The Clavien-Dindo complication classification modified for foot and ankle orthopaedic surgery

Validation of the Clavien-Madadi Classification for Unexpected Events in Pediatric Surgery: A Collaborative ERNICA Project

BACKGROUND

The Clavien-Madadi classification is a novel instrument for the assessment and grading of unexpected events in pediatric surgery, based on the Clavien-Dindo classification. The system has been adjusted to better fit the pediatric population in a prospective single-center study. There is a need now to validate the Clavien-Madadi classification within an international expert network.

METHODS

A pediatric surgical working group created 19 case scenarios with unexpected events in a multi-staged process. Those were circulated within the European Reference Network of Inherited and Congenital Anomalies (ERNICA) and surgeons were instructed to rate the scenarios according to the Clavien-Madadi vs. Clavien-Dindo classification.

RESULTS

59 surgeons from 12 European countries completed the questionnaire. Based on ratings of the case scenarios, the Clavien-Madadi classification showed significantly superior agreement rates of the respondents (85.9% vs 76.2%; p < 0.05) and was less frequently considered inaccurate for rating the pediatric population compared to Clavien-Dindo (2.1% vs 11.1%; p = 0.05). Fleiss' kappa analysis showed slightly higher strength of agreement using the Clavien-Madadi classification (0.74 vs 0.69). Additionally, intraclass correlation coefficient was slightly higher for the Clavien-Madadi compared to the Clavien-Dindo classification (ICCjust 0.93 vs 0.89; ICCunjust 0.93 vs 0.89). More pediatric surgeons preferred the Clavien-Madadi classification for the case scenarios (43.0% vs 11.8%; p = 0.002) and advantages of the Clavien-Madadi were confirmed by 81.4% of the surgeons.

CONCLUSION

The Clavien-Madadi classification is an accurate and reliable instrument for the grading of unexpected events in pediatric surgery. We therefore recommend its application in clinical and academic pediatric surgical practice.

LEVEL OF EVIDENCE

III.

Open Reduction Internal Fixation vs Primary Arthrodesis for Displaced Lisfranc Injuries: A Multicenter Randomized Controlled Trial

BACKGROUND

There is no consensus whether the primary surgical method should be open reduction and internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries. The aim of our randomized controlled trial was to compare ORIF and PA for displaced Lisfranc injuries.

METHODS

This study was a national multicenter randomized controlled trial. Altogether 43 displaced Lisfranc injuries were enrolled in this trial. The primary outcome measure was Visual Analogue Scale Foot and Ankle (VAS-FA) at a 24-months follow-up. The secondary outcome measures were VAS-FA pain, function, and other complaints subscales and the American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6, 12, and 24 months. We were unable to reach the planned sample size of 60 patients; thus, the study remains underpowered.

RESULTS

The mean VAS-FA Overall score in the ORIF group was 86.5 (95% CI 77.9, 95.1) and 80.1 (95% CI 72.0, 88.1) in the PA group at the 24-month follow-up. We did not find eligible evidence of a difference in VAS-FA Overall scores (mean between-group difference 6.5 [95% CI -5.3, 18.2], Cohen d = 0.100).

CONCLUSION

We did not find evidence of a difference in VAS-FA between ORIF and PA in patients with displaced Lisfranc injuries, and thus both are viable options for the initial surgical method. The trial is underpowered; however, the data may be included in a meta-analysis of similarly designed randomized controlled trials.ClinicalTrials.gov identifier: NCT02953067 24 October 2016.

Improvement in clinical outcomes following arthroscopic all-inside medial lateral ligament reconstruction for rotational ankle instability

PURPOSE

Rotational ankle instability can be diagnosed in up to 18% of cases of chronic lateral ankle instability. It is characterised by an abnormal increase of talar rotation within the tibiofibular mortise, due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligament. The aim of this prospective observational study was to investigate the clinical outcomes following arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability.

METHODS

A prospective observational study of consecutive patients undergoing arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with minimum 6-month follow-up. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire. Secondary outcomes included the EQ-5D, European Foot and Ankle Society score and complications.

RESULTS

Between 2020 and 2023, 12 patients underwent primary arthroscopic all-inside medial and lateral ligament reconstruction for rotational ankle instability with pre- and post-operative PROMs available for all 12 patients. The mean ± standard deviation age was 33.9 ± 7.2 years and the mean follow-up was 1.9 ± 1.2 (range: 0.5-3.8, interquartile range: 0.9-3.0) years. There was a significant improvement in all Manchester-Oxford Foot Questionnaire domain scores (p < 0.05): Index 53.1 ± 19.1 to 26.4 ± 27.6, Pain 46.7 ± 20.3 to 26.2 ± 26.8, Walking/Standing 58.7 ± 26.0 to 27.0 ± 30.0 and Social Interaction 51.2 ± 19.5 to 25.6 ± 30.1. There were improvements in EQ-5D-5L Index, VAS and VAS Pain; however, these were not statistically significant. There was one complication-a superficial peroneal nerve injury which resolved with a corticosteroid injection.

