Automated decision support for Hallux Valgus treatment options using anteroposterior foot radiographs

BACKGROUND

Assessment of the potential utility of deep learning with subsequent image analysis to automate the measurement of hallux valgus and intermetatarsal angles from radiographs to serve as a preoperative aid in establishing hallux valgus severity for clinical decision-making.

AIM

To investigate the accuracy of automated measurements of angles of hallux valgus from radiographs for further integration with the preoperative planning process.

METHODS

The data comprises 265 consecutive digital anteroposterior weightbearing foot radiographs. 181 radiographs were utilized for training (161) and validating (20) a U-Net neural network to achieve a mean Sørensen–Dice index > 97% on bone segmentation. 84 test radiographs were used for manual (computer assisted) and automated measurements of hallux valgus severity determined by hallux valgus (HVA) and intermetatarsal angles (IMA). The reliability of manual and computer-based measurements was calculated using the interclass correlation coefficient (ICC) and standard error of measurement (SEM). Inter- and intraobserver reliability coefficients were also compared. An operative treatment recommendation was then applied to compare results between automated and manual angle measurements.

RESULTS

Very high reliability was achieved for HVA and IMA between the manual measurements of three independent clinicians. For HVA, the ICC between manual measurements was 0.96-0.99. For IMA, ICC was 0.78-0.95. Comparing manual against automated computer measurement, the reliability was high as well. For HVA, absolute agreement ICC and consistency ICC were 0.97, and SEM was 0.32. For IMA, absolute agreement ICC was 0.75, consistency ICC was 0.89, and SEM was 0.21. Additionally, a strong correlation (0.80) was observed between our approach and traditional clinical adjudication for preoperative planning of hallux valgus, according to an operative treatment algorithm proposed by EFORT.

CONCLUSION

The proposed automated, artificial intelligence assisted determination of hallux valgus angles based on deep learning holds great potential as an accurate and efficient tool, with comparable accuracy to manual measurements by expert clinicians. Our approach can be effectively implemented in clinical practice to determine the angles of hallux valgus from radiographs, classify the deformity severity, streamline preoperative decision-making prior to corrective surgery.

Validation of the Polish versions of the Lower Limb Task Questionnaire, Lower Limb Functional Index, and Lower Limb Functional Index-10

BACKGROUND

Physicians who treat patients with lower limb diseases should pay attention not only to the patients' clinical condition but also to their individual needs and expectations. For this purpose, many different questionnaires can be employed. This study aimed to validate the Lower Limb Task Questionnaire (LLTQ), Lower Limb Functional Index (LLFI), and Lower Limb Functional Index-10 (LLFI-10) for their use in Polish conditions and to perform a mutual comparison and analysis of differences in subjective assessments by patients who undergo hip or knee arthroplasty.

METHODS

The LLTQ, LLFI, and LLFI-10 were translated into Polish. A total of 103 patients who qualified for hip or knee arthroplasty at a University Hospital in from 2019 to 2021 were included in this study. The patients were asked to complete the Polish versions of the LLTQ, LLFI, LLFI-10, Lower Extremity Functional Scale (LEFS), and Short Form-36 four times - twice before and twice after their surgeries.

RESULTS

The Polish versions of the LLTQ, LLFI, and LLFI-10 had good psychometric properties. One year after surgery, the Cohen's standard response mean revealed high improvement of limb functionality and thus quality of life among all patients. We observed better treatment outcomes among patients who had hip osteoarthritis.

CONCLUSIONS

The questionnaires were validated and can be used both in everyday health practice and in further research in Poland.

Relationship between Optimism, Self-Efficacy and Quality of Life: A Cross-Sectional Study in Elderly People with Knee Osteoarthritis

BACKGROUND

Due to the presence of numerous problems in osteoarthritis, e.g., the presence of one or more chronic diseases, reduced self-esteem and reduced ability to cope, patients must undertake readaptation activities. In such circumstances, resources that are necessary for optimal adaptation become of particular importance. This cross-sectional study aimed to assess the impact of behavioral resources, namely self-efficacy and optimism, on quality of life perception in early-old-age patients with knee osteoarthritis.

METHODS

An anonymous survey was conducted using recognized research tools: the Index of Severity for Knee Disease, Life Orientation Test, General Self-Efficacy Scale and World Health Organization Quality of Life BEFF. The study involved 300 people aged between 60 and 75 years old, including 150 patients diagnosed with gonarthrosis and 150 people without diagnosed joint and muscular diseases of the lower limbs. Non-parametric tests (e.g., Mann-Whitney U test, Kruskal-Wallis test, Spearman's correlation coefficient) were used for the statistical analysis of the results, assuming a significance level of p < 0.05.

RESULTS

The level of the examined personal resources was significantly lower in the group of people with gonarthrosis (p < 0.001), among whom low self-efficacy and a tendency toward pessimism prevailed. The results in terms of the level of lower limb joints impairment among the respondents correlated significantly and negatively with self-efficacy (r = -0.239; p = 0.003) and dispositional optimism (r = -0.318; p < 0.001). A higher level of the studied psychosocial resources led to a more favorable assessment of quality of life (p < 0.001) and own health (p < 0.001). In addition, a higher sense of self-competence was associated with better quality of life in the psychological (p = 0.044), social (p < 0.001) and environmental (p < 0.001) domains, while a tendency toward optimism was associated with higher quality of life perception in the social domain (p < 0.001).

CONCLUSIONS

It would seem to be reasonable to introduce a routine diagnosis, assessing the level of personal capabilities of elderly people with knee osteoarthritis, which may have a beneficial effect on their perception of their quality of life and their own health.

