treated patients after a minimum follow-up of 2 years. Methods: All patients with an osteochondral lesion of the talus treated with the AMIC technique completing a minimum follow-up of 2 years were enrolled in the study for clinical and radiological follow-up. Patients with additional procedures such as lateral ligament reconstruction or corrective calcaneal osteotomy were excluded. 31 of the 47 eligible patients (28 males, 13 females; mean age at surgery 35.7 (range, 13-75) years); body mass index 27.1+-4.7 kg/m2) could be retrospectively evaluated after a mean follow-up of 4.6 (range, 2.3-7.9) years. The preoperative defect size was 0.9+-0.5 (range 0.4-2.3) cm2. Only two osteochondral lesions were localized laterally. Data analysis included general demographics, the visual analogue scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle function, the Tegner Score for sports activity, and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system for radiological evaluation. Results: The VAS improved significantly from 6.5+-2.0 preoperatively to 1.5+-2.2 at follow-up (p<0.001). The mean AOFAS score was 93.0+-8.2 (range, 74-100) points. The sports activity level improved significantly from 3.5+-1.8 points preoperatively to 4.9+-1.8 points at follow-up (p<0.001), but 29% did not reach their pre-injury level of activity. The MOCART score averaged 61.5+-21.2 (range, 0-95) points. Complete filling of the defect was seen in 41%, hypertrophy of the cartilage layer in 53%. Normal or nearly normal signal intensity was detected in 67%. All patients showed subchondral bone edema or cysts. The MRI findings did not correlate with the clinical outcome. 91% were satisfied with the outcome and would undergo the same procedure again. Conclusion: AMIC is a reliable procedure to treat osteochondral lesions of the talus. Significant pain reduction and high ankle function were observed after a mean midterm follow-up of 4.5 years. MRI findings did not reflect the good clinical results and therefore should only be performed to rule out other pathologies that might cause persistent symptoms

Long-term Prognosis After Successful Nonoperative Treatment of Osteochondral Lesions of the Talus: An Observational 14-Year Follow-up Study

Background Little is known about the long-term prognosis of osteochondral lesions of the talus (OLTs) after nonoperative treatment. Purpose To evaluate the clinical and radiological long-term results of initially successfully treated OLTs after a minimum follow-up of 10 years. Study Design Case series; Level of evidence, 4. Methods Between 1998 and 2006, 48 patients (50 ankles) with OLTs were successfully treated nonoperatively. These patients were enrolled in a retrospective long-term follow-up, for which 24 patients could not be reached or were available only by telephone. A further 2 OLTs (6%) that had been treated surgically were excluded from the analysis and documented as failures of nonoperative treatment. The final study group of 22 patients (mean age at injury, 42 years; range, 10-69 years) with 24 OLTs (mean size, 1.4 cm$^{2}$; range, 0.2-3.8 cm$^{2}$) underwent clinical and radiological evaluation after a mean follow-up of 14 years (range, 11-20 years). Ankle pain was evaluated with a visual analog scale (VAS), ankle function with the American Orthopaedic Foot and Ankle Society (AOFAS) score, and sports activity with the Tegner score. Progression of ankle osteoarthritis was analyzed based on plain ankle radiographs at the initial presentation and the final follow-up according to the Van Dijk classification. Results At final follow-up, the 24 cases (ie, ankles) showed a median VAS score of 0 (IQR, 0.0-2.25) and a median AOFAS score of 94.0 (IQR, 85.0-100). Pain had improved in 18 cases (75%), was unchanged in 3 cases (13%), and had increased in 3 cases (13%). The median Tegner score was 4.0 (IQR, 3.0-5.0). Persistent ankle pain had led to a decrease in sports activity in 38% of cases. At the final follow-up, 11 cases (73%) showed no progression of ankle osteoarthritis and 4 cases (27%) showed progression by 1 grade. Conclusion Osteochondral lesions of the talus that successfully undergo an initial nonoperative treatment period have minimal symptoms in the long term, a low failure rate, and no relevant ankle osteoarthritis progression. However, a decrease in sports activity due to sports-related ankle pain was observed in more than one-third of patients

Autologous Matrix-Induced Chondrogenesis for Osteochondral Lesions of the Talus: A Clinical and Radiological 2- to 8-Year Follow-up Study

