Does foot shape really matter? Correlation of patient reported outcomes with radiographic assessment in progressive collapsing foot deformity reconstruction: A systematic review

BACKGROUND

In progressive collapsing foot deformity (PCFD), the goal of surgery is to obtain a well-balanced plantigrade foot. It remains unclear if restoration of the alignment and subsequent improvement in radiological parameters is associated with improved patient-reported outcome measures (PROMs). The aim of the current systematic review was to investigate whether there is a correlation between radiographic assessment and PROMs in patients treated surgically for flexible PCFD.

MATERIALS AND METHODS

The study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A comprehensive literature search was performed in Pubmed, EMBASE, Cochrane Central Register of Controlled Trails (CENTRAL), and KINAHL. We included all the studies reporting both PROMs and radiological outcomes in patients treated surgically for PCFD. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool.

RESULTS

Six retrospective studies were included. Radiological parameters related to forefoot plantarflexion were associated with statistically significant differences in postoperative PROMs. A neutral hindfoot and midfoot position was positively correlated with postoperative PROMs but a statistically significant difference could not be established in all studies. The medial arch height was positively correlated with PROMs, but in one study this was the case only in revision surgeries.

CONCLUSION

The literature so far suggests restoration of the alignment may be associated with improved PROMs. Future prospective studies that investigate possible radiological and clinical correlations in PCFD surgery are needed.

LEVEL OF EVIDENCE

III.

To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures

PURPOSE

Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate.

METHODS

MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias.

RESULTS

Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal.

CONCLUSION

ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.

Magnetic Resonance Imaging in the Management of Significantly Displaced Adolescent Posterior Sternoclavicular Joint Injuries

BACKGROUND

Computed tomography (CT) scans are the standard imaging modality for the diagnosis and treatment guide for adolescent posterior sternoclavicular joint (SCJ) injuries. However, the medial clavicular physis is not visualized and it is not possible to differentiate between a true SCJ dislocation and a physeal injury (PI). An magnetic resonance imaging (MRI) scan can visualize the bone and the physis.

METHODS

We treated a series of patients with adolescent posterior SCJ injuries diagnosed on CT scan. Patients underwent an MRI scan to differentiate between a true SCJ dislocation and a PI and to further differentiate between a PI with or without residual medial end clavicular bone contact. Patients with a true SCJ dislocation and a PI with no contact underwent an open reduction and fixation. Patients with a PI with contact were treated nonoperatively with repeat CT scans at 1 and 3 months. At final follow-up SCJ clinical function was assessed using Quick-DASH, Rockwood, modified Constant, and single assessment numeric evaluation (SANE) scores.

RESULTS

Thirteen patients (2 female and 11 male) with an average age of 14.9 years (12 to 17) were included in the study. Twelve patients were available at final follow-up (mean 50 mo, 26 to 84). One patient had a true SCJ dislocation and 3 had an off-ended PI and were treated with an open reduction and fixation. Eight patients had a PI with residual bone contact and were treated nonoperatively. For these patients serial CT scans showed that the position was maintained, with a serial increase in callus formation and bone remodeling. The average follow-up was 42.9 months (24 to 62). At final follow-up the mean Quick-disabilities of the arm, shoulder and hand (DASH) was 0.4 (0 to 2.3), Rockwood was 15, modified Constant was 98.8 (89 to 100) and SANE was 99.5% (95 to 100).

CONCLUSION

In this case series of significantly displaced adolescent posterior SCJ injuries MRI scans allowed identification of true SCJ dislocations and off-ended PIs, which were successfully treated by open reduction, and PIs with residual physeal contact which were successfully treated nonoperatively.

LEVEL OF EVIDENCE

Level IV-case series.

The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm

Aim

Non-unions have been traditionally classified as atrophic, oligotrophic and hypertrophic and their management was primarily dictated by that. In our Unit, we have based our treatment rationale mainly on the stability of the metalwork and the presence of symptoms rather than the radiologic appearance of the non-union or the presence of infection. The aim was to present the treatment algorithm for lower limb long bone non-union following operative fixation.

Materials and methods

All patients treated for a femoral or tibial non-union following fixation between 2014 and 2020 in our unit and with a minimum follow-up of 2 years were included. Non-union was defined as having no evidence of fracture healing in any cortices six months after the index procedure. Union was defined as bridging callus in at least three cortices visualized on at least two orthogonal radiographs. Information retrieved included demographic and fracture characteristics, presence of infection, evidence of metalwork stability and treatment. Outcome measures included union rate, time to union and complications. Data were analysed with the Statistical Program for Social Sciences (SPSS) using contingency tables and linear regression. A p-value of less than 0.05 was considered statistically significant.

Results

Seventy-seven consecutive patients were included in the study. Union was achieved in 91% of the cases, while union was noted in all the patients treated non-operatively. The mean time to union was 14.49 months (9.98). Complications were encountered in 20 of the patients and the most common were docking site non-union and metalwork breakage. Infection was the only factor that affected time to union in a statistically significant manner (p = 0.006).