Automated correction angle calculation in high tibial osteotomy planning

High tibial osteotomy correction angle calculation is a process that is usually performed manually or in a semi-automated way. The process, according to the Miniaci method, is divided into several stages to find specific points: the center of the femoral head, the edges of the tibial plateau, the Fujisawa point, the center of the ankle joint, and the Hinge point. In this paper, we proposed an end-to-end approach that consists of different techniques for finding each point. We used YOLOv4 to detect regions of interest. To identify the center of the femoral head, we used the YOLOv4 and the Hough transform. For the other points, we used a combined method of YOLOv4 with the ASM/AAM algorithm and YOLOv4 with image processing algorithms. Our fully-automated method achieved a mean error rate of 0.5[Formula: see text] (0[Formula: see text]-2.76[Formula: see text]) ICC 0.99 (0.98-0.99) 95% CI on our own dataset of standing long-leg Anterior Posterior view X-rays. This might be the first method that automatically calculates the correction angle of high tibial osteotomy.

The Impact of Chronic Pain, Stiffness and Difficulties in Performing Daily Activities on the Quality of Life of Older Patients with Knee Osteoarthritis

Osteoarthritis causes a number of physical ailments, which result in the deterioration of a persons' general health and reduction of their ability to move freely. This cross-sectional study was designed to assess the impact of physical ailments in the course of knee osteoarthritis (KOA) on the quality of life (QoL) of patients in early old age. An anonymous survey was conducted by the use of the recognized research tools: Western Ontario scale and McMaster Osteoarthritis Index (WOMAC), The Index of Severity for Knee Disease (ISK) and World Health Organization Quality of Life-BEFF (WHOQOL-BREF). The study involved 300 people aged between 60 and 75 years old, including 150 patients diagnosed with gonarthrosis and 150 people without lower limb complaints. The significant intensification of the symptoms of knee osteoarthritis was associated with a worse assessment of health (p < 0.001), overall quality of life (p < 0.001) and in the following domains: physical (p < 0.001), mental (p < 0.001) and environmental (p < 0.001) in a group of patients with KOA. These findings suggest that taking measures to reduce knee pain and improve function may have an impact on improving the overall quality of the life of people in their early old age.

Physical Therapy Following Saucerisation of Discoid Meniscus – a Case Study

Introduction: Discoid meniscus is a structure with altered shape, which causes it to frequently undergo injuries and lesions. Pain, limping, limited range of motion of the knee joint and swelling are characteristic signs of this pathology. Therapeutic possibilities include meniscectomy and saucerisation. Research objective: The study aim was assessment of the therapeutic effectiveness in a patient after saucerisation of discoid meniscus. Material and methods: A 12-year-old female patient after saucerisation of lower left limb lateral discoid meniscus (type I) was subjected to 32-week physical therapy treatment. Testing included determining the range of knee joint flexion and extension movements, as well as measuring the circumference of the lower extremities 15 cm above the patella. The Kujala Score (Anterior Knee Pain Scale) and Ikeuchi grading system were employed during the 1st, 3rd, 8th, 21st and 32nd weeks postoperatively. Results: In the final stage of physical therapy, complete range of knee joint motion was achieved, the Kujala Scale score totalled 98 points and the thigh circumference of the operated limb increased by 4 cm. The circumferences of the lower extremities differed by 2 cm in the final phase of physical therapy. Conclusions: The employed postoperative protocol effectively influenced the functional state of the patient.

The effect of cervical spine rotation on electromyographic activity of the trapezius and serratus anterior during selected shoulder complex movements

PURPOSE

The purpose of the study was the assessment of the effect of cervical spine rotation on the activity of the upper (UT) and lower (LT) trapezius and serratus anterior (SA) muscles during selected shoulder movements.

METHODS

The investigation included 33 healthy individuals (mean age ± SD: 22 ± 1.73 years). Bioelectrical activity of the right (R) and left (L) UT, LT, SA muscles was assessed during the following movements: elevation, flexion, abduction in the scapular and right coronal planes of the dominant (right) arm accompanied by three cervical spine positions (neutral, right rotation, left rotation).

RESULTS

RLT EMG activity was higher during right shoulder abduction with right spine rotation vs. that registered during abduction without cervical spine rotation ( p < 0.001). RUT EMG activity during right shoulder abduction was higher when abduction was associated with left cervical spine rotation ( p < 0.01) and lower during right shoulder flexing with right cervical spine rotation, compared to shoulder movements with neutral spine position ( p < 0.001). A higher RSA EMG activity was seen during shoulder flexing ( p < 0.001) and abducting ( p < 0.05) (both in the frontal and scapular plane) when the movement was performed with right cervical spine rotation, compared to RSA activity during shoulder movements without spinal rotation.

CONCLUSIONS

The present results suggest that inclusion of appropriate cervical spine rotation during shoulder movements may result in improved activity of the trapezius and serratus anterior.

Quadriceps muscle strength recovery with the use of high tone power therapy after anterior cruciate ligament reconstruction: a randomized controlled trial

Background

There are no scientific reports clearly describing the effectiveness of the High Tone Power Therapy in patients after ACL reconstruction. This caused that in own research an attempt was made to present the possibilities of using the selected method of electrical stimulation in the treatment of an orthopaedic patient. The aim was to assess the effectiveness of electro stimulation of the quadriceps muscle in patients after ACL reconstruction, with the use of High Tone Power Therapy.

Methods

In randomized controlled trial took part thirty-five men, aged 21–50, after ACL reconstruction. The tests were carried prior to and 6 months following the ACL reconstruction. After the surgery, the patients were randomly divided into experimental group (17 patients) with the High Tone Power Therapy in rehabilitation and control group (18 patients) without the High Tone Power Therapy. Patients were subjected to 6-month rehabilitation. Research tools included the measurement of muscle strength torque, ROM, knee and thigh circumference measurements, the Lysholm and the VAS scale.

Results

After applying HiToP, the analysis showed a statistically significant improvement of muscle torque (p = 0.041, Es = 3.71), knee circumference (p = 0.039, Es = 1.65), thigh circumference (p = 0.049, Es = 1.26), knee extension (p < 0.001, Es = 2.20) in Experimental group compared to the control group. Only the results of the VAS scale did not differ statistically significantly both within a given group and between groups.