CONCLUSION

The arthroscopic all-inside medial and lateral ligament reconstruction technique is a reliable and safe method for treating rotational ankle instability, demonstrating significant improvement in PROMs at a mean 1.9-year follow-up.

LEVEL OF EVIDENCE

Level IV.

Cartiva interpositional arthroplasty versus arthrodesis in the treatment of Hallux rigidus: A retrospective comparative study with mean 2 year follow up

BACKGROUND

Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief, but sacrifices ROM. The Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is limited. The aim was to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre.

METHODS

A retrospective cohort study was conducted, enrolling all adult patients who underwent primary first MTPJ SCI arthroplasty or arthrodesis for the treatment hallux rigidus. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included EQ-5D, complication rates, VAS Pain and FAAM (ADL).

RESULTS

Between 2017 and 2020 there were 33 cases divided into two groups (17 Cartiva SCI, 16 arthrodesis, mean age 59.0 ± 9.9 years) with a mean follow up of 2.3 years. There was no statistically significant difference in any of the MOXFQ, EQ-5D, VAS Pain or FAAM (ADL) outcome scores between the Arthrodesis and SCI groups (p > 0.05). The mean MOXFQ Index score was 7.2 ± 6.4 for the SCI group and 3.9 ± 5.8 for the Arthrodesis group at final follow up (p = 0.15). Although complications were high in both groups, the overall hallux reoperation rate was 29.4 % in the SCI cohort and 0.0 % for arthrodesis.

CONCLUSION

This retrospective comparative study found no significant superiority of Cartiva SCI over arthrodesis in terms of PROMs. Due to the higher rate of further surgical intervention in the SCI cohort, we recommend arthrodesis as the preferred surgical option for hallux rigidus.

LEVEL OF EVIDENCE

III.

Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects

BACKGROUND

We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.

METHODS

Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

RESULTS

We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001.

CONCLUSIONS

Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications.

Fourth-Generation Minimally Invasive Hallux Valgus Surgery With Metaphyseal Extra-Articular Transverse and Akin Osteotomy (META): 12 Month Clinical and Radiologic Results

BACKGROUND

Fourth-generation minimally invasive surgery (MIS) includes the multiplanar rotational deformity correction achieved through manipulation of an extra-articular distal first metatarsal osteotomy that is held with rigid fixation using 2 fully threaded screws, of which one must be bicortical to provide rotational and biomechanical stability. The aim of this study is to report the clinical and radiologic outcomes of an evolved fourth-generation MIS hallux valgus technique.

METHODS

A prospective single-surgeon series of consecutive patients undergoing fourth-generation MIS was performed using a distal transverse osteotomy with a minimum 12-month follow-up. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated clinical patient-reported outcome measure (PROM). Secondary outcomes included radiographic deformity correction, clinical assessment, and EuroQol-5D-5L PROMs.

RESULTS

Between September 2019 and June 2021, 50 feet underwent fourth-generation MIS. The mean age was 55.8±15.3 years with a mean follow-up of 1.4 years. Preoperative and minimum 12-month primary outcome data were available for 100% of feet. There was a significant improvement in all MOXFQ domain scores, with the index domain improving from 53.4 to 13.1 (P < .001). There was a significant improvement (P < .001) in hallux valgus angle (32.7 to 7.9 degrees), intermetatarsal angle (14.0 to 4.2 degrees) and distal metatarsal articular angle (18.5 to 5.6 degrees). There was a significant improvement in general health-related quality of life EQ-5D-5L index and EQ-VAS scores (P < .05).

CONCLUSION

The fourth-generation MIS technique is a safe and effective approach to hallux valgus deformity correction with significant improvement in clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Comparison of modified Mitchell and Chevron osteotomies for hallux valgus

BACKGROUND

Good clinical and radiological outcomes in mild-moderate hallux valgus (HV) can be achieved with Chevron osteotomy (CO) and modified-Mitchell osteotomy (MMO). The main goal of the present study was to compare the clinical and radiological outcomes after CO and MMO in HV.

METHODS

The study included 45 patients, comprising 40 females with a mean follow-up of 87.5 ± 27.8 months. The outcome measurements of metatarsal length (MT1), HV angle (HVA), intermetatarsal angle (IMA), clinical outcomes, and metatarsalgia were evaluated pre- and postoperatively.

RESULTS

No significant difference was determined between the MMO and CO groups in respect of metatarsalgia and AOFAS scores. The CO resulted in a significantly larger decrease in the MT1. The mean HVA and IMA correction was significantly greater after MMO than after CO.

