Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

Thumb Metacarpal-Trapezoid Impingement as an Etiology of Pain After Trapeziectomy and Basal Joint Soft Tissue Arthroplasty: A Case Series

PURPOSE

To report a poorly described etiology for pain after trapeziectomy and soft tissue basal joint arthroplasty, diagnosed with the aid of nuclear imaging.

METHODS

Five patients (4 women and 1 man), average age 62 years (range, 59-65 years) presented with pain an average of 7 months (range, 2-11 months) after basal joint arthroplasty. The dominant hand was involved in all cases. Advanced imaging including 25 mCi ^99mTc methylene diphosphonate bone scintigraphy and single-photon emission computed tomography (CT) showed intense tracer uptake between the base of the thumb metacarpal and residual trapezoid. Computed tomography scans confirmed abutment between these bones. The symptoms were attributed to this finding, and revision surgery consisting of excision of the trapezoid and arthrodesis of the index and middle finger carpometacarpal joints was performed.

RESULTS

Mean follow-up was 40 months (range, 12-60 months). Grip strength improved from a mean of 10.5 to 23 kg, and lateral pinch strength improved from a mean of 3 to 6.75 kg. Radiographic fusion of the index finger metacarpal to capitate was confirmed in 4 of 5 patients; it was indeterminate in one patient who was completely pain-free. Radiographic fusion of long finger carpometacarpal joints was indeterminate in 3 patients. Patient-Rated Wrist Evaluation pain scores improved from 35 to 6, Patient-Rated Wrist Evaluation function scores from 78 to 14, and Quick-Disabilities of the Arm, Shoulder, and Hand scores from 37 to 18.

CONCLUSIONS

Impingement between the base of the thumb metacarpal and remaining trapezoid should be considered a potential source of pain after trapeziectomy and soft tissue arthroplasty. Advanced imaging (bone scintigraphy and single-photon emission CT and standard CT) are helpful to confirm the diagnosis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Does the ASA grading influence the outcomes of best practice tariff in fracture neck of femurs

Objectives:

The aim of this study is to find the significance of different ASA grades in achieving the Best Practice Tariff (BPT) and their outcomes in patients with fracture neck of femur.

Methods:

A retrospective study over a five years period. Patient demographics, ASA grading, hospital admission timing, time to theatre and discharge date were recorded. The 30 day mortality rate and length of stay were calculated for each ASA grades for patients who met and failed BPT.

Results:

1798 patients were included in the study. 54% was ASA grade 3, grade 4 represented 22% and grade 2, 19%. The mean AMT score was 6.4 who met BPT and 4.4 who failed BPT (p<0.001). 319 patients with ASA≤2 met BPT and 53 patients failed to meet BPT. In ASA ≥3, 1200 patients who met BPT and 225 patients failed BPT. The 30-day mortality in patients with ASA≤2 who met BPT was 2.57% and those who failed were 1.92%. In ASA ≥3 the 30-day mortality was 12.63% and who failed BPT was 25% which is statistically significant.

Conclusion:

In patients with ASA≥3 the 30-day mortality is significantly higher in those who failed BPT compared to ASA≤2 patients whether they achieved BPT or not.

The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat?

This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.

Revision of Failed Open Reduction of Developmental Dysplasia of the Hip

Background

The most common causes of re-dislocation after open reduction are inadequate exposure and failure to release the obstructing soft tissues inside and around the hip.

Methods

This clinical study included 33 consecutive children (34 hips) who underwent a revision surgery after failed open reduction of developmental dysplasia of the hip (DDH).

Results

According to the McKay clinical criteria, the results were good in 28 cases (82.4%), fair in 4 cases (11.8%), and poor in 2 cases with re-dislocation (5.9%). Radiological results according to the modified Severin criteria were as follows: 28 hips (82.4%) were identified as category 2 (good), 4 hips (11.8%) category 4 (fair), and 2 hips (5.9%) category 5 (poor).

Conclusions

Revision surgery for DDH is demanding and the long-term consequences are usually serious, but stable, concentric reduction should be obtained either at the first or second open reduction by addressing the causes of failure. Failed acetabulum remodeling and technical errors with inadequate soft-tissue release were the most common causes of failure in the primary operation. Based on the results, the outcome of revision surgery after failed open reduction for DDH was good.