Conclusions

The results confirm the hypothesis that the use of HiToP in patients after ACLr have a beneficial effect on muscle strength, reduction of joint effusion, muscle mass gain and joint function. The assumption that HiToP significantly reduces pain levels is not supported - the results in both groups are statistically insignificant.

Trial registration

The research project was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of first registration 11.10.2016. Registration number: ACTRN12616001416482.

Impact of the SARS-CoV-2 Coronavirus Pandemic on Physical Activity, Mental Health and Quality of Life in Professional Athletes-A Systematic Review

Due to the rapid rate of spread of the SARS-CoV-2 coronavirus, a number of restrictions have been introduced into public spaces, including those related to the operation of sports facilities, compounding the difficulty for athletes to conduct appropriate forms of training. The aim of this study was to review current scientific reports assessing the impact of the pandemic on the physical activity, mental state, and quality of life of professional athletes. Popular scientific databases—PubMed, Scopus, and Embase—were systematically searched from the beginning of the pandemic until 12 July 2021. According to the adopted criteria, 14 articles were included in the review. Ten of the qualified studies determined the impact of the pandemic on the physical activity of athletes. The authors of 11 papers assessed the mental state and quality of life of athletes during the pandemic. The studies showed negative effects of the pandemic: a decrease in overall physical fitness and number of days and hours of training, as well as an increase in the occurrence of negative emotions (stress, fatigue, and depression) and a decrease in sleep quality. Changes in physical activity had an impact on overall well-being ratings, which depended on the sex of the subjects. Women were more likely to experience negative emotions compared to men. The mental state of the athletes affected the quality of sleep. This review summarises the negative effects of the SARS-CoV-2 coronavirus pandemic on the physical and mental health of professional athletes.

The use of an alternating magnetic field in the resorption of postoperative joint effusion following anterior cruciate ligament reconstruction: A randomized double-blind controlled trial

CONTEXT

There are no scientific reports unambiguously describing the efficacy of alternating magnetic field therapy in patients after anterior cruciate ligament (ACL) reconstruction in the early postoperative period.

OBJECTIVE

This study aims to evaluate the efficacy of using an alternating magnetic field in the resorption of postoperative joint effusion in patients after ACL reconstruction.

STUDY DESIGN

A randomized, double-blind placebo-controlled study.

SETTING

Inpatients.

PARTICIPANTS

Forty patients were enrolled in the trial. However, the final study group consisted of 38 patients (28 men and 10 women) after ACL reconstruction who were randomly divided into an experimental group (19 patients) and a control group (19 patients).

INTERVENTION

Each group received magnetic field therapy in the postoperative period, but only 1 apparatus emitted a magnetic field (the experimental group). Patients used the apparatus every day for 30 minutes for the next 11 days. The parameters in both devices were the same-3 mT and 10 Hz.

MAIN OUTCOME MEASURES

The measurement of the knee circumference and range of motion were made. The knee circumference measurement was performed before magnetic field therapy began and for 11 days after magnetic field treatment. The active knee range of motion was evaluated before and after magnetic field therapy was completed.

RESULTS

There were no statistically significant differences between the groups in the reduction of post-operative joint effusion or knee joint function.

CONCLUSION

In patients after ACL reconstruction, in whom an alternating magnetic field was used to treat postoperative joint effusion, there were no beneficial effects on the analyzed variables compared to the control group.

Association between cardiovascular disease, cardiovascular drug therapy, and in-hospital outcomes in patients with COVID-19: data from a large single-center registry in Poland

BACKGROUND

COVID-19 recently became one of the leading causes of death worldwide, similar to cardiovascular disease (CVD). Coexisting CVD may influence the prognosis of patients with COVID-19.

AIMS

To analyze the impact of CVD and use of cardiovascular drugs on the in-hospital course and mortality of patients with COVID-19.

METHODS

We retrospectively studied data for consecutive patients admitted to our hospital, with COVID-19 between March 6th and October 15th, 2020.

RESULTS

1729 patients (median (Q1 - Q3) age 63 (50-75) years; women 48.8%) were included. Overall, in-hospital mortality was 12.9%. The most prevalent CVD was arterial hypertension (56.1%), followed by hyperlipidemia (27.4%), diabetes mellitus (DM) (25.7%), coronary artery disease (16.8%), heart failure (HF) (10.3%), atrial fibrillation (13.5%), and stroke (8%). Angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) were used in 25.0% of patients, β-blockers in 40.7%, statins in 15.6%, and antiplatelet therapy in 19.9%. Age over 65 years (odds ratio [OR] 6.4, 95% CI 4.3-9.6), male sex (OR 1.4, 95% CI 1.1-2.0), pre-existing DM (OR 1.5, 95% CI 1.1-2.1), and HF (OR 2.3, 95% CI 1.5-3.5) were independent predictors of in-hospital death, whereas treatment with ACEIs/ARBs (OR 0.4, 95% CI 0.3-0.6), β-blockers (OR 0.6, 95% CI 0.4-0.9), statins (OR 0.5, 95% CI 0.3-0.8), or antiplatelet therapy (OR 0.6, 95% CI 0.4-0.9) was associated with lower risk of death.

CONCLUSION

Among cardiovascular risk factors and diseases, HF and DM appeared to increase in-hospital COVID-19 mortality, whereas the use of cardiovascular drugs was associated with lower mortality.

Does kinesiotaping can improve static stability of the knee after anterior cruciate ligament rupture? A randomized single-blind, placebo-controlled trial

Background

The aim of the study was the assessment of the early impact of the selected kinesiotaping technique on the static stability of the knee joint in patients with ACL rupture on the basis of stabilographic parameters.