CONCLUSION

Since MMO may prevent MT1 shortening, which is a typical problem in the Mitchell osteotomy, MMO may be preferred over CO in patients with preoperative shortened first metatarsal.

The Learning Curve of Third-Generation Percutaneous Chevron and Akin Osteotomy (PECA) for Hallux Valgus

The learning curve to reach technical proficiency for third-generation percutaneous or minimally invasive chevron and Akin osteotomies (PECA/MICA) is recognized to be steep however it is poorly defined in the literature. This study is a retrospective review of the first 58 consecutive PECA cases of a single surgeon. The primary outcome was the number of cases required to reach technical proficiency as defined by the operation time. Secondary outcomes included radiation exposure, radiographic deformity correction, and complication rates. Between November 2017 and March 2019, 61 consecutive PECA cases were performed with outcome data available for 58 of these (95%). Technical proficiency was reached after 38 cases. Operation time and radiation exposure significantly decreased after this transition point (p < .05). There was no difference in complication rate or radiographic deformity correction regardless of position along the learning curve (p > .05). In conclusion, the mean number of cases required to reach technical proficiency in third-generation PECA is 38 cases. The complication rate does not correlate to the number of cases performed, therefore surgeons interested in learning minimally invasive surgery can be reassured that there is unlikely to be an additional risk of harm to a patient during the learning curve.

Transvaginal natural orifice endoscopic surgery for myomectomy: Can it be a conventional surgery?

INTRODUCTION

As a new minimally invasive surgery, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been proved to be suitable for the treatment of a variety of gynecological benign diseases. However, compared with other minimally invasive surgeries that have been widely used, such as conventional multiport laparoscopy and transumbilical laparoendoscopic single-site surgery (LESS), their advantages and disadvantages and how to choose are still unknown. The purpose of our study is to compare the advantages and disadvantages of the three minimally invasive surgeries in myomectomy and to provide theoretical basis for the wider development of vNOTES surgery.

MATERIAL AND METHODS

This retrospective study included 282 patients at our hospital who underwent laparoscopic myomectomy from May 2021 to March 2022. Based on the surgical approach, patients were classified into multiport, transumbilical LESS, and vNOTES groups. The patients' demographic characteristics and follow-up data were collected during the perioperative period and at 1 month postoperatively.

RESULTS

Among the three procedures, vNOTES had the shortest anal exhaust time but also the highest postoperative infection rate. Multiple linear regression analysis showed that the operative time increased by 3.5 min for each 1 cm increase in myoma, and intraoperative bleeding increased by approximately 12 ml. The average duration of single pores increased by 25 min compared to that of multiports, and the operative duration increased by 10.48 min for each degree of adhesion.

CONCLUSIONS

For gynecologists who have mastered vNOTES, this procedure has the same efficacy and safety as the two existing minimally invasive surgeries in myomectomy, but it shows obvious advantages in postoperative recovery.

Clinical outcomes following surgical management of insertional Achilles tendinopathy using a double-row suture bridge technique with mean two-year follow-up

BACKGROUND

The clinical outcomes following surgical management of insertional Achilles tendinopathy (IAT) vary depending on the surgical technique used to reattach the Achilles tendon following debridement. The aim of this study was to investigate the clinical outcomes of patients with IAT who underwent surgical management with a double-row suture bridge technique used to reattach the Achilles tendon.

METHODS

A retrospective review of consecutive patients diagnosed with IAT, who underwent surgical management utilising a double-row suture bridge technique (Arthex Speedbridge), and a minimum of 3-month follow-up were included. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOXFQ) Index score which is a patient reported outcome measure (PROM). Secondary outcomes included EuroQol EQ-5D-5L health-related quality of life PROM and complication rates.

RESULTS

Between July 2013 and June 2020, 50 consecutive patients (23 male; 27 female) were included. The mean age (± standard deviation) was 52.3 ± 11.3 (range 29.0-84.3). Pre- and post-operative PROM data were available for all cases. The mean follow-up was 2.4 ± 1.9 years. The MOXFQ Index score improved from 48.5 to 12.4 (p < 0.01), EQ-5D-5L improved from 2.7 ± 0.46 to 1.2 ± 0.37 (p < 0.01), and EQ-VAS improved from 48.0 ± 18.4 to 84.1 ± 12.6 (p < 0.01). Four patients had complications which were of minimal clinical relevance and caused no deviation from routine recovery. There were no cases of tendon rupture.

CONCLUSION

This study has demonstrated that surgical management of IAT is safe and effective with clinical improvement in both clinical and general health-related quality of life outcome PROMs.

LEVEL OF EVIDENCE

IV.