Conclusion

The results of our study suggest that in cases of long bone non-union following operative fixation using signs of metalwork instability and the presence of clinical symptoms as the main indication for surgical intervention provides a satisfactory outcome. This approach prevented operative management in a large proportion of patients.

Clinical significance

This article presents an algorithmic approach that could aid clinicians in their decision-making in long-bone non-union management.

Level of evidence

Therapeutic level III.

How to cite this article

Poutoglidou F, Krkovic M. The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm. Strategies Trauma Limb Reconstr 2023;18(2):100-105.

Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis

BACKGROUND

The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT.

METHODS

PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95 % confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4).

RESULTS

Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia.

CONCLUSIONS

The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

LEVEL OF EVIDENCE

II.

Amputation versus Reconstruction in Severe Lower Extremity Injury: A Systematic Review and Meta-Analysis

Objectives

Cases of severe lower limb injuries that previously were amenable only to amputation can now, in certain circumstances, be managed with reconstruction. The present systematic review and meta-analysis was designed to compare the results of amputation and reconstruction in severe lower extremity injuries.

Methods

PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were comprehensively searched for studies comparing amputation and reconstruction for severe lower extremity injuries. The search terms used were the following: "amputation", "reconstruction", "salvage", "lower limb", "lower extremity", and "mangled limb", "mangled extremity", "mangled foot". Two investigators screened eligible studies, assessed the risk of bias and extracted the data from each study. Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). The I2 index was used to assess heterogeneity.

Results

Fifteen studies with 2,732 patients were included. Amputation is associated with lower rehospitalization rates, lower length of stay in the hospital, lower number of operations and additional surgery and fewer cases of infection and osteomyelitis. Limb reconstruction leads to faster return to work and lower rates of depression. The outcomes with respect to function and pain are variable among the studies. Statistically significance was achieved only with regards to rehospitalization and infection rates.

Conclusion

This meta-analysis suggests that amputation yields better outcomes in variables during the early postoperative period, while reconstruction is associated with improved outcomes in certain long-term parameters. Severe lower limb injuries should be managed on their individual merit. The results of this study may be a useful tool to aid in the decision-making for the treating surgeon. High-quality Randomized Controlled Studies are still required to further our conclusions.

Removal of a Broken Intramedullary Nail: A Case Report and Technical Description

The removal of a broken intramedullary nail is a challenging procedure. Several surgical techniques have been described to remove the distal end of the nail. Here, we report the surgical technique for removing broken Fitbone® lengthening nail using a cerclage wire. This is an effective and reproducible technique that does not require specialized equipment, the development of a cortical window, or an arthrotomy and is applicable for all types of intramedullary nails.

Stumped by the Mystery: A Case Report of Progressive Shortening of Bone Following an Above-Knee Amputation

Several studies have investigated the anatomical adaptations in amputation stumps. In this study, we present a case report of a patient who underwent an above-the-knee amputation and, over the course of time, the length of the residual bone spontaneously shortened. The patient had undergone a total hip replacement in the same leg, and the cement mantle of the hip replacement, which could be seen within the medullary canal in the early postoperative X-rays, protruded due to bone resorption one year after the amputation. Although changes in bone microarchitecture in amputation stumps are well established, this is the first report of macroscopic changes in its actual length.

A Modified Tension Band Fixation Technique for the Management of Patellar Fractures Using Crossed Pins and a Lateral Parapatellar Approach

The use of the tension band technique for patellar fracture fixation has been associated with a loss of the rigidity of the construct after cyclic loading. Biomechanical studies have shown the biomechanical superiority of the crossed pin configuration relative to the traditional parallel one. Here, we describe a modified tension band technique that involves the use of crossed pins and a figure-of-eight passed as close to the bone as possible through a lateral parapatellar approach. The basic surgical technique and our case series are reviewed.

Plate fixation versus percutaneous rush pinning for osteosynthesis of the fibula in pilon fractures. A retrospective comparative study

BACKGROUND

Pilon fractures are complex injuries of the ankle associated with many postoperative complications. The optimal treatment for pilon fractures has not yet been established. This study aimed to determine the efficacy and compare the results of percutaneous rush pinning of the associated fibular fracture to the conventional open reduction and internal fixation.

METHODS

We included in the study all patients admitted in our department with the diagnosis of pilon fracture and associated fracture of the distal fibula and treated with primary open reduction and internal fixation between 2012 and 2018. We excluded patients treated with a two-stage approach, and those with an open fracture or neurovascular insufficiency.

RESULTS

The study included 87 patients; 45 had their distal fibular fracture operatively fixed with a one-third tubular plate (ORIF group), and the remaining 42 patients underwent percutaneous intramedullary pinning of the fibula fracture with a rush nail (Rush group). There were no statistically significant differences between the groups regarding age, gender, mechanism of injury, operating, and hospitalization time. The superficial infection rate was lower in the Rush group (p =0.039), but there were no statistically significant differences in the deep tissue infection, nonunion, and malunion incidence between the groups.

CONCLUSION

Percutaneous intramedullary rush pinning of the concomitant fibular fracture is a safe and reliable alternative treatment option in managing pilon fractures that could reduce the incidence of postoperative wound complications HIPPOKRATIA 2021, 25 (2):63-68.