Methods

Sixty-two patients with a complete ACL rupture (32 patients in experimental group and 30 patients in placebo group) took part in the randomized single-blind, placebo-controlled trial. The ligament technique of KT was taken into consideration. Application of a KT tape only on the injured knee was to stabilize the knee joint. Experimental group had application of KT on the injured knee and the placebo group had a KT placebo application (with no tension on KT). Intervention and stabilographic test in both groups was the same.

Research tools included measurements of static stabilographic parameters on stabilometric platform CQStab2P®. Outcome measures were assessed before intervention and after KT application. The analysis included evaluation of outcome variables – total path length, (SP), statokinesiogram path length in the XY axes (SPML, SPAP), and mean velocities in the XY axes (MV, MVML, MVAP).

Results

The results show a statistically significant shortening of the SP, SPAP and SPML variables only in experimental group. In the placebo group the results were not significant. The analysis also showed a significant improvement in all analyzed variables in the experimental group compared to the healthy side. In the placebo group, the results did not improve significantly after KT application compared to the healthy side.

Conclusions

Application o

f KT in patients after ACL rupture shortened the total path length and improved the value of parameters in the frontal and sagittal planes in experimental group, which may suggest the potentially greater improvement in these parameters. By improving the values of the analyzed variables, the KT application is able to compensate for the loss of static stability of the knee.

Trial Registration

This study was registered retrospectively in the Australian New Zealand Clinical Trials Registry (ANZCTR). Registration number: ACTRN12616001407482.

Changes in postural stability on balance platform in patients after meniscal repair – two years follow up

Purpose: The aim of this work was to evaluate postural stability on the balance platform averagely 2 years following meniscal repair. Methods: This is a retrospective, case-control comparative analysis of patients who underwent surgical repair for the isolated longitudinal traumatic meniscal tear versus matched healthy controls. The study group consisted of 30 patients (mean age 29.93 years; averagely 2.3 years after surgery) and the control group – of 30 people. Following physical examination and completion of the IKDC, and the Lysholm questionnaires, the evaluation of the postural stability using two single-leg stabilometry tests was performed. In the static test, the analyzed variables included deviations from the horizontal, vertical axes and the length of the balance path travelled. In the dynamic test, the length of the path travelled and the time to complete task were recorded. Between-limb and between-groups comparison of collected stabilometry tests were performed. Additionally, the IKDC and the Lysholm questionnaires scores were compared between the study and heathy groups. Results: No abnormalities were found on clinical examination in the study group nor any differences between the operated and contralateral knee (p > 0.05). In stabilometry: (1) in the study group, the operated extremity scored worse than the contralateral limb (length of path traveled in: A) static test x = 56.7 cm SD = 37.91 cm vs. x = 21.6 cm SD = 9.06 cm; p = 0.002 and B) dynamic test x = 82.57 cm, SD = 50.43 cm vs. x = 53.32 cm, SD = 13.82 cm; p = 0.003); (2) In the control group, no leg-related differences were noted (p > 0.05); (3) Between-group comparison revealed that the study group scored worse than the control group (length of path traveled in: A) static test x = 56.7 cm, SD = 37.91 cm vs. x = 17.23 cm, SD = 3.39 cm; p = 0.001 and B) dynamic test x = 82.57 cm, SD = 50.43 cm vs. x = 32.13 cm, SD = 9.41 cm; p < 0.001). Study group scored worse on IKDC scores (p < 0.001) but not on Lysholm score (p > 0.05). Conclusions: Postural stability deficit persists despite a successful meniscal repair.

Changes in postural stability on balance platform in patients after meniscal repair - two years follow up

PURPOSE

The aim of this work was to evaluate postural stability on the balance platform averagely 2 years following meniscal repair.

METHODS

This is a retrospective, case-control comparative analysis of patients who underwent surgical repair for the isolated longitudinal traumatic meniscal tear versus matched healthy controls. The study group consisted of 30 patients (mean age 29.93 years; averagely 2.3 years after surgery) and the control group - of 30 people. Following physical examination and completion of the IKDC, and the Lysholm questionnaires, the evaluation of the postural stability using two single-leg stabilometry tests was performed. In the static test, the analyzed variables included deviations from the horizontal, vertical axes and the length of the balance path travelled. In the dynamic test, the length of the path travelled and the time to complete task were recorded. Between-limb and between-groups comparison of collected stabilometry tests were performed. Additionally, the IKDC and the Lysholm questionnaires scores were compared between the study and heathy groups.

RESULTS

No abnormalities were found on clinical examination in the study group nor any differences between the operated and contralateral knee ( p > 0.05). In stabilometry: (1) in the study group, the operated extremity scored worse than the contralateral limb (length of path traveled in: A) static test x = 56.7 cm SD = 37.91 cm vs. x = 21.6 cm SD = 9.06 cm; p = 0.002 and B) dynamic test x = 82.57 cm, SD = 50.43 cm vs. x = 53.32 cm, SD = 13.82 cm; p = 0.003); (2) In the control group, no leg-related differences were noted ( p > 0.05); (3) Between-group comparison revealed that the study group scored worse than the control group (length of path traveled in: A) static test x = 56.7 cm, SD = 37.91 cm vs. x = 17.23 cm, SD = 3.39 cm; p = 0.001 and B) dynamic test x = 82.57 cm, SD = 50.43 cm vs. x = 32.13 cm, SD = 9.41 cm; p < 0.001). Study group scored worse on IKDC scores ( p < 0.001) but not on Lysholm score ( p > 0.05).

CONCLUSIONS

Postural stability deficit persists despite a successful meniscal repair.

Percutaneous Transosseous Suture Fixation of the Akin Osteotomy and Minimally Invasive Chevron for Correction of Hallux Valgus

BACKGROUND

The objective of the study was evaluation of the clinical and radiologic outcomes and complications following the minimally invasive chevron procedure employing the Akin osteotomy with percutaneous transosseous suture as compared to screw fixation.

