Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity: Operative Technique and Radiological Outcomes

BACKGROUND

Correction of hammertoe deformities at the proximal interphalangeal (PIP) joint results in an inherent loss of motion that can be a concern for active patients who want to maintain toe function and grip strength. Diaphyseal proximal phalangeal shortening osteotomy (DPPSO) is a joint-sparing procedure resecting a cylindrical portion of the proximal phalanx on the middiaphysis.

PATIENTS/METHODS

This was a retrospective review including patients treated using DPPSO with at least a 1-year follow-up. Demographic, comorbidity, and Visual Analogue Scale (VAS) scores and complication data were obtained. Radiological assessment included union status and alignment. Medial frontal anatomical (mFAA), frontal proximal interphalangeal (mFIA), plantar lateral anatomical (pLAA), and medial and plantar lateral interphalangeal angles (pLIA) were measured.

RESULTS

A total of 31 patients (45 toes) were included, with a mean age of 59 years (range: 24-72) and follow-up of 35 months (range: 12-60; mean preoperative VAS score was 4.9 ± 1.72 improving to 1.62 ± 2.28; P < .01). Union occurred in all patients at an average of 11.2 weeks. Complications were present on 4 toes (8.8%), with no recurrences. The pLIA significantly changed from 44.9° to 17.9°. There were no significant differences in the preoperative and postoperative values of the mFAA, pLAA, and mFIA.

CONCLUSIONS

DPPSO provides adequate pain relief and corrects the PIP joint in the lateral plane without significantly affecting the coronal plane or the anatomical axis of the phalanx in the frontal and lateral views, nor producing secondary deformities. DPPSO is a safe, effective, and reproducible technique with a low complication rate.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

P–559 Proof of principle for Extended Carrier Screening (ECS) in medically assisted reproduction: First 33 cases of genetic matching for donors and recipients

Study question

Does implementation of ECS to reduce reproductive risk when using a donor with a known carrier status serves as a wider model for ART patients.

Summary answer

ECS should be routinely offered to ART patients using their own or donor gametes to reduce risk of having a child with a recessive condition.

What is known already

Responsible implementation of ECS in assisted reproduction is required as commercial offerings increase and become more accessible; ESHRE ethical guidelines are shortly to be published after consideration of stakeholder reviews. Increasingly ECS is included in donor screening, rejecting potential donors for a known carrier status will reduce donor gamete availability. Clinics should consider potential match yield in carrier panels to develop tools and specialist support to deliver and guide patients to help make informed decisions for ECS.

Study design, size, duration

Retrospective evaluation of ECS results for the first 33 patients who undertook counter screening in the clinic setting from April 2020 to December 2020 before using a donor with known carrier status. The findings would serve as proof of concept for wider application.

Participants/materials, setting, methods

Patients had opted to undertake ECS after discussion of risk estimates, family history review and personal options.Testing was commissioned between two ECS providers for international donor banks using panels of 283+ genes. Incidence of carrier match, the number of variants reported, and their clinical significance were reviewed. Main results and the role of chance: Of the 33 co-carrier tests, one carrier match for a patient and potential donor was identified. 41%, 26%, 9% and 3% of patients were carriers of 1, 2, 3 and 4 pathogenic variants respectively in 30 different genes. In 21% of patients, no pathogenic variants were reported. Of the variants identified as incidental findings, six were actionable and eligible for cascade screening to the wider family. This included Cystic Fibrosis, Sickle cell and Thalassemia. A variant for Familial hypercholesterolemia had preventative value. An incidental finding of a fragile X pre-mutation allowed for PGT-M as part of planned treatment

Limitations, reasons for caution

Findings from this first cohort of 33 tests may not represent the general population, follow up evaluation as participant numbers increase is required.

Wider implications of the findings: Implementation of guidelines is required to ensure consistency of methodology and availability of transparent information for ECS to ART patients. Incidental findings may be of value to the patient and wider family.

