Anterior Slope Correction-Flexion Osteotomy in Traumatic Genu Recurvatum

A decreased posterior tibial slope has been associated with an increased risk of posterior cruciate ligament failure, anterior knee pain, and premature knee osteoarthritis. Trauma is a common cause of osseous genu recurvatum. Surgical management is recommended to correct the tibial slope and prevent knee pain and osteoarthritis progression. This article discusses our preferred treatment using a proximal tibial opening-wedge osteotomy for surgical management of genu recurvatum secondary to significant anterior tibial slope.

Is bilateral hallux valgus chevron osteotomy a safe procedure for ambulatory surgery?

INTRODUCTION

Several osteotomies of the first metatarsal have been described for treatment of hallux valgus but chevron osteotomy is one of the most common and well-established procedure for treating this deformity. Although there is a trend towards considering bilateral surgery there is lack of publications addressing bilateral treatment in ambulatory units. The aim of this study is to analyze results of bilateral and unilateral distal chevron osteotomies associated with lateral soft tissue release as ambulatory procedures.

MATERIALS AND METHODS

A retrospective review was made about the patients treated at our ambulatory unit over a period of five years. Initially, general information as patient's satisfaction's rate and return to normal activity's time and evaluation of standardized follow-up charts and records made by the surgeon were recorded. Secondly, the hallux metatarsophalangeal interphalangeal scale developed by the American Orthopedic Foot & Ankle Society was used.

RESULTS

A total of 194 patients with 230 feet operated were included in this study. We found 29 patients that didn't meet the inclusion criteria and were excluded. The unilateral group was composed by 139 feet and the bilateral group by 52 feet. The improvement between preoperative and discharge clinical and radiographic results was significant independently in both groups. A total of 14% of complications were found in our study, 19% in the unilateral group and 12% at the bilateral group. None of them required revision surgery.

CONCLUSION

Bilateral distal chevron osteotomies, associated with lateral soft tissue release, are safe and effective ambulatory procedures. It was found a satisfactory deformity correction in moderate HV. Both patients that underwent unilateral and bilateral procedures had similar clinical and radiological outcomes with no increase in complications or return to normal activity time. With this study it was demonstrated that bilateral chevron osteotomies can be performed as ambulatory procedures.

Validation of the Ottawa ankle rules: Strategies for increasing specificity

INTRODUCTION

The majority of patients with ankle injuries undergo radiological examinations of the foot, ankle or both. The objective of this study was in the first place to validate the Ottawa Ankle Rules (OARs) for the population of our centre. Secondly, an attempt was made to identify parameters that contribute to improve the specificity of the method, with a view to reduce the need for patients to be exposed to radiation as well as optimizing the expenses of the Emergency Ward (EW).

MATERIALS AND METHODS

This was a prospective study conducted during a 9-month period. The study population included 148 patients, in 54 (36%) of the patients a fracture was present on the exams performed. Patients were submitted to a sequential protocol in the EW with a form completion, evaluation of OARs, application of the Visual Analog Pain Scale (VAS) and radiographic exams.

RESULTS

We found a sensitivity of OARs in ankle injuries of 100%, specificity of 26% and in midfoot injuries of 100% and 62% respectively. All patients with fractures had a VAS of 5 or more points in any of the tested sites. With the VAS criterium, we found a significant increase of global specificity (38% vs 15%), as well as when applied only to the ankle (26% to 47%) or to midfoot trauma (62% to 67%). In both, there would have been a 100% reduction of CT scans. Patients with a fracture or with fractures who required surgical treatment had a mean VAS significantly higher than patients with no fracture or fractures submitted to conservative treatment respectively. Although there was a lower percentage of fractures in the group of injuries in Work Accidents (31% vs 37% Sports Activity and 38% Leisure Activity), there was a statistically significant increase in the sum of average VAS in Accidents at Work vs Leisure Activities and vs Sports Activities.

CONCLUSION

We seek to confirm the usefulness of OARs for our population and we investigated strategies to further reduce the need for unnecessary radiographs. The introduction of parameters for grading pain and adapting to the context of the accident seem promising.