METHODS

Between 2018 and 2019, the authors performed 103 minimally invasive chevron (MIC) with Akin osteotomies. In 54 patients, the Akin osteotomy was performed with screw stabilization (group A), and in 49 with percutaneous transosseous suture (group B). Preoperatively and 1 year later, the authors employed anteroposterior and lateral weightbearing radiographs of the feet to evaluate interphalangeal angle (IPA), distal phalangeal articular angle (DPAA), proximal phalangeal articular angle (PPAA), intermetatarsal angle (IMA), hallux valgus angle (HVA), and functional result using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. Furthermore, all additional procedures and complications were recorded.

RESULTS

Both groups demonstrated a statistically significant decrease of the value of HVA (group A: from 34.1° to 14.0°, group B: from 33.6° to 13.0°), DPAA (group A: from 12.1° to 4.0°, group B: from 11.5° to 3.4°), PPAA (group A: from 4.6° to 1.7°, group B: from 4.3° to 1.5°), IMA (group A: from 15.1° to 8.0°, group B: from 14.7° to 7.5°) and IPA (group A: from 14.1° to 6.3°, group B: from 12.9° to 5.1°). Functional improvement as measured using the AOFAS scale was achieved in both groups (group A: from 42 to 90 points, group B: from 40 to 89 points). No cases of bone nonunion or delayed union and permanent damage to the medial dorsal cutaneous nerve were seen. Two group B patients underwent conversion of the fixation of the Akin osteotomy to screws, 3 patients had their MICA screws and 1 Akin screw removed in the outpatient setting.

CONCLUSION

The minimally invasive chevron osteotomy with transosseous suture stabilization of the Akin osteotomy was a safe method with good functional results that were comparable to the outcomes achieved when using screw fixation.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Multiple Glomus Tumors in the Left Foot of 41-year-old Woman. A Case Report

Glomus tumors are very uncommon neoplasms arising from glomus bodies. They differ in the proportion of components, i.e. smooth muscle tissue, vessels and glomus cells. The most common location of this kind of tumor is the subungual area of digits. In other locations, glomus tumors are very rare but have been reported, among others, in bone, lungs, trachea and stomach. Glomus tumors are often misdiagnosed because of diverse clinical presentations. They can be asymptomatic, may lead to cosmetic discomfort, but clinical presentation often involves pain, tenderness and cold hypersensitivity. We present a case of multiple glomus tumor in the foot of a 41-year-old woman. After several surgical consultations, she had been referred for further surgery including possible ampu-tation, which she declined. Simultaneous multiple excisions of the tumors resulted in complete symptomatic relief. This case confirms that glomus tumors should be considered in a patient with multiple lesions producing ex-cruciating pain.

Comparison of the Type of Fixation of Akin Osteotomy

BACKGROUND:

The objective of the study was to assess the influence of the type of fixation of the Akin osteotomy when used during hallux valgus surgery.

METHODS:

Between 2013 and 2016, we performed 138 Akin osteotomy procedures employing a staple (group A, 43 patients), screw (group B, 47 patients), and single or double transosseous suture stabilization (group C, 48 patients). We assessed the pre- and postoperative interphalangeal angle (IPA), hallux valgus angle (HVA), and intermetatarsal angle (IMA) on dorsoplantar and lateral foot weightbearing x-rays and used the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for preoperative and 12-month postoperative follow-up clinical assessment. All the complications and costs of implant usage were recorded.

RESULTS:

In all the groups, the average HVA (A: from 33.4 to 13.1 degrees; B: from 32.8 to 14.1 degrees; C: from 31.9 to 12.9 degrees), IMA (A: from 14.4 to 7.2 degrees; B: from 13.9 to 6.9 degrees; C: from 14.5 to 7.1 degrees), and IPA (A: from 12.1 to 5.6 degrees; B: from 11.7 to 6.0 degrees; C: from 12.5 to 5.9 degrees) decreased. The average AOFAS score improved in groups A (from 45 to 91 points), B (from 42 to 90 points), and C (from 42 to 91 points). We observed 1 recurrence after the single-tunnel suture fixation, 1 prominent screw, and 1 staple soft tissue irritation. We did not find a delayed union or nonunion.

CONCLUSION:

The suture fixation of the Akin osteotomy provides results comparable to other forms of stabilization. The procedure is cost saving and helps to avoid hardware-related complications. Despite the type of bunion surgery used, fixation of the Akin osteotomy with suture was as good as more expensive and potentially more complicated fixation methods.

LEVEL OF EVIDENCE:

Level III, retrospective comparative study.

Results of Scarf Osteotomy Without Implant Fixation in the Treatment of Hallux Valgus

BACKGROUND

The main goal of the study was to evaluate the costs, clinical and radiologic results, and complications of hallux valgus surgery using scarf osteotomy, depending on the type of fixation (with or without screws).

METHODS

We evaluated 169 patients who underwent scarf osteotomy between January 2013 and August 2016. The patients were separated into 3 groups depending on the type of stabilization: A, 2 screws (50 patients); B, modified with 1 screw (55 patients); C, modified without implant (64 patients). We assessed duration of surgery, additional procedures, pre- and postoperative hallux valgus angle (HVA) and intermetatarsal angle (IMA) on anteroposterior and lateral foot weightbearing radiographs, the American Orthopaedic Foot & Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for the clinical assessment preoperatively and at the 12-month follow-up. We recorded all the complications and compared the costs between the groups.

RESULTS

Both the average HVA (A: from 33.7 to 12.6 degrees, B: 35.0 to 13.2 degrees, C: 34.7 to 12.4 degrees) and IMA (A: from 14.9 to 7.5 degrees, B: 15.2 to 6.9 degrees, C: 15.5 to 7.8 degrees) decreased in all groups without significant intergroup differences. The average AOFAS score improved in all the groups (A: from 40 to 88 points, B: 38 to 89 points, C: 42 to 91 points). A similar complication rate was observed (A: 9%, B: 10%, C: 11%). In group C, we noted a shorter time of surgery, and the procedure was the most cost-effective.