Trial registration number

Not applicable

Radiographic Assessment of Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity

Category:

Lesser Toes

Introduction/Purpose:

Hammertoe deformities are a result of imbalance between static and dynamic stabilizers of the lesser toes. Flexor-to-extensor tendon transfer and PIP joint arthrodesis/arthroplasty are the gold standards of treatment. Tendon transfers are associated with stiffness, edema and recurrence. PIP arthrodesis/arthroplasty sacrifices the PIP joint producing loss of both motion and toe grip. Phalangeal sustraction osteotomies have been proposed for correcting these deformities by theoretically relaxing the surrounding soft tissue structures and correcting the hammertoe deformity at the PIP joint. We present the results of a new joint sparing procedure consisting on a Diaphyseal Proximal Phalangeal Shortening Osteotomy (DPPSO) with resection of a 3-4 mm cilindrical bone section.

Methods:

Retrospective study. Review of medical records of patients who underwent phalangeal shortening osteotomy for hammer toe correction from 2010 to 2016 by the senior author (L.S.). Patients with previous surgery on the toe were excluded of the study as well as patients with incomplete radiological follow-up. Demographic and comorbidities data were noted as well as postoperative complications and secondary procedures. We performed a radiographic analysis of preoperative and postoperative x-rays-Union was defined as the existence of brigding of at least 3 cortices on the osteotomy site. Preoperatively and 6 months follow up x-rays were additionally analyzed to obtain the following measurements (Figure 1): Frontal anatomic angle (medial) FAAm Lateral anatomic angle (plantar) LAAp Frontal proximal interphalangeal angle (medial) mFPIA Lateral interphalangeal angle (plantar) pLIPP Statistical analysis: t-test for paired samples to compare preoperative and postoperative angles.

Results:

Forty-five toes (31 patients) were included in the study. The mean age of the patients was 59,5 years and the mean follow-up was 27.9 months (range:12-52). Concomitant procedures were performed on 29 patients, most commonly Hallux Valgus correction. All patients evolved with radiographic union at an average 11,2 weeks. Two patients presented with delayed healing (15 and 19 weeks). Complications were present on 4 toes corresponding to Superficial infection (3 patients) and a symptomatic floating toe (1 patient). There were not recurrences in this group. Radiographic measurements showed no significant differences between the preoperative and postoperative mFFA (p:0,43), pLAA (p:0,239) and mFIA (p:0,239). In the other hand, the Plantar lateral interphalangeal angle (pLIA) that corresponds with the hammertoe deformity, was significantly corrected (p<0,05).

Conclusion:

DPPSO is a safe and reproducible procedure with a low rate of complications. This procedure has a corrective effect on the PIP joint on the sagittal plane, reducing significantly the plantar lateral interphalangeal angle and consequently the hammertoe deformity. There was no significant effect on the PIP joint on the coronal plane and neither on the anatomical axis of the proximal phalanx in the frontal and lateral planes, therefore not producing secondary deformities of the toe.The location of the osteotomy improves bone contact and anatomical alignment of the toe while obtaining a significant correction power of the deformity.

Complications of Supine Surgical Achilles Tendon Repair

BACKGROUND

Open Achilles tendon surgery with the patient in the supine position potentially avoids the complications of the prone position, but the safety and viability of the supine position for this procedure are not known. The aim of this study was to test the hypothesis that supine positioning for open repair of acute Achilles tendon ruptures would be safe, with low wound and neurologic complication rates.

METHODS

Supine position safety in acute Achilles tendon repair was investigated. Consecutive cases of supine Achilles tendon surgical repair performed by one surgeon from 2010 to 2015 were retrospectively reviewed. Patients were included if they were surgically treated with primary repair in the supine position within 15 days of injury and did not undergo concomitant surgery. A paramedian incision 1 cm medial to the Achilles sheath was used. Initial chart review identified 161 patients who underwent any type of Achilles tendon surgery in the supine position, of whom 45 patients met the inclusion criteria. This group included 39 men and 6 women with an average age of 41 years (range, 20-66 years). Median length of follow-up was 116 days (range, 25-1,589 days). Average body mass index was 29 kg/m² (range, 23-36 kg/m²).