Percutaneous Scaphoid Fixation: Experience Value among Different Approaches

Background  Percutaneous scaphoid osteosynthesis is an attractive and increasingly popular option, as a treatment for acute scaphoid fractures in selected cases, and as an alternative to conservative treatment. The purpose of this study is to assess the radiographic positioning of the screw in percutaneous scaphoid fixation, taking into consideration the surgeons' experience, and the difference between volar and dorsal approaches. Methods  We retrospectively assessed patients undergoing percutaneous scaphoid fixation from 2013 to 2019. Inclusion criteria are as follows: (1) scaphoid waist fractures (Herbert's B2), (2) a minimum of 18 years of age and a maximum of 55 years of age, (3) dominant hand, (4) manual work, (5) minimum follow-up time of 6 months, and (6) without associated lesions. Criteria for correct positioning are as follows: (1) on the axis or parallel to the scaphoid axis with a maximum deviation of 1.5 mm volar/dorsal, (2) without proximal/dorsal prominence, (3) correct scaphoid alignment/reduction, and (4) absence of threads in the fracture site. Radiographs were evaluated separately by a hand surgeon, a general orthopaedic surgeon, and an orthopaedic resident. Results  With a total of 39 patients, a dorsal approach was performed in 10 patients and a palmar approach in 29 patients. We verified a very good interobserver reliability. The hand surgeon's team correctly positioned 15 (83.3%, 15/18), while the other team did 9 correctly (42.9%, 9/21). Comparing teams according to the approach used, the dorsal approach did not show a statistical difference, while the same was not true for the volar approach ( p  < 0.05). Conclusion  This points to a positive impact on the team's experience in the positioning of the screws, and therefore in the benefit of treatment by teams dedicated to the area, while daring to suggest that less-experienced surgeons should utilize the dorsal approach.

Trapeziectomy and Suture-Button Suspensionplasty for Basilar Thumb Arthritis: Is It Enough to Prevent First Ray Subsidence?

Introduction  Trapeziectomy and suture-button suspensionplasty (SBS) are a novel option to treat end-stage trapeziometacarpal (TMC) osteoarthritis. Our purpose is to evaluate our outcomes with this technique and in this setting, with a minimum of 18 months of follow-up. Materials and Methods  Twenty-eight patients were included, operated between 2016 and 2018. We recorded demographic data, preoperative Eaton stage, follow-up and operative times. The patients completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and tip pinch, key pinch, and grip strength were measured. First metacarpal subsidence was calculated, and postoperative complications were documented. Results  The average follow-up was 34 months. The mean QuickDASH was 32 at the final follow-up. The average strength results were 20 kg for grip, 3.6 kg for tip pinch, and 4.2 kg for key pinch. The rate of first ray subsidence was 10.7%. We encountered three complications: a hardware intolerance, a second metacarpal fracture, and a suture rupture. There was one reoperation to remove an implant. Conclusion  Trapeziectomy and SBS functional results are similar to other techniques, with less subsidence of the first ray and allowing for early mobilization and fast recovery. This procedure is a safe and promising option in the treatment of TMC osteoarthritis, with good medium-term outcomes.

Bronchopulmonary dysplasia: clinical practices in five Portuguese neonatal intensive care units

With the advent of surfactant, prenatal corticosteroids (PNC) and advances in technology, the survival rate of extremely low birth weight (ELBW) infants has improved dramatically. Rates of bronchopulmonary dysplasia (BPD) vary widely among neonatal intensive care units (NICUs) and many studies using multiple interventions have shown some improvement in BPD rates. Implementing potentially better practices to reduce BPD has been an effort made over the last few decades.

AIM

To compare five Portuguese NICUs in terms of clinical practices in very low birth weight (VLBW) infants, in order to develop better practices to prevent BPD.

PATIENTS AND METHODS

256 preterm neonates, gestational age (GA) <30 weeks and/or birthweight (BW) <1250g admitted to five Portuguese NICUs (centers 1 to 5) between 1st January 2004 and 31st December 2006, were studied. VLBW infants with major malformations, grade IV intraventricular haemorrhage in the first week of life and metabolic or neuromuscular disease were excluded. BPD was defined as oxygen dependency at 36 weeks of postconceptional age. We considered a practice to be improved as clinically significant whenever a decrease greater than 10% in the prevalence of BPD adjusted for the practice, GA and BW was achieved compared to BPD prevalence adjusted only for GA and BW.

RESULTS

The overall prevalence of BPD was 12.9%. Our results revealed that PNC use should be improved in centers 4 and 5; fluid policy in center 4; oxygen therapy and sepsis prevention in centers 1 and 2. Patent ductus arteriosus (PDA) treatment should be improved in center 2.

CONCLUSION

The implementation of potentially better practices to reduce lung injury in neonates in Portuguese NICUs, according to each NICU, must be addressed to increase the prescription of PNC, to use a lower FiO2, to be careful with fluid administration in the first weeks of life and to prevent PDA and sepsis. It is necessary to follow guidelines, recommendations or protocols to improve quality in the prevention of BPD.