CONCLUSION

Scarf osteotomy without implant stabilization was faster and cost-effective and gave comparable results. It was technically demanding and required patient compliance.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Stabilometric indicators as an element of verifying rehabilitation of patients before and after reconstruction of anterior cruciate ligament

PURPOSE

The aim of the study was to evaluate effectiveness of rehabilitation in patients before and after rACL, based on stabilographic indicators.

METHODS

The research group was comprised of 31 men aged 20-57 with anterior cruciate ligament injury, qualified for reconstruction surgery. A measurement of static stabilometric indicators and muscle strength was taken twice for each patient - before surgery and after 6 months. To assess stabilographic indicators the stabilographic platform was used and to asses muscle strength a dynamometer was used. In order to assess knee function the Lysholm scale and VAS scale were used.

RESULTS

The rehabilitation programme improved static stability of the knee in the frontal plane, which is manifested by a significant shortening of the SPML path length. Rehabilitation proceedings should focus on improving static stability of the knee joint in the sagittal plane, because the results obtained indicate only a slight shortening of the SPAP length. The results of the Lysholm and VAS scales point to a positive influence of the applied rehabilitation.

CONCLUSION

Inclusion into rehabilitation diagnostic tools to assess stabilometric indicators enables for effective verification of rehabilitation proceedings focused on restoring body posture control before and after the rACL.

Functional assessment of patients after total knee replacement

Introduction: In the society of the 21st century, osteoarthritis is considered one of the primary causes of the occurrence of pain and disability. Arthroplasty is the treatment of choice for advanced degenerative changes. The aim of the study was to carry out a functional assessment of patients at early stages of rehabilitation after total knee replacement.

Material and methods: The research material included 35 individuals qualified for the total knee replacement. The group consisted of 26 females with an average age of 68.6 ± 7.0 and 9 males with an average age of 70.8 ± 9.1. To assess their functional status, the following tools were used: 100-point Lysholm-Gillquist scale, the VAS scale, the Timed Up and Go test, the Lovett scale and the range of motion measurement made with a goniometer. The level of significance was set at p<0.05.

Results: The research revealed statistically significant differences in the measurements of active and passive ranges of flexion and active extension in the knee joint, knee flexors and extensors muscle strength, the VAS scale and the 100-point Lysholm-Gillquist scale.

Conclusions: 1 After applying the treatment in the form of a total knee replacement, the functional state of the patients improved at early stages of rehabilitation. 2 The study proved the effectiveness of treating advanced degenerative changes through total knee replacement and the patients’ functional improvement at early stages of rehabilitation.

Preemptive Local Anesthesia in Ankle Arthroscopy

BACKGROUND

Complex anesthesia is increasingly used in order to reduce postoperative pain and accelerate rehabilitation. The aim of this study was to evaluate the efficacy and safety of preemptive local anesthesia combined with general or spinal anesthesia in ankle arthroscopy.

METHODS

From January 2014 to February 2016, 80 ankle anterior arthroscopies were performed. Patients were randomly assigned to one of 4 groups, depending on the type of anesthesia: A, general and local preemptive; B, spinal and local preemptive; C, general and placebo; D, spinal and placebo. After general or spinal anesthesia, each patient randomly received an injection of 7 mL of a mixture of local anesthetics or the same amount of normal saline. After 2, 4, 8, 12, 16, 24, 48, and 72 hours following the release of the tourniquet, the pain intensity level was measured with a visual analog scale (VAS). The use of additional analgesics and any adverse effects were also noted.

RESULTS

Preemptive local anesthesia (groups A and B) resulted in a significantly lower level of pain intensity during the first 24 hours after surgery. Until 8 hours after the release of the tourniquet, the pain intensity level was statistically lower in the groups A, B, and D in comparison to C. During hospitalization, none of the patients from groups A and B received on-demand ketoprofen intravenously. No side effects of local anesthetic agents were observed. Two patients had transient numbness and paresthesia in the field of sensory nerve innervation of the dorsal intermediate cutaneous nerve of the foot.

CONCLUSION

Preemptive operative site infiltration with a mixture of local anesthetics performed in ankle arthroscopy was a safe procedure. It reduced the level of intensity of postoperative pain and the amount of analgesics used.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Adult tonsillectomy: postoperative pain depends on indications

Introduction

Intense pain is one of the most important postoperative complaints after tonsillectomy. It is often described by patients as comparable to the pain that accompanies an acute tonsillitis. Although recurrent tonsillitis is the most frequent indication for surgery, many tonsillectomies are performed due to other indications and these patients may be unfamiliar with such pain.

Objective

To verify whether individuals with recurrent tonsillitis experience different post-tonsillectomy pain intensity than those with other indications for surgery, with no history of episodes of acute tonsillitis.

Methods

A total of 61 tonsillectomies were performed under general anesthesia, using a potassium titanyl phosphate (KTP) laser (to eliminate the potential influence on the study results of forceful dissection of fibrotic tonsils in patients with history of recurrent tonsillitis) and multiple ligations of blood vessels within the tonsillar beds. The patients received 37.5 mg Tramadoli hydrochloridum + 325 mg Paracetamol tablets for 10 days. Postoperative variables included the duration of hospital stay, postoperative hemorrhage and readmission rate. The patients reported pain intensity on consecutive days, pain duration, weight loss on postoperative day 10, character, intensity and duration of swallowing difficulties, and the need for additional doses of painkillers. Healing was also assessed. Capsular nerve fibers were histologically examined in the resected tonsils by immunostainings for general and sensory markers.