BACKGROUND Autologous matrix-induced chondrogenesis (AMIC) has become an interesting treatment option for osteochondral lesions of the talus (OLTs) with promising clinical short- to midterm results. PURPOSE To investigate the clinical and radiological outcome of the AMIC procedure for OLTs, extending the follow-up to 8 years. STUDY DESIGN Case series; Level of evidence, 4. METHODS Thirty-three patients (mean age, 35.1 years; body mass index, 26.8) with osteochondral lesions of the medial talar dome were retrospectively evaluated after open AMIC repair at a mean follow-up of 4.7 years (range, 2.3-8.0 years). Patients requiring additional surgical procedures were excluded. All OLTs (mean size, 0.9 cm; range, 0.4-2.3 cm) were approached through a medial malleolar osteotomy, and 28 patients received subchondral autologous bone grafting. Data analysis included the visual analog scale for pain, the American Orthopaedic Foot and Ankle Society score for ankle function, the Tegner score for sports activity, and the MOCART (magnetic resonance observation of cartilage repair tissue) scoring system for repair cartilage and subchondral bone evaluation. RESULTS Mean ± SD visual analog scale score improved significantly from 6.4 ± 1.9 preoperatively to 1.4 ± 2.0 at latest follow-up ( P < .001). The mean American Orthopaedic Foot and Ankle Society score was 93.0 ± 7.5 (range, 75-100). The Tegner score improved significantly from 3.5 ± 1.8 preoperatively to 5.2 ± 1.7 at latest follow-up ( P < .001), and 79% returned to their previous sports levels. The MOCART score averaged 60.6 ± 21.2 (range, 0-100). Complete filling of the defect was seen in 88% of cases, but 52% showed hypertrophy of the cartilage layer. All but 1 patient showed persistent subchondral bone edema. The patient's age and body mass index, the size of the osteochondral lesion, and the MOCART score did not show significant correlation with the clinical outcome. There were no cases of revision surgery for failed AMIC. Fifty-eight percent underwent reoperation, mainly for symptomatic hardware after malleolar osteotomy. CONCLUSION AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging

Acromial roof in patients with concentric osteoarthritis and massive rotator cuff tears: multiplanar analysis of 115 computed tomography scans

BACKGROUND There is evidence for differences of scapular shape between shoulders with rotator cuff tears (RCT) and osteoarthritic shoulders (OA). This study analyzed orientation and shape of the acromion in patients with massive RCT and concentric OA (COA) in a multiplanar computed tomography (CT) analysis. METHODS CT scans of 70 shoulders with degenerative RCT and 45 shoulders with COA undergoing primary shoulder arthroplasty were analyzed. The 2 groups were compared in relation of (1) shape of the acromion, (2) its orientation in space, and (3) the anteroposterior glenoid coverage in relation to the scapular plane. RESULTS Lateral acromial roof extension was an average of 4.6 mm wider and the acromial area was an average of 156 mm larger in RCT than in COA (P < .001). Significant differences of the lateral extension of the acromion margin were limited to the anterior two-thirds. Acromial roof orientation in RCT was average of 10.8° more "externally rotated" (axial plane: P < .001) and an average of 7.8° more tilted downward (coronal plane: P < .001) than in COA. The glenoid in RCT was an average of 5.5° (P < .001) more covered posteriorly compared with COA. CONCLUSIONS A more externally rotated (axial plane), more downward tilted (coronal plane), and wider posterior covering acromion was more frequent in patients with massive RCT than COA

Three-Dimensional Correction of Complex Ankle Deformities With Computer-Assisted Planning and Patient-Specific Surgical Guides

Three-dimensional computer-assisted preoperative planning, combined with patient-specific surgical guides, has become an effective technique for treating complex extra- and intraarticular bone malunions by corrective osteotomy. The feasibility and accuracy of such a technique has not yet been evaluated for ankle deformities. Four surgical cases of varying complexity and location were selected for evaluation. Three-dimensional bone models of the affected and contralateral healthy lower limb were generated from computed tomography scans. The preoperative planning software permitted quantification of the deformity in 3 dimensions and subsequent simulation of reduction, yielding a precise surgical plan. Patient-specific surgical guides were designed, manufactured, and finally applied during surgery to reproduce the preoperative plan. Evaluation of the postoperative computed tomography scans indicated adequate reduction accuracy with residual translational and rotational errors of <3 mm and <6°, respectively. Two patients required revision surgery owing to anterior osseous impingement or delayed union of the osteotomy. All patients were satisfied with the postoperative course and were pain free at a mean follow-up period of 2.5 (range 1 to 4) years. These promising results require confirmation in a clinical study with a larger sample size