Cranial bone flap resorption-pathological features and their implications for clinical treatment

Cranioplasty following decompressive craniectomy (DC) has a primary complication when using the autologous bone: aseptic bone resorption (ABR). So far, risk factors such as age, number of fragments, and hydrocephalus have been identified but a thorough understanding of the underlying pathophysiology is still missing. The aim of this osteopathological investigation was to gain a better understanding of the underlying processes. Clinical data of patients who underwent surgical revision due to ABR was collected. Demographics, the time interval between craniectomy and cranioplasty, and endocrine serum parameters affecting bone metabolism were collected. Removed specimens underwent qualitative and quantitative histological examination. Two grafts without ABR were examined as controls. Compared to the controls, the typical layering of the cortical and cancellous bone was largely eliminated in the grafts. Histological investigations revealed the coexistence of osteolytic and osteoblastic activity within the necrosis. Bone appositions were distributed over the entire graft area. Remaining marrow spaces were predominantly fibrotic or necrotic. In areas with marrow cavity fibrosis, hardly any new bone tissue was found in the adjacent bone, while there were increased signs of osteoclastic resorption. Insufficient reintegration of the flap may be due to residual fatty bone marrow contained in the bone flap which seems to act as a barrier for osteogenesis. This may obstruct the reorganization of the bone structure, inducing aseptic bone necrosis. Following a path already taken in orthopedic surgery, thorough lavage of the implant to remove the bone marrow may be a possibility, but will need further investigation.

Surgical Management of Symptomatic Boxing-Induced Spinal Cerebrospinal Fluid Leak After Failed Epidural Blood Patch

BACKGROUND

Spontaneous spinal cerebrospinal fluid (CSF) leak is an increasingly recognized condition responsible for spontaneous intracranial hypotension. A host of connective tissue disorders and mechanical factors may precipitate the condition. Conservative treatment has limited efficacy, and many patients with persistent symptoms ultimately require epidural blood patch (EBP). However, about 23%-44% of patients experience recurrence of symptoms after EBP. Unidentified or multiple sites of CSF leaks are thought to be responsible for the failure of EBP. Using our previously published technique, we treated a patient who developed a large spontaneous CSF leak in her cervicothoracic spine after a boxing class, offering further evidence of the utility of the technique for select patients.

CASE DESCRIPTION

A 28-year-old woman was referred to our center with recurrent, severe headaches and associated nausea and vomiting. She underwent EBP 3 times with no resolution of her symptoms. A right-side partial C7-T1 hemilaminotomy was performed to identify a large meningocele filled with CSF. After dissection, dural sealant was applied using an angled needle with a syringe to buttress the meningocele to allow for normalization of the hydrostatic pressure. At 5-month follow-up, her symptoms have resolved with no headaches and paresthesias in upper limbs.

CONCLUSIONS

Commonplace events, such as a boxing/sparring class, may precipitate a spontaneous spinal CSF leak. Our minimally invasive surgical approach can be safely used in patients with spontaneous intracranial hypotension with recurrent symptoms, no identified leak site, and prior failed attempts of EBP.

VBAC: Changes over Last 10 Years

Introduction

Vaginal birth after caesarean section (VBAC) has been historically studied to be a standard and a safe procedure with good successful results.

Aims

This study was conducted to determine changes in pattern of VBAC by the same author over a period of 10 years.

Results

Data for 1 year between 2005-2006 and 2014-2015 were compared, and successful VBAC was found to be 74.46% in 2005-2006 period compared to only 34.42% in 2014-2015. Neonatal mortality and maternal morbidity were, however, much higher 10 years ago.

Conclusions

It was concluded that better diagnostic techniques, awareness of patients and medico legal fear have led to safer health of mother and child and lesser incidence of VBAC over the last 10 years.

How to Recognize a Failed Burn Resuscitation

Failed burn resuscitation can occur at various points. Early failed resuscitation will be largely caused by prehospital factors. During resuscitation, failure will present as a patient's nonresponse to adjunctive therapy. Late failure will occur in the setting of multiple organ dysfunction syndrome. Burn care providers must be vigilant during the resuscitation to identify a threatened resuscitation so that adjunctive therapies or rescue maneuvers can be used to convert to a successful resuscitation. However, when a patient's resuscitative course becomes unsalvageable, transition to comfort care should be taken to avoid prolongation of suffering.

Evaluation and treatment of failed shoulder instability procedures

Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. Detailed understanding of the native shoulder anatomy, including its static and dynamic restraints, is necessary for determining the patient’s primary pathology. In addition, evaluation of the patient’s history, physical exam, and imaging is important for identifying the cause for failure after the initial procedure. Common mistakes include under-appreciation of bony defects, failure to recognize capsular laxity, technical errors, and missed associated pathology. Many potential treatment options exist for revision surgery, including open or arthroscopic Bankart repair, bony augmentation procedures, and management of Hill Sachs defects. The aim of this narrative review is to discuss in-depth the common risk factors for post-surgical failure, components for appropriate evaluation, and the different surgical options available for revision stabilization.

Level of evidence Level V.