Results

Indications for the surgery were: recurrent acute tonsillitis (34 patients), no history of recurrent tonsillitis: focus tonsil (20) and intense malodour (7). Pain intensity on postoperative days 3–4 and incidence of readmissions due to dehydration were significantly higher in the group with no history of recurrent tonsillitis. No significant differences in relative densities of protein gene product (PGP) 9.5- and calcitonin gene-related peptide (CGRP)-immunoreactive nerve fibers were observed.

Conclusion

Patients with recurrent tonsillitis qualified for tonsillectomy reported lower pain intensity than those without recurrent tonsillitis and the pain scores were unrelated to nerve fibers density.

[Effectiveness and safety of intra-articular use of hyaluronic acid (Suplasyn I-Shot) in the treatment of knee osteoarthritis]

Osteoarthritis (OA) is one of the leading causes of disability in the elderly. The changes in the lubricating properties of synovial fluid lead to significant pain and loss of function. Viscosupplementation, in which hyaluronic acid (HA) is injected into the knee joint, has evolved into an important part of our current therapeutic regimen in addressing the patient with knee pain due to OA. Intra-articular HA has proven to be an effective, safe, and tolerable treatment for symptomatic knee OA. In an effort to limit cardiovascular, gastrointestinal and renal safety concerns with COX-2 selective and nonselective NSAIDs and maximize HA efficacy, it is even proposed using HA earlier in the treatment paradigm for knee OA and also as part of a comprehensive treatment strategy. Our study reconfirmed effectiveness and safety of intra-articular use of hyaluronic acid (Suplasyn) in the treatment of knee osteoarthritis.

Intra-articular pathologies associated with chronic ankle instability

Chronic ankle instability causes intra-articular lesions, which may lead to secondary degenerative changes. The aim of this study was to evaluate the usefulness of the ankle arthroscopy for the evaluation and treatment of intra-articular pathologies associated with chronic ankle instability. Between January 2013 and March 2016, 25 anterior ankle arthroscopies with modi ed anatomic Broström-Duquennoy-Tourne lateral ankle ligaments reconstructions were performed. In arthroscopy all patients (100%) had some intra-articular pathologies: 75% synovitis or so tissue scarring, 19% - deep chondral defect, 56% - superficial chondral lesion, 52% - osteophytes, 24% - bony or avulsion fragments, 20% - loose bodies. All intra-articular pathologies were treated during procedure. In conclusion, it is recommended to perform anterior ankle arthroscopy in addition to lateral ankle ligament reconstruction to diagnose and treat intra-articular lesions.

[The impact of the type of anesthesia on postoperative pain after surgical correction of hallux valgus deformity]

BACKGROUND

Different kind of anesthesia are used in hallux valgus surgery e.g general and spinal anesthesia, peripheral blocks (sciatic, femoral, ankle), patient controlled analgesia (PCA), multimodal anesthesia and preemptive local anesthesia. The type of anesthesia can play a key role in postoperative pain control. The aim of the study was to compare the effectiveness of different types of anesthesia in reduction of postoperative pain.

MATERIAL AND METHODS

In the years 2009-2015,260 hallux valgus surgeries were performed using chevron, scarf, Mitchell-Kramer or Kramer method. Depending on the kind of anesthesia, patients were assigned to one of the five groups: group A--general, group B--spinal, group C--general with local preemptive, group D--spinal with local preemptive, group E--sciatic (popliteal) block. The level of postoperative pain intensity was measured using a visual analogue scale (VAS) in 2, 4, 8, 12, 16, 24, 48 and 72 hours after surgery. Regardless of the type of anesthesia each patient received three doses of 1000 mg paracetamol, two doses of 100 mg ketoprofen and at the request 7.5 mg morphine sulphate intravenously. During discharge from the hospital followed a day after surgery each patient received a prescription for 325 mg paracetamol + 37.5 mg tramadol hydrochloride . All adverse effects of anesthesia and drugs were reported.

RESULTS

During the first 24 hours average pain intensity measured by VAS was increased in group A compared to others (p < 0.05). Between 8 and 24 hours, a similar relationship was observed in group B compared to C, D and E (p < 0.05). At the second and third day after surgery the differences in VAS were not statistically significant. In groups C, D and E we observed decreased use of 7.5 mg morphine sulphate on demand and 325 mg paracetamol + 37.5 mg tramadol hydrochloride. In two patients of group A and one in group B dizziness and nausea after use of 325 mg paracetamol + 37.5 mg of tramadol hydrochloride were noted. Two patients in group B and one of group D had incident of bradycardia. Three patients of group A and C had nausea and vomiting. We did not observe side effects of injected solution of local anesthetics.

CONCLUSIONS

Preemptive local anesthetic infiltration combined with general or spinal anesthesia and sciatic (popliteal) block are more effective than isolated general and spinal anesthesia in reducing the level of postoperative pain after hallux valgus surgery. They are also associated with decreased number of complications and reduction of applied analgesics.

[The influence of the local preemptive anesthesia on postoperative pain after open reduction and internal fixation of distal radius fractures]

BACKGROUND

Severe postoperative pain is one of the causes of prolonged hospitalization, rehabilitation and complications after surgical treatment of distal radius fractures. Preemptive local anesthesia is effective in reduction of postoperative pain in general surgery, neurosurgery, gynecology and orthopedic surgery. The aim of the study was to assess the role and effectiveness of preoperative local anesthetic infiltration of the surgical site in open reduction and internal fixation (ORIF) of distal radius fractures under general anesthesia.

MATERIAL AND METHODS

88 patients with acute distal radius intra-articular and unstable fractures were randomly assigned to receive preoperative infiltration of the surgical site with a mixture of local anesthetic agents or with saline. We measured the time from the fracture to surgery and intensity of pain at 4, 8, 12, 16, 24, 48 and 72 hours after the release of the tourniquet using a visual analogue scale (VAS). We noted all the side effects and the requirement for intravenous (IV) rescue analgesia. From analysis of chart review of their follow up visits at 2, 6 and 12 weeks we obtained DASH (Disabilities of the Arm, Shoulder and Hand) score, ROM (Range of Motion) of the wrist and grip strength of the hand.