RESULTS

There were no infections, sural nerve injuries, or reruptures.

CONCLUSIONS

The supine position was safe for primary open Achilles tendon repair, with no wound or neurologic complications.

LEVEL OF EVIDENCE

Level IV, case series.

Supine Surgical Achilles Tendon Repair

Category:

Ankle, Hindfoot, Trauma

Introduction/Purpose:

Open Achilles tendon repair is typically performed in the prone position for easy visibility of the tendon, but serious complications may be associated with general anesthesia in this position. Open Achilles tendon repair with supine position has been described and potentially avoids these issues, but it is not known whether this position is safe. We reviewed the complication rate of supine open Achilles tendon repair in a retrospective series of patients, looking specifically at wound healing, infection, re-rupture, and sural nerve injury.

Methods:

CPT codes for Achilles tendon rupture were used to search the records of one surgeon for the years 2010-2014. The charts were then reviewed. Patients were included if they had an Achilles tendon rupture that was surgically treated with primary repair in the supine position within 15 days of injury. Patients were excluded if further reconstruction or tendon transfer was performed. A paramedian incision was utilized 1 cm medial to the Achilles sheath.

Results:

A total of 37 patients met the inclusion criteria. Of these 37 patients, 31 were men and 6 were women. The average age was 40.0 years (range, 20 to 66 years). Average length of follow-up was 159 days (range 25 to 1589 days). The average BMI was 28 (range 24-36). There were no major complications, including no infections or wound complications. No reruptures and no sural nerve injuries were observed.

Conclusion:

In 37 patients with early follow-up, supine open Achilles tendon repair had a complication rate equivalent to reported historical data for the prone procedure.

Classical anomia: a neuropsychological perspective on speech production

We present data collected from two anomic aphasics. Thorough assessment of comprehension, oral reading and repetition revealed no underlying impairments suggesting that both patients were examples of classical anomia--word-finding difficulties without impaired semantics or phonology. We describe a series of experiments in which the degree of anomia was both increased and decreased, by cueing or priming with either a semantically related word or the target item. One of the patients also presented with an 'acquired' tip-of-the-tongue phenomenon. He was able to indicate with a high-degree of accuracy the syllable length of the target, and whether or not it was a compound word. Neither patient could provide the first sound/letter. The data are discussed in terms of discrete two-stage models of speech production, an interactive-activation theory and a distributed model in which the positive and negative computational consequences of the arbitrary relationship between sound and meaning are emphasised.

A ceramic system for delivering interleukin-2

Interleukin-2 (IL-2) is a potentially effective cytokine to be used for cancer treatment. Since keeping IL-2 doses at a low, continuous level is important to avoid side effects which accompany high IL-2 doses, a ceramic which release IL-2 could prove to be a beneficial method of drug delivery for cancer patients [1]. In vitro studies were performed to determine the optimal hydroxyapatite (HA) to IL-2 ratio for continuous release of IL-2 from HA using both a matrix and insert ceramic pellet. In the matrix pellet experiment, HA to IL-2 ratios of 25:1, 50:1 and 100:1 were tested by compressing a homogenous mixture of each variable in triplicate and placing each ceramic in 2.5 mL simulated body fluid (SBF) at 37 degrees C. The fluid was collected and replaced for each ceramic every two hours for 12 hours and at 24 hours. The collected fluid was then assayed for IL-2 content. Pellets consisting of 25:1 ceramic to drug ratio delivered almost the entire amount of IL-2 at the fastest rate. Composites of 100:1 IL-2 to HA delivered the least amount of IL-2 at the slowest rate. Release of IL-2 from the 50:1 ratio pellets was intermediate with respect to speed and amount of delivery. In the insert pellet experiment, similar laboratory procedures were used to show that 100:1 ratio insert pellets delivered IL-2 at a slower rate and in lesser amounts than 50:1 ratio insert pellets. Results of this study show that HA can deliver IL-2 at different rates by varying the ratio of HA to IL-2 in both matrix and insert ceramic pellets.