RESULTS

The level of postoperative pain measured by the VAS scale decreased significantly during first 24 hours after surgery in the study group in comparison to the placebo group (p<0.05). We observed a positive correlation between the time elapsed between the fracture and surgery and the average VAS score in the study group. Chart review of follow up visits at 2, 6 and 12 weeks revealed significant decreased DASH score at 2 weeks and significant increased wrist flexion and extension at 2 and 6 weeks postoperatively. Six patients from the control and three subjects from the experimental group used rescue analgesia. We did not observe any side effects of the drugs. In one patient from the control group, we noted complex regional pain syndrome in late follow-up.

CONCLUSION

Preemptive local anesthesia is effective in reduction of postoperative pain after ORIF of distal radius fractures within first 24 hours. The effectiveness of preemptive local anesthesia decreases with the time elapsed between the fracture and operation. It is safe and reduces the use of rescue analgesia.

Postoperative pain and preemptive local anesthetic infiltration in hallux valgus surgery

BACKGROUND

Several techniques of anesthesia are used in foot surgery. Preemptive analgesia helps to prevent the development of hypersensitivity in the perioperative period. The aim of our study was to assess the role of preemptive local anesthetic infiltration and postoperative pain after hallux valgus surgery.

METHODS

We evaluated 118 patients who underwent modified chevron and mini-invasive Mitchell-Kramer bunionectomy of the first distal metatarsal. After spinal anesthesia each patient randomly received an infiltration of local anesthetic or the same amount of normal saline 10 minutes before the skin incision. We measured the intensity of pain 4, 8, 12, 16, 24, and 72 hours after the release of the tourniquet using a visual analogue scale (VAS). Rescue analgesia and all other side effects were noted.

RESULTS

Preemptive analgesia resulted in less pain during the first 24 hours after surgery. The decrease of VAS score was significantly lower in the study group during all the short postoperative periods measured. The rescue analgesia was administered in 11.9% of patients in the injected group and 42.4% in the placebo group (P < .05). In the injected group we did not observe significant difference in VAS score between patients post-chevron and miniinvasive Mitchell-Kramer osteotomy of the first distal metatarsal. No systemic adverse effects were noted. One persistent injury of dorsomedial cutaneous nerve was observed.

CONCLUSION

Preemptive local anesthetic infiltration was an efficient and safe method to reduce postoperative pain after hallux valgus surgery. The analgesic effect was satisfactory in both traditional and minimally invasive techniques.

[Preemptive local anesthetic infiltration in hallux valgus one-day surgery]

BACKGROUND

The surgical treatment of hallux valgus deformity is connected with significant postoperative pain. Spinal and general anesthesia as well as peripheral blocks are successfully used in foot surgery. The purpose of this study was to evaluate the influence of local anesthetic infiltration before hallux valgus one-day surgery on postoperative pain and the need for analgesics.

MATERIAL AND METHODS

134 patients underwent chevron or miniinvasive Mitchell-Kramer osteotomy of the first distal metatarsal. After general anesthesia each patient randomly received an infiltration of 7ml of local anesthetic (4 ml of 0.25% bupivacaine and 3 ml of 2% lidocaine) or the same amount of normal saline 15 minutes before the skin incision. Both the patient and the surgeon were blinded. The patient was discharged after approximately 2 hours of observation. 2, 4, 8, 12, 16, 24 and 72 hours after the release of the tourniquet the level of pain was assessed by the visual analogue scale (VAS). Rescue analgesia, side effects and the use of painkillers were noted.

RESULTS

Preemptive local anesthetic infiltration significantly decreased pain during the first 24 hours after the surgery. None of the patients from the injected group and 38 from the placebo group received 100 mg of ketoprofen intravenously for rescue analgesia in the first 2 hours after the release of the tourniquet. During the first 24 hours we noted significantly decreased use of 1000 mg of paracetamol and 100 mg mg of ketoprofen orally in the injected group. No systemic adverse effects were noted. One patient from placebo group had allergic rush after use of 100 mg ketoprofen.

CONCLUSIONS

Preemptive local anesthetic infiltration in one-day hallux valgus surgery significantly decreases postoperative pain. It is safe, efficient and allows fast discharge.

Mini-invasive mitchell-kramer method in the operative treatment of hallux valgus deformity

BACKGROUND

The mini-invasive Mitchell-Kramer procedure is a new method of operative correction of mild to moderate hallux valgus deformity. The aim of this study was to describe the technique and evaluate the results of the procedure.

METHODS

We evaluated 54 patients who underwent mini-invasive distal metatarsal osteotomy of the first metatarsal with preservation of the lateral cortex of the distal fragment. We did percutaneous 2-mm K-wire stabilization of the osteotomy and did not use cast immobilization with postoperative offloading of the forefoot. We used anteroposterior and lateral foot standing X-rays, visual analog scale (VAS), and American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale for the clinical assessment at 18 months' follow-up.

RESULTS

Preoperatively, mean hallux valgus angle was 33.9 degrees; intermetatarsal angle, 14.8 degrees; VAS, 8.9; and AOFAS, 37.0. At follow-up period, hallux valgus angle was 14.2; intermetatarsal angle, 9.7; VAS, 2.6; and AOFAS, 90.7. The average first metatarsal shortening was 2.7 mm. No transfer metatarsalgia was noted at 18 months' follow-up. We found 1 superficial infection, but all patients were satisfied.

CONCLUSIONS

The mini-invasive Mitchell-Kramer method was indicated in mild to moderate hallux valgus deformity. Cast immobilization was unnecessary, and full weightbearing was allowed early. Using the minioscillating saw allowed for reduced surgical exposure. The technique of the osteotomy also allowed for rotational stability of the osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.